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When requests become orders - A formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service

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Abstract

The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services. An in-depth qualitative study using observation, focus groups and interviews with pathology staff, managers, clinicians and information systems staff during implementation of a CPOE system in 2004 at a major Australian teaching hospital. Pathology laboratories experienced a shift in their work roles resulting in altered work practices, responsibilities and procedures. These changes were marked by terminological and procedural changes in the test order process from when clinicians issued a request for a test, to the new system that established clinical orders at the point of care. This change was accompanied by some organizational dysfunctions including the emergence of a new category of "frustrated" orders without specimens; problems with the procedure of adding tests to previously existing specimens; the appearance of discrepancies in the recorded time of specimen collection. In response to these changes, hospital and pathology staff adopted a variety of means to cope with their changed circumstances. These ranged from efforts to increase clinical awareness to compensatory laboratory workarounds and enforced rule changes. CPOE systems can have a major impact on the nature of the work of pathology laboratories. Understanding how and why these changes occur can be enhanced through considering the organizational and social contexts involved. The effectiveness of CPOE systems will rely on how administrators and staff approach and deal with these challenges.

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... Non-contextual user interfaces [3] Never ending systems demands [6] Unfavourable workflow issues [2] Fear of downtime [9,18] Fragmented health information system technology [16,19] Time costs [11,14] Training shortcomings [23] Navigation problems [3,20] Misleading default values [3,4] Medical error [20,25,23] Silos of clinical work are disconnected from silos of IT support work [9] The evolving socio-technical network in the context of different worlds [11,15,16] ...
... (2007) point out, that allied health participants sometimes did not ask relevant questions during bedside consultations, "even the question we need to [sic]" [25]. Other participants altered their clinical communication style ("I'm conscious of what I say . . . ...
... 'Data fragmentation' is linked to security and refers to records that are scattered, incomplete or isolated. Study findings suggest STM factors at the hospitals combined to cause more work for clinicians, jeopardised health care outcomes, fragmented data and threatened the confidentiality of patient information [10,11,25]. ...
Article
This paper introduces two concepts into analyses of information security and hospital-based information systems - a Socio-Technical-Material theoretical framework and the Natural Hospital Environment. The research is grounded in a review of pertinent literature with previously published Australian (Victoria) case study data to analyse the way clinicians work with privacy and security in their work. The analysis was sorted into thematic categories, providing the basis for the Natural Hospital Environment and Socio-Technical-Material framework theories discussed here. Natural Hospital Environments feature inadequate yet pervasive computer use, aural privacy shortcomings, shared workspace, meagre budgets, complex regulation that hinders training outcomes and out-dated infrastructure and are highly interruptive. Working collaboratively in many cases, participants found ways to avoid or misuse security tools, such as passwords or screensavers for patient care. Workgroup infrastructure was old, architecturally limited, haphazard in some instances, and was less useful than paper handover sheets to ensure the quality of patient care outcomes. Despite valiant efforts by some participants, they were unable to control factors influencing the privacy of patient health information in public hospital settings. Future improvements to hospital-based organisational frameworks for e-health can only be made when there is an improved understanding of the Socio-Technical-Material theoretical framework and Natural Hospital Environment contexts. Aspects within control of clinicians and administrators can be addressed directly although some others are beyond their control. An understanding and acknowledgement of these issues will benefit the management and planning of improved and secure hospital settings.
... As a result, workflow issues have been found highly relevant not only for a successful implementation of CPOE systems but also for patient safety practices678. Studies of the actual use of health care information technology (HIT) in successful implementation sites have raised concerns about how and with what consequences these systems are operational in practice [7,91011. In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. ...
... Studies of the actual use of health care information technology (HIT) in successful implementation sites have raised concerns about how and with what consequences these systems are operational in practice [7,91011. In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. They found that providers responded in different ways to the workflow issues faced after a CPOE implementation , ranging from soft responses and workarounds to hard responses such as new organizational rules [10]. ...
... In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. They found that providers responded in different ways to the workflow issues faced after a CPOE implementation , ranging from soft responses and workarounds to hard responses such as new organizational rules [10]. Vogelsmeier and colleagues characterized two categories of workarounds in working with an electronic administration record: those related to workflow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology [11] . ...
... Non-contextual user interfaces [3] Never ending systems demands [6] Unfavourable workflow issues [2] Fear of downtime [9,18] Fragmented health information system technology [16,19] Time costs [11,14] Training shortcomings [23] Navigation problems [3,20] Misleading default values [3,4] Medical error [20,25,23] Silos of clinical work are disconnected from silos of IT support work [9] The evolving socio-technical network in the context of different worlds [11,15,16] ...
... (2007) point out, that allied health participants sometimes did not ask relevant questions during bedside consultations, "even the question we need to [sic]" [25]. Other participants altered their clinical communication style ("I'm conscious of what I say . . . ...
... 'Data fragmentation' is linked to security and refers to records that are scattered, incomplete or isolated. Study findings suggest STM factors at the hospitals combined to cause more work for clinicians, jeopardised health care outcomes, fragmented data and threatened the confidentiality of patient information [10,11,25]. ...
Article
Objectives This paper introduces two concepts into analyses of information security and hospital-based information systems - a Socio-Technical- Material theoretical framework and the Natural Hospital Environment. Method The research is grounded in a review of pertinent literature with previously published Australian (Victoria) case study data to analyse the way clinicians work with privacy and security in their work. The analysis was sorted into thematic categories, providing the basis for the Natural Hospital Environment and Socio-Technical-Material framework theories discussed here. Results Natural Hospital Environments feature inadequate yet pervasive computer use, aural privacy shortcomings, shared workspace, meagre budgets, complex regulation that hinders training outcomes and out-dated infrastructure and are highly interruptive. Discussion Working collaboratively in many cases, participants found ways to avoid or misuse security tools, such as passwords or screensavers for patient care. Workgroup infrastructure was old, architecturally limited, haphazard in some instances, and was less useful than paper handover sheets to ensure the quality of patient care outcomes. Despite valiant efforts by some participants, they were unable to control factors influencing the privacy of patient health information in public hospital settings. Conclusion Future improvements to hospital-based organisational frameworks for e-health can only be made when there is an improved understanding of the Socio-Technical- Material theoretical framework and Natural Hospital Environment contexts. Aspects within control of clinicians and administrators can be addressed directly although some others are beyond their control. An understanding and acknowledgement of these issues will benefit the management and planning of improved and secure hospital settings.
... As a result, workflow issues have been found highly relevant not only for a successful implementation of CPOE systems but also for patient safety practices678. Studies of the actual use of health care information technology (HIT) in successful implementation sites have raised concerns about how and with what consequences these systems are operational in practice [7,91011. In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. ...
... Studies of the actual use of health care information technology (HIT) in successful implementation sites have raised concerns about how and with what consequences these systems are operational in practice [7,91011. In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. They found that providers responded in different ways to the workflow issues faced after a CPOE implementation , ranging from soft responses and workarounds to hard responses such as new organizational rules [10]. ...
... In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. They found that providers responded in different ways to the workflow issues faced after a CPOE implementation , ranging from soft responses and workarounds to hard responses such as new organizational rules [10]. Vogelsmeier and colleagues characterized two categories of workarounds in working with an electronic administration record: those related to workflow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology [11] . ...
... Resistance toward CPOE is common among physicians, specialists, and sub-specialists in many hospitals in developed countries [49]. Studies in different countries demonstrate that the introduction of electronic health records represents a substantial change in doctors' workflow, and imposes a greater burden on them [47,49,50]. ...
... Resistance toward CPOE is common among physicians, specialists, and sub-specialists in many hospitals in developed countries [49]. Studies in different countries demonstrate that the introduction of electronic health records represents a substantial change in doctors' workflow, and imposes a greater burden on them [47,49,50]. ...
... All these good features of LIS have made its users to have a positive intention for using the system. LISusers opined that the system did not delay their work nor caused less cooperation and appreciation from other doctors and nurses [2,5,24,35,36,[45][46][47][48][49][50][51]. ...
... It can lead to mistakes and errors while performing analysis, thus causing uncertainty in the results. Together, it indicates that the LIS system does not consider and include every aspect of the users' preconditions which obligates them to find different ways to finish their daily routine [16,46,47]. Similarly, around half of the respondents were occasionally blamed for errors related to the system or work processes. ...
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Background: The goal of the present survey is to investigate the effect of the Laboratory Information System (LIS) among users in a tertiary healthcare facility in Saudi Arabia. Methods: The current cross-sectional descriptive study was carried out at the National Guard laboratory department of KAMC in Riyadh. All the active users of LIS at the laboratory department were included in the study. A total of 427 questionnaires were distributed of which 268 were returned completed. The response rate was 62.76%. The study instrument was developed to examine the effect of LIS on end-users based on five interrelated variables; External Communication, Service Outcomes, Personal Intentions, Personal Hassles, and Increased Blame. Descriptive statistics, Pearson's correlation, and ANOVA were used to analyze the data. Results: The users had a general positive perception towards the LIS system. A statistically significant relationship between user characteristics and External Communication, Service Outcomes, Personal Hassles and Increased Blame variables exists. The results showed a strong positive correlation between External Communication and Service Outcomes variables and it showed a moderate positive correlation between Personal Hassles and Increased Blame variables. Conclusions: Overall, the study participants demonstrated a positive attitude towards the LIS on personal basis and on the basis of their daily work routine. It is a good implication of LIS success in health care sector and paves the way for incorporation of more advanced and efficient LIS system in the future.
... Research suggests that practices using electronic health records (EHR) experience several benefits including improvements in efficiency, care quality, and patient outcomes. [1][2][3][4][5] Still, rates of EHR adoption and use have generally been low in the US compared to other developed nations. 6 7 Providers in small practices, rural and non-teaching hospitals, and hospitals with a larger share of Medicaid and minority patients have especially lagged in EHR implementation. ...
Article
To identify area-level correlates of electronic health record (EHR) adoption and meaningful use (MU) among primary care providers (PCPs) enrolled in the Regional Extension Center (REC) Program. County-level data on 2013 EHR adoption and MU among REC-enrolled PCPs were obtained from the Office of the National Coordinator for Health Information Technology and linked with other county-level data sources including the Area Resource File, American Community Survey, and Federal Communications Commission's broadband availability database. Hierarchical models with random intercepts for RECs were employed to assess associations between a broad set of area-level factors and county-level rates of EHR adoption and MU. Among the 2715 counties examined, the average county-level EHR adoption and MU rates for REC-enrolled PCPs were 87.5% and 54.2%, respectively. Community health center presence and Medicaid enrollment concentration were positively associated with EHR adoption, while metropolitan status and Medicare Advantage enrollment concentration were positively associated with MU. Health professional shortage area status and minority concentration were negatively associated with EHR adoption and MU. Increased financial incentives in areas with greater concentrations of Medicaid and Medicare enrollees may be encouraging EHR adoption and MU among REC-enrolled PCPs. Disparities in EHR adoption and MU in some low-resource and underserved areas remain a concern. Federal efforts to spur EHR adoption and MU have demonstrated some early success; however, some geographic variations in EHR diffusion indicate that greater attention needs to be paid to ensuring equitable uptake and use of EHRs throughout the US.
... An issue with ICT evaluation in health is the complexity of the evaluation object. Researchers use a variety of methods and criteria for assessing the impact of ICT on the participants in the health care process (33)(34)(35)(36). In our study, we assess the impact of ICT on the individual causes of errors by the HFMEA. ...
Article
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Abstract Objective: The purpose of this research is to track and reduce risks so as to prevent errors within the process of health care. The aim is to design an organizational information model using error prevention methods for risk assessment. Method: In order to assess the risk of errors, the Health Care Failure Mode and Effect Analysis is used. To determine the causes of the errors, the Root Cause Analysis is used. Results: Results of the process analysis following corrective measures shows that the risk assessment of individual error causes reduced by73.6 percent. Re-evaluation of the risks to the whole process shows that the overall risk score was decreased by 45.5 percent. The proposed model has a significant impact on professional attention, communication and information, critical thinking, experience and knowledge. The average impact of information communication technology on the reduction of medication administration errors is 56 percent. These findings represent an increase in the quality of care. Conclusions: The results of our research are theoretically and practically useful and verifiable in other environments, if the level of the organizational culture and the culture of recording errors in combination with the precise recording of data to assess the risk of errors in the process. The model provides a standardized data format that can be used for the purpose of defining factors for the occurrence of errors, for developing a base of knowledge for learning from mistakes and for continuous verification and adaptation to changes in the environment in order to prevent errors. Key words: health care, patient safety, errors, information communication technology
... Aural privacy shortcomings meant, as Georgiou, Westbrook and Braithwaite et al. point out [6], that participants sometimes did not ask relevant questions during bedside consultations, "even the question we need to [sic]". Other participants altered their clinical communication style ("I'm conscious of what I say … and who's listening"). ...
Article
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Enthusiasts of eHealth implementations for use in clinical care settings claim axiomatic privacy and security (P&S) outcomes. Evidently, "eHealth" has acquired meaning for the enthusiasts when, as with Jabberwocky, the claims seem to make their own sense. Yet emerging work suggests the claim may be nonsensical. The openEHR and other international endeavours have advanced efforts to overcome the technical mismatch between clinical settings and much eHealth, so enabling technically secure tools. However an understanding of the actual work context is needed to fully appreciate the factors that influence P&S in eHealth. Thus, this work analyses clinician critiques of eHealth experiences in relation to the Jabberwocky to support an understanding of P&S in care contexts. Twenty three medical, nursing and allied health clinicians working in Australia (Victoria) participated in this qualitative study examining work practices with P&S for patient care. Participants criticised slow, inefficient eHealth information systems permeated by usability errors. EHealth applications expanded workloads and system demands were onerous, increasing the clinicians' scepticism of reliance on information technology. Consequently many clinicians had developed trade-offs to avoid reliance on them. The trade-offs include IT support avoidance and shared passwords to PKI and computer accounts. Handover-sheets populated by transcribed notes were circulated between clinicians. The practices ensure paper persistence and escalate threats to data confidentiality, integrity and availability. Study evidence suggests claims about P&S tools that are inherent to eHealth applications are nonsensical, foster unintended consequences, hamper patient care and represent a larger P&S threat than indicated by most studies to date.
... Shifts in responsibility and role are often understandably seen by some as negative consequences of technology. 78,79 Our study reinforces the necessity to address such concerns rather than ignore them. ...
Article
Study objective: We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. Methods: A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. Results: Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. Conclusion: Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed.
... In a systematic review of the CPOE literature, Georgiou et al. (2007) found that 11 studies (eight with some form of decision support) investigated the impact of CPOE on test volumes or costs, or both; three showed no change in test volume, one showed an increase, and seven were able to demonstrate a decrease in tests ordered after implementation of CPOE. Five of these studies investigated impacts on costs; four showed significant decreases and the other showed no change. ...
... Process redesign is restricted to those departments, divisions, and hierarchy levels that use the additional functionality (Huang et al, 2001). Consequently, the degree of process redesign and user training are low when assessed at the firm level (Georgiou et al, 2007). The costs for the additional hardware and software components are low to medium. ...
Article
Full-text available
Firms change their information systems (IS) for various reasons, ranging from compliance with government regulations to the development of new capabilities. When making these changes a firm can choose between four different IS change types: IS introduction, IS extension, IS replacement, and IS merger. This paper proposes that change reasons and change types are interrelated, and that certain reason-type combinations are more likely than others to result in a successful IS change. To identify these combinations, an IS change reason–IS change type matrix is developed. While the matrix is created from prior IS research, we conducted a focus group study of IS professionals to further explore and refine the matrix. The findings from the focus group study reveal that some IS change reason–IS change type combinations are more appropriate than others to carry out the IS change project successfully. We also present three examples of IS change projects to illustrate the use and value of the matrix in practice.
... Extending CPOE systems to handle add-on testing can be logistically challenging as the add-on test process does not follow the same steps as a new test order. [32] One study did report the implementation of add-on order functionality within CPOE and demonstrated marked improvement in the efficiency of the process as well as the completeness of CPOE add-on documentation as compared to the prior verbal process. [33] Computerized provider order entry benefits: decision support ...
Article
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Clinicians have traditionally ordered laboratory tests using paper-based orders and requisitions. However, paper orders are becoming increasingly incompatible with the complexities, challenges, and resource constraints of our modern healthcare systems and are being replaced by electronic order entry systems. Electronic systems that allow direct provider input of diagnostic testing or medication orders into a computer system are known as Computerized Provider Order Entry (CPOE) systems. Adoption of laboratory CPOE systems may offer institutions many benefits, including reduced test turnaround time, improved test utilization, and better adherence to practice guidelines. In this review, we outline the functionality of various CPOE implementations, review the reported benefits, and discuss strategies for using CPOE to improve the test ordering process. Further, we discuss barriers to the implementation of CPOE systems that have prevented their more widespread adoption.
... These trends were making it increasingly difficult to determine the boundaries of local systems [1, 4, 27, 28]. Today, a socio-technical system such as an electronic health records system embedded in the department of a hospital will be impacted by other departments and sections in that hospital [29, 30]. It will also be affected by the external environment, which may include the health organisation, funding bodies and government regulators. ...
Article
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This discussion paper considers the adoption of socio-technical perspectives and their theoretical and practical influence within the discipline of health informatics. The paper highlights the paucity of discussion of the philosophy, theory and concepts of socio-technical perspectives within health informatics. Instead of a solid theoretical base from which to describe, study and understand human-information technology interactions we continue to have fragmented, unelaborated understandings. This has resulted in a continuing focus on technical system performance and increasingly managerial outputs to the detriment of social and technical systems analysis. It has also limited critical analyses and the adaptation of socio-technical approaches beyond the immediate environment to the broader social systems of contemporary society, an expansion which is increasingly mandated in today's complex health environment.
... Key performance indicators for safety and productivity (e.g. medication errors [25], diagnostic turnaround times [38], and patient waiting times [39]) exist from evaluation literature in the field, and will be selected and measured in conjunction with context-dependent issues or indicators identified from analysis of qualitative data both pre and post system implementation. To elucidate impacts of the computerised system, data from both before and after implementation of the system will be elicited from relevant administration databases as well as paper documentation. ...
Article
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Process-supporting information technology holds the potential to increase efficiency, reduce errors, and alter professional roles and responsibilities in a manner which allows improvement in the delivery of patient care. However, clashes between the model of health care work inscribed in these tools with the actual nature of work has resulted in staff resistance and decreased organisational uptake of ICT, as well as the facilitation of unexpected and negative effects in efficiency and patient safety. Sociotechnical theory provides a paradigm against which workflow and transfusion of ICT in healthcare could be better explored and understood. This paper will conceptualise a formative, multi-method longitudinal evaluation process to explore the impact of ICT with an appreciation of the relationship between the social and technical systems within a clinical department. Departmental culture, including clinical work processes and communication patterns will be thoroughly explored before system implementation using both quantitative and qualitative research methods. Findings will be compared with post implementation data, which will incorporate measurement of safety and workflow efficiency indicators. Sociotechnical theory provides a paradigm against which workflow and transfusion of ICT in healthcare could be better explored and understood. However, sociotechnical and multimethod approaches to evaluation do not exist without criticism. Inherent in the protocol are limitations of sociotechnical theory and criticism of the multimethod approach; testing of the methodology in real clinical settings will serve to verify efficacy and refine the process.
... Gurses et al. show how clinicians have developed sophisticated paper-based artifacts to workaround, and use in conjunction with, an EHR [23] . Others have classified workarounds to other HIT applications, and attributed workarounds to inadequate technological design, as well as organizational processes that do not effectively integrate with technology [24,25] , and insufficient mechanisms for negotiation between services departments [26]. Future redesign of the EHR and consult package for the VA and others should consider these potential workaround causes to create a more effective system. ...
Article
The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Other barriers may include workarounds and communication breakdowns with the potential to adversely impact delivery of quality medical care. We investigated current challenges to the electronic outpatient consult management process in the United States Veterans Health Administration (VHA). We conducted ethnographic observation and semi-structured interviews in nine different specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical Center (VAMC). We also performed a national-level query of 'electronic error and enhancement requests' (E3Rs) related to the consult package in the VA's electronic health record (EHR) submitted over a 5-year period (2005-2009). Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. E3Rs from the national query were reviewed and categorized based on the nature of the enhancement requests. We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements. Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests.
... Rollen, Aufgaben und Verantwortlichkeiten seien Aarts et al. 1 zufolge in der Realität oft weniger klar umrissen, als die Software-Designer von CPOE-Systemen annehmen. Georgiou et al. 121 illustrieren dies beispielsweise an der Existenz impliziter, nicht-formalisierter Handlungen (z. B. dynamisch sich ändernde Rollen, Aufgaben, Verantwortlichkeiten oder Absprachen unter Ärzten und Krankenschwestern oder abteilungs-übergreifend), die ein Computerprogramm zur erfolgreichen Bearbeitung jedoch in explizierter, formalisierter Art benötigt. ...
Article
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Gesundheitspolitischer Hintergrund Softwaresysteme, mit deren Hilfe ein Arzt Arzneimittelverordnungen elektronisch eingibt (CPOE-Systeme) und die darüber hinaus mit Werkzeugen zur Entscheidungsunterstützung (CDS) ausgerüstet sein können), werden in Deutschland von verschiedenen Unternehmen angeboten, sowohl für Krankenhäuser als auch für Arztpraxen. Es handelt sich dabei großteils um eine Entwicklung der letzten fünf bis zehn Jahre. Wissenschaftlicher Hintergrund CPOE-Systeme an sich gibt es seit den 1970er Jahren. Meist werden auch klinische Entscheidungshilfen (CDS-Systeme) in das CPOE-System integriert, um Fehler zu vermeiden. Fragestellung In diesem HTA-Bericht sollen die Effektivität und die Effizienz von CPOE-/CDS-Systemen geklärt sowie die damit verbundenen ethischen, sozialen und juristischen Aspekte dargestellt werden. Methodik Die systematische Literatursuche (27 internationale Literaturdatenbanken) ergab 791 Zusammenfassungen. Nach einem zweiteiligen Selektionsprozess verbleiben zwölf zu bewertende Publikationen. Ergebnisse Alle im vorliegenden Bericht eingeschlossenen Übersichtsarbeiten und Primärstudien berichten von einer Reduktion der Medikationsfehlerrate durch CPOE-/CDS-Systeme, wobei geringfügige Verordnungsfehler fast vollständig eliminiert werden können. Der Einfluss von CPOE-/CDS-Systemen auf die Rate von unerwünschten Arzneimittelereignissen (UAE) wird nur in zwei Primärstudien betrachtet. Die Ergebnisse hierzu sind widersprüchlich. Die Ergebnisse der ökonomischen Studien sind schwer vergleichbar, da sie verschiedene Settings, Interventionen und Zeiträume betrachten. Erschwerend kommt die teilweise mangelhafte Transparenz der Dokumentation hinzu. Alle vier eingeschlossenen Studien erfassen Kosten und Effekte aus Sicht eines Krankenhauses oder Krankenhausverbundes. Im Hinblick auf soziale Aspekte thematisiert die entsprechende Literatur die Veränderungsprozesse, die im Spannungsfeld Technik und Mensch aus der Einführung von CPOE-Systemen erwachsen. Erfahrungen aus Einrichtungen, in denen die Einführung von CPOE-Systemen mit Problemen behaftet war, haben gezeigt, dass die Berücksichtigung des sozio-organisationalen Kontexts zum Teil unterschätzt wurde. Diskussion CPOE-/CDS-Systeme sind in der Lage, die Medikationsfehlerrate bei der Verordnung von Arzneimitteln zu reduzieren. Auch die Einhaltung von Richtlinien, Kommunikation, Patientenbetreuung und Zufriedenheit der Belegschaft kann positiv beeinflusst werden. Es wird jedoch auch von negativen Auswirkungen berichtet, da durch die Anrwendung von CPOE-/CDS-Systemen neue Fehler generiert werden können. Dies macht eine ständige Überprüfung der Systeme bzw. ggf. die Aktualisierung der verwendeten Daten erforderlich. Hinsichtlich der Kosten-Nutzen-Relation aus Krankenhaussicht kommen die zwei qualitativ besten ökonomischen Studien zu widersprüchlichen Ergebnissen. Von einer positiven Kosten-Nutzen-Relation für einzelne Krankenhäuser kann deshalb nicht sicher ausgegangen werden, insbesondere da die Ergebnisse nicht generalisierbar sind. Schlussfolgerung Wird die Implementierung eines CPOE-/CDS-Systems sorgfältig geplant, durchgeführt, das System an die Bedürfnisse der Institution angepasst, fortlaufend überwacht und ggf. aktualisiert, kann die Medikationsverordnungsfehlerrate durch die Verwendung von CPOE-/CDS-Systemen deutlich gesenkt werden. Allerdings ist nicht klar, inwieweit dies eine Reduktion von UAE bewirkt. Es werden prospektive, systematische Multizentren-Evaluierungsstudien mit klarer Methodik gefordert, die eine Analyse der Benutzerfreundlichkeit und sozialer bzw. -technischer Aspekte einschließen und den Einfluss eines CPOE-/CDS-Systems auf die UAE-Rate und Mortalität untersuchen. Unabdingbar ist eine genaue Beschreibung des verwendeten Systems und des untersuchten Krankenhauses. Nach Möglichkeit haben auch eine Erhebung und transparente Dokumentation der Kosten und Kosteneffekte zu erfolgen.
... In 2011, a LIS integrated with a HIS was implemented at the Hospital for Tropical Diseases in Bangkok, ailand. e LIS in our hospital, particularly for the automation of the hematology analyzer, was implemented to obtain real-time complete blood count (CBC) results, system security, data entry control, medical reports, and data retrieval and storage to improve clinical care and ultimately reduced the probability of human errors [3][4][5][6]. ...
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The implementation of a laboratory information system (LIS) at the Hospital for Tropical Diseases in Thailand provides valuable medical resources, particularly for dengue. Hematocrit (Hct), which is often derived from hemoglobin (Hgb), is important in the diagnosis and management of dengue. This study aimed to evaluate the Hct value obtained from the LIS automated analyzer. We prospectively enrolled 163 hospitalized adults with dengue, for whom 1,141 real-time complete blood count (CBC) results were obtained via a hematology analyzer and updated in the LIS database. The median (interquartile range (IQR)) duration of analytic turnaround times (TATs) was 40.0 (30.0–53.0) minutes. Linear regression analysis indicated a significant relationship between Hgb and Hct with a coefficient of determination (Pearson’s R2) of 0.92 at red blood cell distribution width (RDW) ≤18, but Pearson’s R2 decreased to 0.78 at RDW >18. The Hct calculated from the three-fold conversion method and from the analyzer had a Pearson’s R2 of 0.92. At Hgb
... The study was framed using Strauss' theory of negotiated order (1978) and applied to doctors' relationships and interactions within the hospital organisational setting, to test their capacity to work interprofessionally. A multi-faceted negotiated order is embedded in the work practices of health professionals and the organisation of hospitals in which they work (Georgiou et al., 2007). Essentially, there are workplace trade-offs, agreements, and bargains struck in a steady stream in busy interactive environments. ...
Article
Abstract Collaborative practice among early career staff is at the bedrock of interprofessional care. This study investigated factors influencing the enactment of interprofessional practice by using the day-to-day role of six junior doctors in three teaching hospitals as a gateway to understand the various professions' interactive behaviours. The contextual framework used for the study was Strauss' theory of negotiated order. Ethnographic techniques were applied to observe the actions and interactions of participants on typical working days in their hospital environments. Field notes were created and thematic analysis was applied to the data. Three themes explored were culture, communication, and collaboration. Issues identified highlight the bounded organisational and professional cultures within which junior doctors work, and systemic problems in interprofessional interaction and communication in the wards of hospitals. There are indications that early career doctors are interprofessional isolates. The constraints of short training terms and pressure from multi-faceted demands on junior doctors can interfere with the establishment of meaningful relationships with nurses and other health professionals. The realisation of sustained interprofessional practice is, therefore, practically and structurally difficult. Enabling factors supporting the sharing of expertise are outweighed by barriers associated with professional and hospital organisational cultures, poor interprofessional communication, and the pressure of competing individual task demands in the course of daily practice.
... Explanations or special instructions for orders may have been entered into a comment field in the EHR order form, but that information may not be effectively passed through the interface into the LIS. This often results in calls to clinician offices for clarification, potentially missed test orders, performance of tests on the wrong date, and disruption of normal laboratory specimen processing and workflow, 16 all of which create customer dissatisfaction with laboratory services. Furthermore, if an order is released in error, a test performed, and a charge generated, the laboratory typically must write off the charge because the work was not required during that visit, 17 creating compliance issues and increasing laboratory costs. ...
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In the era of the electronic health record, the success of laboratories and pathologists will depend on effective presentation and management of laboratory information, including test orders and results, and effective exchange of data between the laboratory information system and the electronic health record. In this third paper of a series that explores empowerment of pathology in the era of the electronic health record, we review key elements of managing laboratory information within the electronic health record and examine functional issues pertinent to pathologists and laboratories in the exchange of laboratory information between electronic health records and both anatomic and clinical pathology laboratory information systems. Issues with electronic order-entry and results-reporting interfaces are described, and considerations for setting up these interfaces are detailed in tables. The role of the laboratory medical director as mandated by the Clinical Laboratory Improvement Amendments of 1988 and the impacts of discordance between laboratory results and their display in the electronic health record are also discussed.
... A computer physician order entry (CPOE) system is a software that allows clinicians to enter orders directly into computer. These systems not only automate the clinical ordering process but also incorporate several features such as decision support mechanisms that improve the quality of healthcare and final patient outcomes (6). In addition, CPOE technology could potentially help users to separate laboratory activity related to routine healthcare from the activity linked to big research studies or randomized clinical trials. ...
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Introduction Most of clinical laboratories are not properly reimbursed for their activity related to clinical trials (CTs) conducted in their institutions due to a lack of measurement strategies. We implemented a specific computer physician order entry (CPOE) environment for CTs in order to facilitate ordering to providers and estimate the associated costs to be compared with the standard of care (SOC). Materials and methods Four specific electronic formularies, restricted to two new virtual CTs clinical services (onco - CT and haemo - CT), were implemented in January 2015. For each clinical trial displayed in the panels there were several box-cells that contained several profiles based on the different phase of the trials. Tests included in the profiles were the tests required by protocol. Laboratory costs (€) per patient were compared between the CTs services and their regular outpatients clinical services (onco - Out and haemo - Out, considered the SOC) for three years. Results Costs per patient were higher for CTs services and increased progressively each year (25%, 70% and 70% and 0.6%, 2.7% and 17% in 2015, 2016 and 2017 for Oncology and Haematology, respectively). Taking into account all these differences and the number of patients attending a total difference in expense of + 130,377.7 € for the period 2015-2017 was obtained between CTs and outpatients services. Conclusions Strategies through CPOE systems based on restricted and specific profiles for CTs ordering are a promising tool that can improve laboratory associated costs estimation and provide robust evidence in reimbursement negotiation processes with CTs sponsors.
... Second, the use of formative and reflective measurements has been extensively studied [19,31,32,37,45,92]. The constructs in our model have been modeled as reflective, and we call for using formative and reflective measures to understand the impact of institutional pressures on success determinants and in turn on IS adoption success. ...
Article
Firms frequently adopt new information systems (IS). To better understand IS adoption, research focused on motives for an IS adoption. In this study, three legitimacy-based motives (coercive, mimetic, and normative pressure) are examined for their impact on two success determinants (i.e., project management approach and team competence) and the subsequent impact of the success determinants on IS adoption success. In a quantitative study of Australian firms, we found that coercive and normative pressure impact on the project management approach whereas mimetic pressure impacts on team competence. Both project management approach and team competence in turn impact on IS adoption success.
Article
An unprecedented federal effort is under way to boost the adoption of electronic health records and spur innovation in health care delivery. We reviewed the recent literature on health information technology to determine its effect on outcomes, including quality, efficiency, and provider satisfaction. We found that 92 percent of the recent articles on health information technology reached conclusions that were positive overall. We also found that the benefits of the technology are beginning to emerge in smaller practices and organizations, as well as in large organizations that were early adopters. However, dissatisfaction with electronic health records among some providers remains a problem and a barrier to achieving the potential of health information technology. These realities highlight the need for studies that document the challenging aspects of implementing health information technology more specifically and how these challenges might be addressed.
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Computerized provider order entry (CPOE) systems have been strongly promoted as a means to improve the quality and efficiency of healthcare. This systematic review aimed to assess the evidence of the impact of CPOE on medical-imaging services and patient outcomes. Fourteen studies met the inclusion criteria, most of which (10/14) used a pre-/postintervention comparison design. Eight studies demonstrated benefits, such as decreased test utilization, associated with decision-support systems promoting adherence to test ordering guidelines. Three studies evaluating medical-imaging ordering and reporting times showed statistically significant decreases in turnaround times. The findings reveal the potential for CPOE to contribute to significant efficiency and effectiveness gains in imaging services. The diversity and scope of the research evidence can be strengthened through increased attention to the circumstances and mechanisms that contribute to the success (or otherwise) of CPOE and its contribution to the enhancement of patient care delivery.
Chapter
Healthcare systems around the globe are facing a number of challenges. Thus Increasing focus is being placed on constructing appropriate healthcare reforms which are attempting to address how to tackle these challenges. A critical enabler in these reforms is the adoption of an e-health solution. Such e-health solutions are not only expensive and complex endeavours, but also have far reaching implications. Given that the implementation and adoption of these e-health solutions is so important, not to mention also requiring a substantial investment in various resources such as time and money, it is therefore essential to ensure their success. The following proffers a socio-technical analysis as an appropriate strategy to ensure more successful outcomes. An exemplar case study of the Personally Controlled Electronic Health Record (PCEHR), the chosen e-health solution by the Australian government is provided to illustrate the benefits such an analysis might provide
Article
To evaluate the problems experienced after implementing a computerized physician order entry (CPOE) system, their possible root causes, and the responses of providers in order to incorporate the system into daily workflow. A qualitative study in the medication-use process after implementation of a CPOE system in an academic hospital in The Netherlands. Data included 21 interviews with clinical end-users, paper-based and system-generated documents used daily in the process, and educational materials used to train users. The problems in the medication-use process included cognitive overload on physicians and nurses, unmet information needs, miscommunication of orders and ideas, problematic coordination of interrelated tasks between co-working professionals, a potentially faulty administration phase, and suboptimal monitoring of the medication plans. These problems were mainly rooted in the lack of mobile computer devices, the uneasy integration of coexisting electronic and paper-based systems, suboptimal usability of the system, and certain organizational factors with regard to procuring drugs affecting the technology use. Various types of workarounds were used to address the difficulties, including phone calls, taking multiple paper notes, issuing paper-based and verbal orders, double-checking, using other patients' procured drugs or another department's drug supply, and modifying and annotating the printed orders. This study shows how providers are actively involved in working around the interruptions in workflow by bypassing the technology or adapting the work processes. Although certain workarounds help to maintain smooth workflow and/or to ensure patient safety, others may burden providers by necessitating extra time and effort and/or endangering patient safety. It is important that workarounds having a negative nature are recognized and discussed in order to find solutions to mitigate their effects.
Chapter
Surgical pathology workflow involves manual tasks and lacks standardization. Leveraging informatics tools and innovative technologies in the surgical laboratory workflow lab leads to a more standardized workflow and reduces the involvement of laboratory personnel in repetitive processes. Patient safety requires the establishment of an operational system and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. The end goal of this is a reduction and prevention in errors, particularly in the preanalytical and analytical portions of the surgical pathology specimen life cycle. Creating auditable events in the workflow using bar coding and tracking also leads to real-time data capture into the laboratory information system which is available for real-time quality assurance (QA) monitoring and creating “dashboards” for data monitoring and reviewing errors in real-time, providing additional opportunities to reduce them. Additional novel tools such as synoptic reporting, computerized provider order entry (CPOE), and novel QA methods such as laboratory information-triggered pre-sign-out random QA help improve quality and contribute to significant error reduction in surgical pathology. Newer technologies such as digital pathology, deep learning and artificial intelligence methods may also be leveraged to create innovative ways to prevent and reduce errors in surgical pathology
Article
The provision of relevant clinical information on pathology requests is an important part of facilitating appropriate laboratory utilization and accurate results interpretation and reporting. (1) To determine the quantity and importance of handwritten clinical information provided by physicians to the Microbiology Department of a hospital pathology service; and (2) to examine the impact of a Computerized Provider Order Entry (CPOE) system on the nature of clinical information communication to the laboratory. A multi-method and multi-stage investigation which included: (a) a retrospective audit of all handwritten Microbiology requests received over a 1-month period in the Microbiology Department of a large metropolitan teaching hospital; (b) the administration of a survey to laboratory professionals to investigate the impact of different clinical information on the processing and/or interpretation of tests; (c) an expert panel consisting of medical staff and senior scientists to assess the survey findings and their impact on pathology practice and patient care; and (d) a comparison of the provision and value of clinical information before CPOE, and across 3 years after its implementation. The audit of handwritten requests found that 43% (n=4215) contained patient-related clinical information. The laboratory survey showed that 97% (84/86) of the different types of clinical information provided for wound specimens and 86% (43/50) for stool specimens were shown to have an effect on the processing or interpretation of the specimens by one or more laboratory professionals. The evaluation of the impact of CPOE revealed a significant improvement in the provision of useful clinical information from 2005 to 2008, rising from 90.1% (n=749) to 99.8% (n=915) (p<.0001) for wound specimens and 34% (n=129) to 86% (n=422) (p<.0001) for stool specimens. This study showed that the CPOE system provided an integrated platform to access and exchange valuable patient-related information between physicians and the laboratory. These findings have important implications for helping to inform decisions about the design and structure of CPOE screens and what data entry fields should be designated or made voluntary.
Chapter
This chapter considers how assimilation theories can be used to explain success with the adoption and use of healthcare information systems in public hospitals. A number of authors have explored the applicability of innovation assimilation theory, technology-organisation-environment model and resource-based theory to the IS/IT domain, mainly at a conceptual level. Overall they infer that stages of assimilation begin from the organisation’s initial evaluation to its formal adoption and end with a well-accepted deployment of the system to a point where it becomes part of the value chain activities in the organisation. This paper is based on in-depth single case study research in a public healthcare facility, which identified global and local barriers to the assimilation of the HIS, with the people, process, technology and environment components as key facilitators for success. These factors together provide the motivation for this study in developing a technology innovation assimilation model for hospitals to successfully assimilate their healthcare information systems (HIS). Successfully assimilating HIS is also seen as having a possible impact on decreasing technology, organisation, environment and process issues pertaining to acquisition and deployment.
Chapter
Healthcare systems around the world are facing a number of challenges. Increasing focus is thus being placed on constructing appropriate healthcare reforms to address challenges and streamline healthcare services. One of the critical enablers in this reform is the adoption of an e-health solution. These e-health solutions are not only expensive and complex endeavours but also have far-reaching implications. Given that the implementation and adoption of these e-health solutions is so important; it is also vital to have an extensive evaluation and analysis of these systems with a theoretically informed lens. This then will serve to maximise and sustain the benefits of the proposed solution and realise its full potential for achieving superior healthcare delivery. To date the literature is void of such evaluations. Hence, this paper proffers the use of a sociotechnical systems (STS) analysis. The exemplar case study under consideration is that of the personally controlled electronic health record (PCEHR), the chosen e-health solution by the Australian government.
Article
Add-on test requests, where a clinician requests further test assays on an existing specimen, contribute disproportionately to pathology service workload. However, little research has quantified the volume, rates, source or types of add-on tests. This study provides a descriptive analysis of add-on testing within a pathology service serving five hospitals. We analyzed 6 months of test data extracted from a pathology service in metropolitan Sydney, Australia. Add-on requests were analyzed in terms of total volume and as a proportion of all test requests and test assays; ten most frequently requested add-on test types for clinical chemistry and hematology; by patient registration category; and proportions of add-on requests received within 1-, 4-, 8-, and 24-h of specimen collection. Add-on test requests constituted 3.7% (n=19,541) of the total 529,361 test requests. Clinical chemistry and hematology add-on requests accounted for 76.9% of all add-on requests. The add-on request rate was higher in the clinical chemistry (5.4%) than in hematology (1.3%). Patients who entered hospital via the emergency department had the highest rates of add-on requests. A total of 79.5% of add-on requests across the pathology service were made within 24-h of specimen collection. The volume of add-on requests is substantial and varies considerably by test type and patient registration category thus impacting differentially upon pathology service departments. While some add-on requests are unavoidable in clinical practice, others are precipitated by inadequate information at the point of care. Improving appropriate utilization of add-on testing will reduce their burden on pathology services.
Chapter
The international movement to reform health care and improve patient safety encompasses a range of strategies. These strategies include restructuring (Braithwaite et al 2005), policy reform measures (World Health Organization 2005; Garling 2008; National Health and Hospitals Reform Commission 2009; Hurst 2010) and programmes to standardise practice (Pronovost et al 2006; Gawande 2009; Iedema et al 2006). A social movement approach has been used to promote large scale change to the way in which patient safety is perceived and enacted within and across health services and systems (Bate et al 2004). Examples of this approach include international campaigns such as Five Moments for Hand Hygiene (World Health Organization 2006) and 5 Million Lives Campaign (McCannon et al 2007).
Article
The importance of information systems/information technology (IS/IT) to healthcare organisations is being recognised today as paramount and critical in order to realise superior healthcare delivery. Successful assimilation of IS/IT, which is the central focus of this study, then becomes a key consideration in ensuring that IS/IT is appropriately and systematically deployed into a healthcare organisation. The key findings from this research indicate that there are people, process, technology and environment elements that should be considered as facilitators to the healthcare information systems (HIS) assimilation process, as well as barriers that the healthcare organisation should overcome throughout the entire assimilation process or at specific stages. This research, therefore, is not only topical but especially beneficial to management and administrators in the web of healthcare players as they grapple with trying to successfully assimilate HIS into their respective organisations.
Article
Objectives: This study mainly integrates the mature Technology-Organization-Environment (TOE) framework and recently developed Human-Organization-Technology (HOT) fit model to identify factors that affect the hospital decision in adopting Hospital Information System (HIS). Methods Accordingly, a hybrid Multi-Criteria-Decision-Making (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) approaches. The initial model of the study is designed by considering four main dimensions with 13 variables as organizational innovation adoption factors with respect to HIS. By using DEMATEL, the interdependencies strength among the dimensions and variables are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and is used to identify how these factors are weighted and prioritized by the public hospital professionals, who are wholly familiar with the HIS and have years of experience in decision making in hospitals' Information System (IS) department. ResultsThe results of this study indicate that from the experts' viewpoint "Perceived Technical Competence" is the most important factor in the Human dimension. In the Technology dimension, the experts agree that the "Relative Advantage" is more important in relation to the other factors. In the Organization dimension, "Hospital Size" is considered more important rather than others. And, in the Environment dimension, according to the experts judgment, "Government Policy" is the most important factor. The results of ANP survey from experts also reveal that the experts in the HIS field believed that these factors should not be overlooked by managers of hospitals and the adoption of HIS is more related to more consideration of these factors. In addition, from the results, it is found that the experts are more concerned about Environment and Technology for the adoption HIS. Conclusions The findings of this study make a novel contribution in the context of healthcare industry that is to improve the decision process of innovation in adoption stage and to help enhance more the diffusion of IS in the hospital setting, which by doing so, can provide plenty of profits to the patient community and the hospitals.
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Objective To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction. Methods Controlled pre–post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession. Results eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001). Conclusions eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.
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The aim of this study was to examine the impact of the Electronic Medical Record (EMR) on the quality of laboratory test orders made by clinicians. The study assessed the type and frequency of pre-analytical laboratory test order errors that were associated with the EMR across three hospitals and one pathology service. This involved a retrospective audit of the laboratory error logs for the period 1 March 2010 to 9 October 2011. Test order problems associated with the EMR occurred at a total rate of 1.34 per 1000 test order episodes across the three hospitals. In the majority of cases these errors were caused by the inappropriate use of the EMR system by clinicians. The errors resulted in increased data entry time for laboratory staff in the Central Specimen Reception area and led to a median increase of 181 minutes in test turnaround times for those test orders. The study highlights the importance of monitoring and comparing the impact of EMR systems in different locations over time in order to identify (and act upon) factors that can adversely impact on the effectiveness of pathology laboratory processes.
Article
Pre-analytical variables are common across all laboratories and can negatively impact on patient care. The aim of this study was to review the impact of electronic requesting in Primary Care on the number of pre-analytical errors seen by the laboratory. Error data were reviewed during two six-month periods, pre- and post-implementation of Primary Care electronic requesting. The outcome measures related to: the correct information on the sample tube (patient name, unique patient ID number, date of collection); the correct sample received and the availability of a clinical history. There was a marked decrease in the number of pre-analytical errors following the introduction of electronic requesting (2764 pre-implementation vs. 498 post-implementation, P < 0.001). There was an improvement in the quality of information provided with each request in the forms of clinical history, date and time of sample collection. The introduction of electronic requesting in Primary Care can reduce the number of pre-analytical errors and can improve the quality of information received with each request.
Article
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Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6].
Article
Healthcare systems around the globe are facing a number of challenges. Thus Increasing focus is being placed on constructing appropriate healthcare reforms which are attempting to address how to tackle these challenges. A critical enabler in these reforms is the adoption of an e-health solution. Such e-health solutions are not only expensive and complex endeavours, but also have far reaching implications. Given that the implementation and adoption of these e-health solutions is so important, not to mention also requiring a substantial investment in various resources such as time and money, it is therefore essential to ensure their success. The following proffers a socio-technical analysis as an appropriate strategy to ensure more successful outcomes. An exemplar case study of the Personally Controlled Electronic Health Record (PCEHR), the chosen e-health solution by the Australian government is provided to illustrate the benefits such an analysis might provide
Article
Given the current pressures on healthcare delivery to be cost effective yet provide high quality, healthcare systems are turning to ICT (information communication technology) to help resolve this conundrum. Such e-health solutions range from being on one-side patient controlled to the other end of the spectrum being provider controlled. However, most agree that these solutions should be patient-centric. Australia has opted for a unique solution in an attempt to have the best of both worlds; i.e, some level of patient control and some level of provider control. This system is known as the PCEHR (personally controlled electronic health record). The following serves to investigate this system and if it is patient centric. In particular, how well patient focus, patient activity and patient empowerment are supported and/or enabled.
Conference Paper
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The patient care context comprises outdated infrastructure, pervasive computer use, shared clinical workspace, aural privacy shortcomings, interruptive work settings, confusing legislation, poor privacy and security (P&S) eHealth training outcomes and inadequate budgets. Twenty three medical, nursing and allied health clinicians working in Australia (Victoria) participated in qualitative research examining work practices with P&S for patient care. They criticised a slow, inefficient eHealth information system (eHIS) environment permeated by usability errors. EHealth systems expanded workloads and system demands were onerous, increasing the clinicians' scepticism of reliance on information technology. Consequently many clinicians had developed trade-offs to avoid reliance an eHIS. The trade-offs include IT support avoidance and shared passwords to PKI and computer accounts. Handover-sheets populated by transcribed notes were circulated between all clinicians present. The practices ensure paper persistence and escalate P&S threats to data confidentiality, integrity and availability. Study evidence suggests poor eHISs hamper patient care and may represent a larger P&S threat than indicated by studies to date.
Article
This work describes and illustrates the use of simulation modeling for evaluating and analyzing the impacts of workflow changes in healthcare resulting from the deployment of a computerized provider order entry (CPOE) system. It is motivated by our longitudinal research program which purports to explore simulation modeling as one of the means that can be applied not merely to contribute to an increased acceptance and use of CPOE systems, but also to aid in decision making. The setting used is The Ottawa Hospital, one of the Canada's largest teaching hospitals, and its multi-phase, multi-year CPOE deployment project for laboratory and diagnostic imaging orders to improve both patient safety and quality of care. The preliminary results indicate that the proposed simulation-based tool can be effectively applied in its current level of development to quantitatively evaluate and compare different options of workflow changes within a given set of operational and organizational constraints.
Article
Background: In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (MI) remains unclear. Methods and results: Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on acute MI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation MI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status. Conclusions: EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.
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The study of technology adoption rarely extends beyond its immediate organizational influence. Yet e-prescribing directly connects previously decoupled organizations suggesting that change introduced in one part of the medication management system will ripple to other parts of the system. While role changes are known to be induced by technology, system designers oftentimes overlook the extent of change. Early evidence of looking at the workflow across organizations that are coupled to e-prescribing, evidence for technologically-induced changes are explored using a roles-artifact-routine analytical framework applied to prescribing activities in physician offices and pharmacies. Early observations suggest that this framework offers system designers a practice-based tool to examine the impact of adopting new technologies.
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This research examines the impact of various factors on the use of IT in clinical practice, prescriptions, and patient information. This was done using a national sample of 3425 physicians who worked in a solo or group practice in the United States. Besides the extent of use of electronic medical records by physicians and number of physicians in practice, none of the other factors consistently impacted the use of IT in clinical practice, prescriptions, and patient information, respectively. The results of this study highlight the need to develop specific strategies to increase the use of information technology in healthcare.
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Just as EHRs are transforming the practice of medicine and health care information management, practicing in the EHR era offers opportunities, if not imperatives, for pathologists to take on new and "transformative" professional and leadership roles for the organizations they serve. Experience indicates that clinicians will perceive pathologists and laboratories as responsible for all aspects of laboratory testing and information management, including order entry and results reporting, even though such functions may fall beyond the control of the laboratory. As described and expanded upon in the previous four articles of this series, the use of EHRs dictates changes in how clinicians interact with laboratory information. In this environment, pathologists are uniquely positioned to act as the stewards for laboratory information in EHRs and throughout health care organizations.
Article
Physician requests for additional testing on an existing laboratory specimen (add-ons) are resource intensive and generally require a phone call to the laboratory. Verbal orders such as these have been noted to be associated with errors in accuracy. The aim of this study was to compare a novel computerized system for add-on requests to the prior verbal system. We compare the computerized add-on request system to the verbal system with respect to order completeness and workflow. We demonstrate that the computerized add-on system resulted in the complete in-laboratory documentation of the add-on request 100% of the time, compared to 58% with the verbal add-on system. In addition, we show that documentation of a verbal add-on request in the electronic medical record (EMR) occurred for 4% of requests, while in the computerized system EMR documentation occurred 100% of the time. We further demonstrate that the computerized add-on request process was well accepted by providers and did not significantly change the test mix of the add-on requests. In computerized physician order entry (CPOE) implementations, add-on order functionality should be considered so these orders are documented in the EMR.
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The aim of this article is to outline in discursive-linguistic terms how doctor-managers (or 'physician-executives' as they are termed in the USA) manage the incommensurate dimensions of their boundary position between profession and organization. In order to achieve this we undertook a discourse analytical study of both recorded, situated talk and open interview data focusing on one doctor-manager navigating between profession and organization. The doctor-manager at the centre of this study locates himself on the boundary of at least three discourses which, in many respects, are incommensurate. These are the profession-specific discourse of clinical medicine, the resource-efficiency and systematization discourse of management, and an inter-personalizing discourse devoted to hedging and mitigating contradictions. While this multi-vocality in itself is not surprising, data show that the doctor-manager positions himself across these discourses and manages their inherent incommensurabilities before a heterogeneous audience and on occasions even within the one utterance. In this particular case, boundary management is achieved by weaving incommensurable positions together into the social and linguistic dynamics of a single, heteroglossic p stream of talk. This highly complex and dialogic strategy enables the doctor-manager to dissimulate the disjunction between his reluctance to impose organizational rules on his medical colleagues and his perception that such rules, in the future (to some extent at least), will be the appropriate means for managing the clinical work, and through that the organization.
Conference Paper
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The paper reports on the preliminary findings of an in-depth case study of the implementation of a computerized order entry (COE) system at a medium sized, acute care hospital. We propose a theoretically grounded framework, based on work by S.R. Barley (1986; 1990), for analyzing organizational changes that may result from COE introduction and use the framework to analyze findings at the research site. The hospital studied was largely successful in implementing and utilizing the system. However, use of the COE has altered the content and structure of order related information that passes between key participants in clinical care, affecting how these occupational groups and departments communicate and interact by creating ambiguity and uncertainty about order information. Use of the system may also be enabling increased organizational control over clinical care practices, exercised through professional norms and the clinical administrative hierarchy. Findings were consistent with other studies of COE use, suggesting that future research could focus on the consequences of structuring the content of order related communications on interactions between clinical and ancillary departments and the need to integrate the COE with other clinical systems to minimize disruptions
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In this essay we argue that organization theory's effort to make sense of postbureaucratic organizing is hampered by a dearth of detailed studies of work. We review the history of organization theory to show that, in the past, studies of work provided an empirical foundation for theories of bureaucracy, and explain how such research became marginalized or ignored. We then discuss methodological requirements for reintegrating work studies into organization theory and indicate what the conceptual payoffs of such integration might be. These payoffs include breaking new conceptual ground, resolving theoretical puzzles, envisioning organizing processes, and revitalizing old concepts
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Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into a network of physicians' interactive microcomputer workstations are reported. The task proved difficult because the guidelines often lack explicit definitions (e.g., for symptom severity and adverse events) that are necessary to navigate the AHCPR algorithm. They also focus more on errors of omission (not doing the right thing) than on errors of commission (doing the wrong thing) and do not account for comorbid conditions, concurrent drug therapy, or the timing of most interventions and follow-up. As they stand, the heart failure guidelines give good general guidance to individual practitioners, but cannot be used to assess quality or care without extensive "translation" into the local environment. Specific recommendations are made so that future guidelines will prove useful to a wide range of prospective users.
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Background: Qualitative research involves the collection, analysis and interpretation of data that are not easily reduced to numbers. These data relate to the social world and the concepts and behaviours of people within it. Qualitative research can be found in all social sciences and in the applied fields that derive from them, for example, research in health services, nursing and pharmacy. These research methods are not a recent invention but their application in health technology assessment (HTA) or health services research may be novel. In order for commissioners and researchers to utilise these methods and gain valuable knowledge from the results obtained, it is important that they understand the principles of qualitative methods and the way that they may be used to set benchmark standards. Objective: The objective of this review was to examine the nature and status of qualitative methods in relation to their potential uses in HTA. Methods: The search tools often used for systematic reviews were not appropriate for this review as it would be necessary to cover the equivalents of MEDLINE in a range of disciplines and applied fields, many of which do not have databases of comparable coverage. In addition, important methodological writing in the field of social science started long before indexing for computer databases, and much of the most significant work has been published in books rather than journals. Having set the boundaries and organised the categories for this review, therefore, the authors read as widely and as comprehensively as was feasible in the time available. The authors have compared different researchers' approaches to the same issue and examined the work of authors who offer different perspectives. Perspective: Idealists versus realists. Qualitative work is often identified with idealism while quantitative work is identified with realism. However, most qualitative researchers accept that there is an objective, material world, as do realists, but question our ability to know this directly. In the social sciences, what people perceive or believe is the basis of their actions rather than what an impartial observer might think was actually true. Qualitative versus quantitative methods: The goal of all research in HTA should be to establish knowledge about which we can be reasonably confident, and to provide findings that are relevant to policy makers and practitioners. Therefore, decisions about whether qualitative or quantitative methods (or a combination of both) are most appropriate to a particular research problem should be made on the basis of which approach is likely to answer the question most effectively and efficiently. Qualitative methods are useful in the exploratory stages of a research project, where they will often help to clarify or even set the research question, aid conceptualisation and generate hypotheses for later research. Qualitative methods may also be used to interpret, qualify or illuminate the findings of quantitative research and to test hypotheses. Qualitative research is particularly useful to policy makers and planners by providing descriptive information and understanding of the context in which policies will be implemented. Sampling and generalising: In sampling decisions in qualitative research, pragmatic considerations should be integrated with sampling in a systematic way just as in quantitative research; opportunistic sampling should be avoided if possible. The emergent nature of qualitative research means that sampling decisions need to be made throughout the study; such decisions should again be systematic and principled. Where the aim is to build or develop theory, subjects should be selected accordingly; such theoretical sampling makes use of existing theory to make predictions, and then seeks subjects who allow the researcher to test the robustness of such predictions under different conditions. Methods of qualitative research: Participant observation. Participant observation can be used to study the impact of technologies upon the routine functioning of the setting in which they are to be implemented. Participant observation may also be used to review health technologies currently in practice, and has the potential for uncovering the process through which professional inputs are transformed into patient/client outcomes thereby identifying opportunities for modifying current practice to improve outcomes. Interviews: Qualitative interview techniques are used, particularly in exploratory research, to study the range and complexity of ideas and definitions employed by individuals and groups involved in the implementation of health technologies. Both qualitative and quantitative interviewing share the same fundamental problem, however, in that they rely upon interviewees' reports and such reports are necessarily constrained by the context in which they are collected. Written records: The analysis of written records has an important contribution to make to our understanding of the processes and consequences associated with new technologies. In addition, documents such as health diaries may provide important data on the implementation of health technologies. Conversation analysis: The techniques of conversation analysis can provide detailed data on the impact of new technologies upon healthcare settings, the organisation of professional work and the interactions between health professionals and patients. Research ethics: The same ethical principles apply to qualitative and quantitative research in HTA. The mechanical application of ethical codes developed in the context of biomedicine may be unduly constraining in qualitative research and may distract from those ethical risks which are specific to qualitative research. Covert research will rarely, if ever, be justified in HTA. Such research is likely to be a betrayal of trust and a gross invasion of privacy. Assessment of qualitative research: The same assessment criteria of validity and relevance are appropriate for both qualitative and quantitative research in HTA. Relevance: The relevance of HTA research is related to its potential generalisability to groups or settings beyond those studied. Given that most qualitative research is based on a single case or only a small number of subjects, the generalisability of qualitative research is achieved by the generation of theoretical statements, which may guide policy makers but remain to be tested through application in other contexts. Data handling: HTA commissioners should look for evidence that applicants intend to use systematic methods for coding and handling their qualitative data and that methods proposed for analysing such data are appropriate to the research objective. Computerised analysis packages for qualitative data offer an efficient way of handling qualitative data sets and may improve the rigour of the analysis by facilitating searches for falsifying evidence. However, such programs should be used only as a means of facilitating the analysis process rather than carrying out the analysis, which depends upon the theoretical sensitivity of the analyst. Judgements about the validity of research depend upon being able to form a judgement of the research process. Researchers therefore need to provide a detailed record of their methods. Given the non-standardized nature of qualitative research, such records are likely to be more elaborate than in reports of quantitative research. The trustworthiness of data analyses is enhanced where researchers can demonstrate that they have considered alternative plausible explanations for their data. The validity of research findings is enhanced where the researchers increase our understanding of all members in a setting and do not present one-sided accounts. Confidence in the validity of findings is increased where there is evidence of researcher sensitivity to the ways in which the data have been shaped by the researchers' presence. While the practices of respondent validation and triangulation may increase the comprehensiveness of a study, neither can be treated as tests of the validity findings. Conclusion: There are strengths and limitations to qualitative approaches as there are to quantitative methods. However, where qualitative research is conducted properly and data analysed thoroughly, this approach can provide valuable information on the implementation and impact of health technologies on both health professionals and patients.
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Describe the complex interplay of perspectives of physicians, administrators, and information technology staff regarding computerized physician order entry (POE) in hospitals. Linstone's Multiple Perspectives Model provided a framework for organizing the results of a qualitative study done at four sites. Data from observation, focus groups, and formal and informal interviews were analyzed by four researchers using a grounded approach. It is not a simple matter of physicians hating POE and others loving it. The issues involved are both complex and emotional. All groups see both positive and negative aspects of POE. The Multiple Perspectives Model was useful for organizing a description to aid in understanding all points of view. It is imperative that those implementing POE understand all views and plan implementation strategies accordingly.
Article
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To interpret the results of a cross-site study of physician order entry (POE) in hospitals using a diffusion of innovations theory framework. Qualitative study using observation, focus groups, and interviews. Data were analyzed by an interdisciplinary team of researchers using a grounded approach to identify themes. Themes were then interpreted using classical Diffusion of Innovations (DOI) theory as described by Rogers [1]. Four high level themes were identified: organizational issues; clinical and professional issues; technology implementation issues; and issues related to the organization of information and knowledge. Further analysis using the DOI framework indicated that POE is an especially complex information technology innovation when one considers communication, time, and social system issues in addition to attributes of the innovation itself. Implementation strategies for POE should be designed to account for its complex nature. The ideal would be a system that is both customizable and integrated with other parts of the information system, is implemented with maximum involvement of users and high levels of support, and is surrounded by an atmosphere of trust and collaboration.
Article
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Concerns with health care quality and medical errors are evident in media reports and research studies. A number of studies have demonstrated that computerized physician order entry (CPOE) can reduce medication error rates. In response, the California government and the Leapfrog Group have called for hospitals to implement CPOE for medications. However, few hospitals now use CPOE. Barriers include the large investment needed and the state of commercial CPOE systems. We argue that government, employers, and insurers should share the costs of CPOE and should fund further research into its benefits and means of implementation.
Article
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The aim of this paper is to examine the adequacy of the concept of Physician Order Entry (POE) as a model for clinical systems, and to suggest an alternative understanding of the order creation and communication process. The study is based on an interpretative analysis of POE as a model for clinical systems and the results of our recent fieldwork. Observations from our recent fieldwork suggest that orders, like patient care in general, emerge from interactions among patients, physicians, nurses, family members, and others, employing a variety of technologies and information resources in the process. Orders as we have observed them originate, are negotiated, and are carried out in a dynamically evolving group with fluctuating membership and shifting role responsibilities. Furthermore, orders by themselves represent only a partial picture of what is done for the patient. We argue that information systems are more likely to be helpful if they accommodate and facilitate POE as a multidisciplinary collaboration effort and fit better into the larger system of patient care.
Article
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To assess the impact of a computerised pathology order entry system on laboratory turnaround times and test ordering within a teaching hospital. A controlled before and after study compared test assays ordered from 11 wards two months before (n = 97 851) and after (n = 113 762) the implementation of a computerised pathology order entry system (Cerner Millennium Powerchart). Comparisons were made of laboratory turnaround times, frequency of tests ordered and specimens taken, proportions of patients having tests, average number per patient, and percentage of gentamicin and vancomycin specimens labelled as random. Intervention wards experienced an average decrease in turnaround of 15.5 minutes/test assay (range 73.8 to 58.3 minutes; p<0.001). Reductions were significant for prioritised and non-prioritised tests, and for those done within and outside business hours. There was no significant change in the average number of tests (p = 0.228), or specimens per patient (p = 0.324), and no change in turnaround time for the control ward (p = 0.218). Use of structured order screens enhanced data provided to laboratories. Removing three test assays from the liver function order set resulted in significantly fewer of these tests being done. Computerised order entry systems are an important element in achieving faster test results. These systems can influence test ordering patterns through structured order screens, manipulation of order sets, and analysis of real time data to assess the impact of such changes, not possible with paper based systems. The extent to which improvements translate into improved patient outcomes remains to be determined. A potentially limiting factor is clinicians' capacity to respond to, and make use of, faster test results.
Article
Objective: The aim of this paper is twofold. First, we describe two important dimensions of patient care information systems (PCIS) evaluation: the domain of evaluation and the different phases of the PCIS implementation. Second, we claim that, though Randomized Controlled Trials (RCTs) are often still seen as the standard approach, this type of design hardly generates relevant information for the organizational decision maker. Method: Interpretive study of evaluation literature. Results and Conclusions: The field of evaluation is scattered and the types of questions that can be asked and methods that can be used seem infinite and badly demarcated. Different stakeholders, moreover, often have different priorities in evaluating ICT. The most important reason for the lack of relevance of RCTs is that they are ill suited for investigating why and how a PCIS is being used, or not, and what the (often unplanned) effects and consequences are. Subsequently, our aim is to contribute to the discussion about the viability of qualitative versus quantitative methods in PCIS evaluation, by arguing for a specific integration of quantitative and qualitative research methods. The joint utilization of these methods, we claim, yields the richest results.
Article
Objectives: The aim of this paper is to examine the adequacy of the concept of Physician Order Entry (POE) as a model for clinical systems, and to suggest an alternative understanding of the order creation and communication process. Methods: The study is based on an interpretative analysis of POE as a model for clinical systems and the results of our recent fieldwork. Results: Observations from our recent fieldwork suggest that orders, like patient care in general, emerge from interactions among patients, physicians, nurses, family members, and others, employing a variety of technologies and information resources in the process. Orders as we have observed them originate, are negotiated, and are carried out in a dynamically evolving group with fluctuating membership and shifting role responsibilities. Furthermore, orders by themselves represent only a partial picture of what is done for the patient. Conclusion: We argue that information systems are more likely to be helpful if they accommodate and facilitate POE as a multidisciplinary collaboration effort and fit better into the larger system of patient care.
Chapter
Some health care information systems (HCIS) do succeed, but the majority are likely to fail in some way. To explain why this happens, and how failure rates may be reduced, the chapter describes the “ITPOSMO” model of conception-reality gaps. This argues that the greater the change gap between current realities and the design conceptions (i.e., requirements and assumptions) of a new healthcare information system, the greater the risk of failure. Three archetypal large design-reality gaps affect the HCIS domain and are associated with an increased risk of failure: • Rationality—reality gaps: that arise from the formal, rational way in which many HCIS are conceived, which mismatches the behavioral realities of some healthcare organizations. • Private—public sector gaps: that arise from application in public sector contexts of HCIS developed for the private sector. • Country gaps: that arise from application in one country of HCIS developed in a different country.
Chapter
Up to this point, the discussion of evaluation has focused on the information technology itself or on the individuals who use or are affected by the technology. Evaluation from a technology perspective considers hardware, software, telecommunications technology, and databases. Evaluation from a people perspective focuses on training, personnel, attitudes of personnel, ergonomics, and regulations affecting employment. It also is important to consider the nature of the work individuals do and the tasks they perform. Designers and evaluators increasingly are recognizing that compatibility of an information resource with work practices is an important concern, and some new methodologies are premised on the assumption that design must be based on work routines.1–10
Article
: In 1988 the University of Virginia Medical Center began implementation of a medical information system based on mandatory physician order entry. The implementation process was much more difficult than expected. The program experienced considerable delays, and cost much more than was originally estimated. Although there were some legitimate questions concerning the user-friendliness of the new technology, these were less significant than the cultural and behavioral problems encountered. The new system challenged basic institutional assumptions; it disturbed traditional patterns of conduct and forced people to modify established practice routines. Real progress toward the integration of the system into the center's operational culture occurred only after a senior management team representing important sectors of the hospital staff and administration began meeting regularly to address the institution-wide issues that had been raised. The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain. The center's experience provides insight into the issue of technology-driven organizational transformation in academic medical centers. Recommendations for successful introduction of similar agents of institutional change are presented. Academic Medicine 68(1993):20-25.
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This study investigated the impact of two organizational constraints, technological compatibility and operational capacity, on the success of business-to-business (B2B) electronic commerce (e-commerce) efforts over a range of business settings. We focused specifically on the transactional efficiencies gained through the use of B2B e-commerce. To accomplish this, we considered an instrument originally developed to measure the benefits of intra-organizational information systems and applied it in two inter-organizational contexts: electronic data interchange (EDI) usage, and B2B technology usage by firms without EDI. Analysis was carried out on 86 firms in the consumer electronics industry, approximately half of which were product-manufacturing firms and the other half service-providing firms. Our findings showed that the inter-organizational context had a significant bearing on which constraints have a greater impact on the success of B2B e-commerce efforts.
Book
Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data--systematically obtained and analyzed in social research--can be furthered. The discovery of theory from data--grounded theory--is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena--political, educational, economic, industrial-- especially If their studies are based on qualitative data.
Article
In this case study, computer systems are explored as catalysts for new interactions between departments in health care organizations. Hypotheses investigated changes in the extent to which members of different departments (1) exchange information and (2) understand each other's work following implementation of an integrated medical information system. Analyses showed that communication-based forms of involvement in implementation (communicating with systems personnel and trainers, communicating about new ways to use the system, and receiving support from supervisors for doing so) were overwhelmingly more important than either general participation or computer use in predicting increases in interdepartmental interaction. Changes in tasks and roles also led to new, informal, face-to-face contacts to support computer system use, as well as greater administrative control over the organization as a whole. In addition, results of interviews and observations over the two-year study period illustrate the importance of work group identification in predicting changes accompanying computerization.
Article
This paper explores the effects of computerized medical information systems on the occupational communities of health care professionals in hospitals. Interviews were conducted with informants from the pharmacy and nursing departments at two hospitals currently using medical information systems for communicating physicians' medication orders from the nursing station to the pharmacy. Results showed changes in tasks for both pharmacy and nursing, resulting in increased interdependence between the two departments. This interdependence was accompanied by improved communication and cooperation, providing an opportunity to encourage better working relationships between departments. The use and maintenance of the common computerized data base became a superordinate goal for the two groups, with the computer system itself as the topic of communication.
Article
A longitudinal study is being conducted of a clinical laboratory computer information system's impact. This paper reports on effects that laboratory directors anticipated prior to installation, and effects reported by laboratory technologists 7 months postimplementation. Primary changes caused by the computer system were increases in the amount of paper work performed by technologists, and improvements in laboratory results reporting. The system generally was well accepted, but laboratory technologists differed in their responses to it. Technologists in some laboratories focused on work increases, whereas in other laboratories they emphasized improved information flow. The paper considers how changes in processes and outcomes of work might affect responses to a computer system. It also considers the implementation process, and suggests some areas where management could benefit from an improved understanding of responses to a computer information system.
Article
The clinical laboratory is examined as a microcosm of the entire health care delivery system. The introduction of computers into the clinical laboratory raises issues that are difficult to resolve by the methods of information science or medical science applied in isolation. The melding of these two disciplines, together with the contributions of other disciplines, has created a new field of study called medical information science. The emergence of this new discipline and some specific problem-solving approaches used in its application in the clinical laboratory are examined.
Article
In 1988 the University of Virginia Medical Center began implementation of a medical information system based on mandatory physician order entry. The implementation process was much more difficult than expected. The program experienced considerable delays, and cost much more than was originally estimated. Although there were some legitimate questions concerning the user-friendliness of the new technology, these were less significant than the cultural and behavioral problems encountered. The new system challenged basic institutional assumptions; it disturbed traditional patterns of conduct and forced people to modify established practice routines. Real progress toward the integration of the system into the center's operational culture occurred only after a senior management team representing important sectors of the hospital staff and administration began meeting regularly to address the institution-wide issues that had been raised. The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain. The center's experience provides insight into the issue of technology-driven organizational transformation in academic medical centers. Recommendations for successful introduction of similar agents of institutional change are presented.
Article
Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes. To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted. Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings. A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect. Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.
Article
The radical changes made in the delivery of modern health care have serious implications for laboratory services, because reasoning in laboratory medicine should follow a clinical rather than a technological logic. Appropriate test requesting and interpretation coupled with a patient-oriented vision improve the outcomes for patients, and so ensure the best cost containment strategy. The fact that analytical operations are standardized and quality controlled, may lead to a greater recognition of the importance of pre- and post-analytical issues. Particularly critical aspects are the formulation of the clinical question and the interpretation of laboratory results. Laboratory-clinic communication is fundamental in achieving and maintaining total quality in laboratory services. Effective consultancy stands or falls with the knowledge and experience of laboratorians, as well as continuous education is required to maintain the best utilization of laboratory information in clinical decision-making. As clinical audit is an important tool for reviewing and improving the quality of the service in clinical laboratories, it should make up an important part of programs for accreditation and quality improvement. If a patient-centered vision predominates, the clinical laboratory will be linked to both physicians and patients, making it more tangible to the latter.
Article
This paper outlines a role-based approach for conceptualizing and investigating the contention in some previous research that technologies change organizational and occupational structures by transforming patterns of action and interaction. Building on Nadel's theory of social structure, the paper argues that the microsocial dynamics occasioned by new technologies reverberate up levels of analysis in an orderly manner. Specifically, a technology's material attributes are said to have an immediate impact on the nonrelational elements of one or more work roles. These changes, in turn, influence the role's relational elements, which eventually affect the structure of an organization's social networks. Consequently, roles and social networks are held to mediate a technology's structural effects. The theory is illustrated by ethnographic and sociometric data drawn from a comparative field study of the use of traditional and computerized imaging devices in two radiology departments.
Article
This article summarizes the origins of informatics, which is based on the science, engineering, and technology of computer hardware, software, and communications. In just four decades, from the 1950s to the 1990s,computer technology has progressed from slow, first- generation vacuum tubes, through the invention of the transistor and its incorporation into microprocessor chips, and ultimately, to fast, fourth-generation very-large-scale-integrated silicon chips. Programming has undergone a parallel transformation, from cumbersome, first-generation, machine languages to efficient, fourth-generation application-oriented languages. Communication has evolved from simple copper wires to complex fiberoptic cables in computer-linked networks. The digital computer has profound implications for the development and practice of clinical medicine.
Article
New medical imaging devices, such as the CT scanner, have begun to challenge traditional role relations among radiologists and radiological technologists. Under some conditions, these technologies may actually alter the organizational and occupational structure of radiological work. However, current theories of technology and organizational form are insensitive to the potential number of structural variations implicit in role-based change. This paper expands recent sociological thought on the link between institution and action to outline a theory of how technology might occasion different organizational structures by altering institutionalized roles and patterns of interaction. In so doing, technology is treated as a social rather than a physical object, and structure is conceptualized as a process rather than an entity. The implications of the theory are illustrated by showing how identical CT scanners occasioned similar structuring processes in two radiology departments and yet led to divergent forms of organization. The data suggest that to understand how technologies alter organizational structures researchers may need to integrate the study of social action and the study of social form.
Article
To conduct a review of the literature for current information pertaining to turnaround times in the clinical laboratory. To evaluate the methods previously used for improving turnaround times and provide a reference for laboratories. The literature was reviewed for information related to turnaround times in the laboratory. Information was limited to literature published from 1989 to present in order to cover the more technological innovations. Several methods have been used in recent years for the improvement of turnaround times in the clinical laboratory. Among these are pneumatic tubing systems, satellite laboratories, point-of-care testing, and computer technology. There is still the need for faster turnaround times. Technological advances are enabling laboratories to better meet these needs leading to improved user satisfaction.
Article
To investigate the impact of a physician's order entry (POE) system on physicians' ordering patterns and patient length of stay. Prospective time series study at pre-POE, 3 months and 6 months after POE at a tertiary teaching hospital in Korea. The study period was from June 1999 to May 2000. The number of orders (doctor's, PRN, medication, changed, canceled orders), number of tests (complete blood count, chemistry, chest X-ray, stat laboratory, serum electrolytes tests), appropriateness and length of patient stay were measured through chart review of 171 in-patients (liver disease, renal disease, gastrectomy, simple mastectomy). The number of doctors' orders, PRN, and medication orders significantly increased after POE. The numbers of changed and canceled orders were not significantly different between pre- and post-POE. The number of stat lab tests significantly decreased after POE. There was no change in appropriateness of patients' hospital stay between pre- and post-POE. Length of stay significantly decreased (P=0.049). POE contributed to improving the quality of care in two ways: improvement of auditability by recording the medical services for patients in more precise and transparent manner, and more appropriate utilization of resources by decreasing the number of stat diagnostic tests and length of stay.
Article
Participant observation, focus group and oral history techniques were used to collect data from four distinctly different sites across the U.S. Data were examined initially to identify success factors for computerized physician order entry (CPOE) implementation. These data, reexamined for communication issues, revealed significant impacts on communication channels and relationships unanticipated by the implementers. Effects on physician-nurse interactions, pharmacy roles, and patient communications that vary by time and location were noted. The importance of robust bi-directional information channels between administration and staff was demonstrated to be potentially "mission-critical." The recommendation for implementers is "Plan to be surprised." Careful planning and pre-work are important but, no matter how much an institution prepares for the upheaval of CPOE, unforeseen consequences are inevitable. The presence of a prepared and capable implementation support group is essential.
Article
To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals. A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data. Patterns and themes concerning perceptions of POE were identified. Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions. An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.
Article
To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. The theme we call Special People is explored here in detail. A taxonomy of types of Special People includes administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users. The recognition and nurturing of Special People should be among the highest priorities of those implementing computerized physician order entry. Their education and training must be a goal of teaching programs in health administration and medical informatics.
Article
Several analyses have detected substantial quality problems throughout the health care system. Information technology has consistently been identified as an important component of any approach for improvement. Computerized physician order entry (CPOE) is a promising technology that allows physicians to enter orders into a computer instead of handwriting them. Because CPOE fundamentally changes the ordering process, it can substantially decrease the overuse, underuse, and misuse of health care services. Studies have documented that CPOE can decrease costs, shorten length of stay, decrease medical errors, and improve compliance with several types of guidelines. The costs of CPOE are substantial both in terms of technology and organizational process analysis and redesign, system implementation, and user training and support. Computerized physician order entry is a relatively new technology, and there is no consensus on the best approaches to many of the challenges it presents. This technology can yield many significant benefits and is an important platform for future changes to the health care system. Organizational leaders must advocate for CPOE as a critical tool in improving health care quality.
Article
Many hospitals in the United States are in early stages of decision making and planning to implement computerized physician order entry (CPOE) to improve patient safety and quality of care. The targeted processes and the software for CPOE are complex, and implementation is a large-scale change effort for most hospitals. Hospitals can increase the likelihood of success by understanding and addressing gaps in CPOE readiness. ASSESSING CPOE READINESS: A CPOE readiness assessment tool was developed that includes several different components: external environment; organizational leadership, structure, and culture; care standardization;, order management; access to information; information technology composition; and infrastructure. The presence or absence of these indicators in a particular hospital was determined by on-site interviews, walkarounds with direct observations, and document review. Assessment results for the first 17 hospitals (bed size, 75-906 beds) indicated that the lowest average component score was in care standardization, while the highest average component score was in organizational structure and function. Organizational culture and the order management process also had low average scores. This CPOE readiness assessment revealed significant gaps in all the hospitals examined. Identifying these gaps and addressing them before CPOE implementation can reduce risks. Organizations need to develop expertise at accomplishing and sustaining change; understanding and building CPOE readiness is an important first step.
Article
The aim of this paper is twofold. First, we describe two important dimensions of patient care information systems (PCIS) evaluation: the domain of evaluation and the different phases of the PCIS implementation. Second, we claim that, though Randomized Controlled Trials (RCTs) are often still seen as the standard approach, this type of design hardly generates relevant information for the organizational decision maker. Interpretive study of evaluation literature. The field of evaluation is scattered and the types of questions that can be asked and methods that can be used seem infinite and badly demarcated. Different stakeholders, moreover, often have different priorities in evaluating ICT. The most important reason for the lack of relevance of RCTs is that they are ill suited for investigating why and how a PCIS is being used, or not, and what the (often unplanned) effects and consequences are. Subsequently, our aim is to contribute to the discussion about the viability of qualitative versus quantitative methods in PCIS evaluation, by arguing for a specific integration of quantitative and qualitative research methods. The joint utilization of these methods, we claim, yields the richest results.
Article
To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it. Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997. Availability: computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer. The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51-90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way. Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.
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Computerized physician order entry (CPOE) has had demonstrated benefits in error reduction and guideline adherence, but its implementation has often been complicated by disruptions in established workflow processes. We conducted an observational study of the healthcare team in an intensive care unit after the implementation of mandatory CPOE. We found that policies designed to increase flexibility and safety led to an increased coordination load on the healthcare team, and created opportunities for new sources of error. We attribute this in part to implicit assumptions in the CPOE system design that execution of physician orders is a linear work process. Observational workflow studies are an important tool to understand how to redesign CPOE systems so as to avoid harm and achieve the full potential of benefit for improved patient safety.