Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation: Analysis and Mitigation Strategies

Objective

Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.

Methods

Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.

Results

Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.

Conclusions

Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.     

Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge

Introduction

Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge.

Objectives

This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients.

Methods

Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status.

Results

Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 – 1.0) and 1.6% (95% CI 0.6 – 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group.

Conclusions

Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.     

Computerized Physician Order Entry (CPOE) in pediatric and neonatal intensive care: Recommendations how to meet clinical requirements

Objective

To identify and summarize the requirements of an optimized CPOE application for pediatric intensive care.

Methods

We analyzed the medication process and its documentation in the pediatric and neonatal intensive care units (PICU/NICU) of two university hospitals using workflow analysis techniques, with the aim of implementing computer-supported physician order entry (CPOE).

Results

In both PICU/NICU, we identified similar processes that differed considerably from adult medication routine. For example, both PICU/NICU prepare IV pump syringes on the ward, but receive individualized ready-to-use mixed IV bags for each patient from the hospital pharmacy on the basis of a daily order. For drug dose calculation, both PICU/NICU employ electronic calculation tools that are either incorporated within the CPOE system, or are external modules invoked via interface.

Conclusion

On the basis of this analysis, we provide suggestions to optimize CPOE applications for use in the pediatric and neonatal intensive care unit in the form of three catalogues of desiderata for drug order entry support.     

Using Computerized Provider Order Entry to Enforce Documentation of Tests with Pending Results at Hospital Discharge

Background

Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.

Objective

Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.

Methods

We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.

Results

Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming.

Conclusions

A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.     

Impact of an Interactive Online Nursing Educational Module on Insulin Errors in Hospitalized Pediatric Patients

OBJECTIVE

To determine the effectiveness of an online module for reducing insulin administration errors by nurses caring for hospitalized pediatric patients.

RESEARCH DESIGN AND METHODS

Pediatric nursing staff completed a mandatory online educational module teaching insulin pharmacokinetics and the insulin order form, using diluted insulin and finishing with 15 interactive cases. A chart audit to determine all possible insulin errors of patients receiving insulin was done before and 2–6 months after the educational module.

RESULTS

All of the medical center''s 283 pediatric nurses successfully completed the educational module. A total of 24 charts were audited in the preintervention phase and 22 in the postintervention phase. The preintervention insulin error rate was 14.8%, reduced to 1.7% (P < 0.001) postintervention. Improvement occurred in correct insulin dosing and type, timing of administration, and timely blood glucose monitoring and documentation.

CONCLUSIONS

An interactive online educational module can be an effective strategy for reducing pediatric nurses'' insulin administration errors.Insulin administration errors pose a serious problem for hospitalized patients, specifically for children (1,2), and are responsible for 39% of the serious medication errors causing harm to patients (3). Insulin has a narrow therapeutic window, and incorrect dosing of insulin can cause hypoglycemia, hyperglycemia, and fatalities (4–6). Children (with their developing renal and hepatic systems, limited ability to communicate, and potential needs for diluted insulin) are particularly vulnerable to medication errors (7). In response, the Joint Commission (8) has mandated that health care organizations develop strategies to manage high-risk medications.At our academic children''s hospital, a failure modes effect analysis of reported insulin errors identified knowledge deficits among nurses regarding care of the child with diabetes or hyperglycemia. A root cause analysis identified problems with insulin dosing, insulin omission, and calculating and administering a diluted dose of insulin, all due to a lack of a standardized educational process and infrequent treatment of children with diabetes. This study was conducted to evaluate the effectiveness of an educational module on reducing pediatric nurses'' insulin administration errors.     

Implementing Black Box Warnings (BBWs) in Health Information Systems: An Organizing Taxonomy Identifying Opportunities and Challenges

Objective

To develop a practical approach for implementing clinical decision support (CDS) for medication black box warnings (BBWs) into health information systems (HIS).

Methods

We reviewed all existing medication BBWs and organized them into a taxonomy that identifies opportunities and challenges for implementing CDS for BBWs into HIS.

Results

Of the over 400 BBWs that currently exist, they can be organized into 4 categories with 9 sub-categories based on the types of information contained in the BBWs, who should be notified, and potential actions to that could be taken by the person receiving the BBW. Informatics oriented categories and sub-categories of BBWs include – interactions (13%) (drug-drug (4%) and drug-diagnosis (9%)), testing (21%) (baseline (9%) and on-going (12%)), notifications (29%) (drug prescribers (7%), drug dispensers (2%), drug administrators (9%), patients (10%), and third parties (1%)), and non-actionable (37%). This categorization helps identify BBWs for which CDS can be easily implemented into HIS today (such as drug-drug interaction BBWs), those that cannot be easily implemented into HIS today (such as non-actionable BBWs), and those where advanced and/or integrated HIS need to be in place to implement CDS for BBWs (such a drug dispensers BBWs).

Conclusions

HIS have the potential to improve patient safety by implementing CDS for BBWs. A key to building CDS for BBWs into HIS is developing a taxonomy to serve as an organizing roadmap for implementation. The informatics oriented BBWs taxonomy presented here identified types of BBWs in which CDS can be implemented easily into HIS currently (a minority of the BBWs) and those types of BBWs where CDS cannot be easily implemented today (a majority of BBWs).     

Applying justice and commitment constructs to patient�Chealth care provider relationships

Objective

To examine patients’ experiences of fairness and commitment in the health care context with an emphasis on primary care providers.

Design

Qualitative, semistructured, individual interviews were used to gather evidence for the justice and commitment frameworks across a variety of settings with an emphasis on primary care relationships.

Setting

Rural, urban, and semiurban communities in Nova Scotia.

Participants

Patients (ages ranged from 19 to 80 years) with varying health care needs and views on their health care providers.

Methods

Participants were recruited through a variety of means, including posters in practice settings and communication with administrative staff in clinics. Individual interviews were conducted and were audiotaped and transcribed verbatim. A modified grounded theory approach was used to interpret the data.

Main findings

Current conceptualizations of justice (distributive, procedural, interpersonal, informational) and commitment (affective, normative, continuance) capture important elements of patient–health care provider interactions and relationships.

Conclusion

Justice and commitment frameworks developed in other contexts encompass important dimensions of the patient–health care provider relationship with some exceptions. For example, commonly understood subcomponents of justice (eg, procedural consistency) might require modification to apply fully to patient–health care provider relationships. Moreover, the results suggest that factors outside the patient–health care provider dyad (eg, familial connections) might also influence the patient’s commitment to his or her health care provider.     

Insight into the Sharing of Medical Images: Physician,Other Health Care Providers,and Staff Experience in a Variety of Medical Settings

Background

Scant knowledge exists describing health care providers’ and staffs’ experiences sharing imaging studies. Additional research is needed to determine the extent to which imaging studies are shared in diverse health care settings, and the extent to which provider or practice characteristics are associated with barriers to viewing external imaging studies on portable media.

Objective

This analysis uses qualitative data to 1) examine how providers and their staff accessed outside medical imaging studies, 2) examine whether use or the desire to use imaging studies conducted at outside facilities varied by provider specialty or location (urban, suburban, and small town) and 3) delineate difficulties experienced by providers or staff as they attempted to view and use imaging studies available on portable media.

Methods

Semi-structured interviews were conducted with 85 health care providers and medical facility staff from urban, suburban, and small town medical practices in North Carolina and Virginia. The interviews were audio recorded, transcribed, then systematically analyzed using ATLAS.ti.

Results

Physicians at family and pediatric medicine practices rely primarily on written reports for medical studies other than X-rays; and thus do not report difficulties accessing outside imaging studies. Subspecialists in urban, suburban, and small towns view imaging studies through internal communication systems, internet portals, or portable media. Many subspecialists and their staff report experiencing difficulty and time delays in accessing and using imaging studies on portable media.

Conclusion

Subspecialists have distinct needs for viewing imaging studies that are not shared by typical primary care providers. As development and implementation of technical strategies to share medical records continue, this variation in need and use should be noted. The sharing and viewing of medical imaging studies on portable media is often inefficient and fails to meet the needs of many subspeciality physicians, and can lead to repeated imaging studies.     

Primary care role in expanded newborn screening: After the heel prick test

Objective

To examine the role of primary care providers in informing and supporting families who receive positive screening results.

Design

Cross-sectional survey.

Setting

Ontario.

Participants

Family physicians, pediatricians, and midwives involved in newborn care.

Main outcome measures

Beliefs, practices, and barriers related to providing information to families who receive positive screening results for their newborns.

Results

A total of 819 providers participated (adjusted response rate of 60.9%). Of the respondents, 67.4% to 81.0% agreed that it was their responsibility to provide care to families of newborns who received positive screening results, and 64.2% to 84.8% agreed they should provide brochures or engage in general discussions about the identified conditions. Of the pediatricians, 67.3% endorsed having detailed discussions with families, but only 24.1% of family physicians and 27.6% of midwives endorsed this practice. All provider groups reported less involvement in information provision than they believed they should have. This discrepancy was most evident for family physicians: most stated that they should provide brochures (64.2%) or engage in general discussions (73.5%), but only a minority did so (15.3% and 27.7%, respectively). Family physicians reported insufficient time (42.2%), compensation (52.2%), and training (72.3%) to play this role, and only a minority agreed they were up to date (18.5%) or confident (16.5%) regarding newborn screening.

Conclusion

Providers of primary newborn care see an information-provision role for themselves in caring for families who receive positive newborn screening results. Efforts to further define the scope of this role combined with efforts to mitigate existing barriers are warranted.     

Clinical Decision Support and Palivizumab: A Means to Protect from Respiratory Syncytial Virus

Background and Objectives

Palivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration.

Methods

We developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons.

Results

There were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p < 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05).

Conclusions

Workflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration.     

Emergency department use: Is frequent use associated with a lack of primary care provider?

Objective

To determine if having a primary care provider is an important factor in frequency of emergency department (ED) use.

Design

Analysis of a central computerized health network database.

Setting

Three EDs in southern New Brunswick.

Participants

All ED visits during 1 calendar year to an urban regional hospital (URH), an urban urgent care centre (UCC), and a rural community hospital (RCH) were captured.

Main outcome measures

Patients with and without listed primary care providers were compared in terms of number of visits to the ED. A logistic regression analysis was used to determine factors predictive of frequent attendance.

Results

In total, 48 505, 41 004, and 27 900 visits were made to the URH, UCC, and RCH, respectively, in 2009. The proportion of patients with listed primary care providers was 36.6% for the URH, 37.1% for the UCC, and 89.4% for the RCH. Among ED patients at all sites, frequent attenders (4 or more visits to an ED in 1 year) were significantly more likely (59.6% vs 45.1%, P < .001) to have listed primary care providers. Other factors that predicted frequent use included attendance at a rural ED, female sex, and older age.

Conclusion

This study characterizes attendance rates for 3 EDs in southern New Brunswick. Our findings highlight interesting differences between urban and rural ED populations, and suggest that frequent use of the ED might not be related to lack of a listed primary care provider.     

Optimizing pediatric clinical care and advocacy in an online era: Report of the Canadian Paediatric Society Infectious Diseases and Immunization Committee

Objective

To help busy FPs find useful current information and keep up to date on pediatric infectious disease and immunization topics by highlighting the work of one excellent source of reliable information in this area, the Canadian Paediatric Society Infectious Diseases and Immunization Committee.

Composition of the committee

Committee members were appointed to represent the Canadian Paediatric Society, the College of Family Physicians of Canada, the Public Health Agency of Canada, the American Academy of Pediatrics, and the National Advisory Committee on Immunization.

Methods

This article highlights important pediatric practice points generated by the Canadian Paediatric Society Infectious Diseases and Immunization Committee at a typical meeting in January 2013 from the perspective of an FP liaison. It also describes the committee’s work methods and its background thinking related to the most current and changing issues.

Report

Learn specific online links to updated pediatric infectious disease topics from the detailed content of this report. Topics include caring for kids new to Canada, vaccine-hesitant parents, influenza, human papillomavirus, pertussis, sexually transmitted infections, multidrug-resistant bacteria, and advocacy, among others.

Conclusion

Learn where to find this new and continuously changing information and how to stay evergreen in your knowledge.     

Reduction in Clinical Variance Using Targeted Design Changes in Computerized Provider Order Entry (CPOE) Order Sets: Impact on Hospitalized Children with Acute Asthma Exacerbation

Objectives

Unwarranted variance in healthcare has been associated with prolonged length of stay, diminished health and increased cost. Practice variance in the management of asthma can be significant and few investigators have evaluated strategies to reduce this variance. We hypothesized that selective redesign of order sets using different ways to frame the order and physician decision-making in a computerized provider order entry system could increase adherence to evidence-based care and reduce population-specific variance.

Patients and Methods

The study focused on the use of an evidence-based asthma exacerbation order set in the electronic health record (EHR) before and after order set redesign. In the Baseline period, the EHR was queried for frequency of use of an asthma exacerbation order set and its individual orders. Important individual orders with suboptimal use were targeted for redesign. Data from a Post-Intervention period were then analyzed.

Results

In the Baseline period there were 245 patient visits in which the acute asthma exacerbation order set was selected. The utilization frequency of most orders in the order set during this period exceeded 90%. Three care items were targeted for intervention due to suboptimal utilization: admission weight, activity center use and peak flow measurements. In the Post-Intervention period there were 213 patient visits. Order set redesign using different default order content resulted in significant improvement in the utilization of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001), activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9% utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age increased from 42.7% to 94.1% (p<0.001).

Conclusions

Details of order set design greatly influence clinician prescribing behavior. Queries of the EHR reveal variance associated with ordering frequencies. Targeting and changing order set design elements in a CPOE system results in improved selection of evidence-based care.     

Do patients’ expectations influence their use of medications?: Qualitative study

OBJECTIVE

To investigate whether patients’ expectations influence how they take their medications by looking at the expectations patients have of their medications and the factors that affect these expectations.

DESIGN

Qualitative study using in-depth interviews and a grounded-theory approach.

SETTING

A large city in Ontario.

PARTICIPANTS

A total of 18 community-dwelling adult patients taking medication for at least 6 months.

METHOD

Both purposive and convenience sampling techniques were used. The initial strategy comprised stratified, maximum variation, and typical case sampling. The research team developed a semistructured interview guide after a preliminary review of the literature. Individual, face-to-face, in-depth interviews were conducted and audiotaped. At the end of the interviews, basic demographic information was collected. Interviewers were debriefed following each interview and their comments on relevant contextual information, general impressions of the interview, and possible changes to the interview guide were audiotaped. Audiotapes of each interview, including the debriefing, were transcribed verbatim, cleaned, and given a unique identifying number. At least 2 team members participated in analyzing the data using an operational code book that was modified to accommodate emerging themes as analysis continued.

MAIN FINDINGS

Patients’ expectations were more realistic than idealistic. Many participants acted on their expectations by changing their medication regimens on their own or by seeking additional information on their medications. Expectations were affected by patients’ beliefs, past experiences with medications, relationships with their health care providers, other people’s beliefs, and the cost of medication. Patients actively engaged in strategies to confirm or modify their expectations of their medications.

CONCLUSION

A range of factors (most notably past experiences with medications and relationships with health care providers) influenced patients’ expectations of their medications. More comprehensive discussion between patients and their health care providers about these factors could affect whether medications are used optimally.     

Care of adults with developmental disabilities: Effects of a continuing education course for primary care providers

Objective

To evaluate the effects of an interdisciplinary, guideline-based continuing education course on measures related to the care of adults with developmental disabilities (DD).

Design

Before-and-after study with a control group.

Setting

Ontario.

Participants

Forty-seven primary care providers (physicians, registered nurses, and nurse practitioners).

Intervention

Participants either only received reference material about primary care of people with DD (control group) or participated in a continuing education course on primary care of people with DD in addition to receiving the reference material (intervention group).

Main outcome measures

Participants reported on 5 key measures related to care of adults with DD: frequency of using guidelines, frequency of performing periodic health examinations, frequency of assessing patients who present with behaviour changes, level of comfort while caring for adults with DD, and knowledge of primary care related to adults with DD.

Results

Over time, the intervention group showed significant increases in 4 of the 5 key measures of care compared with the control group: the frequency of guideline use (P < .001), frequency of assessment of patients’ behaviour change (P = .03), comfort level in caring for people with DD (P = .01), and knowledge of primary care related to adults with DD (P = .01).

Conclusion

A continuing education course on primary care of adults with DD is a useful interdisciplinary model to train health professionals who provide primary care services to these patients.     

Family-centred care delivery: Comparing models of primary care service delivery in Ontario

Objective

To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC.

Design

Cross-sectional study.

Setting

Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery.

Participants

A total of 137 practices, 363 providers, and 5144 patients.

Main outcome measures

Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations.

Results

Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural.

Conclusion

Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.     

Awareness of do-not-resuscitate orders: What do patients know and want?

Objective

To assess outpatient understanding of and previous experiences with do-not-resuscitate (DNR) orders and to gauge patient preferences with respect to DNR discussions.

Design

Cross-sectional, self-administered survey.

Setting

Four urban primary care physician offices in Vancouver, BC.

Participants

A total of 429 consecutive patients 40 years of age and older presenting for routine primary care between March and May 2009.

Main outcome measures

Awareness of, knowledge about, and experiences with DNR decisions; when, where, and with whom patients wished to discuss DNR decisions; and differences in responses by sex, age, and ethnicity, assessed using χ² tests of independence.

Results

The response rate was 90%, with 386 of 429 patients completing the surveys. Most (84%) respondents had heard of the terms do not resuscitate or DNR. Eighty-six percent chose family physicians as among the people they most preferred to discuss DNR decisions with; 56% believed that initial DNR discussions should occur while they were healthy; and 46% thought the discussion should take place in the office setting. Of those who were previously aware of DNR orders, 70% had contemplated DNR for their own care, with those older than 60 years more likely to have done so (P = .02); however, only 8% of respondents who were aware of DNR orders had ever discussed the subject with a health care provider. Few patients (16%) found this topic stressful.

Conclusion

Most respondents were well informed about the meaning of DNR, thought DNR discussions should take place when patients were still healthy, preferred to discuss DNR decisions with family physicians, and did not consider the topic stressful. Yet few respondents reported having had a conversation about DNR decisions with any health care provider. Disparity between patient preferences and experiences suggests that family physicians can and should initiate DNR discussions with younger and healthier patients.     

Capturing Information Needs of Care Providers to Support Knowledge Sharing and Distributed Decision Making

Background

This paper reports on work carried out to elicit information needs at a trans-disciplinary, nurse-managed health care clinic that serves a medically disadvantaged urban population. The trans-disciplinary model provides a “one-stop shop” for patients who can receive a wide range of services beyond traditional primary care. However, this model of health care presents knowledge sharing challenges because little is known about how data collected from the non-traditional services can be integrated into the traditional electronic medical record (EMR) and shared with other care providers. There is also little known about how health information technology (HIT) can be used to support the workflow in such a practice.

Objectives

The objective of this case study was to identify the information needs of care providers in order to inform the design of HIT to support knowledge sharing and distributed decision making.

Methods

A participatory design approach is presented as a successful technique to specify requirements for HIT applications that can support a trans-disciplinary model of care.

Results

Using this design approach, the researchers identified the information needs of care providers working at the clinic and suggested HIT improvements to integrate non-traditional information into the EMR. These modifications allow knowledge sharing among care providers and support better health decisions.

Conclusions

We have identified information needs of care providers as they are relevant to the design of health information systems. As new technology is designed and integrated into various workflows it is clear that understanding information needs is crucial to acceptance of that technology.