Overall, physicians randomized to use the Gopher spent 2.12 minutes (6.2 percent) longer per patient writing orders than did control physicians who used paper-based methods. Unfortunately, physicians in the intervention group continued to perform certain tasks using paper-based methods even though the computer was automatically performing those tasks for them. For example, they would, in some cases, manually complete a paper superbill even though the Gopher created an acceptable superbill for them. The time wasted on these unnecessary or duplicative tasks was more than a minute per patient. If we could eliminate this wasted time through further training and process improvement, we estimate the net time cost of POE system use would be only 0.92 minutes per patient. Furthermore, the above figures include the time for users early in their experience with the computer as well as later. We found that the time costs declined with experience, so the time costs for using the POE system could be very small.
Only a few other studies report time data for order entry, and several of those report the blended results from implementing POE and a computerized patient record. Medscape, for example, cites 20 percent productivity improvements with their Logician product when implementing order entry along with a computerized patient record.19
In the Kaiser Permanente Northwest region, clinicians spent an additional 2.2 minutes per patient when the organization introduced POE and a computerized patient record into their outpatient practices.8
These physicians used the system to order tests and prescriptions only 70 to 80 percent of the time. We and others20,21
have previously reported that POE at least doubled the time to record orders for inpatient services.
Most of the time required to use POE is the time to enter individual orders. Developers have tailored the user interface for POE to minimize the time required to enter individual orders in outpatient prescription writing. Reported average times to generate prescriptions using computer-based POE systems or paper-based systems range from less than 30 seconds for the simplest to 252 seconds for complex prescriptions.22,23
Most other data come from inpatient settings. In a study in Japan, investigators found that physicians and other personnel required 102±121 seconds to enter a new prescription, 76±109 seconds to enter a laboratory order, and 54±82 seconds for a radiological study.24
Physicians using the HELP system at LDS Hospital required 132 seconds per order.25
We previously reported average test-ordering times of 30 seconds per test on an earlier version of the Gopher used by medicine residents in an inpatient setting.14
The Gopher was much faster to use than any of these previously described systems, requiring only 20 seconds on average to complete a prescription. We attribute the speed with which physicians can write orders using the Gopher to parsimonious design, ease of locating desired items, and preconstructed or previous “sigs,” which the residents used almost 90 percent of the time.
Compared with their first observed use of POE, physicians' last observed use took 3.73 minutes less per patient. Others have reported similar results, stating that while POE initially requires more time to use than paper-based methods, this difference disappears over 4 to 8 weeks.26
Schroeder and Pierpaoli27
state that “after 1 or 2 weeks of use, most physicians find that they can enter orders in the computer terminals faster than they could write them by hand.” Finally, Allen et al.28
report that order times were 82 seconds for novice users and 18 seconds for expert users in an outpatient prescription writing system. Not only are physicians learning to use the program, they are usually also learning a vocabulary, discovering what the things they want to order are called in the system.
The Medical Gopher provided a number of benefits while requiring slightly more time than paper-based methods. First, workflow was improved: Ancillary personal did not have to complete requisitions, records were legible and always available, physicians wrote consequent orders more often, and the practice saved money on forms. We have also shown, in previous studies,29–31
that cost efficiency can be improved by decreasing the number of tests ordered. Third, clinicians received feedback, such as drug– drug and drug–diagnosis interactions, passive and active order menus, and academic detailing as well as reminders about relevant test results that, as published evidence demonstrates, improves the quality of patient care.32–34
Finally, clinicians had ready access—from home, from the hospital, and from secondary practice locations—to the data they recorded using the Gopher.
The study has some limitations. First, the results are based on use of a specific POE system and may not be generalizable to other systems. However, they do indicate that direct POE using a well-designed system may require only minimal additional time and may even, with continued use, represent a time savings. The Medical Gopher has been used in our outpatient practices for more than 15 years, and during that time has been carefully adapted to the patterns and processes of our practices. Approximately a quarter of the physicians in our study had some experience using the Gopher for inpatient order entry before the study.
Second, the providers in our study, who are salaried, may not be representative of physicians in private practice, who may be even more sensitive to time pressure. However, increasing numbers of clinicians are now salaried employees.35
While the practices we studied are affiliated with a medical school and do host some resident teaching activities, they are managed to be viable independent practices, and all but one are remote from the school's campus. In addition, the volumes of patient visits we observed are consistent with Medical Group Management Association (MGMA) benchmarks of 14 to 18 patients per day for general internal medicine practices.36
Third, the subjects of this study are general internists, and our results may not apply to physicians in other specialties, such as obstetrics or orthopedics.