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1.  A Cross-site Qualitative Study of Physician Order Entry 
Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals.
Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data.
Measurements: Patterns and themes concerning perceptions of POE were identified.
Results: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions.
Conclusion: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.
doi:10.1197/jamia.M770
PMCID: PMC150372  PMID: 12595408
2.  Perceptions of house officers who use physician order entry. 
OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process.
PMCID: PMC2232743  PMID: 10566403
3.  Multiple perspectives on physician order entry. 
OBJECTIVE: Describe the complex interplay of perspectives of physicians, administrators, and information technology staff regarding computerized physician order entry (POE) in hospitals. METHODS: Linstone's Multiple Perspectives Model provided a framework for organizing the results of a qualitative study done at four sites. Data from observation, focus groups, and formal and informal interviews were analyzed by four researchers using a grounded approach. RESULTS: It is not a simple matter of physicians hating POE and others loving it. The issues involved are both complex and emotional. All groups see both positive and negative aspects of POE. CONCLUSION: The Multiple Perspectives Model was useful for organizing a description to aid in understanding all points of view. It is imperative that those implementing POE understand all views and plan implementation strategies accordingly.
PMCID: PMC2243815  PMID: 11079838
4.  What's so special about medications: a pharmacist's observations from the POE study. 
Observations from a multi-site observational study of physician order entry (POE) confirm that implementing POE is problematic, and suggest that implementing medication order entry is particularly difficult. A pharmacist participating in the study group sought to answer the question: What makes medications different? Analysis of themes specific to medication POE in this study's large data set was undertaken using a grounded theory approach. Emerging themes in the data are explored and include: (1) order complexity and the consequences of error; (2) impacts on professional roles; (3) prescribing needs in different settings; and (4) technology impact on medication administration. Awareness of potential roadblocks and lessons learned from previous implementation attempts should help organizations considering medication POE to optimize their own strategies.
PMCID: PMC2243687  PMID: 11825161
5.  Immediate Benefits Realized Following Implementation of Physician Order Entry at an Academic Medical Center 
Objective: To evaluate the benefits of computerized physician order entry (POE) and electronic medication administration record (eMAR) on the delivery of health care.
Design: Inpatient nursing units in an academic health system were the setting for the study. The study comprised before-and-after comparisons between phase 1, pre-implementation of POE (pre-POE) and phase 2, post-implementation of POE (post-POE) and, within phase 2, a comparison of POE and the combination of POE plus eMAR. Length of stay and cost were compared pre- and post-POE for a period of 10 to 12 months across all services in the respective hospitals.
Measurements: Comparisons were made pre- and post-POE for the time intervals between initiation and completion of pharmacy (pre-POE, n=46; post-POE, n=70), radiology (pre-POE, n=11; post-POE, n=54), and laboratory orders (without POE, n=683; with POE, n=1,142); timeliness of countersignature of verbal order (University Hospitals [OSUH]: pre-POE, n=605; post-POE, n=19,225; James Cancer Hospital (James): pre-POE, n=478; post-POE, n=10,771); volume of nursing transcription errors (POE with manual MAR, n=888; POE with eMAR, n=396); length of stay and total cost (OSUH: pre-POE, n=8,228; post-POE, n=8,154; James: (pre-POE, n=6,471; post-POE, n=6,045).
Results: Statistically significant reductions were seen following the implementation of POE for medication turn-around times (64 percent, from 5:28 hr to 1:51 hr; p<0.001), radiology procedure completion times (43 percent, from 7:37 hr to 4:21 hr; p<0.05), and laboratory result reporting times (25 percent, from 31:3 min to 23:4 min; p=0.001). In addition, POE combined with eMAR eliminated all physician and nursing transcription errors. There were 43 and 26 percent improvements in order countersignature by physicians in OSUH and James, respectively. Severity-adjusted length of stay decreased in OSUH (pre-POE, 3.91 days; post-POE, 3.71 days; p=0.002), but not significantly in James (pre-POE, 3.68 days; post-POE, 3.61 days; p=0.356). Although total cost per admission decreased significantly in selected services, it did not change significantly across either institution (OSUH: pre-POE, $5,697; post-POE, $5,661; p=0.687; James: pre-POE, $6,427; post-POE, $6,518; p=0.502).
Conclusion: Physician order entry and eMAR provided the framework for improvements in patient safety and in the timeliness of care. The significant cultural and workflow changes that accompany the implementation of POE did not adversely affect acuity-adjusted length of stay or total cost. The reductions in transcription errors, medication turn-around times, and timely reporting of results supports the view that POE and eMAR provide a good return on investment.
doi:10.1197/jamia.M1038
PMCID: PMC346640  PMID: 12223505
6.  Considerations Regarding the Implementation of Computerized Physician Order Entry: Report of the Menucha Conference 
Implementation of computerized physician order entry (POE) is being increasingly encouraged as an important solution to the challenge of medical error reduction. Use of POE is not widespread, however, in part because it has a reputation for being difficult to implement. To identify success factors for implementing POE, a consensus conference of invited experts holding multiple perspectives was convened near Portland, Oregon on May 10 and 11, 2001. At a retreat center called Menucha, experts from around the world met with members of the Oregon Health & Science University's Physician Order Entry Team (POET) of researchers for the purpose of developing recommendations for POE implementation. Funded by a research grant from the National Library of Medicine, the Menucha consensus conference succeeded in identifying a set of conditions that should exist prior to POE implementation, agreed on considerations for successful implementation, and a list of other considerations that fostered debate within the group and deserve further exploration.
PMCID: PMC2243453
7.  Proactive Office Encounter: A Systematic Approach to Preventive and Chronic Care at Every Patient Encounter 
The Permanente Journal  2010;14(3):38-43.
In 2007, Kaiser Permanente's (KP) Southern California Region designed and implemented a systematic in-reach program, the Proactive Office Encounter (POE), to address the growing needs of its three million patients for preventive care and management of chronic disease. The program sought staff from both primary and specialty care departments to proactively identify gaps in care and to assist physicians in closing those gaps. The POE engaged the entire health team in a proactive patient-care experience, creating standard work flows and using information technology to identify gaps in patient care. The goals were to improve consistency of preventive care and improve quality of care for chronic conditions and to improve reliability of staff support for physicians. The POE has been implemented in all outpatient settings in KP's Southern California Region's 13 medical centers and 148 medical office buildings. The program has contributed to significant improvements in key clinical quality metrics, including cancer screenings, blood pressure control, and tobacco cessation. It is now being extended into the inpatient setting and is being shared with other KP Regions.
PMCID: PMC2937843  PMID: 20844703
8.  A Categorical Typology of Naltrexone Adopting Private Substance Abuse Treatment Centers* 
This study uses a diffusion of innovations theoretical framework (Rogers, 2003) to identify organizational-level predictors of a categorical typology of substance abuse treatment centers based on naltrexone adoption. Data from the National Treatment Center Study (n=158) was used to examine the impact of socio-economic status, organizational personality, and communication behavior on adopter categorization (i.e., innovators, early adopters, early majority, late majority, or laggards). Results from the ordered logistic regression model indicate that organizations’ that did not have on-site 12-step meetings and were familiar with treatment innovations were more likely to be in a more innovative category. Organizations that learned about innovations from professional development seminars and informal conversations with external treatment providers were more likely to be in a less innovative category. Identifying and targeting the early and late majority categories of adopting organizations for better training and community linkages could help to reduce the research to practice gap.
doi:10.1016/j.jsat.2007.08.003
PMCID: PMC2682460  PMID: 17997266
Innovation Adoption; Naltrexone; Categorical Typology; Organizations
9.  Rapid Deployment of Physician Order Entry using Web-Based, Disease-Specific Order Sets. 
Computerized physician order entry (POE) is a disruptive technology that holds great promise to reduce medical errors and improve workflow. However, Studies have reported significant physician resistance. We embarked on a two-pronged strategy to build broad support for POE: To build a secure, open source, browser-based platform to support POE and create a large number of disease-specific order-sets for immediate use. This presentation will demonstrate the conceptual framework and implementation requirements for such an endeavor.
PMCID: PMC1479916  PMID: 14728582
10.  The impact of physician order entry on nursing roles. 
This study examines the impact of physician order entry (POE) on nurses perceptions of work, quality of care, and nurse/physician communication. Four hospitals that have implemented a computerized order-entry system with POE were compared with four similar hospitals using the same computerized system with clerk order entry only. Three factors were extracted from the 29 item survey using principal component extraction with varimax rotation that accounted for 16.5%, 12.4% and 8.7% of the variance respectively. Three scales were constructed from these factors measuring perceptions of impact of the information system on the quality of care, job, control, and nurse/physician communication. Nurses working in the POE environment rated their computer system as having greater impact on the quality of care and lower ratings of perceived control than those working in non-POE environments. No differences were found between nurses working in POE environments and those working in POE in terms of their ratings of frequency of contact and ease of access to physicians.
PMCID: PMC2233002  PMID: 8947758
11.  Physician Order Entry impact on drug turn-around times. 
This paper describes a study of the impact of Physician Order Entry (POE) on pharmacy order turn-around times. The study looked at two surgical services, Neurosurgery and Transplant, of a large Midwestern academic medical center. Pharmacy orders were followed in these units from the time a physician wrote an order to the time the patient received the medication. The first part of the study tracked pharmacy orders for a two-month period before the implementation of POE and the second part of the study tracked pharmacy orders for a two-month period after POE had been implemented. The pre- and post-POE pharmacy turn-around times were compared. It was expected that the data would show a substantial decrease in pharmacy order turn-around times. Our study did, in fact, show a significant reduction in this turn-around-time.
PMCID: PMC2243330  PMID: 11833479
12.  Implementation of physician order entry: user satisfaction and self-reported usage patterns. 
OBJECTIVES: To evaluate user satisfaction, correlates of satisfaction, and self-reported usage patterns regarding physician order entry (POE) in one hospital. DESIGN: Surveys were sent to physician and nurse POE users from medical and surgical services. RESULTS: The users were generally satisfied with POE (mean = 5.07 on a 1 to 7 scale). The physicians were more satisfied than the nurses, and the medical staff were more satisfied than the surgical staff; satisfaction levels were acceptable (more than 3.50) even in the less satisfied groups. Satisfaction was highly correlated with perceptions about POE's effects on productivity, ease of use, and speed. POE features directed at improving the quality of care were less strongly correlated with satisfaction. The physicians valued POE's off-floor accessibility most, and the nurses valued legibility and accuracy of POE orders most. Some features, such as off-floor ordering, were perceived to be highly useful and reported to be frequently used by the physicians; while other features, such as "quick mode'' ordering and personal order sets, received little self-reported use. CONCLUSIONS: Survey of POE users showed that satisfaction with POE was good. Satisfaction was more correlated with perceptions about POE's effect on productivity than with POE's effect on quality of care. Physicians and nurses constitute two very different types of users, underscoring the importance of involving both physicians and nonphysicians in POE development. The results suggest that development efforts should focus on improving system speed, adding on-line help, and emphasizing quality benefits of POE.
PMCID: PMC116286  PMID: 8750389
13.  Principles for a Successful Computerized Physician Order Entry Implementation 
To identify success factors for implementing computerized physician order entry (CPOE), our research team took both a top-down and bottom-up approach and reconciled the results to develop twelve overarching principles to guide implementation. A consensus panel of experts produced ten Considerations with nearly 150 sub-considerations, and a three year project using qualitative methods at multiple successful sites for a grounded theory approach yielded ten general themes with 24 sub-themes. After reconciliation using a meta-matrix approach, twelve Principles, which cluster into groups forming the mnemonic CPOE emerged. Computer technology principles include: temporal concerns; technology and meeting information needs; multidimensional integration; and costs. Personal principles are: value to users and tradeoffs; essential people; and training and support. Organizational principles include: foundational underpinnings; collaborative project management; terms, concepts and connotations; and improvement through evaluation and learning. Finally, Environmental issues include the motivation and context for implementing such systems.
PMCID: PMC1480169  PMID: 14728129
14.  Ambulatory Computerized Physician Order Entry Implementation 
As part of a broader effort to identify success factors for implementing computerized physician order entry (CPOE), factors specific to the ambulatory setting were investigated in the field at Kaiser Permanente Northwest. A multidisciplinary team of five qualitative researchers spent seven months at four clinics conducting observations, interviews, and focus groups. The team analyzed the data using a combination of template and grounded theory approaches. The result is a description of fourteen themes, clustered into technology, organizational, personal, and environmental categories. While similar to inpatient study results in many respects, this outpatient CPO investigation generated subtly different themes.
PMCID: PMC1560502  PMID: 16778992
15.  The Impact of Computerized Physician Order Entry on Medication Error Prevention 
Background: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events.
Objective: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors.
Design: Prospective time series analysis, with four periods.
Setting and participants: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period.
Intervention: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings.
Main outcome measure: Medication errors, excluding missed dose errors.
Results: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001).
Conclusions: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.
PMCID: PMC61372  PMID: 10428004
16.  Contrasting Views of Physicians and Nurses about an Inpatient Computer-based Provider Order-entry System 
Objective: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care.
Design: Survey.
Measurements: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses.
Results: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency.
Conclusion: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.
PMCID: PMC61363  PMID: 10332656
17.  Variability in User Interaction with Physician Order Entry System 
Physician order entry systems offer numerous benefits to users and institutions, including the reduction of medical errors, and increase in the speed and quality of written communication. Standardization of care is also often cited as an important outcome facilitated by POE. However, order entry systems are frequently very complex and sophisticated tools that produce consistent results only if used in an efficient and consistent manner. The numerous benefits that order entry offers can only be realized when this technology is used to its full potential. This study characterizes the variations in user strategies in completing a task and the ensuing inconsistencies of output. Seven physicians were asked to enter orders based on a clinical scenario requiring inpatient admission. Inefficient task completion strategies, redundancy, omissions and errors in the entered orders are outlined and discussed.
PMCID: PMC2244383
18.  The Cognitive Complexity of a Provider Order Entry Interface 
Computer-based provider order entry (POE) can reduce the frequency of preventable medical errors. However, overly complex interfaces frequently pose a challenge to users and impede clinical efficacy. We present a cognitive analysis of clinician interaction with a commercial POE system. Our investigation was informed by the distributed resources model, a novel approach designed to describe the dimensions of user interfaces that introduce unnecessary cognitive complexity. This approach characterizes the relative distribution of user’s internal representations and external representations embodied in the system or environmental artifacts. The research consisted of two component analyses: a modified cognitive walkthrough evaluation and a simulated clinical ordering task performed by seven physicians. The analysis revealed that the configuration of resources placed unnecessarily heavy cognitive demands on the user, especially those who lacked a robust conceptual model of the system. The resources model was also used to account for patterns of errors produced by clinicians.
PMCID: PMC1480200  PMID: 14728181
19.  Controlled Trial of Direct Physician Order Entry 
Objective: Direct physician order entry (POE) offers many potential benefits, but evidence suggests that POE requires substantially more time than traditional paper-based ordering methods. The Medical Gopher is a well-accepted system for direct POE that has been in use for more than 15 years. The authors hypothesized that physicians using the Gopher would not spend any more time writing orders than physicians using paper-based methods.
Design: A randomized controlled trial of POE using the Medical Gopher system in 11 primary care internal medicine practices.
Measurements: The authors collected detailed time use data using time motion studies of the physicians and surveyed their opinions about the POE system.
Results: The authors found that physicians using the Gopher spent 2.2 min more per patient overall, but when duplicative and administrative tasks were taken into account, physicians were found to have spent only 0.43 min more per patient. With experience, the order entry time fell by 3.73 min per patient. The survey revealed that the physicians believed that the system improved their patient care and wanted the Gopher to continue to be available in their practices.
Conclusions: Little extra time, if any, was required for physicians to use the POE system. With experience in its use, physicians may even save time while enjoying the many benefits of POE.
PMCID: PMC130081  PMID: 11418543
20.  Cross-site study of the implementation of information technology innovations in health sciences centers. 
An interpretive oral history technique was used to identify factors most important in the implementation stage of information technology innovation diffusion. Electronic mail, end user literature searching, and aspects of the computer-based patient record were the innovations selected for study at academic health sciences centers. Transcripts of thirty-four interviews with key individuals were analyzed to determine six categories of factors. Word counts were then used to determine underlying emphases. Analysis of variance tested whether there were significant differences in uses of words by categories of individuals, by those at different institutions, and when different innovations were described. Results indicate that the innovations themselves correlate significantly with different word categories, where category of individual and institution do not. Words related to the computer based patient record characterize further critical factors in implementing that particular innovation.
PMCID: PMC2579203  PMID: 8563400
21.  The Effects of Creating Psychological Ownership on Physicians' Acceptance of Clinical Information Systems 
Objective: Motivated by the need to push further our understanding of physicians' acceptance of clinical information systems, we propose a relatively new construct, namely, psychological ownership. We situated the construct within a nomological net using a prevailing and dominant information technology adoption behavior model as a logical starting point.
Design: A mail survey was sent to the population of users of a regional physician order entry (POE) system aimed at speeding up the transmission of clinical data, mainly laboratory tests and radiology examinations, within a community health network.
Measurements: All scales, but one, were measured using previously validated instruments. For its part, the psychological ownership scale was developed using a multistage iterative procedure.
Results: Ninety-one questionnaires were returned to the researchers, for a response rate of 72.8%. Our findings reveal that, in order to foster physicians' adoption of a clinical information system, it is important to encourage and cultivate a positive attitude toward using the new system. In this connection, positive perception of the technology's usefulness is crucial. Second, results demonstrate that psychological ownership of a POE system is positively associated with physicians' perceptions of system utility and system user friendliness. Last, through their active involvement and participation, physicians feel they have greater influence on the development process, thereby developing feelings of ownership toward the clinical system.
Conclusion: Psychological ownership's highly significant associations with user participation and crucial beliefs driving technology acceptance behaviors among physicians affirm the value of this construct in extending our understanding of POE adoption.
doi:10.1197/jamia.M1930
PMCID: PMC1447539  PMID: 16357351
22.  Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations theory 
Background
Computerized provider order entry (CPOE) systems have been introduced to reduce medication errors, increase safety, improve work-flow efficiency, and increase medical service quality at the moment of prescription. Making the impact of CPOE systems more observable may facilitate their adoption by users. We set out to examine factors associated with the adoption of a CPOE system for inter-organizational and intra-organizational care.
Methods
The diffusion of innovation theory was used to understand physicians' and nurses' attitudes and thoughts about implementation and use of the CPOE system. Two online survey questionnaires were distributed to all physicians and nurses using a CPOE system in county-wide healthcare organizations. The number of complete questionnaires analyzed was 134 from 200 nurses (67.0%) and 176 from 741 physicians (23.8%). Data were analyzed using descriptive-analytical statistical methods.
Results
More nurses (56.7%) than physicians (31.3%) stated that the CPOE system introduction had worked well in their clinical setting (P < 0.001). Similarly, more physicians (73.9%) than nurses (50.7%) reported that they found the system not adapted to their specific professional practice (P = < 0.001). Also more physicians (25.0%) than nurses (13.4%) stated that they did want to return to the previous system (P = 0.041). We found that in particular the received relative advantages of the CPOE system were estimated to be significantly (P < 0.001) higher among nurses (39.6%) than physicians (16.5%). However, physicians' agreements with the compatibility of the CPOE and with its complexity were significantly higher than the nurses (P < 0.001).
Conclusions
Qualifications for CPOE adoption as defined by three attributes of diffusion of innovation theory were not satisfied in the study setting. CPOE systems are introduced as a response to the present limitations in paper-based systems. In consequence, user expectations are often high on their relative advantages as well as on a low level of complexity. Building CPOE systems therefore requires designs that can provide rather important additional advantages, e.g. by preventing prescription errors and ultimately improving patient safety and safety of clinical work. The decision-making process leading to the implementation and use of CPOE systems in healthcare therefore has to be improved. As any change in health service settings usually faces resistance, we emphasize that CPOE system designers and healthcare decision-makers should continually collect users' feedback about the systems, while not forgetting that it also is necessary to inform the users about the potential benefits involved.
doi:10.1186/1472-6947-9-52
PMCID: PMC2809050  PMID: 20043843
23.  EHR Acceptance Factors in Ambulatory Care: A Survey of Physician Perceptions 
With the U.S. government calling for electronic health records (EHRs) for all Americans by the year 2014, adoption of an interoperable EHR is imminent in America's future. However, recent estimates for EHR implementation in the ambulatory care environment are just over 10 percent. This second part of a two-part study examines EHR acceptance factors in an academic-based healthcare system. Innovation diffusion theory and the Technology Acceptance Model provide a combined theoretical framework for this case study. An online questionnaire was administered to 802 faculty, fellow, and resident physicians to explore the factors affecting attitudes toward EHR adoption. In this study, age, years in practice, clinical specialty, health system relationship, and prior computer experience were not predictors of EHR acceptance. In order to facilitate successful adoption of health information systems, social and behavioral factors must be addressed during the EHR planning phase.
PMCID: PMC2805555  PMID: 20697466
electronic health records; barriers; user adoption; physicians; attitudes; technology acceptance; health information systems; ambulatory care; diffusion of innovations; perceptions
24.  Implementation of electronic medical records 
Canadian Family Physician  2011;57(10):e390-e397.
Abstract
Objective
To apply the diffusion-of-innovations theory to the examination of factors that are perceived by family physicians as influencing the implementation of electronic medical records (EMRs).
Design
Qualitative study with 2 focus groups 18 months after EMR implementation; participants also took part in a concurrent quantitative study examining EMR implementation and preventive services.
Setting
Toronto, Ont.
Participants
Twelve community-based family physicians.
Methods
We employed a semistructured interview guide. The interviews were audiotaped and transcribed verbatim; 2 researchers independently categorized and coded the transcripts and then met to compare and contrast their findings, category mapping, and interpretations. Findings were then mapped to an existing theoretical framework.
Main findings
Multiple barriers to EMR implementation were described. These included lack of relative advantage for many processes, high complexity of the system, low compatibility with physician needs and past experiences, difficulty with adaptation of the EMR to the organization and adaptation of the organization to the EMR, and lack of organizational slack. Positive factors were the presence of a champion and relative advantages for some processes.
Conclusion
Early EMR implementation experience is consistent with theoretical concepts associated with implementation of innovations. A problematic implementation process helps to explain, at least in part, the lack of improvement in preventive services in our quantitative results.
PMCID: PMC3192105  PMID: 21998247
25.  Physician order entry in U.S. hospitals. 
OBJECTIVE: Determine the percent of U.S. hospitals where computerized physician order entry (POE) is available and the extent of its use. METHODS: A survey was sent to a systematic sample of 1,000 U.S. hospitals asking about availability of POE, whether usage is required, percent of physicians using it, and percent of orders entered by computer. RESULTS: About 66% do not have POE available. Of the 32.1% that have it completely or partially available, 4.9% require its usage, over half report usage by under 10% of physicians, and over half report that fewer than 10% of orders are entered this way. Analysis of comments showed that many hospitals have POE available for use by non-physicians only, but that they hope to offer it to physicians after careful planning. CONCLUSION: Most U.S. hospitals have not yet implemented POE. Complete availability throughout the hospital is rare, very few require its use, low percentages of physicians are actual users, and low percentages of orders are entered this way. On a national basis, computerized order entry by physicians is not yet widespread.
PMCID: PMC2232213  PMID: 9929217

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