Evaluating the medication process in the context of CPOE use: The significance of working around the system
Highlights
► Comprehensive study of workarounds can help improving post-CPOE workflow. ► Sociotechnical and organizational factors’ linkage aids workaround generation. ► The situatedness of workarounds helps users to tackle local workflow obstacles. ► CPOE orders do not mean that the paper or verbal orders are not used any more. ► Coordinators with an overview on the entire process can foster a balanced workflow.
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.
Section snippets
Background
The implementation of an information technology such as a CPOE system is a process of mutual transformation in which the organization and the system transform each other [17]. Wynne referred to the “practical contextualization of technology” by users in which they develop informal operating rules by adapting general principles to specific circumstances in order to make the technology work in that situation [18]. This “contextualization” process may not follow the full scope of technology, so
Study site and the CPOE system
We studied a vendor-based CPOE system, Medicatie/EVS® (version 2.30), iSOFT, The Netherlands (now iSofthealth), at Erasmus University Medical Center, a 1237-bed academic hospital in Rotterdam, The Netherlands. A detailed description of an earlier version of Medicatie/EVS® has been published elsewhere [23]. The hospital began to implement the system in 2001. It took 5 years to implement the system hospital-wide in both inpatient and outpatient settings. The last inpatient unit started using the
Findings
We present our findings based on the five phases in the medication-use cycle (Fig. 4). In each of these phases, we focus on the problems – interruptions and workflow blocks – encountered and on the workarounds devised to cope with them. It is noteworthy that in real practice these phases are highly interrelated and they overlap without a clear-cut distinction between them. For example, issues in the prescribing phase may partly overlap with those in the monitoring phase. Table 1 provides
Discussion
Our study deals with the impact of CPOE use on workflow, and reasons for problems that occurred, and for workarounds. The problems in the post-CPOE medication process differed in their nature and affected one or more providers (Table 1). They included cognitive overload on physicians in the decision-making phase (e.g., to recall patient information from the memory) and their unmet information needs, miscommunication of orders and ideas between physicians and nurses, problematic coordination of
Conclusion
Our study further reinforces the complexity of the medication-use process in a CPOE context that connects providers from different professional groups within and between departments and their competing interests and conflicts. It shows how the features of a CPOE system affect and are affected by the work practice over time. It demonstrates that providers are actively involved in bypassing the technology or in adapting the work process to cope with difficulties in their workflow. This in many
Authors’ contributions
ZN and HP collected data. ZN designed the study, analyzed data, and wrote the early draft of the manuscript. HP assisted in the analysis of data and was also involved in critical review of the content. HS and JA critically reviewed the manuscript and commented on that.
Conflict of interests
HS was the project manager of the CPOE implementation team in this hospital. The opinions reported in this paper are those of the authors. The authors declare that they have no competing interests.
Acknowledgement
The authors gratefully acknowledge the study participants for their time and valuable information.
References (31)
- et al.
The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review
J. Am. Med. Inform. Assoc.
(2009) - et al.
Impact of a computerized physician order entry system on nurse–physician collaboration in the medication process
Int. J. Med. Inform.
(2008) - et al.
Impact of CPOE on doctor–nurse cooperation for the medication ordering and administration process
Int. J. Med. Inform.
(2005) - et al.
Types of unintended consequences related to computerized provider order entry
J. Am. Med. Inform. Assoc.
(2006) - et al.
When requests become orders—a formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service
Int. J. Med. Inform.
(2007) - et al.
Technology implementation and workarounds in the nursing home
J. Am. Med. Inform. Assoc.
(2008) - et al.
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety
J. Am. Med. Inform. Assoc.
(2008) - et al.
Getting to the point: developing IT for the sharp end of healthcare
J. Biomed. Inform.
(2005) - et al.
Electronic inpatient whiteboards: improving multidisciplinary communication and coordination of care
Int. J. Med. Inform.
(2009) - et al.
Immediate benefits realized following implementation of physician order entry at an academic medical center
J. Am. Med. Inform. Assoc.
(2002)
Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system
J. Am. Med. Inform. Assoc.
A consensus statement on considerations for a successful CPOE implementation
J. Am. Med. Inform. Assoc.
Role of computerized physician order entry systems in facilitating medication errors
JAMA
Extending the understanding of computerized physician order entry: implications for professional collaboration, workflow and quality of care
Int. J. Med. Inform.
What's so special about medications: a pharmacist's observations from the POE study
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