Sociotechnical model dimension | Lessons learnt from implementation of CPOE | Follow-up of alerts related to abnormal diagnostic imaging results |
Hardware and software | The majority of computer terminals were linked to the hospital computer system via wireless signal, and communication bandwidth was often exceeded during peak operational periods, which created additional delays between each click on the computer mouse | Alerts should be retracted when the patient dies, the radiologist calls or the patient is admitted before the alert is acknowledged. However, this can be done only through a centralised organisational policy. |
Clinical content | No intensive-care-unit-specific order sets were available at the time of CPOE implementation. The hurried implementation timeline established by the leaders in the organisation prohibited their development. | Interventions to reduce alert overload and improve the signal to noise ratio should be explored. Unnecessary alerts should be minimised. However, people (physicians) may not agree as to which alerts are essential and which ones are not.55 |
Human–computer interface | The process of entering orders often required an average of 10 clicks on the computer mouse per order, which translated to 1–2 min to enter a single order. Organisational leaders eventually hired additional clinicians to ‘work the CPOE system’ while others cared for the patients. | Unacknowledged alerts must stay active on the EMR screen for longer periods, perhaps even indefinitely, and should require the provider's signature and statement of action before they are allowed to drop off the screen. However, providers might not want to spend additional time stating their actions; who will make this decision? |
People | Leaders at all levels of the institution made implementation decisions (re: hardware placement, software configuration, content development, user interface design, etc) that placed patient care in jeopardy | Many clinicians did not know how to use many of the EMR's advanced features that greatly facilitated the processing of alerts so training should be revamped. However, providers are only given 4 h of training time by the institution |
Workflow and communication | Rapid implementation timeline did not allow time for clinicians to adapt to their new routines and responsibilities. In addition, poor hardware and software design and configuration decisions complicated the workflow issues. | Communicating alerts to two recipients, which occurred when tests were ordered by a healthcare practitioner other than the patient's regular PCP, significantly increased the odds that the alert would not be read and would not receive timely follow-up action. No policy was available that stated who was responsible for follow-up. |
Organisational policies and procedures | Order entry was not allowed until after the patient had physically arrived at the hospital and been fully registered into the clinical information system | Every institution must develop and publicise a policy regarding who is responsible (PCP vs the ordering provider, who may be a consultant) for taking action on abnormal results. Also meets External Joint commission requirements. |
External rules, regulations, and pressures | Following the IOM's report ‘To Err is Human: Building a Safer Health System’ and subsequent congressional hearings, the issue of patient safety has risen to a position of highest priority among healthcare organisations | Poor reimbursement and heavy workload of patients put productivity pressure on providers. The nature of high-risk transitions between healthcare practitioners, settings and systems of care makes timely and effective electronic communication particularly challenging. |
System measurement and monitoring | Monitoring identified a significant increase in patient mortality following CPOE implementation | An audit and performance feedback system should be established to give providers information on timely follow-up of patients' test results on a regular basis. However, providers may not want feedback, or the institution might not have the persons required to do so. |
CPOE, computer-based provider order entry; EMR, Electronic Medical Record; IOM, Institute of Medicine; PCP, Primary Care Physician.