Extending the understanding of computerized physician order entry: Implications for professional collaboration, workflow and quality of care

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Abstract

Objective: To describe the perceived effect of computerized physician order entry (CPOE) on professional collaboration, workflow and quality of care. Design: Semi-structured interviews with experts involved in the design, implementation and evaluation of computerized physician order systems in the United States. Measurements: The interview transcripts were analyzed using six key concepts that identify context, professional collaboration, workflow and quality of care. Results: The interviews reveal the complexity of CPOE. Although providers enter the orders, others collaborate in the decision-making process. There is a profound impact on workflow beyond that of the provider. While quality of care is the main impetus for implementation, it remains terribly difficult to measure the impact on quality. Conclusions: A proper understanding of CPOE as a collaborative effort and the transformation of the health care activities into integrated care programs requires an understanding of how orders are created and processed, how CPOE as part of an integrated system can support the workflow, and how risks affecting patient care can be identified and reduced, especially during hand-offs in the workflow.

Introduction

Computerized physician order entry (CPOE) is defined as a process that allows a physician to enter medical orders directly and to manage the results of these orders. The concept is receiving an increasing level of attention because the Institute of Medicine notes that CPOE holds potential for decreasing the number of medical errors in health care organizations and recommends full-fledged implementation [1]. The Leapfrog Group – a coalition of over 150 public and private organizations providing health care benefits – has echoed this plea by recommending that hospitals introduce computer systems to computerize drug prescribing and that they be rewarded for it [2]. The California State Health and Safety Code, Section 1339.63, requires the introduction of technology, such as CPOE, that has been shown effective in eliminating or substantially reducing medication-related errors, in all California hospitals by 1 January 2005.

In reality, the implementation of CPOE has been problematic. In a recent survey, Ash et al. found that less than 10% of the US hospitals have implemented CPOE, a figure even lower than the results of an earlier survey by the same authors [3], [4]. Several case studies describe how physicians have opposed CPOE for different reasons, such as the amount of time spent at the computer and concerns about clerical work that fall outside of their professional practice [5], [6], [7], [8].

Order communication is a highly collaborative process. A case study by Goorman and Berg suggests that the notion of interdependence in work is a key feature in creating medical orders and that nurses play an active role in entering medical orders in computerized systems [9]. Gorman et al. contend that the model of health care delivery underpinning CPOE is too naïve and suggest a model of distributed cognition among professionals to understand the creation of medical orders in a collaborative environment [10]. In a study about communication among health care providers in the ICU Pronovost et al. found how a daily goals form – developed to improve a common understanding of the daily goals of therapy – was associated with improved patient outcomes [11].

High-level CPOE experts recognize the difficulties with getting CPOE systems to work in everyday health care settings. This paper reports results of interviews with these experts to combine their rich experience and insights with theoretical insights from medical sociology and the field of computer supported cooperative work (CSCW). The goal is to enhance the general understanding of CPOE implementation and use. More specifically, the notions of professional collaboration and workflow are core themes in this understanding. A proper understanding of these themes is a sine qua non to reap the full benefits of CPOE technology in health care work.

The experts have been selected from among attendees of a consensus panel meeting to identify principles for the successful implementation of CPOE; the first and second authors took part in this meeting [12].

Section snippets

Extending the understanding of CPOE

CPOE systems have primarily been designed with the tasks and responsibilities of individual physicians in mind and implementation efforts have been primarily targeted at them. Goorman and Berg, however, argue that the model underpinning CPOE contains a projection of medical activities that does not match the activities of physicians as they actually take place on a ward [9]. In their study of order creation, Gorman et al. also suggest that the implicit model underlying CPOE does not take

Research methods

To extend the general understanding of CPOE, this research focused on the perceptions of experts about professional collaboration, workflow and quality of care. In October and November, 2003, the first author conducted 16 semi-structured interviews with 17 experts involved in CPOE implementations (see Table 1). The experts were partly selected from the participants in the first consensus meeting on the successful implementation of CPOE in which the first and second authors participated [31].

Results

The interviews resulted in 269 typewritten pages (single line spacing, A4 paper format). We will now briefly highlight some findings from the interviews focusing on context, professional collaboration, workflow and quality of care. The context encompasses the first three interview topics; and they are not listed separately. Organizations described in this section are those associated with the interviewees.

Discussion

Not surprisingly, several dimensions of complexity of CPOE implementation and use emerges from the interviews. First, implementation is a thoroughly social process in which the roles and responsibilities of health professionals are changing. Second, CPOE needs to fit the workflow, which is not always well understood. Third, evidence of a positive impact on the quality of care is still limited. The results of this study are consistent with theoretical insights from the sociology of medical work

Conclusion

The interviews show a rich picture of CPOE that includes practical issues of use and implementation and policy issues related to organizational strategy and changing health care practices. The interviewees acknowledge the complexity of integrating those issues into a comprehensive approach. But the next step might require the abandonment of accepted truths, such as the belief that only a licensed physician can enter orders and that this will therefore increase patient care quality. As one

Acknowledgments

The first author was supported by travel grant R96-223 of The Netherlands Organization for Scientific Research (NWO) and a grant of Erasmus University Rotterdam Trust Fund. As a visiting scientist the first author acknowledges the hospitality of the Department of Medical Informatics and Clinical Epidemiology of the Oregon Health & Science University in Portland, OR. The larger effort is supported by National Library of Medicine grant LM06942. The authors would especially like to thank the

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