Unintended transformations of clinical relations with a computerized physician order entry system

https://doi.org/10.1016/j.ijmedinf.2007.07.007Get rights and content

Abstract

A socio-technical approach was used to study the qualitative effects of deploying a medication computerized physician order entry system (CPOE with no decision support) at two internal medical wards in a hospital in Denmark. Our results show spatial and temporal transformations of core acts and relations in medication work, i.e. of the intended use of the system inscribed in hardware and software, in the relations of care between doctors and patients, of collaboration between doctors and nurses, and prospectively of the patients’ trajectories when readmitted to hospital or another health care institution, reusing data from the system. This study throws light on problems of continuity of patient care paths, patient-related and IT-system-related error handling and time spent on core activities—when ubiquitous IT is used locally in a real physical setting with specific traditions of performing or ‘doing medication’. The paper argues for the project organization to support the local collaboration and renegotiation of time and place of enacting medication with CPOE, as well as set up feedback for maturation of the software for future clinical use.

Introduction

This study pays special attention to the technique and role of a computerized order entry system (CPOE) in the work processes of medication at two wards of internal medicine in a middle-sized Danish hospital. From the view of health care management, “the cockpit crew” [1], CPOE systems are expected to reduce errors and medical costs, give better quality and continuity of care and improve cooperation between health care professionals [2]. The aim of the qualitative study presented here, though, is to bring in the view of the “fire brigade” [1], the clinicians responsible for the medication outcome, and to support their articulation of experiences as the primary users of the system. These articulations might, in spite of their local, qualitative origin, be of interest to other implementers and developers of CPOE systems, as learning on design, change management and the nature of clinical work [3], [4] seem to be the imperative of improving information systems in health care. Classen et al. state that evaluation of CPOE installation in individual organizations is more pressing than ever [5, p. 51]. “All organizations will need to perform ongoing evaluation of their CPOE applications and their electronic health record (EHR) if the potential benefits of these technologies are to be actually realized” [6, p. 53]. Georgiou et al. concluded that further research is needed, especially as “(f)ew data are available regarding the impact of CPOE on patient outcomes” [6, p. 514]. Pragmatic discussions on health care improvements from CPOE call for more attention to detail and appropriate support to clinicians’ workflow [7]. The following ethnographic study illuminates usability and utility problems of clinicians interacting with CPOE in real life settings.

The theoretical background is socio-technical understanding of work processes, which basically means that work processes do not take place automatically, controlled more or less by either the technologies at hand or the professionals in place. Instead, technological artefacts and human actors are closely intertwined, and will be analyzed accordingly. Medication processes include a variety of persons and techniques, from patients, physicians, doctors’ rounds, writing tools, note books, etc. They are also termed ‘actants’, as they all – humans as well as techniques – contribute to the production or ‘enactment’ of medication as an ongoing activity in concrete temporal and material settings [8], [9].

Section snippets

Materials and method

The object of study is the medication process with a CPOE system in two Danish internal medical wards. Qualitative methods have been used for in-depth analysis of 48 h observation, six semi-structured interviews with primary users (two physicians and four nurses) and an analysis of the user interface and of other documents. Based on the observations, three use scenarios for central events in the medication process were constructed. The actants were among others drugs, physicians, nurses and the

Results

The following shows how the CPOE system participates in the transformation of three central relations for enacting right medication, i.e. between doctor and patient treatment when prescribing and ordering drugs, between doctor and nurse and their collaboration around ordering and decisions on proper dosage for the patient, and in the coordination between hospital and future situations of treatment. These transformations point to unintended consequences that cannot alone, though, be reduced to

Discussion

The role of CPOE systems in fostering new errors as well as reducing old ones is known [3], [12] and forms the debate on IT development in health care as such [1], [5], [6], [7], [12], [13], [14], [15]. The point seems to be that, despite disappointments in improving the quality of health care with information technology, HIT [16], including CPOE systems, is indispensable to modern health care. It also follows that the complexities of health care make flawless systems a priori impossible [7],

Conclusion

Expectations of more quality and continuity in health care from simply implementing vendor-built CPOE systems are naive and bound to be disappointed. ‘Rational medication’ can never be detached from local interactions between wide ranges of actants. System design and implementation has to take the pragmatic rationalities of concrete tempo-spatial interaction into consideration and negotiation. The presented study points to critical situations of enacting medication with CPOE, that demands more

References (24)

  • Indenrigs- og Sundhedsministeriet. National IT-strategi for sundhedsvæsenet 2003–2007....
  • E.M. Cambell et al.

    Types of unintended consequences related to computerized provider order entry

    J. Am. Med. Inform. Assoc.

    (2006)
  • Cited by (21)

    • Classification of antecedents towards safety use of health information technology: A systematic review

      2015, International Journal of Medical Informatics
      Citation Excerpt :

      Reliance on memory can cause healthcare practitioners to unintentionally make errors when processing e-prescriptions [53]. Besides, healthcare practitioners cognitive burden increased when they memorised the patient information due to information presented on different screen, and too few computers as well computer work place was separated from patients’ bed [53,60]. Cognitive load was also connected to multitasking that required healthcare practitioners’ focus attention, and resulted in high level of cognitive load [45,104].

    • Examining the role of collaboration in studies of health information technologies in biomedical informatics: A systematic review of 25 years of research

      2015, Journal of Biomedical Informatics
      Citation Excerpt :

      In order to direct workflow, sometimes the rules dictated by the system and policies are ignored. For example, Wentzer et al. [96] found that some physicians would log in the system and allow nurses to continue medication work under their user rights. The collaboration space model also draws attention to the fact that HIT needs to be designed to support specific processes of collaborative care delivery and integrate the collaborative workflows of different healthcare professionals.

    • The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units

      2013, International Journal of Medical Informatics
      Citation Excerpt :

      Especially communication timeliness was significantly lower at R2. Studies in many countries, including Australia [35–37], Denmark [38], France [17], The Netherlands [19,39–42], and the USA [43–51], have shown that communication is disrupted after CPOE implementation, and that face-to-face communication is replaced by asynchronous communication. Results of observational studies show that the time spent on communication is actually reduced after CPOE implementation [47,51].

    View all citing articles on Scopus
    View full text