Computerized provider order entry system field research: the impact of contextual factors on study implementation

Attention to contextual factors is essential to the conduct of high quality informatics field research. This is particularly true when the research focus is on complex information technology innovations like computerized provider order entry (CPOE) systems. From a field research perspective, CPOE systems are considered an organizational intervention. They are designed, implemented and used within an organizational context that encompasses cultural, economic, social and physical aspects. It is essential that informatics researchers address contextual factors when assessing the impact of CPOE systems. Inclusion of organizational contextual factors in CPOE system field studies permits a more accurate evaluation of the true impact these systems have on medication practice processes and outcomes. The goals of this paper are to: (1) identify contextual factors that influenced implementation of a federally-funded field study undertaken to examine the impact of a community hospital CPOE system on medication error outcomes; and (2) describe how these contextual factors influenced study methodology and implementation.     

A comparison of the impact of CPOE implementation and organizational determinants on doctor–nurse communications and cooperation

ObjectiveTo compare the impact of CPOE implementation and of the workplace organizational determinants on the doctor–nurse cooperation and communication processes.MethodA first study was undertaken in eight different wards aimed to identify the different workplace organizations that support doctor–nurse communications’. A second study compared the impact of these organizations and of a CPOE on medication-related doctor–nurse communications.ResultsThe doctor–nurse communications could be structured into three typical workplace organizations: the common round, the briefing and the opportunistic exchange organizations. The results (i) confirmed the impact of the organizational determinants on the cooperative activities and (ii) demonstrated the CPOE system has no significant impact within a given workplace organization.ConclusionThe success of the implementation of HIT applications relies partly on the identification of the actual (and sometimes hidden) structuring variables of teamwork and ultimately on their control at the time of implementation to ensure the quality and safety of the patient care provided.     

A framework to build capacity for a reflex-testing program for Lynch syndrome

PurposeLynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada.MethodsWe recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed.ResultsTwenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified.ConclusionsThis study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.     

The impact of computerised physician order entry systems on pathology services: a systematic review

PURPOSE: Computerised physician order entry (CPOE) systems hold the promise of significant improvements to health care delivery and patient care. The implementation of such systems is costly and complex. The purpose of this paper is to review current evidence of the impact of CPOE on hospital pathology services. METHODS: This paper presents a review of the literature (1990-August 2004) about CPOE systems and identifies indicators for measuring the impact of CPOE on pathology services. RESULTS: Nineteen studies which contained some form of 'control' group, were identified. They featured a variety of designs including randomised controlled trials, quasi-experimental and before and after studies. We categorised these into three groups: studies comparing pathology CPOE systems (with no decision support) to paper systems; pathology CPOE systems (with decision support) to paper systems; and pathology CPOE systems with specific pathology features compared to systems without those features. We identified 10 areas of impact assessment and 39 indicators used to measure the impact of CPOE on different stages of the pathology test ordering and reporting process. CONCLUSION: We conclude that while some data suggest that CPOE systems are beneficial for clinical and laboratory work processes, these data are limited, and further research is needed. Few data are available regarding the impact of CPOE on patient outcomes.     

Australian psychologists' knowledge of and attitudes towards animal‐assisted therapy

Background: Research on registered psychologists’ knowledge of and attitudes toward Animal‐Assisted Therapy (AAT) is virtually nonexistent. Aim: To explore Australian psychologists' knowledge of and attitudes toward AAT. Materials and Methods: This paper presents a thematic analysis of qualitative data collected from 9 psychologists speaking about AAT during individual interviews. Results: The first research question explored psychologists’ knowledge of AAT and identified 3 key themes: AAT use across the client lifespan in various health settings; training is inadequate; and efficacy studies are lacking. The second question exploring psychologists’ attitudes towards AAT identified further themes: AAT enhances therapeutic relationships; AAT used purposefully or incidentally is effective; and there are barriers to AAT implementation. Conclusion: Whilst AAT is deemed to be a useful intervention by some psychologists, its evidence base and training in such interventions are lacking.     

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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

The state of the evidence for computerized provider order entry: A systematic review and analysis of the quality of the literature

Objective

This paper presents the results of a systematic literature review and a formal analysis of the scientific quality of empirical research on computerized provider order-entry (CPOE) applications.

Design

Formal, systematic review techniques were used to search the literature, determine study relevance, and evaluate study quality.

Measurement

A search of multiple databases from 1976 through mid-2007 yielded a final set of 46 articles. Relevance criteria included: (1) a direct comparison of a CPOE system with a non-CPOE system; (2) implementation in a clinical setting; and (3) clinically relevant outcomes.

Results

Study quality varied widely. Three major areas were identified for improvement in future studies: (1) internal validity, especially in terms of study designs, blinding, and instrumentation bias; (2) construct validity of the phenomenon of CPOE itself; and (3) measurement strategies, including reliability and validity assessments.

Conclusions

The evidence for the impact of CPOE needs to be improved to support scientific generalizability. Several common confounds are found in this literature. Future researchers will want to address them to improve the strength of the inference between CPOE and clinical outcomes. Discussion focuses on methods to improve future CPOE research.     

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors

PurposeIn order to better understand physicians’ perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs).MethodsWe conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005.ResultsTwo major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies.ConclusionsHealth care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians’ perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.     

The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units

The literature shows that communication in health care is one of the most important factors associated with quality of care and patients safety. Especially in Intensive Care Units (ICUs) communication is of importance, due to the characteristics of the setting. However, relatively little is known about the different aspects of communication in health care and how Computerized Provider Order Entry (CPOE) implementation may impact communication, and consequently, quality of care. In this study we adapted an existing questionnaire developed by Shortell et al. [11] to examine the impact of CPOE implementation on communication in a repeated cross-sectional design (6 months before implementation, 3 months after implementation and one-year after implementation). Results show overall that CPOE did not have a negative effect on communication, especially in the long term.     

Impact of electronic prescribing in a hospital setting: a process-focused evaluation

OBJECTIVE: To evaluate effects of a natural CPOE implementation in a hospital setting and inform the efficacy of using CPOE rather than traditional paper medication orders. DESIGN: A multiple-baseline, quasi-experimental study of a naturally occurring CPOE intervention, with a non-equivalent control site. MEASUREMENTS: Compliance with medication-ordering protocols and time to first dose of antibiotics. RESULTS: Medication orders placed using CPOE were significantly more compliant than paper-based medication orders, and first doses of antibiotics were delivered significantly faster when ordered with CPOE than when placed using the standard paper-based system (p<.01). CONCLUSION: Findings support the use of CPOE and justify the need for interventions to increase CPOE adoption and consistent use among physicians.     

Junior doctors’ prescribing work after-hours and the impact of computerized decision support

Background and objectivecomputerized provider order entry (CPOE) systems with integrated decision support (DS) can reduce prescribing errors, but their impact may vary depending on the clinical setting. This study aimed to assess the impact of partial implementation of CPOE on junior doctors’ prescribing work after-hours and to examine differences in junior doctors’ use of DS during transcribing and their own prescribing tasks.MethodsTwelve junior doctors at a 350-bed teaching hospital in Sydney, Australia were shadowed between 16:30 and 22:30 over eight weeks for 65 h. CPOE was available on all wards except for the emergency department (ED). All medication tasks, computerized alerts, prescriber responses, and uses of reference material were recorded.ResultsOf 306 medication orders entered into the CPOE, 78.4% were transcribed from paper ED charts. A total of 113 alerts were triggered, most (78%) were read but only 6 (5%) resulted in prescribers changing an order. Reference material was accessed three times more frequently when junior doctors made their own prescribing decisions than when they transcribed other doctors’ orders, but a similar proportion of alerts was read during decision-making and transcribing tasks.ConclusionJunior doctors spent most of their after-hours prescribing time transcribing other doctors’ orders. This is a new task brought about by partial CPOE implementation. Junior doctors read computerized alerts and used online reference material to support their decision-making. However they rarely made changes to a medication order following alert generation, suggesting the alert information was often not clinically relevant.     

医生电子化医嘱对临床医护协同流程的影响研究

在设计支持临床诊疗流程的电子医嘱系统过程中,人们首先需要深入了解医疗流程,同时还要把握医生电子医嘱应用后临床工作流程的变化。为此,研究了电子医嘱应用实施不同阶段的临床工作流程变化。分析表明,电子医嘱对临床工作流程的影响有正面和负面两个方面,而且软件系统的可用性和临床工作流程的改进对软件的应用效果至关重要。尽管目前的电子医嘱软件已经支持工作流程的改变,但仍然需要改进以克服工作流程模拟手工纸张流程所带来的障碍。     

Analysis of a large sample of diary dreams—how typical are these typical dreams?

Typical dreams are defined as dreams with similar contents reported by a high percentage of dreamers. Up to now, the frequencies of typical dream themes have been studied with questionnaires, indicating that the rank order of 55 typical dream themes is quite stable over different sample populations. The study presented here is the first to look at the frequencies of typical dream themes in a large sample of diary dreams reported by 425 students (321 women, 64 men; mean age 23 years). Overall, almost all typical dream themes were found in the diary dreams, even though some themes occurred very rarely. The rank correlation between diary data and questionnaire data is relatively high, but for some typical dream themes like “Trying again and again to do something” and “Falling” the ranks differed considerably. Future research should adopt various ways of identifying typical dream themes (e.g. qualitative analysis of large dream samples, themes dreamers themselves identify as typical) and develop a more precise definition for each theme. This would be the prerequisite for empirical studies investigating the question why these dream themes are typical, i.e. how these dreams are related to the waking-life experiences of the dreamer.     

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit

PurposeTo develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.MethodsWe developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).ResultsSixteen unique relevant vulnerabilities were identified as a result of the PRA team's efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing “issues list” of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n = 7) or shortly thereafter (n = 9). No other issues were identified beside those identified by the team.ConclusionsGenerally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.