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1.  Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment 
The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting.
Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions.
Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption.
Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.
PMCID: PMC2996338  PMID: 21087524
2.  Toward successful migration to computerized physician order entry for chemotherapy 
Current Oncology  2014;21(2):e221-e228.
Computerized physician order entry (cpoe) systems allow for medical order management in a clinical setting. Use of a cpoe has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Usability of these systems has been identified as a critical factor in their successful adoption. However, there is a paucity of literature investigating the usability of cpoe for chemotherapy and describing the experiences of cancer care providers in implementing and using a cpoe system.
A mixed-methods study, including a national survey and a workshop, was conducted to determine the current status of cpoe adoption in Canadian oncology institutions, to identify and prioritize knowledge gaps in cpoe usability and adoption, and to establish a research agenda to bridge those gaps. Survey respondents were representatives of cancer care providers from each Canadian province. The workshop participants were oncology clinicians, human factors engineers, patient safety researchers, policymakers, and hospital administrators from across Canada, with participation from the United States.
A variety of issues related to implementing and using a cpoe for chemotherapy were identified. The major issues concerned the need for better understanding of current practices of chemotherapy ordering, preparation, and administration; a lack of system selection and procurement guidance; a lack of implementation and maintenance guidance; poor cpoe usability and workflow support; and other cpoe system design issues. An additional three research themes for addressing the existing challenges and advancing successful adoption of cpoe for chemotherapy were identified: The need to investigate variances in workflows and practices in chemotherapy ordering and administrationThe need to develop best-practice cpoe procurement and implementation guidance specifically for chemotherapyThe need to measure the effects of cpoe implementation in medical oncology
Addressing the existing challenges in cpoe usability and adoption for chemotherapy, and accelerating successful migration to cpoe by cancer care providers requires future research focusing on workflow variations, chemotherapy-specific cpoe procurement needs, and implementation guidance needs.
PMCID: PMC3997455  PMID: 24764707
Chemotherapy; cpoe; computerized physician order entry; usability
3.  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
4.  Adding insight: A qualitative cross-site study of physician order entry 
The research questions, strategies, and results of a 7-year qualitative study of computerized physician order entry implementation (CPOE) at successful sites are reviewed over time. The iterative nature of qualitative inquiry stimulates a consecutive stream of research foci, which, with each iteration, add further insight into the overarching research question. A multidisciplinary team of researchers studied CPOE implementation in four organizations using a multi-method approach to address the question “what are the success factors for implementing CPOE?” Four major themes emerged after studying three sites; ten themes resulted from blending the first results with those from a fourth site; and twelve principles were generated when results of a qualitative analysis of consensus conference transcripts were combined with the field data. The study has produced detailed descriptions of factors related to CPOE success and insight into the implementation process.
PMCID: PMC1524826  PMID: 15964780
Attitude to computers; Hospital information systems; User-computer interface; Physician order entry
5.  Computerized Prescriber Order Entry Implementation in a Physician Assistant–Managed Hematology and Oncology Inpatient Service: Effects on Workflow and Task Switching 
Journal of Oncology Practice  2012;9(4):e103-e114.
The authors found that CPOE implementation did not negatively affect time available for direct patient care and that workflow fragmentation decreased, which is likely beneficial.
Little is known about the impact of computerized prescriber order entry (CPOE) systems on inpatient hematology/oncology services. The objective of this study was to quantify the impact of an inpatient CPOE implementation on workflow, with an emphasis on ordering and direct patient care time.
We conducted a direct-observation time-and-motion study of the provider team of a hematology/oncology inpatient service both before and after CPOE implementation, characterizing workflow into 60 distinct activity categories. The provider team comprised physician assistants supervised by attending physicians. Results were adjusted to account for variations in the census. We also conducted an analysis of computer logs to assess CPOE system usage.
Study participants were observed for 228.0 hours over 53 observation sessions. There was little change in the proportion of census-adjusted time spent on ordering (10.2% before v 11.4% after) and on direct patient care (50.7% before v 47.8% after). Workflow fragmentation decreased, with providers spending an average of 131.2 seconds on a continuous task before implementation and 218.3 seconds after (P < .01). An eight-fold decrease in the number of pages was observed during the course of the study.
CPOE implementation did not negatively affect time available for direct patient care. Workflow fragmentation decreased, which is likely beneficial.
PMCID: PMC3710176  PMID: 23942926
6.  Contextual Implementation Model: A Framework for Assisting Clinical Information System Implementations 
This paper presents a multiple perspectives model of clinical information system implementation, the Contextual Implementation Model (CIM). Although other implementation models have been developed, few are grounded in data and others fail to take adequate account of the clinical environment and users’ requirements.
The CIM arose from qualitative data collected from four clinical units in two large Australian teaching hospitals. The aim of the study was to explore physicians’ test management work practices associated with the compulsory use of a hospital-wide, mandatory computerized provider order entry (CPOE) system.1 The dataset consisted of non-participatory observations of physicians using CPOE (n=55 sessions) and interviews with health professionals (n=28) about test management work practices. Data were analyzed by two researchers independently using an iterative grounded approach.
A core underlying theme of ‘contextual differences’ emerged which explained physicians’ use of the CPOE system in the sites. The CIM focuses attention on diversity at three contextual levels: the organizational level; the clinical or departmental level, and the individual level. Within each of these levels there are dimensions for consideration (for example, organizational culture, leadership and diverse ways of working) which affect physicians’ attitudes to, and use of, CPOE.
The CIM provides a contextual differences perspective which can be used to facilitate the implementation of clinical information systems. Developing a clinical information system implementation model serves as a framework to guide future implementations to ensure their safe and efficient use and also improve the likelihood of uptake by physicians.
PMCID: PMC2274802  PMID: 18096917
7.  The Effect of Physicians’ Long-term Use of CPOE on Their Test Management Work Practices 
To explore physicians’ work practices in relation to their long-term use of a computerized physician order entry system (CPOE).
A cross-sectional qualitative study was conducted in four clinical units in two large Australian teaching hospitals. One hospital had used CPOE for over 10 years to order all clinical laboratory and radiology tests and view test results and the other had used the computerized viewing facility of the system for over seven years with tests ordered manually. Data were collected by non-participatory observations of physicians (55 sessions) and 28 interviews.
Content analysis of the observation field notes, reflections on observations and interview transcripts were conducted by two researchers independently. A thematic grounded theory approach was used to derive key themes that would explain physicians work practices associated with CPOE use.
Three themes relating to physicians’ established use of CPOE were identified: (1) the effect of the hospital and clinical environment; (2) changes to work practices; and (3) physicians’ management of information. Physicians’ test management work practices using CPOE were related to diversity between: the hospitals; the clinical units’ environment, and the users of the system.
Hospitals need to understand and analyze physicians’ test management work practices prior to and during the implementation of CPOE to accommodate their diverse ways of working with computerized information systems. In the current mixed media environment, physicians’ use of manual and computerized information systems for sourcing and recording information impacts on efficiency and patient safety.
PMCID: PMC1656955  PMID: 16929035
8.  Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations theory 
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.
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.
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).
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.
PMCID: PMC2809050  PMID: 20043843
To identify and describe physicians' beliefs about use of electronic medical records (EMR) and computerized provider order entry (CPOE) for inpatient and outpatient care, to build an understanding of what factors shape information technology (IT) use behavior in the unique context of health care delivery.
Semi-structured qualitative research interviews were carried out, following the beliefs elicitation approach. Twenty physicians from two large Midwest US hospitals participated. Physicians were asked questions to elicit beliefs and experiences pertaining to their use of EMR and CPOE. Questions were based on a broad set of behavior-shaping beliefs and the methods commonly used to elicit those beliefs.
Qualitative analysis revealed numerous themes related to the perceived emotional and instrumental outcomes of EMR and CPOE use; perceived external and personal normative pressure to use those systems; perceived volitional control over use behavior; perceived facilitators and barriers to system use; and perceptions about the systems and how they were implemented. EMR and CPOE were commonly believed to both improve and worsen the ease and quality of personal performance, productivity and efficiency, and patient outcomes. Physicians felt encouraged by employers and others to use the systems but also had personal role-related and moral concerns about doing so. Perceived facilitators and barriers were numerous and had their sources in all aspects of the work system.
Given the breadth and detail of elicited beliefs, numerous design and policy implications can be identified. Additionally, the findings are a first step toward developing a theory of health IT acceptance and use contextualized to the unique setting of health care.
PMCID: PMC2821328  PMID: 20071219
electronic medical records; computerized provider order entry; beliefs elicitation; theory of planned behavior
10.  Evaluation and Certification of Computerized Provider Order Entry Systems 
Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance.
PMCID: PMC2215075  PMID: 17077453
11.  Computerized provider order entry systems – Research imperatives and organizational challenges facing pathology services 
Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.
PMCID: PMC2929545  PMID: 20805962
Computerized provider order entry; evaluation studies; hospital information systems; laboratories; pathology
12.  Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study 
Computerized Provider Order Entry (CPOE) can improve patient safety, quality and efficiency, but hospitals face a host of barriers to adopting CPOE, ranging from resistance among physicians to the cost of the systems. In response to the incentives for meaningful use of health information technology and other market forces, hospitals in the United States are increasingly moving toward the adoption of CPOE. The purpose of this study was to characterize the experiences of hospitals that have successfully implemented CPOE.
We used a qualitative approach to observe clinical activities and capture the experiences of physicians, nurses, pharmacists and administrators at five community hospitals in Massachusetts (USA) that adopted CPOE in the past few years. We conducted formal, structured observations of care processes in diverse inpatient settings within each of the hospitals and completed in-depth, semi-structured interviews with clinicians and staff by telephone. After transcribing the audiorecorded interviews, we analyzed the content of the transcripts iteratively, guided by principles of the Immersion and Crystallization analytic approach. Our objective was to identify attitudes, behaviors and experiences that would constitute useful lessons for other hospitals embarking on CPOE implementation.
Analysis of observations and interviews resulted in findings about the CPOE implementation process in five domains: governance, preparation, support, perceptions and consequences. Successful institutions implemented clear organizational decision-making mechanisms that involved clinicians (governance). They anticipated the need for education and training of a wide range of users (preparation). These hospitals deployed ample human resources for live, in-person training and support during implementation. Successful implementation hinged on the ability of clinical leaders to address and manage perceptions and the fear of change. Implementation proceeded smoothly when institutions identified and anticipated the consequences of the change.
The lessons learned in the five domains identified in this study may be useful for other community hospitals embarking on CPOE adoption.
PMCID: PMC3695777  PMID: 23800211
Quality of care; Clinical decision support; Meaningful use; Transformation
13.  Implementation of computerized physician order entry in National Guard hospitals: Assessment of critical success factors 
The purpose of this study is to describe the needs, process and experience of implementing a computerized physician order entry (CPOE) system in a leading healthcare organization in Saudi Arabia.
Materials and Methods:
The National Guard Health Affairs (NGHA) deployed the CPOE in a pilot department, which was the intensive care unit (ICU) in order to assess its benefits and risks and to test the system. After the CPOE was implemented in the ICU area, a survey was sent to the ICU clinicians to assess their perception on the importance of 32 critical success factors (CSFs) that was acquired from the literature. The project team also had several meetings to gather lessons learned from the pilot project in order to utilize them for the expansion of the project to other NGHA clinics and hospitals.
The results of the survey indicated that the selected CSFs, even though they were developed with regard to international settings, are very much applicable for the pilot area. The top three CSFs rated by the survey respondents were: The “before go-live training”, the adequate clinical resources during implementation, and the ordering time. After the assessment of the survey and the lessons learned from the pilot project, NGHA decided that the potential benefits of the CPOE are expected to be greater the risks expected. The project was then expanded to cover all NGHA clinics and hospitals in a phased approach. Currently, the project is in its final stages and expected to be completed by the end of 2011.
The role of CPOE systems is very important in hospitals in order to reduce medication errors and to improve the quality of care. In spite of their great benefits, many studies suggest that a high percentage of these projects fail. In order to increase the chances of success and due to the fact that CPOE is a clinical system, NGHA implemented the system first in a pilot area in order to test the system without putting patients at risk and to learn from mistakes before expanding the system to other areas. As a result of the pilot project, NGHA developed a list of CSFs to increase the likelihood of project success for the expansion of the system to other clinics and hospitals. The authors recommend a future study for the CPOE implementation to be done that covers the implementation in all the four NGHA hospitals. The results of the study can then be generalized to other hospitals in Saudi Arabia.
PMCID: PMC3237203  PMID: 22175042
Computerized physician order entry; critical success factor; health information systems; Saudi hospitals
14.  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.
PMCID: PMC150372  PMID: 12595408
15.  Physician Order Entry Or Nurse Order Entry? Comparison of Two Implementation Strategies for a Computerized Order Entry System Aimed at Reducing Dosing Medication Errors 
Despite the significant effect of computerized physician order entry (CPOE) in reducing nonintercepted medication errors among neonatal inpatients, only a minority of hospitals have successfully implemented such systems. Physicians' resistance and users' frustration seem to be two of the most important barriers. One solution might be to involve nurses in the order entry process to reduce physicians’ data entry workload and resistance. However, the effect of this collaborative order entry method in reducing medication errors should be compared with a strictly physician order entry method.
To investigate whether a collaborative order entry method consisting of nurse order entry (NOE) followed by physician verification and countersignature is as effective as a strictly physician order entry (POE) method in reducing nonintercepted dose and frequency medication errors in the neonatal ward of an Iranian teaching hospital.
A four-month prospective study was designed with two equal periods. During the first period POE was used and during the second period NOE was used. In both methods, a warning appeared when the dose or frequency of the prescribed medication was incorrect that suggested the appropriate dosage to the physicians. Physicians’ responses to the warnings were recorded in a database and subsequently analyzed. Relevant paper-based and electronic medical records were reviewed to increase credibility.
Medication prescribing for 158 neonates was studied. The rate of nonintercepted medication errors during the NOE period was 40% lower than during the POE period (rate ratio 0.60; 95% confidence interval [CI] .50, .71;P < .001). During the POE period, 80% of nonintercepted errors occurred at the prescription stage, while during the NOE period, 60% of nonintercepted errors occurred in that stage. Prescription errors decreased from 10.3% during the POE period to 4.6% during the NOE period (P < .001), and the number of warnings with which physicians complied increased from 44% to 68% respectively (P < .001). Meanwhile, transcription errors showed a nonsignificant increase from the POE period to the NOE period. The median error per patient was reduced from 2 during the POE period to 0 during the NOE period (P = .005). Underdose and curtailed and prolonged interval errors were significantly reduced from the POE period to the NOE period. The rate of nonintercepted overdose errors remained constant between the two periods. However, the severity of overdose errors was lower in the NOE period (P = .02).
NOE can increase physicians' compliance with warnings and recommended dose and frequency and reduce nonintercepted medication dosing errors in the neonatal ward as effectively as POE or even better. In settings where there is major physician resistance to implementation of CPOE, and nurses are willing to participate in the order entry and are capable of doing so, NOE may be considered a beneficial alternative order entry method.
PMCID: PMC2855204  PMID: 20185400
Medical order entry systems; decision support systems, clinical; medication erors; Iran; infant, newborn; patient safety
16.  Computerized Provider Order Entry Adoption: Implications for Clinical Workflow 
To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.
We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.
CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.
As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.
PMCID: PMC2607519  PMID: 19020942
attitude to computers; hospital information systems; user–computer interface; physician order entry
17.  Caregiver involvement in a large clinical systems project. 
The Kaiser Permanente Northern California Region (KPNCR) CareGiver Workstation (CGW) Project's mission is to develop and implement a clinical workstation system that will enhance each caregiver-member interaction and aid in the decision-making processes of direct patient care in the inpatient and outpatient settings. The requirements analysis approach for CareGiver Workstation (CGW) is based on the belief that extensive caregiver involvement will provide a better understanding of the diverse needs of Kaiser Permanente Northern California Region (KPNCR). In order to involve as many caregivers as reasonably possible, CGW included a 16 member caregiver core team and 6 different Medical Centers in the requirements definition process. The Medical Centers are referred to as "focus facilities". A "focus group" (caregiver team) at each selected focus facility consisted of a site coordinator and a 24-30 person multidisciplinary team involving physicians, nurses, therapists and other caregivers. The Medical Center selection process identified facilities that provided the best cross-sectional representation of KPNCR. The Lead Focus Facility participated in the initial round of requirements definition activities. These sessions assisted in the design of a simulation that was used at five additional Medical Centers to validate requirements. The five additional Focus Facilities participated in simulation review sessions. Feedback from these sessions was used to revise the simulation and update the requirements document. Caregivers from all six focus facilities and other identified groups participated in a requirements survey to assist CGW with identification of high priority features. Caregiver commitment and continuing involvement are essential for the success of CGW.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC2247837  PMID: 7949953
18.  Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward 
Pediatric inpatient settings are known for their high medication error rate. The aim of this study was to investigate whether the Health Care Failure Mode and Effect Analysis (HFMEA) is a valid proactive method to evaluate circumscribed health care processes like prescription up to and including administration of chemotherapy (vincristine) in the pediatric oncology inpatient setting.
A multidisciplinary team consisting of a team leader, pharmacy, nursing and medical staff and a patient's parent was assembled in a pediatric oncology ward with a computerized physician order entry system. A flow diagram of the process was made and potential failure modes were identified and evaluated using a hazard scoring matrix. Using a decision tree, it was determined for which failure mode recommendations had to be made.
The process was divided into three main parts: prescription, processing by the pharmacy, and administration. Fourteen out of 61 failure modes were classified as high risk, 10 of which were sufficiently covered by current protocols. For the other four failure modes, five recommendations were made. Four additional recommendations were made concerning non‐high risk failure modes. Most of them were implemented by the hospital management. The whole process took seven meetings and a total of 140 man‐hours.
The systematic approach of HFMEA by a multidisciplinary team is a useful method for detecting failure modes. A patient or a parent of a patient contributes to the multidisciplinarity of the team.
PMCID: PMC2564000  PMID: 16456212
failure mode and effect analysis; medication error; patient safety; children
19.  Computer order entry systems in the emergency department significantly reduce the time to medication delivery for high acuity patients 
Computerized physician order entry (CPOE) systems are designed to increase safety and improve quality of care; however, their impact on efficiency in the ED has not yet been validated. This study examined the impact of CPOE on process times for medication delivery, laboratory utilization and diagnostic imaging in the early, late and control phases of a regional ED-CPOE implementation.
Setting: Three tertiary care hospitals serving a population in excess of 1 million inhabitants that initiated the same CPOE system during the same 3-week time window. Patients were stratified into three groupings: Control, Early CPOE and Late CPOE (n = 200 patients per group/hospital site). Eligible patients consisted of a stratified (40% CTAS 2 and 60% CTAS 3) random sample of all patients seen 30 days preceding CPOE implementation (Control), 30 days immediately after CPOE implementation (Early CPOE) and 5–6 months after CPOE implementation (Late CPOE). Primary outcomes were time to (TT) from physician assignment (MD-sign) up to MD-order completion. An ANOVA and t-test were employed for statistical analysis.
In comparison with control, TT 1st MD-Ordered Medication decreased in both the Early and Late CPOE groups (102.6 min control, 62.8 Early and 65.7 late, p < 0.001). TT 1st MD-ordered laboratory results increased in both the Early and Late CPOE groups compared to Control (76.4, 85.3 and 73.8 min, respectively, p < 0.001). TT 1st X-Ray also significantly increased in both the Early and Late CPOE groups (80.4, 84.8 min, respectively, compared to 68.1, p < 0.001). Given that CT and ultrasound imaging inherently takes increased time, these imaging studies were not included, and only X-ray was examined. There was no statistical difference found between TT discharge and consult request.
Regional implementation of CPOE afforded important efficiencies in time to medication delivery for high acuity ED patients. Increased times observed for laboratory and radiology results may reflect system issues outside of the emergency department and as a result of potential confounding may not be a reflection of CPOE impact.
PMCID: PMC3707763  PMID: 23830095
20.  Computerized Provider Order Entry in Pediatric Oncology: Design, Implementation, and Outcomes 
Journal of Oncology Practice  2011;7(4):218-222.
Implementation of computerized provider order entry required extensive customization but improved patient safety in a highly complex pediatric oncology environment.
Pediatric oncology is a challenging environment for computerized provider order entry (CPOE). Our goal was to build on the proven safety features of CPOE and facilitate input of expert clinicians.
A standard, commercially available CPOE system was implemented throughout the hospital. The design of the pediatric oncology implementation was a collaborative effort by a multidisciplinary team of clinicians and information technology experts.
During 9 months of configuration effort, 30 medical logic modules and 110 order sets were developed to support pediatric oncology. The proportion of chemotherapy orders submitted using specific research protocol or standard-of-care order sets increased from 57% to 84% as the number of active order sets grew to 200. The number of medication-related patient safety events decreased 39% after implementation of CPOE in pediatric oncology. Acceptance of the system is high in all clinical disciplines.
Implementation of CPOE required extensive customization but improved patient safety in this highly complex pediatric oncology environment.
PMCID: PMC3140441  PMID: 22043183
21.  Ranked Levels of Influence Model: Selecting Influence Techniques to Minimize IT Resistance 
Journal of biomedical informatics  2010;44(3):497-504.
Implementation of electronic health records (EHR), particularly computerized physician/provider order entry systems (CPOE), is often met with resistance. Influence presented at the right time, in the right manner, may minimize resistance or at least limit the risk of complete system failure. Combining established theories on power, influence tactics, and resistance, we developed the Ranked Levels of Influence model. Applying it to documented examples of EHR/CPOE failures at Cedars-Sinai and Kaiser Permanente in Hawaii, we evaluated the influence applied, the resistance encountered, and the resulting risk to the system implementation. Using the Ranked Levels of Influence model as a guideline, we demonstrate that these system failures were associated with the use of hard influence tactics that resulted in higher levels of resistance. We suggest that when influence tactics remain at the soft tactics level, the level of resistance stabilizes or de-escalates and the system can be saved.
PMCID: PMC2892561  PMID: 20176135
power; resistance; influence; electronic health records; clinical informatics; socio-technical; human factors; hospital information systems; medical order entry systems
22.  Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study 
The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S.
Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices.
The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction.
These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.
PMCID: PMC3334687  PMID: 22333210
23.  Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting 
Journal of Oncology Practice  2011;7(4):233-237.
EHR/CPOE systems improve completeness of medical record and chemotherapy order documentation, as well as user satisfaction with the medical record system.
Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites.
This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems.
The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system.
Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety.
PMCID: PMC3140445  PMID: 22043187
24.  Embedding guidelines into direct physician order entry: simple methods, powerful results. 
Kaiser Permanente in the Northwest Region has implemented a comprehensive outpatient computer-based patient record (CPR). Using this system, clinicians electronically order laboratory tests, radiology tests, and prescriptions. Clinicians also use this comprehensive CPR to document encounters, code diagnoses and procedures, maintain problem lists, and to send patient-specific messages and referrals to other medical providers. Healthcare for our entire membership of 440,000 covered lives is now provided through this system [1]. Implementation of a comprehensive CPR with direct physician order-entry provides the opportunity to embed guidelines into the ordering process. This article describes the underlying theme and various simple but effective methods we use to embed guidelines into the ordering process. Our experience demonstrates the powerful effect of these simple methods to reduce unnecessary variation and to reduce cost while maintaining or improving the quality of care delivery.
PMCID: PMC2232642  PMID: 10566353
25.  Web-based Physician Order Entry: An Open Source Solution with Broad Physician Involvement. 
Computerized physician order entry (CPOE) is a disruptive technology but holds great promise for reducing medical errors, improving workflow and in the long run, producing cost-savings. However, many studies have reported significant physician resistance to implementing CPOE. In this manuscript we present a two-prong strategy for quick implementation of CPOE: 1) a web-based deployment tool using an open source, secure environment that allows rapid development and deployment of content, and 2) the development of a large set of disease specific order sets and knowledge bases based on established vocabulary standards such as LOINC and SNOMED CT by teams of multidisciplinary content experts at the departmental level. The order sets can be viewed, edited and signed through a standard browser interface. This paper presents the conceptual framework and implementation requirements for such an endeavor.
PMCID: PMC1480193  PMID: 14728268

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