Adding insight: A qualitative cross-site study of physician order entry

doi:10.1016/j.ijmedinf.2005.05.005

International Journal of Medical Informatics

Volume 74, Issues 7–8, August 2005, Pages 623-628

https://doi.org/10.1016/j.ijmedinf.2005.05.005 Get rights and content

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.

Introduction

Computerized physician or provider order entry (CPOE) is a process, which allows direct entry of medical orders by the health care decision maker. It has been shown to be effective in improving patient care [1], [2], [3], [4], [5], [6]. A team of researchers at Oregon Health and Science University, the physician order entry team (POET), began conducting studies in 1997. The first, a survey to discover what percent of US hospitals have CPOE, concluded that less than one third had CPOE and those that had it reported low usage [7]. The POET, intrigued by these results, endeavored next to discover why diffusion of CPOE was so low by identifying barriers to implementation and the key ingredients for successful implementation. We started by trying to find out why so few US hospitals were using CPOE. Since house officers are usually required to use CPOE in institutions where it is available, we decided to study teaching hospitals. We also wanted to study sites that were community hospitals, since most US hospitals are in this category. We further hoped to gain insight into outpatient as well as inpatient CPOE.

We used qualitative methods to appropriately address the new research question: What are the success factors for implementing CPOE? The study design for fieldwork included focus groups, oral history interviews, and observations that were accomplished by an interdisciplinary team. Results were blended, or triangulated, with those from an expert panel. To enhance trustworthiness (the qualitative equivalent of external validity) [8], we selected multiple sites for study. The data gathering and analysis process was iterative. Results from each phase added to and enriched those from prior phases, thus offering new insight. The following offers a summary of the research foci, strategies, and results of 7 years of study. Because details concerning methods and results have been described elsewhere, this paper simply provides a brief overview with references to prior more in-depth publications.

Section snippets

Sample selection

Criteria for site selection for the multi-center qualitative study included geography, type of hospital, and length of experience with CPOE; a panel of experts assisted with selection. The University of Virginia was selected first because its early negative experience during implementation has been well documented [9], it is on the East coast, and is a teaching hospital. The Veterans Affairs Puget Sound Health Care System campuses in Seattle and American Lake, WA were chosen because the

Results

After we had visited both the University of Virginia and the VA Puget Sound site in Seattle, we completed the first iteration of analysis dealing with house staff perceptions of CPOE. In summary, house officers were proud of being facile with CPOE and appreciated the decision support it offered, but were resentful of the additional time it took. Entering orders from any location, ready access to results, and having everyone reading off the same page were considered benefits. There were,

Discussion

Qualitative research is iterative in nature and often offers surprises. For example, as informaticians, we understand the benefits of entering structured data, yet in the field we saw how cumbersome and time consuming this is for users. We are well aware of the evidence indicating that CPOE can reduce medical errors, yet we also saw and heard about many new kinds of errors caused by the information system. We know that good training and support are necessary, but we learned a great deal about

Conclusion

While it is difficult to summarize the lessons from 7 years of work with multiple researchers across four organizations, which resulted in over 2000 pages of data, we were able to draw some solid conclusions about both our methods and CPOE implementation success factors. The selected methods allowed us to accomplish what we set out to do, and, although qualitative research is labor-intensive, we became more efficient using these techniques over time. Regarding success factors, CPOE

Acknowledgements

This work was supported by Mr. Paul Mongerson and grant DE-FG03-94ER61918 from the US Department of Energy and grant LM06942-01 from the US National Library of Medicine. Special thanks go to Tom Massaro and Gerri Frantz at the University of Virginia, Tom Payne and Paul Nichol at the VA Puget Sound Health Care System and the University of Washington, Bart Lally and Lynda Winterberg at El Camino Hospital, and Homer Chin at Kaiser Permanente Northwest for their assistance with the study.

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View full text

Adding insight: A qualitative cross-site study of physician order entry

Summary

Introduction

Section snippets

Sample selection

Results

Discussion

Conclusion

Acknowledgements

Int. J. Med. Informatics

J. Am. Med. Informatics Assoc.

Int. J. Med. Informatics

J. Am. Med. Informatics Assoc.

J. Am. Med. Informatics Assoc.

To Err is Human: Building a Safer Health System

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients

Arch. Intern. Med.

A randomized trial of “corollary orders” to prevent errors of omission

J. Am. Med. Informatics Assoc.

Computer-based physician order entry: The state of the art

J. Am. Med. Informatics Assoc.

Relationship between medication errors and adverse drug events

J. Gen. Intern. Med.

Effects of computerized physician order entry on prescribing practices

Arch. Intern. Med.

Physician order entry in U.S. hospitals

J. Am. Med. Informatics Assoc. Symp. Suppl.

Qualitative Data Analysis: An Expanded Sourcebook

Introducing physician order entry at a major academic medical center

Acad. Med.

The transition to direct practitioner order entry in a teaching hospital: the VA Puget Sound experience

J. Am. Med. Informatics Assoc. Symp. Suppl.