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Health Information Technology and Victory
Abstract
is apattern of fantasy and projection on the part of informationtechnologyadvocates.Fordecades,wehaveheardthetechnofantasythatthepresentproblemsofcomputerizationwillbesolvedbymorecomputerization: in particular the “next generation” of computers,operating systems, applications, or users. If fantasy is insufficient,then projection isanother defense, the common notion among thecomputerati that uncooperative people are the main barriers toprogress through computing. Both these defenses only deflectattention from the real problem: the persistent failure to achieve agoalthatseemstobecontinuouslyreceding.Atleast1generationofphysicians and multiple generations of hardware and software havecome and gone during this effort, suggesting that escalating ourcommitment tothe current healthinformation technology strategyisnotreasonable
... The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 distributed nearly $26 billion dollars in a nation-wide effort to deploy electronic health record systems (EHRs) and improve patient safety and improve healthcare efficiency. Much has been written regarding the failure of these systems to deliver on those promises [1][2][3]. EHRs are complex, expensive software products which require substantial financial investment to implement [4]. Yet, the designers of these systems largely neglected to properly design the human-computer interface. ...
... The causes of this failure are legion, however the interface between the emergency physician (human) and EHR is a frequently-cited factor [2][3][4]. While EHRs have been represented to place patient information such as history, laboratory findings and medication lists, at the fingertips of clinicians, physicians continue to struggle to efficiently and safely use these systems. ...
... Many experts suggest that human-computer interface issues are impairing the fulfillment of the promise of increased efficiency and improved patient safety, often touted as the driver of widespread deployment of electronic health records [1,2,5,24]. Yet, there is a paucity of information regarding the limitations and issues of electronic health records. ...
Background Through the Health Information Technology for Economic and Clinical Health Act of 2009, the federal government invested $26 billion in electronic health records (EHRs) to improve physician performance and patient safety; however, these systems have not met expectations. One of the cited issues with EHRs is the human–computer interaction, as exhibited by the excessive number of interactions with the interface, which reduces clinician efficiency. In contrast, real-time location systems (RTLS)—technologies that can track the location of people and objects—have been shown to increase clinician efficiency. RTLS can improve patient flow in part through the optimization of patient verification activities. However, the data collected by RTLS have not been effectively applied to optimize interaction with EHR systems.
Objectives We conducted a pilot study with the intention of improving the human–computer interaction of EHR systems by incorporating a RTLS. The aim of this study is to determine the impact of RTLS on process metrics (i.e., provider time, number of rooms searched to find a patient, and the number of interactions with the computer interface), and the outcome metric of patient identification accuracy
Methods A pilot study was conducted in a simulated emergency department using a locally developed camera-based RTLS-equipped EHR that detected the proximity of subjects to simulated patients and displayed patient information when subjects entered the exam rooms. Ten volunteers participated in 10 patient encounters with the RTLS activated (RTLS-A) and then deactivated (RTLS-D). Each volunteer was monitored and actions recorded by trained observers. We sought a 50% improvement in time to locate patients, number of rooms searched to locate patients, and the number of mouse clicks necessary to perform those tasks.
Results The time required to locate patients (RTLS-A = 11.9 ± 2.0 seconds vs. RTLS-D = 36.0 ± 5.7 seconds, p < 0.001), rooms searched to find patient (RTLS-A = 1.0 ± 1.06 vs. RTLS-D = 3.8 ± 0.5, p < 0.001), and number of clicks to access patient data (RTLS-A = 1.0 ± 0.06 vs. RTLS-D = 4.1 ± 0.13, p < 0.001) were significantly reduced with RTLS-A relative to RTLS-D. There was no significant difference between RTLS-A and RTLS-D for patient identification accuracy.
Conclusion This pilot demonstrated in simulation that an EHR equipped with real-time location services improved performance in locating patients and reduced error compared with an EHR without RTLS. Furthermore, RTLS decreased the number of mouse clicks required to access information. This study suggests EHRs equipped with real-time location services that automates patient location and other repetitive tasks may improve physician efficiency, and ultimately, patient safety.
... Emergency medicine electronic health record usability: where to from here? Katie Walker ,1,2 Tim Dwyer, 3 Heather A Heaton 4 Information technology (IT) usability is the degree to which software can be used by specified consumers (eg, doctors) to achieve quantified objectives (eg, manage emergency patients in an emergency department (ED)) with effectiveness, efficiency and satisfaction with each interaction. 1 Usability is relevant to new learners, infrequent users and regular users, and for people with a wide variety of capabilities. ...
... The issue of EHR usability is not new, with articles published over the years calling for improvements, describing how large sums of health money has been spent on unproven IT systems without any evidence of improvements in safety, quality or efficiency. 3 The authors mention that some may feel that the concept of usability is nebulous, however, usability is well defined. 2 The computer science discipline, known as Human Computer Interaction, has studied the science and developed the practice of creating usable systems for decades. ...
... The HIT Loops are rooted in the tradition of clinical informatics and embody the principle that software must be usable and functional to be beneficial. 21 The dominant PDSAs ensure that the software interventions are ultimately about improving health care quality. All team members (QI and HIT) are involved in all phases of each PDSA cycle irrespective of intervention type. ...
The implementation of health information technology (HIT) is complex. A method for mitigating complexity is incrementalism. Incrementalism forms the foundation of both incremental software development models, like agile, and the Plan-Do-Study-Act cycles (PDSAs) of quality improvement (QI), yet we often fail to be incremental at the union of the disciplines. We propose a new model for HIT implementation that explicitly links incremental software development cycles with PDSAs, the QI-HIT Figure 8 (QIHIT-F8). We then detail a subsequent local HIT implementation where we demonstrated its use. The QIHIT-F8 requires a reprioritization of project management activities around tests of change, strong QI principles to detect these changes, and the presence of both baseline and prospective data about the chosen indicators. These conditions are most likely to be present when applied to indicators of high strategic importance to an organization.
... The survey-identified barriers are consistent with prior research in that the two primary errors with health IT are problems with data entry and data display and poor provider communication and coordination with clinical workflow. 23,37 The value of human factors methods for health IT implementation has been highlighted previously 38,39 and is considered core content in the specialty of clinical informatics. 40 The benefit of a human factors approach to improve usability and workflow of CDS was apparent in our study, as those two primary barriers were markedly reduced with the new eCDS tool (Table 3). ...
Background:
Use of electronic clinical decision support (eCDS) has been recommended to improve implementation of clinical decision rules. Many eCDS tools, however, are designed and implemented without taking into account the context in which clinical work is performed. Implementation of the pediatric traumatic brain injury (TBI) clinical decision rule at one Level I pediatric emergency department includes an electronic questionnaire triggered when ordering a head computed tomography using computerized physician order entry (CPOE). Providers use this CPOE tool in less than 20% of trauma resuscitation cases. A human factors engineering approach could identify the implementation barriers that are limiting the use of this tool.
Objectives:
The objective was to design a pediatric TBI eCDS tool for trauma resuscitation using a human factors approach. The hypothesis was that clinical experts will rate a usability-enhanced eCDS tool better than the existing CPOE tool for user interface design and suitability for clinical use.
Methods:
This mixed-methods study followed usability evaluation principles. Pediatric emergency physicians were surveyed to identify barriers to using the existing eCDS tool. Using standard trauma resuscitation protocols, a hierarchical task analysis of pediatric TBI evaluation was developed. Five clinical experts, all board-certified pediatric emergency medicine faculty members, then iteratively modified the hierarchical task analysis until reaching consensus. The software team developed a prototype eCDS display using the hierarchical task analysis. Three human factors engineers provided feedback on the prototype through a heuristic evaluation, and the software team refined the eCDS tool using a rapid prototyping process. The eCDS tool then underwent iterative usability evaluations by the five clinical experts using video review of 50 trauma resuscitation cases. A final eCDS tool was created based on their feedback, with content analysis of the evaluations performed to ensure all concerns were identified and addressed.
Results:
Among 26 EPs (76% response rate), the main barriers to using the existing tool were that the information displayed is redundant and does not fit clinical workflow. After the prototype eCDS tool was developed based on the trauma resuscitation hierarchical task analysis, the human factors engineers rated it to be better than the CPOE tool for nine of 10 standard user interface design heuristics on a three-point scale. The eCDS tool was also rated better for clinical use on the same scale, in 84% of 50 expert-video pairs, and was rated equivalent in the remainder. Clinical experts also rated barriers to use of the eCDS tool as being low.
Conclusions:
An eCDS tool for diagnostic imaging designed using human factors engineering methods has improved perceived usability among pediatric emergency physicians.
... 18 However, some have suggested that computerized physician order entry may result in delays in care and overuse of medical resources, and the benefits of computerized physician order entry on health outcomes are not firmly established. [18][19][20][21][22] ...
Study objective:
Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke.
Methods:
We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center.
Results:
Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality.
Conclusion:
For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.
... ERPs are considered as "invasive [22]". Therefore they elicit powerful social responses, which can either increase or decrease acceptance: Due to traceable user prompts, planners felt that more personal blame for organizational mishaps was placed on them. ...
Background:
Planning and controlling surgical operations hugely impacts upon productivity, patient safety, and surgeons' careers. Established, specialized software for this task is being increasingly replaced by "Operating Room (OR)-modules" appended to enterprise-wide resource planning (ERP) systems. As a result, usability problems are re-emerging and require developers' attention.
Objective:
Systematic evaluation of the functionality and social repercussions of a global, market-leading IT business control system (SAP R3, Germany), adapted for real-time OR process steering.
Methods:
Field study involving document analyses, interviews, and a 73-item survey addressed to 77 qualified (> 1-year system experience) senior planning executives (end users; "planners") working in surgical departments of university hospitals.
Results:
Planners reported that 57% of electronic operation requests contained contradictory information. Key screens contained clinically irrelevant areas (36 +/- 29%). Compared to the legacy system, users reported either no improvements or worse performance, in regard to co-ordination of OR stakeholders, intra-day program changes, and safety. Planners concluded that the ERP-planning module was "non-intuitive" (66%), increased planning work (56%, p=0.002), and did not impact upon either organizational mishap spectrum or frequency. Interviews evidenced intra-institutional power shifts due to increased system complexity. Planners resented e.g. a trend towards increased personal culpability for mishap.
Conclusions:
Highly complex enterprise system extensions may not be directly suited to specific process steering tasks in a high risk/low error-environment like the OR. In view of surgeons' high primary task load, the repeated call for simpler IT is an imperative for ERP extensions. System design should consider a) that current OR IT suffers from an input limitation regarding planning-relevant real-time data, and b) that there are social processes that strongly affect planning and particularly ERP use beyond algorithms. Real improvement of clinical IT tools requires their independent evaluation according to standards developed for pharmaceutical subjects.
... In the banking and aviation industry, human errors are reduced through effective use of IT (Turan and Palvia, 2014), and, in the same way, medical errors are reduced using HIT (Balicer and Cohen-Stavi, 2020;El-Kareh et al., 2013;Rodziewicz and Hipskind, 2019). If there is available electronic access to complete a patient's health information, this will reduce medical errors that occur because of gaps in knowledge about issues like allergies, relevant medication and laboratory information, past medical history, and poor communication among providers (Risko et al., 2014;Rodziewicz and Hipskind, 2019;Wears, 2015). ...
The research purposed in this paper is to investigate the impact of the health information technology on hospital performance through the health information quality as mediating variable, as new evidence from the teaching hospitals in the north of Jordan. Research design and methodology approach based on a survey that is conducted to collect the requested data to develop a model connect between the health information technologies, health information quality and hospital performance by using the Structural Equation Modeling approach. The research findings show that there is an intertwined and reciprocal relation between Health Information Technologies (HITs), hospital performance, and health information quality. HITs have direct positive impacts on both hospital performance and health information quality. Health information quality has also a direct impact on hospital performance. Besides, health information quality functioned as a partial mediator between HITs and hospital performance. The study did not examine the factors that influence the relationship between HITs, hospital performance and health information quality. This paper is evidence for the investor in the healthcare sector to invest more in HITs and health information quality, where the expected results are productivity improvement, performance leveraging and error reduction. The research originality is to introduce new evidence support literature form the Middle East countries is the main contribution of this paper.
The next generation of health IT is poised to both evolve from the present and be quite different. We are in the early stages of an inevitable and much to be desired transition from a siloized, fragmented health care "non-system" to a more articulated, comprehensive health system. Information technology is both an enabler of the goals of this new system and a forcing function creating the technology imperative that is itself a driver. In this chapter we pull together many of the aspects of health and health care and the IT system to support them that have been discussed throughout this book. Our discussion will focus on eleven disruptive factors that together are creating a sort of "perfect storm" that will make the health system of 10 years from now quite different from, although derived from and combining significant parts of, our current system. The disruptive forces variously have scientific, technology, policy, regulation/standards, or social/cultural origins, but all have significant IT architecture and function implications. The mantra going forward can be summed up by three words: integration, interoperability, and innovation. As we continue to move ahead in the disparate developments and innovations of this field, there will be increasing emphasis on aligning our efforts, making them interoperable, and creating a more integrated ecosystem aimed at optimizing health. © Springer International Publishing Switzerland 2016. All rights reserved.
With their health information technology (HIT) safety framework, Drs Hardeep Singh and Dean Sittig offer many admirable suggestions to improve the safety of computerised provider order entry and electronic health records (EHRs).1 As I shall try to explain, however, I find their proposed framework less than the sum of its parts because: (1) some of its parts, in my opinion, are misdirected; (2) they make errors in their assumptions about what we can know about errors and HIT and (3) their key recommendations lack regulatory or legal teeth. Despite the authors’ fine intentions and several excellent insights and recommendations, I fear their proposal will function more as a distraction than as a useful plan for improving HIT safety—something to make us feel useful while we do not address the underlying problems.
The purpose of electronic health record systems (EHR-S) functionalities is to improve patient safety by reducing medical errors that lead to harm and to facilitate the measurement of care quality by providing access to process and outcomes data. Through collaborative standards development, the definition and translation of healthcare work into specific system functionalities for improving clinical data capture, communication and coordination has evolved from technical "wish lists" into commercially available products that meet the needs of multiple stakeholders: patients, clinicians, managers, systems developers, payers and regulatory agencies. Important technical drivers in the development and adoption of EHR-S functionalities have been: (a) progressive regulatory requirements for reporting quality measures and (b) lessons learned from deployment of EHR systems and other health information technology. A growing area of attention and challenge for health IT functionality development is in supporting longitudinal care coordination for patients with complex and chronic disease across time, providers and resources. Work in this domain has focused on (a) aligning and connecting Patient Centered Medical Homes and Medical Neighborhoods via data/communication standards to facilitate health information exchange (HIE) and (b) building the information infrastructures to facilitate the collection and reporting of quality measures related to care processes and outcomes. © Springer International Publishing Switzerland 2016. All rights reserved.
Introduction
The management of health information is a key pillar in both emergencies reception and handling facilities, given the strategic position and the potential of these facilities within hospitals, and in the monitoring of public health and epidemiology. With the technological revolution, computerization made the information systems evolve in emergency departments, especially in developed countries, with improved performance in terms of care quality, productivity and patient satisfaction. This study analyses the situation of Benin in this field, through the case of the Academic Clinic of Emergency Department of the National University Teaching Hospital of Cotonou, the national reference hospital.
Methods
The study is cross-sectional and evaluative. Collection techniques are literature review and structured interviews. The components rated are resources, indicators, data sources, data management and the use-dissemination of the information through a model adapted from Health Metrics Network framework. We used quantitative and qualitative analysis.
Results
The absence of a regulatory framework restricts the operation of the system in all components and accounts for the lack and inadequacy of the dedicated resources.
Conclusion
Dedication of more resources for this system for crucial needs such as computerization requires sensitization and greater awareness of the administrative authorities about the fact that an effective health information management system is of prime importance in this type of facility.
Available at: http://aisel.aisnet.org/thci/vol7/iss3/4
Many healthcare providers in the US are seeking increased efficiency and effectiveness by rapidly adopting information technology (IT) solutions such as electronic medical record (EMR) systems. Legislation such as the Health Information Technology for Economic and Clinical Health Act (HITECH), which codified the adoption and “meaningful use” of electronic records in the US, has further spurred the industry-wide adoption of EMR. However, despite what are often large investments in EMR, studies indicate that the healthcare industry maintains a culture of system workarounds. Though perhaps not uncommon, the creation of informal workflows among healthcare workers is problematic for assuring information security and patient privacy, particularly when involving decisions of information management (e.g., information storage, retrieval, and/or transmission). Drawing on the framework of contextual integrity, we assert that one can often explain workarounds involving information transmissions in terms of trade-offs informed by context-specific informational norms. We surveyed healthcare workers and analyzed their willingness to engage in a series of EMR workaround scenarios. Our results indicate that contextual integrity provides a useful framework for understanding information transmission and workaround decisions in the health sector. Armed with these findings, managers and system designers should be better able to anticipate healthcare workers’ information transmission principles (e.g., privacy norms) and workaround patterns (e.g., usage norms). We present our findings and discuss their significance for research and practice.
The use of information technology will continue to play a large role in improving the quality of care, controlling costs, and boosting efficiency in all industries. Health Information Technology (HIT) is being sought as one of the key tactics to streamline the process of providing healthcare to improve quality and harness costs. It is believed that HIT will lead to a more cost-efficient healthcare system than the current one. Surprisingly, there is no agreed definition of HIT in academic literature or government documentation. HIT refers to a broad base of information technologies used in healthcare from robotics surgery to chronic disease home monitoring devices. However, there is a consensus on the purpose of HIT as the use of computers for the management of information in order to ensure that it is available to the right person at the right time and place. HIT is the basis for a more patient-centered and evidence-based medicine with the real-time availability of high-quality information and the potential to perform broad-scale analytics.
Study objective
Electronic health record implementation can improve care, but may also adversely affect emergency department (ED) efficiency. We examine how a custom, ED provider, electronic documentation system (eDoc), which replaced paper documentation, affects operational performance.
Methods
We analyzed retrospective operational data for 1-year periods before and after eDoc implementation in a single ED. We computed daily operational statistics, reflecting 60,870 pre- and 59,337 postimplementation patient encounters. The prespecified primary outcome was daily mean length of stay; secondary outcomes were daily mean length of stay for admitted and discharged patients and daily mean arrival time to disposition for admitted patients. We used a prespecified multiple regression model to identify differences in outcomes while controlling for prespecified confounding variables.
Results
The unadjusted change in length of stay was 8.4 minutes; unadjusted changes in secondary outcomes were length of stay for admitted patients 11.4 minutes, length of stay for discharged patients 1.8 minutes, and time to disposition 1.8 minutes. With a prespecified regression analysis to control for variations in operational characteristics, there were significant increases in length of stay (6.3 minutes [95% confidence interval 3.5 to 9.1 minutes]) and length of stay for discharged patients (5.1 minutes [95% confidence interval 1.9 to 8.3 minutes]). There was no statistically significant change in length of stay for admitted patients or time to disposition.
Conclusion
In our single-center study, the isolated implementation of eDoc was associated with increases in overall and discharge length of stay. Our findings suggest that a custom-designed electronic provider documentation may negatively affect ED throughput. Strategies to mitigate these effects, such as reducing documentation requirements or adding clinical staff, scribes, or voice recognition, would be a valuable area of future research.
In discussions of the quality and safety problems of modern, Western healthcare, one of the most frequently heard criticisms has been that: "It is not standardised." This paper explores issues around standardisation that illustrate its surprising complexity, its potential advantages and disadvantages, and its political and sociological implications, in the hope that discourses around standardisation might become more fruitful.
Background and objective
Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors.
Materials and methods
We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements.
Results
We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.
Conclusions
We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.
We cast the psychology of human-computer interaction (HCI) in terms of task analysis and the invention of artifacts. We consider the implications of this for attempts to define HCI in terms of a priori conceptions of psychology. We suggest that artifacts can be considered theory-like in HCI, and observe that they do play a theory-like role in the field as practiced. Our proposal resolves the current methodological perplexity about the legitimacy and composition of the field. We conclude that HCI is a distinct son of science: a design science.
Emergency department (ED) electronic tracking boards provide a snapshot view of patient status and a quick link to other clinical applications, such as a web-based image viewer client to view current and previous radiology images from the picture archiving and communication systems (PACS). We describe a case where an update to Microsoft Internet Explorer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased web-based image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001). Single-click user interfaces that transfer user and patient contexts are efficient mechanisms to link disparate clinical systems. Maintaining hazard analyses and rigorously testing all software updates to clinical workstations, including seemingly minor web-browser updates, are important to minimize the risk of unintended consequences.
Although proponents of advanced information technology argue that automation can improve the reliability of health care delivery, the results of introducing new technology into complex systems are mixed. The new forms of failure that accompany automation challenge technical workers, often demanding novel approaches to recovering from failure and restoring system operations. We present a case where automation created a new form of failure that was not foreseen. In this case, human practitioners were the main source of robust and reliable health care delivery and were the primary agents in recovering from a life-threatening automation failure. The features of this case correspond closely to experience with new information technology in other domains and have implications for plans to improve patient safety using technology.
Information technology (IT) is highly promoted as a mechanism for advancing safety in health care. Ironically, little attention has been paid to the issues of safety in health care IT. Computer scientists have extensively studied the problem of assured performance in safety-critical computing systems. They have developed a conceptual approach and set of techniques for use in settings where incorrect or aberrant operation (or results from correct operation that are aberrant in context) might endanger users, the public, or the environment. However, these methods are not commonly used in health care IT, which generally has been developed without specific consideration of the special factors and unique requirements for safe operations. This article provides a brief introduction for health care professionals and informaticians to what has been called “safeware,” a comprehensive approach to hazard analysis, design, operation, and maintenance of both hardware and software systems. This approach considers the entire joint sociotechnical system (including its operators) over its entire lifecycle, from conception through operation and on to decommissioning. Adoption of safeware methods should enhance the trustworthiness of future health IT.
Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.
To identify and quantify the role of CPOE in facilitating prescription error risks.
We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders.
Examples of medication errors caused or exacerbated by the CPOE system.
We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction.
In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
Health care is entering the age of information society. It is evident that the use of modern information and communication technology (ICT) offers tremendous opportunities to improve health care. However, there are also hazards associated with ICT in health care. We want to present an overview of typical hazards associated with ICT in health care, and to discuss how ICT evaluation can be a solution.
We analyze examples of failures and problems associated with ICT in health care. This collection is also made available on a website.
Systematic, continuous evaluation of quality and effects of ICT during the whole life cycle of ICT components seems to be one important approach to detect and prevent possible ICT hazards and failures, supporting a higher quality of patient care. However, empirical studies proving this assumption are needed.
In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care.
Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children's hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed.
Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94-5.55) after adjustment for other mortality covariables.
We have observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.
Test vignettes help evaluate how EHR products handle common documentation needs.
Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. We assessed the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.
We performed a retrospective, cross-sectional analysis of visits in the 2003 and 2004 National Ambulatory Medical Care Survey. We examined EHR use throughout the United States and the association of EHR use with 17 ambulatory quality indicators. Performance on quality indicators was defined as the percentage of applicable visits in which patients received recommended care.
Electronic health records were used in 18% (95% confidence interval [CI], 15%-22%) of the estimated 1.8 billion ambulatory visits (95% CI, 1.7-2.0 billion) in the United States in 2003 and 2004. For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use. Categories of these indicators included medical management of common diseases, recommended antibiotic prescribing, preventive counseling, screening tests, and avoiding potentially inappropriate medication prescribing in elderly patients. For 2 quality indicators, visits to medical practices using EHRs had significantly better performance: avoiding benzodiazepine use for patients with depression (91% vs 84%; P = .01) and avoiding routine urinalysis during general medical examinations (94% vs 91%; P = .003). For 1 quality indicator, visits to practices using EHRs had significantly worse quality: statin prescribing to patients with hypercholesterolemia (33% vs 47%; P = .01).
As implemented, EHRs were not associated with better quality ambulatory care.
Health information technology (HIT) is widely believed to be an essential modality for improving the efficiency, effectiveness, and safety of healthcare, and has its adoption has been vigorously promoted. However, the safety of commercially available HIT systems has never been independently and rigorously assessed. This paper discusses critical issues to be considered in the development of safe and reliable HIT, and identifies a group of structural impediments that may slow or prevent the arrival of HIT that is actually safe enough for routine clinical use. It argues that this situation is analogous to NASA's promotion of the space shuttle not as an experimental, risky technology, but rather as a routine, ready-for-ordinary-use resource.
James Scott taught us what's wrong with seeing like a state. Now, in his most accessible and personal book to date, the acclaimed social scientist makes the case for seeing like an anarchist. Inspired by the core anarchist faith in the possibilities of voluntary cooperation without hierarchy, Two Cheers for Anarchism is an engaging, high-spirited, and often very funny defense of an anarchist way of seeing--one that provides a unique and powerful perspective on everything from everyday social and political interactions to mass protests and revolutions. Through a wide-ranging series of memorable anecdotes and examples, the book describes an anarchist sensibility that celebrates the local knowledge, common sense, and creativity of ordinary people. The result is a kind of handbook on constructive anarchism that challenges us to radically reconsider the value of hierarchy in public and private life, from schools and workplaces to retirement homes and government itself. Beginning with what Scott calls "the law of anarchist calisthenics," an argument for law-breaking inspired by an East German pedestrian crossing, each chapter opens with a story that captures an essential anarchist truth. In the course of telling these stories, Scott touches on a wide variety of subjects: public disorder and riots, desertion, poaching, vernacular knowledge, assembly-line production, globalization, the petty bourgeoisie, school testing, playgrounds, and the practice of historical explanation. Far from a dogmatic manifesto, Two Cheers for Anarchism celebrates the anarchist confidence in the inventiveness and judgment of people who are free to exercise their creative and moral capacities.
Study objective:
This investigation was initiated after the introduction of a new information system into the Nepean Hospital Emergency Department. A retrospective study determined that the problems introduced by the new system led to reduced efficiency of the clinical staff, demonstrated by deterioration in the emergency department's (ED's) performance. This article is an investigation of methods to improve the design and implementation of clinical information systems for an ED by using a process of clinical team-led design and a technology built on a radically new philosophy denoted as emergent clinical information systems.
Methods:
The specific objectives were to construct a system, the Nepean Emergency Department Information Management System (NEDIMS), using a combination of new design methods; determine whether it provided any reduction in time and click burden on the user in comparison to an enterprise proprietary system, Cerner FirstNet; and design and evaluate a model of the effect that any reduction had on patient throughput in the department.
Results:
The methodology for conducting a direct comparison between the 2 systems used the 6 activity centers in the ED of clerking, triage, nursing assessments, fast track, acute care, and nurse unit manager. A quantitative study involved the 2 systems being measured for their efficiency on 17 tasks taken from the activity centers. A total of 332 task instances were measured for duration and number of mouse clicks in live usage on Cerner FirstNet and in reproduction of the same Cerner FirstNet work on NEDIMS as an off-line system. The results showed that NEDIMS is at least 41% more efficient than Cerner FirstNet (95% confidence interval 21.6% to 59.8%). In some cases, the NEDIMS tasks were remodeled to demonstrate the value of feedback to create improvements and the speed and economy of design revision in the emergent clinical information systems approach. The cost of the effort in remodeling the designs showed that the time spent on remodeling is recovered within a few days in time savings to clinicians. An analysis of the differences between Cerner FirstNet and NEDIMS for sequences of patient journeys showed an average difference of 127 seconds and 15.2 clicks. A simulation model of workflows for typical patient journeys for a normal daily attendance of 165 patients showed that NEDIMS saved 23.9 hours of staff time per day compared with Cerner FirstNet.
Conclusion:
The results of this investigation show that information systems that are designed by a clinical team using a technology that enables real-time adaptation provides much greater efficiency for the ED. Staff consider that a point-and-click user interface constantly interrupts their train of thought in a way that does not happen when writing on paper. This is partially overcome by the reduction of cognitive load that arises from minimizing the number of clicks to complete a task in the context of global versus local workflow optimization.
Adverse drug events (ADEs) are a major cause of morbidity in hospitalised and ambulatory patients. Computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) are being widely implemented with the goal of preventing ADEs, but the effectiveness of these systems remains unclear.
We searched the specialised database Agency for Healthcare Research and Quality (AHRQ) Patient Safety Net to identify reviews of the effect of CPOE combined with CDSS on ADE rates in inpatient and outpatient settings. We included systematic and narrative reviews published since 2008 and controlled clinical trials published since 2012.
We included five systematic reviews, one narrative review and two controlled trials. The existing literature consists mostly of studies of homegrown systems conducted in the inpatient setting. CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, and often leads to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects.
CPOE+CDSS does not appear to reliably prevent clinical ADEs. Despite more widespread implementation over the past decade, it remains a work in progress.
This paper examines how the syndrome of authoritarian high modernism, described in detail in the public policy sphere in James C Scott’s Seeing Like a State, serves as the dominant, orthodox ideology informing patient safety. We compare Scott’s conceptual framework to the currently dominant health care safety practices to surface foundational issues that would otherwise remain hidden, but which need to be revealed to make progress in safety. Although the paper focuses on safety in healthcare as a particular, specific exemplar, the elements of the syndrome are relevant to orthodox safety efforts in many hazardous activities.
The prevalence of chronic disease along with the technologies to develop these diseases, have altered the organizational structure of health care. Through documented case studies, the authors demonstrate how health workers confront these issues, guiding the reader through various work sites, the interactions of staff members with each other and with patients, and the overall patient treatment and response. Focusing on the concept of illness trajectory, this book vividly illustrates the complex, contingent nature of modern medical work.
This paper describes how computerization is the byproduct of loosely organized movements rather than simply an industry selling products to an eager market. We briefly examine five “computerization movements”: urban information systems, artificial intelligence, office automation, instructional computing, and personal computing. These computerization movements share key ideological beliefs, which we also characterize. The main alternative normative analyses of appropriate computerization come from counter movements whose interests intersect with some special form of computerization: in workplaces, around intrusions on personal privacy, and on consumer rights. These counter movements articulate how computing should be balanced with competing values such as good jobs, fair information practices, and consumer control. We argue that these counter movement views do not add up to a coherent alternative humanistic vision for appropriate computerization.
From the Publisher:In its first edition, this volume presented a blueprint for introducing the computer-based patient record (CPR) nationwide within the next decade. An expert committee explored the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policy-making, and much more. This revised edition adds new information to the original book. One commentary describes recent developments in the United States, including the creation of a computer-based patient record institute - a strategy recommended in the original volume to promote and facilitate implementation of the CPR. The second commentary highlights developments in Europe. The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
One prominent method for controlling health costs is to find measures for the management of demand. Various options exist for this; and many of them have been tried during the fifty years of the UK's National Health Service. Current policy now focuses on what may be called “scientific-bureaucratic medicine.” This policy is based on the assumptions that valid medical knowledge is derived from accumulated research evidence and that such knowledge should be implemented through clinical guidelines which are enforced to some extent. This UK development has parallels with the US Agency for Health Care Policy and Research whose experience, therefore, raises some policy issues for the UK.
It is commonly expected that individuals will reverse decisions or change behaviors which result in negative consequences. Yet, within investment decision contexts, negative consequences may actually cause decision makers to increase the commitment of resources and undergo the risk of further negative consequences. The research presented here examined this process of escalating commitment through the simulation of a business investment decision. Specifically, 240 business school students participated in a role-playing exercise in which personal responsibility and decision consequences were the manipulated independent variables. Results showed that persons committed the greatest amount of resources to a previously chosen course of action when they were personally responsible for negative consequences.
This chapter represents an adopt a view of representations of work whether created from within the work practices represented or in the context of externally based design initiatives as interpretations in the service of particular interests and purposes, created by actors specifically positioned with respect to the work. It argues the importance of deepening the resources for conceptualizing the intimate relations between work, representations and the politics of organizations. It then aims to a design practice in which representations of work are taken not as proxies for some independently existent organizational processes, but as part of the fabric of meanings within and out of which all working practices the own and others' are made. The sense in which it rings true is particularly remarkable, the large and growing body of literature dedicated to work-flow modeling, business process re-engineering and other methods aimed at representing work in the service of transforming it.
Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.
To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE).
Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences.
Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature.
Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.
Imagine two assembly lines, monitored by two foremen. Foreman 1 walks the line, watching carefully. "I can see you all," he warns. "I have the means to measure your work, and I will do so. I will find those among you who are unprepared or unwilling to do your jobs, and when I do there will be consequences. There are many workers available for these jobs, and you can be replaced." Foreman 2 walks a different line, and he too watches. "I am here to help you if I can," he says. "We are in this together for the long . . .
This article has no abstract; the first 100 words appear below.
PITTSBURGH SUPERCOMPUTING CENTER A workshop entitled "Macromolecular Structure Refinement Workshop for Biomedical Researchers" will take place in Pittsburgh, Oct. 31 and Nov. 1. Deadline for submission of applications is Aug. 1. Contact Cherolyn Brooks, User Services, Pittsburgh Supercomputing Ctr., 4400 5th Ave., Pittsburgh, PA 15213; or call (800) 221–1641 (natl); (800) 222–9310 (Pa.); or (412) 268–5206 (Pa.). CONGRESS OF GENETICS The congress will take place in Toronto, August 20–27. Contact Laurier Forget, National Research Council of Canada, Montreal Rd., Bldg. M58, Ottawa, ON K1A OR6 Canada; or call (613) 993–9009. MEDICAL SEMINARS INTERNATIONAL The following conferences will be held: "Body . . .
Hospitals’ implementation of medical computer-based information systems (MCBISs), both administrative and clinical, has frequently resulted in system rejection and organizational upheaval. While there are many potential causes of these problems, a recent study of the severe implementation difficulties experienced by one hospital indicates that staff interference may cause or contribute to implementation problems. This finding naturally leads to the question: Was the experience of the hospital studies unusual, or is staff interference a more general, but unrecognized, problem? In an attempt to answer this question, a survey of 40 randomly selected hospitals led to the estimate that staff interference with the implementation and use of MCBISs has occurred in nearly half the public and private sector hospitals that have attempted to install such systems. Furthermore, interference can have significant consequences in terms of cost, lost earnings, organizational disruption and poor quality of care.
Process-supporting information technology (IT) has been heralded as
an important building block in attempts to improve the quality and safety
of health care. Two areas in particular have drawn both attention and funding.
The first is clinical decision support; that is, information systems designed
to improve clinicians’ decision making. The second is computerized physician
order entry (CPOE) as a means for reducing medication errors. The literature
in these fields has been characterized by frequent reports of success, often
accompanied by predictions of a bright new (and near) future; however, the
future seems never to arrive. Behind the cheers and high hopes that dominate
conference proceedings, vendor information, and large parts of the scientific
literature, the reality is that systems that are in use in multiple locations,
that have satisfied users, and that effectively and efficiently contribute
to the quality and safety of care are few and far between.1
To describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting.
Ethnographic and interview data were collected by an interdisciplinary team over a 7 month period at four clinics.
Instances of unintended consequences were categorized using an expanded Diffusion of Innovations theory framework.
The framework was clarified and expanded. There are both desirable and undesirable unintended consequences, and they can be either direct or indirect, but there are also many consequences that are not clearly either desirable or undesirable or may even be both, depending on one's perspective. The undesirable consequences include error and security concerns and issues related to alerts, workflow, ergonomics, interpersonal relations, and reimplementations.
Consequences of implementing and reimplementing clinical systems are complex. The expanded Diffusion of Innovations theory framework is a useful tool for analyzing such consequences.
One prominent method for controlling health costs is to find measures for the management of demand. Various options exist for this; and many of them have been tried during the fifty years of the UK's National Health Service. Current policy now focuses on what may be called "scientific-bureaucratic medicine." This policy is based on the assumptions that valid medical knowledge is derived from accumulated research evidence and that such knowledge should be implemented through clinical guidelines which are enforced to some extent. This UK development has parallels with the US Agency for Health Care Policy and Research whose experience, therefore, raises some policy issues for the UK.
In the September/October 2006 issues of JAMIA, Campbell et al.'s article “Types of Unintended Consequences Related to Computerized Provider Order Entry”1 lays out an innovative and comprehensive framework for categorizing the things that can go wrong when CPOE systems are implemented. We commend the authors for helping to move forward our collective understanding of this important area.
As CPOE and other components of health information technology (HIT) logarithmically diffuse across the U.S. health care system, it is clear they will eventually become the standard all-encompassing platform for the delivery of medical care. As has been the case for all previous medical and non-medical technologies, HIT dissemination carries with it both positive and negative consequences. All nine types of “unintended consequences” outlined by Campbell et al. in their article should be …
Many unintended and undesired consequences of Healthcare Information Technologies (HIT) flow from interactions between the HIT and the healthcare organization's sociotechnical system-its workflows, culture, social interactions, and technologies. This paper develops and illustrates a conceptual model of these processes that we call Interactive Sociotechnical Analysis (ISTA). ISTA captures common types of interaction with special emphasis on recursive processes, i.e., feedback loops that alter the newly introduced HIT and promote second-level changes in the social system. ISTA draws on prior studies of unintended consequences, along with research in sociotechnical systems, ergonomics, social informatics, technology-in-practice, and social construction of technology. We present five types of sociotechnical interaction and illustrate each with cases from published research. The ISTA model should further research on emergent and recursive processes in HIT implementation and their unintended consequences. Familiarity with the model can also foster practitioners' awareness of unanticipated consequences that only become evident during HIT implementation.
The ultimate goal of the electronic medical record is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. Drs. Pamela Hartzband and Jerome Groopman write that before blindly embracing electronic records, we should consider their current limitations and potential downsides.
A major glitch for digitized health-care records: savings promised by the government and vendors of information technology are little more than hype
- S Soumerai
- R Koppel
Soumerai S, Koppel R. A major glitch for digitized health-care
records: savings promised by the government and vendors of
information technology are little more than hype. Wall Street
Journal. New York, NY: 2012. Available at: http://online.wsj.com/
article/SB10000872396390443847404577627041964831020.
html?mod¼googlenews_wsj. Accessed September 18, 2012.
000 Patients hit by lab test mixup in Calgary, Alberta
- Ra Tremonti
Tremonti RA. 2,000 Patients hit by lab test mixup in Calgary, Alberta. Available at: http://catless.ncl.ac.uk/Risks/23.94.html#subj1. Accessed July 28, 2005.
Private medical data exposed: insurance benefit letters sent to wrong addresses by Blue Cross and Blue Shield reveal claim histories, open door to ID theft MSNBC. Veterans given wrong drug doses due to glitch
- A Miller
Miller A. Private medical data exposed: insurance benefit letters sent to wrong addresses by Blue Cross and Blue Shield reveal claim histories, open door to ID theft. Atlanta Journal-Constitution. Atlanta, GA; 2008. Available at: http://www.ajc.com/news/content/news/stories/2008/ 07/29/bluecross.html?cxntnid¼amn072908e&cxntlid¼homepage_ tab_newstab. Accessed July 29, 2008. 21. MSNBC. Veterans given wrong drug doses due to glitch. Available at: http://www.msnbc.msn.com/id/28655104. Accessed January 15, 2009.
On safety and cost, electronic health records not living up to some expectations MA: 2013. Available at
- C Conaboy
Conaboy C. On safety and cost, electronic health records not living up to some expectations. Boston Globe. Boston, MA: 2013. Available at: http://www.boston.com/whitecoatnotes/2013/01/11/safety-cost-electronic-health-records-not-living-some-expectations/ jB9NoPWuA0RhIvhl6tsSTK/story.html. Accessed January 13, 2013.
The flaws of electronic records
- J Hancock
Hancock J. The flaws of electronic records. Philadelphia Inquirer.
Philadelphia, PA: 2013. Available at: http://www.philly.com/philly/
entertainment/20130218_The_flaws_of_electronic_records.html.
Accessed February 18, 2013.
More on computer glitches and laboratory result reporting
- R L Wears
Wears RL. More on computer glitches and laboratory result reporting.
Available at: http://catless.ncl.ac.uk/Risks/23.64.html#subj4.
Accessed December 29, 2004.
Canadian medical tests give reversed results
- D Burstein
Burstein D. Canadian medical tests give reversed results. Available at:
http://catless.ncl.ac.uk/Risks/23.19.html#subj2. Accessed February
19, 2004.