Evaluating the medication process in the context of CPOE use: The significance of working around the system

Abstract

Objective

To evaluate the problems experienced after implementing a computerized physician order entry (CPOE) system, their possible root causes, and the responses of providers in order to incorporate the system into daily workflow.

Methods

A qualitative study in the medication-use process after implementation of a CPOE system in an academic hospital in The Netherlands. Data included 21 interviews with clinical end-users, paper-based and system-generated documents used daily in the process, and educational materials used to train users.

Findings

The problems in the medication-use process included cognitive overload on physicians and nurses, unmet information needs, miscommunication of orders and ideas, problematic coordination of interrelated tasks between co-working professionals, a potentially faulty administration phase, and suboptimal monitoring of the medication plans. These problems were mainly rooted in the lack of mobile computer devices, the uneasy integration of coexisting electronic and paper-based systems, suboptimal usability of the system, and certain organizational factors with regard to procuring drugs affecting the technology use. Various types of workarounds were used to address the difficulties, including phone calls, taking multiple paper notes, issuing paper-based and verbal orders, double-checking, using other patients’ procured drugs or another department's drug supply, and modifying and annotating the printed orders.

Conclusion

This study shows how providers are actively involved in working around the interruptions in workflow by bypassing the technology or adapting the work processes. Although certain workarounds help to maintain smooth workflow and/or to ensure patient safety, others may burden providers by necessitating extra time and effort and/or endangering patient safety. It is important that workarounds having a negative nature are recognized and discussed in order to find solutions to mitigate their effects.

Introduction

The implementation of computerized physician order entry (CPOE) systems thoroughly transforms existing work practices [1]. This transformation benefits certain aspects of workflow such as better documentation of orders and shorter order turnaround times [2], [3]. Nevertheless, it also challenges other workflow aspects such as collaboration between providers [4], [5]. As a result, workflow issues have been found highly relevant not only for a successful implementation of CPOE systems but also for patient safety practices [6], [7], [8].

Studies of the actual use of health care information technology (HIT) in successful implementation sites have raised concerns about how and with what consequences these systems are operational in practice [7], [9], [10], [11]. In an in depth qualitative study, Georgiou and colleagues showed how the use of a CPOE system can change the nature of clinical work [10]. They found that providers responded in different ways to the workflow issues faced after a CPOE implementation, ranging from soft responses and workarounds to hard responses such as new organizational rules [10]. Vogelsmeier and colleagues characterized two categories of workarounds in working with an electronic administration record: those related to workflow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology [11]. Koppel and colleagues showed that workarounds are the result of difficulties with the technology as well as of interactions between the technology and other factors such as “environmental, technical, work-processes, workload, training, and policies” [12]. It has been noted that workarounds developed in the use of CPOE systems may blur the workflow problems generated by these systems [7]. Such studies serve to focus attention on the organization of the work with CPOE systems and how it may be affected in a positive or a negative way. In other words, for a smooth as well as a safe workflow, it is highly relevant to evaluate and to understand how health care providers use, misuse, or bypass these systems in practice. However, despite the importance of the issue, only a few studies have attempted to characterize different responses of providers in the implementation environment and their consequences for clinical workflow.

Studies have pointed out the complexity of the medication-use cycle in hospitals, which highly influences CPOE use [13], [14]. In our previous studies on the impact of a medication order entry system on inter-professional communication and workflow, we found that providers often took additional steps beyond the system to cope with disruptions [15], [16]. Intrigued by this finding, in the present study we aimed to investigate how the parties involved in or affected by the implementation handled breakdowns in the medication-use process. These parties were physicians, nurses, the pharmacy department, and the implementation team, whom we will refer to hereafter collectively as “the work organization”. Rather than merely focusing on the relationship between these responses and patient safety practices, which is per se of great importance, we attempted to extend the approach to explore their consequences for the structure of clinical workflow. More specifically, we were keen to evaluate and to understand the difficulties or breakdowns that take place in the medication-use process in the context of CPOE, their probable root causes, and the responses of the work organization to address them. This, we believe, can provide an insight into how these responses influence the providers’ workflow as well as into which strategies can help to improve the situation.