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Computerised Physician Order Entry (CPOE) systems have been promoted in Australia and internationally for their potential to improve the quality of care. The existing research of the effect of CPOE on pathology laboratories has been variable, pointing to the potential to increase efficiency and effectiveness and contribute to enhancing the quality of patient care on the one hand, while leading to significant disruptions in work organisation with a negative impact on departmental relations on the other hand. In this paper we provide an overview of the research evidence about the impact of CPOE on four areas associated with pathology services; a) efficiency of the ordering process, e.g. test turnaround times, b) effectiveness as measured by test ordering volumes and test order appropriateness, c) quality of care, particularly its effects on patient care and d) work organisation patterns, which can be severely disrupted by CPOE. We discuss the possible ramifications of CPOE and offer three broad, but important recommendations for pathology laboratories, based on our own research experience investigating CPOE implementations over three years. Firstly, pathology laboratories need to be active participants in planning the implementation of CPOE. Secondly, the importance of building a firm organisational foundation for the introduction of the new system that includes openness and responsiveness to feedback. And thirdly, the implementation process needs to be underpinned by a strong commitment to a multi-method evaluation at every stage of the process to be able to measure the impact of the system on work practices and outcomes.
CPOE systems allow doctors (and other authorised staff) to enter orders directly into a computer.1 Regarded as an essential building block for the electronic medical record,2 CPOE systems have been promoted for their potential to improve the quality of health care and patient outcomes.3–5 Benefits from CPOE can include improvements in ordering decisions, enhanced efficiency in test processing and increased compliance with evidence-based clinical guidelines.6–8 CPOE systems are high on the implementation agenda for health systems across Europe, the United States and Asia.9–12 These developments have been mirrored in Australia with state and territory health departments embarking on major CPOE implementation projects.13–15
Despite the great enthusiasm for CPOE, their spread within the healthcare system continues to be slow.16 A US survey in 2002 estimated CPOE to have approximately 10% market penetration.16,17 Other findings suggest that smaller hospitals may be particularly resistant to the prospect of CPOE.18 CPOE systems are a costly (and risky) investment,19 in some cases representing the largest single capital investment a hospital is likely to make in a five year period.18 Meanwhile, the attention given to failures of CPOE implementation involving physician resistance to the system,6 the appearance of unexpected errors20,21 and unexpected outcomes, including increased mortality at a paediatric regional referral centre in the US,22 has dampened enthusiasm and raised concerns that implementation processes and systems effects require close monitoring.
The introduction of CPOE systems poses a major challenge for pathology laboratories, which are likely to be among the groups most affected and to experience significant changes in organisational and work relationships.23,24 Research evidence about the impact and outcome of the introduction of CPOE continues to grow, but most of the attention has focused on medication orders5 where the ability of CPOE to reduce errors has been found to be significant.25,26 Less attention has been paid to pathology services, which together with medication and imaging orders constitute a major proportion of orders handled by hospitals.
This paper provides an overview of key research findings about the impact of CPOE implementation on pathology services. In doing so we highlight a series of major challenges and tasks that confront pathology laboratory services and provide recommendations for the way forward.
There are a number of areas where CPOE systems can impact on the clinical/laboratory interface and affect the efficiency, effectiveness and quality of care. These aspects of the pathology ordering process and their intersection with clinical care, and impact on the patient are diagrammatically depicted in the Figure. Decision support mechanisms, including order sets, can facilitate the appropriate choice of tests by doctors and limit the rate of redundant or unnecessary test orders. Access to a broader range of clinical information can help to significantly reduce request errors and improve the laboratory’s capacity to provide accurate results for diagnosis and treatment. In addition, the ability to provide complex evidence based guideline alerts (using information about previous test results, patient characteristics and even available test choices) can also enhance treatment.
The most frequently used indicator of efficiency of the pathology test ordering process is turnaround time.27 Clinical satisfaction with pathology services is often related to the timeliness of test results, because of their effect on treatment particularly in critical care settings.28 Turnaround time can be defined using a variety of time points, including the times of requesting, collection, laboratory receipt, laboratory registration, laboratory reporting and clinician review. Measurements of the impact of CPOE on laboratory turnaround time (from receipt in laboratory to time of dispatch of result) in an intensive care setting and total turnaround time (measuring request and collection of specimens to their reporting times) for tests in intensive and surgical wards showed improvements after the introduction of the new system.4,29,30 Our own research in this area looked at data for eleven wards in a major teaching hospital during a two month period before and after system implementation. We found a significant decrease in the mean laboratory turnaround time per test assay from 73.8 to 58.3 minutes with significant decreases in turnaround times for prioritised and non-prioritised tests as well as for tests performed during and outside business hours.31
While the evidence suggests that CPOE can provide faster results to clinicians, an investigation of the proportion of time US doctors spend writing orders following CPOE implementation showed a significant increase from 2.1% to 9.0%.32 Some of this time may be recovered in other areas e.g. through less time taken to schedule tests or in looking for patients.33 One study looked at telephone activity between the laboratory and a ward after CPOE and found no clear change in the number of calls from the ward, but a decrease in the number of calls from the laboratory to the ward after the system had stabilised.30 The statistical significance of these findings was not reported.
Many CPOE studies involving pathology laboratories have concentrated on the impact on test volumes using a variety of measures including the number of tests ordered per patient, per admission or per doctor. The results from these studies have been mixed. Most have reported an overall reduction of test volumes with CPOE2,34–38 although some (including our own investigation and the only Australian study31) reported no change.39,40 One US study reported major increases of up to 50% in the number of laboratory orders per patient per Diagnosis Related Group after the introduction of CPOE.41 However, this study did not provide a statistical measure of the significance of this result.
Redundant test rates (unnecessary diagnostic tests44) are often seen as a modifiable component of laboratory utilisation,42 and as an important area for potential improvement following CPOE.43 One study by Bates et al. showed that CPOE led to a reduction in the redundant test rate,42 while Neilson et al. reported improvements in test ordering behaviour using CPOE reminders complemented by peer management.35 Other research has shown improvements in test order effectiveness drawing on the ability of CPOE decision support mechanisms to bring about improved compliance with guideline advice,38 or order appropriateness.37 Our own research showed that structured order screens and the manipulation of order sets enhanced the data provided to laboratories and the corresponding quality of test result information reported back to doctors, which may lead to improved patient care.31
Research papers about the impact of CPOE on the quality of patient care have been less numerous. Indicators of the quality of patient care are difficult to quantify and require large sample sizes to detect significant differences.45 Moreover, studies that look at indicators such as mortality rates and patient length of stay are prone to the effect of confounders.
There are some studies that have examined the impact of CPOE on time to treatment and diagnosis,38,46 focusing attention on the interface between the time pathology laboratories issue reports and the accessibility and response to these results by doctors. One of these studies measured the impact of a computerised decision support Laboratory Advisory System on the time taken to reach a diagnosis. It found that the time taken was one day for physicians that used the system and 3.2 days for those that did not.38 Another study compared a computer system that automatically notified the responsible physician of a crucial condition via the hospital’s paging system. The authors reported a significant 38% shorter median time interval (1 hour v 1.6 hours) until an appropriate treatment was ordered when the automatic alerting system was used compared to when it was not used. This is an important area of study that requires wider consideration and attention.31 A study carried out in the UK which investigated the impact of ward computers allowing access to laboratory results found a large proportion (45% for accident and emergency and 29% for inpatient wards) of urgent laboratory test results were never accessed. Of those results never accessed 3% were judged to require an immediate change of patient management.47
CPOE developed as home-grown systems are often reliant on the expertise of enthusiastic hospital IT departments and the backing of clinical champions and senior hospital management. In today’s environment CPOE is often an “off the shelf” system designed for wide application48 across hospital, regional and international boundaries. Such “vendor-developed” systems are not tailor-made and may have difficulty adapting to different environments.49 CPOE is no longer a niche system geared for the hi-tech enthusiasts but is targeted for widespread application and as such has major implications for hospital-wide processes of order management, work organisation and departmental relationships.3,50,51
Studies of the impact of CPOE on organisational processes have shown that in some cases CPOE has the capacity to foster greater communication between clinicians, and across departments. This is often credited to the system’s ability to make information easily accessible across hospital departments with clear audit trails which can contribute to increased levels of accountability and reliability.51–53 At the same time CPOE implementation has been attributed as the cause of internal organisational conflicts. Our own research using focus groups and interviews recorded many laboratory staff feeling that the implementation of the new CPOE system had not taken into account their existing work relationships and ways of performing tasks, and had led to feelings of disenfranchisement.52 A study of the impact of CPOE by Dykstra using participant observation, focus groups and oral history techniques, found that a lack of accessible information about the implementation of the new system had placed stress on existing communication channels between staff across the hospital, a situation that he suggests can lead to an erosion of morale.54 Other researchers have noted that changes in responsibility for tasks like “data entry” and the responsibility for the detection and correction of errors,23 can affect the sense of collaboration and trust within the hospital.18
Many researchers have also highlighted the ability of CPOE to disturb traditional patterns of work organisation and disrupt previous work routines.53,55–57 The changeover to doctors placing electronic orders represents a major structural change in workflows with consequences across departments. This has led many to conclude that the challenges in implementing CPOE lie more in organisational than technological factors.58 One of the underlying problems identified with CPOE systems is that they conceptualise the order process as essentially linear where doctors initiate orders which are then processed by nurses, pharmacists, pathology departments etc.59 But the ordering process is far from linear; like patient care it is a product of collaboration across many professions, and the source of decisions may come from diverse influences and sources.57 This potential discrepancy between the way CPOE conceptualises the ordering process and the way it is carried out within hospitals, has prompted some to warn that CPOE implementation has its ups and downs,60 and hospitals need to be prepared to expect the unexpected.54
There is a large and expanding list of research, opinion pieces and guidelines commenting on what is needed to achieve successful application of CPOE. They come from a mixture of academic,18,58,61–63 management-focused64–68 and policy institution10,50,69 sources. This literature provides a broad overview of the implementation process drawing on wide field experience and research. It is beyond the scope of this paper to summarise their findings and success factors. We do however present three broad (and interconnected) recommendations, which we offer not as a “solution” or “recipe for success”, but as a synthesis of some important lessons that have emanated from our experience investigating the impact of CPOE and pathology services in Australian hospitals.
Over the past decade a substantial body of research about implementation of major Information Communication Technology (ICT) systems like CPOE has sought to overcome the one-sided technological approach where pre-existing organisational needs are expected to be reconciled to a technological solution,70 and implementation is seen primarily as a “technology roll out” devoid of any organisational issues.71 Pathology services are an integral and essential part of clinical service delivery72 and are made up of complex organisational structures with their own formalised rules, conventions and ways of working that have developed and evolved over time.73 It is often these structures, underlying assumptions and work behaviours which CPOE systems confront.55 Sometimes traditional ways of working are challenged by a commercial CPOE system developed in a foreign country using different assumptions about how work processes are undertaken.74 This can become a problem if the site is not adequately prepared for the changes or if pathology departments are given secondary or ancillary roles in the implementation process.52 Our research and field experience demonstrates that pathology departments must be centrally involved in the implementation process if these systems are to bring about improvements in efficiency and effectiveness. Successful implementation should become synonymous with the building of new relationships and improved levels of collaboration across the hospital. Formal communication channels between multi-disciplinary groups which support timely problem-solving as issues arise are crucial.58 Professional silo-based decision-making processes or two-way communication processes between IT staff and each professional interest group will not be sufficient to effectively solve the issues likely to arise.
The changeover to direct physician order represents a major change in the order management process with major implications for clinicians, laboratories and other services.58 The impact of CPOE on pathology laboratories can vary. There is an underlying tension between the potential for computer systems to either decrease interpersonal interaction (e.g. through greater access to remote terminals), or to promote integration with the ability to allow greater access to shared information.75 These tensions can lead to increased levels of task uncertainty or ambiguity, forcing staff to find new ways to incorporate changes into their daily work possibly accompanied by either co-operation or conflict.75
Our research identified a number of areas where CPOE had contributed to shifts in organisational dynamics leading to changes in work practices and processes and the adoption of workarounds by laboratory staff to adjust to the new conditions. At one site clinicians and laboratory scientists reported that the new CPOE system created uncertainty about where responsibility for the cancellation of test orders as in cases where a patient has been discharged or a test is no longer required.76 Previously, when the laboratory carried out this function; it meant binning the redundant hand written requests. But with the new system a cancelled order needs to be performed electronically, otherwise it remains listed within the database as an unfulfilled order. Clinicians and laboratory staff reported an initial period of task uncertainty about who actually performs this task. This uncertainty prompted the laboratories to establish a workaround procedure to check all outstanding orders and cancel them where necessary to ensure the integrity of their database. For the laboratories this was a way of compensating for the change in task responsibilities, but also added to their workload.76
Even routine test ordering processes can be disrupted by the new electronic system. For example, an add-on test occurs when a clinician requires an additional test assay to be carried out on a specimen that has already been delivered to the laboratory. This used to be achieved by a phone call and a new handwritten request signed and faxed to the laboratory. However, with electronic ordering it is not always clear how this procedure is to be carried out, or even if the new CPOE system is able to cope with add ons. At one of our study sites the CPOE system treated an add on as a new test order which led to confusion and frustration in the laboratory, forcing the hospital to revert to the previous status quo where doctors were required to phone and then fax signed hand written requests for add ons.77
It may be, as Aarts et al. assert, that the complexity and unpredictability of socio-technical factors involved with CPOE means that there is no simple formula for successful implementation of the system.71 Certainly, any proposed implementation must start with a recognition and understanding of the enormous challenges involved.24 This implies the existence of a firm organisational foundation for implementation with leadership that is open and responsive to feedback62 and which strives to accentuate the negotiating process by incorporating different communities, interdisciplinary groups and departments.78
The implementation of CPOE systems can benefit from an ongoing commitment to evaluation of the system’s progress. This requires attention to the functions of the system in planning, development, implementation and operation.79 Performed rigorously, evaluation will provide important feedback for decision makers and users who have much to gain from data that can inform and guide decision making.80
Evaluation studies can differ widely according to the subject, target or purpose of the study, and even to the perspective and design and methods employed.81 The choice of evaluation target will be influenced by the question being asked. In the outline of efficiency and effectiveness detailed earlier, the quantitative measures used are most suitable for establishing the size, extent or duration of a certain phenomenon, generally to work out how much (if any) of an effect was experienced.82 Table 1 provides a list of some key indicators which can be used to measure the impact of CPOE on laboratory services. This list is not exhaustive but does provide a starting point.
Qualitative research methods include interviews, observations and document analysis. This type of research can help not only to understand quantitative findings but also to comprehend what is happening and why.83 Table 2 outlines ten important questions that we found valuable to ask in the lead up to and during CPOE implementation.82,84
Pathology laboratory services are likely to be significantly affected by the shifts in work patterns and relationships imposed by the introduction of new CPOE systems. There are a number of imperatives involved in the successful implementation of CPOE, including the participation of pathology laboratory services in preparing for the introduction of the new system, and involvement in the negotiations which will shape the new system. Multi-method evaluation techniques designed to provide timely and reliable data about the impact of the new system are critical to informing the decision-making process. In and of themselves, these strategies do not amount to a recipe for success. They do however provide a sound platform for dealing with the challenges and enhancing the potential of CPOE systems to deliver improvements in work practices and outcomes.
The research experience drawn on in this paper was part of an Australian Research Council Linkage Grant funded project to evaluate the impact of information and communication technologies on organisational processes and outcomes using a multidisciplinary, multi-method approach. The partners in the study are the Centre for Health Informatics and Centre for Clinical Governance Research in Health from the University of New South Wales and the New South Wales Health Department.
Competing Interests: None declared.