Related Articles

OBJECTIVE: To interpret the results of a cross-site study of physician order entry (POE) in hospitals using a diffusion of innovations theory framework. METHODS: Qualitative study using observation, focus groups, and interviews. Data were analyzed by an interdisciplinary team of researchers using a grounded approach to identify themes. Themes were then interpreted using classical Diffusion of Innovations (DOI) theory as described by Rogers [1]. RESULTS: Four high level themes were identified: organizational issues; clinical and professional issues; technology implementation issues; and issues related to the organization of information and knowledge. Further analysis using the DOI framework indicated that POE is an especially complex information technology innovation when one considers communication, time, and social system issues in addition to attributes of the innovation itself. CONCLUSION: Implementation strategies for POE should be designed to account for its complex nature. The ideal would be a system that is both customizable and integrated with other parts of the information system, is implemented with maximum involvement of users and high levels of support, and is surrounded by an atmosphere of trust and collaboration.

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.

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.

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.

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.

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.

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.

Background

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.

Objective

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.

Methods

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.

Results

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).

Conclusions

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.

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.

Objective: To describe strategies that organizations select to support physicians' use of handheld computers (HHCs) in clinical practice and to explore issues about facilitating HHC use.

Design: A multidisciplinary team used focus groups and interviews with clinical, administrative, and information technology (IT) staff to gather data from 161 informants at seven sites. Transcripts were coded using a combination of deductive and inductive approaches to both answer research questions and identify patterns and themes that emerged in the data.

Measurements: Answers to questions about strategies for HHC support and themes about (1) how to facilitate physician adoption and use and (2) organizational concerns.

Results: Three main organizational strategies for HHC support were characterized among sites: (1) active support for broad-based use, (2) active support for niche use, and (3) basic support for individual physician users. Three high-level themes emerged around how to best facilitate physician adoption and use of HHCs: (1) improving usability and usefulness, (2) promoting HHCs and device use, and (3) providing training and support. However, four major themes also emerged related to organizations' concerns about HHC use: (1) security-related concerns, (2) economic concerns, (3) technical concerns, and (4) strategic concerns.

Conclusion: An organizational approach to HHC support that involves individualized attention to existing and potential physician users rather than one-size-fits-all, organization-wide implementation efforts was an important facilitator promoting physician use of HHCs. Health care organizations interested in supporting HHC use must consider issues related to security, economics, and IT strategy that may not be prominent concerns for physician users.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Computerized provider order entry(CPOE) and other clinical information systems can help reduce medical errors, promote practice standardization, and improve the quality of patient care. However, implementing these systems can result in unintended adverse consequences. Our multidisciplinary team used qualitative methods to gather and analyze data describing unintended adverse consequences related to CPOE adoption and use. Overdependence on technology emerged as one of nine major types we identified. Careful analysis of these data revealed three themes: 1) system downtime can create chaos when there are insufficient backup systems in place, 2) users have false expectations regarding data accuracy and processing, and 3) some clinicians cannot work efficiently without computerized systems. We provide recommendations for mitigating these important issues.

Summary

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.

OBJECTIVE

To explore terminally ill patients’ perceptions of their own suffering in order to describe, from these patients’ perspective, some elements of health care providers’ response to suffering.

DESIGN

Qualitative study using content analysis methods suited to a grounded theory approach.

SETTING

Teaching and nonteaching hospital oncology clinics, palliative care services (both ambulatory and in-unit), and family practices.

PARTICIPANTS

Twenty-six patients diagnosed with terminal cancer.

METHODS

Interviews were audiotaped and transcribed verbatim. Data from each interview were coded and categorized to identify and define themes. Themes were discussed and refined until those rating them agreed on them. Data were collected until saturation of emerging issues was reached.

MAIN FINDINGS

In our health care system, patients are caught in a pervasive pattern of suffering avoidance, which in turn contributes to increased suffering. Health care services are perceived as a battlefield where physicians and patients are engaged in a losing struggle to ward off illness and death. Both physicians and patients engage in avoiding skepticism and muffling distress. The unavoidable avowal of powerlessness in the face of terminal disease is perceived as capitulation and therapeutic abandonment. Budgetary restraints and understaffing, along with a pervasive culture that implicitly denies death, produce an environment conducive to the avoidance of suffering. To counter this, health care practices that foster increased overlap and continuity between the spheres of oncology, palliative care, and family medicine seem worth developing.

CONCLUSION

The suffering of gravely ill patients might be hard to alleviate in the context of modern health care organizations. In some cases, health care delivery directly contributes to increased suffering. Providing support while also helping patients and their families to face upcoming harsh realities is a delicate balancing act that needs to be further explored.

ABSTRACT

OBJECTIVE

To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Clinical decision support systems (CDS) coupled with computerized physician/provider order entry (CPOE) can improve the quality of patient care and the efficiency of hospital operations. However, they can also produce unintended consequences. Using qualitative methods, a multidisciplinary team gathered and analyzed data about the unintended consequences of CPOE, identifying nine types, and found that CDS-generated unintended consequences appeared among all types. Further analysis of 47 CDS examples uncovered three themes related to CDS content: elimination or shifting of human roles; difficulty in keeping content current; and inappropriate content. Three additional themes related to CDS presentation were found: rigidity of the system; alert fatigue; and potential for errors. Management of CDS must include careful selection and maintenance of content and prudent decision making about human computer interaction opportunities.

Introduction

In 2006, the Massachusetts League of Community Health Centers convened a collaborative to systematically improve health care delivery for patients with diabetes in 17 community health centers. Our goal was to identify facilitators of and barriers to success reported by teams that participated in this collaborative.

Methods

The collaborative's activities lasted 13 months. At their conclusion, we interviewed participating team members. We asked about their teams' successes, challenges, and take-home messages for future collaborative efforts. We organized their responses into common themes by using the Chronic Care Model as a framework.

Results

Themes that emerged as facilitators of success included shifting clinic focus to more actively involve patients and to promote their self-management; improving the understanding and implementation of professional guidelines; and expanding staff roles to accommodate these goals. Patient registries were perceived as beneficial but lacking adequate technical support. Other barriers were staffing and time constraints.

Conclusions

Cooperative efforts to improve health care delivery for people with diabetes may benefit from educating the health care team about guidelines, establishing a stronger role for the patient as part of the health care team, and providing adequate technical instruction and support for the use of clinical databases.