We discuss each of the five themes below and provide representative examples of each. Although we note that general themes existed in all settings we studied, the representative examples we use to elaborate the themes are site-specific.
CPOE Introduction Exposes Human–Computer Interaction Problems
We found that ergonomic issues can disrupt workflow. For example, some disruptions arise when environments designed prior to the computer era cannot adequately accommodate new hardware. Mobile computers have little flat space to accommodate paper charts. One physician noted: “A computer that doesn’t have a place to put the chart down is no computer I am willing to use.” In addition, when workstations are in short supply, contention for computers can be high in busy work areas, especially after morning rounds.
We noticed many issues related to poor CPOE usability. These included overly cluttered screen design, poor use of available screen space, and inconsistencies in screen design. More specifically, we saw lists that could not be easily sorted, screens that were hard to read or annotate, minimum availability of system defaults, and lack of appropriate safeguards to prevent selecting the wrong patient or entering incorrect data, to name just a few. Not all of these problems occurred at all sites, though all sites reported software design issues that made some work processes awkward. For example, a researcher observed this example of suboptimal design: “I notice that the resident has to perform four mouse clicks to access an element on a list: 1) click on the pick list, 2) open the list with the down arrow, 3) select an item from the list, and 4) hit the return key to exit the pick list. Normally, this wouldn’t be much of a problem, but the list only contains one element!”
CPOE Changes Work Pace, Sequence, and Dynamics
With some CPOE systems, providers find it difficult to access patient information housed in clinical systems that are not integrated with CPOE, require separate system logins, or cannot be accessed simultaneously. A physician explained: “For me to get lab values I would have to exit out of the discharge summary, [look up the lab values] then bring [the discharge summary] up again. It is just easier for me to look up values on a separate computer.”
In addition, CPOE can force the provider to accommodate the system. For example, many systems provide minimal space for free-text entry or limit the use of timesaving shorthand (such as abbreviations or acronyms) and instead require data entry using nested menus, order sets, and pre-configured pick lists. A resident noted “…the order sets are organized in a linear fashion, for one problem at a time…most of [my patient’s] problems are multidimensional…I have to fill out several different order sets…one for each problem.”
The CPOE systems we studied often do not smoothly handle transitions in level or location of care. For example, it is quite common for an admitting clinician to begin to write orders for an emergency department patient prior to transfer to an inpatient bed. Because some CPOE implementations associate orders with a patient’s physical location, the system may prevent the admitting clinician from entering these orders. “There is a major problem with confusion over whether it is the floor accepting the patient or the ER transferring. The difference is who is responsible."
CPOE systems can force rigid scheduling of tests and medications. Some systems assign medication start times when the order becomes active (as opposed to when the medication is given) making it difficult for staff to alter the timing to match reality. This may cause delays in medication administration. “One problem was that the start time in our system doesn’t mean the time the medication is first administered—it means the time the order becomes active and then the administration times are automatically calculated based on that. [A physician ordered] a Q 12 medication. The first scheduled administration time was about 11 hours later so the patient’s post-transplant medication was delayed 11 hours.” In addition some CPOE systems make it difficult for clinical staff to alter the timing of doses when they cannot be given on schedule, such as when patients are absent from the nursing unit when medications are due. Even in systems where medication dosage times can be changed, often the system cannot automatically reschedule subsequent doses after this modification, requiring staff to alter each of the remaining dosage times manually to match the new, corrected administration schedule.
CPOE Provides Only Partial Support for the Work Activities of Involved Clinical Staff
These systems do not fully support the activities of all clinical staff who must process orders entered in the system. Nurses were the most vocal of the non-physician groups: “This is not a nursing system… the nurses are just saying ’Give me a template nurses can use. Give me standard order sets I can sign off with a single review. Get the standard nursing orders into the doctor’s order templates, so we don’t have to remind them to write an order for something like drawing arterial blood gases every 8 hours unless the patient condition changes.’”
Non-physician staff found it bothersome to receive alerts not applicable to them or their clinical setting. For example, some drug–drug interaction alerts may be highly desirable in one context and not another. One intensive care nurse observed: "… the [alerts] warning against prescribing heparin and aspirin—these are CCU patients, the system should know we are going to give these two meds together on this floor and quit warning us about them." In addition, because nurses do not prescribe medications, this alert is targeted at the wrong clinician.
CPOE Reduces Situation Awareness
Dourish and Bellotti define situation awareness as “the understanding of the activities of others which provides a context for your own activity.”27
Collaboration understandably improves when people develop and maintain awareness of what is going on around them.28
We found that CPOE systems, because they allow orders to be entered at any time by providers located outside of the hospital, can contribute to loss of situation awareness. For example: “It was not at all unusual in the paper world to have two or three people generate orders very close to each other but the common thing they had was a paper or a sheet. In the emergency department [there] was literally a different workstation about every two inches down there. We had a lot more instances of within thirty seconds of each other, two, sometimes three providers would enter the same order at approximately the same time and so it really forced us to go back and do more education on being careful to look and see what [orders are] active before you enter a new order.”
Finally, interesting situation awareness issues emerge when providers from different clinical services use CPOE to enter orders simultaneously on the same patient. The orders might appear to conflict, when in fact they do not. “I was sitting there in the ICU looking at my patient and …boom, an order for dopamine shows up. I didn’t write that…and I look at it…and turned out that it was written by the anesthesiologist getting ready for the case tomorrow. So I was seeing all of the pre-op medicines…a good thing, right? Except it surprised me. I’d never seen those orders before, and [the patient] looked like he didn’t need dopamine to me, so I just cancelled the order.”
CPOE Can Highlight Ineffective Implementation of Policy and Procedures
CPOE systems help to formalize organizational policies and procedures.29
In many cases, actual practice does not match this rigid “letter of the law,” so the CPOE system may introduce a significant amount of extra work (perceived or real): “We found that [obstetrics] was one of the most complex places in the hospital because patients were going from the screening room to the pod room to a labor room to the delivery room to postpartum and each of those are a different level of care and so orders need to be rewritten. Although nurses are very good about blending the orders as need be from one [level] to the other, the computer isn’t nearly as flexible."
Difficulties arise when standards are hard to interpret or implement, as when one clinician initiates patient care that must be monitored by other specialists: "Some orders [are] written by certain specialists like anesthesiologists [for] epidurals. No one wants to rewrite those orders. So how should those [orders] traverse the levels of care when the epidural catheter moves with the patient?” In such cases, CPOE can complicate already difficult issues.