► Few studies have examined long term effects of CPOE implementation on communication. ► Few studies have examined what aspects of communication are affected by CPOE. ► CPOE implementation has a short-term, negative effect on communication. ► In the long term the effects revert to the same levels as pre-CPOE implementation.
Successful communication can be defined as the ability to translate information openly, accurately, and in a timely manner [1], [2]. The literature shows that direct communication (face-to-face communication or real-time communication) is the preferred mode of communication in Intensive Care Units (ICUs) [3]. However, due to the interruptive nature of ICU work, direct communication may contribute to communication breakdowns and medical errors [4], [5]. According to the Joint Commission [6], two-thirds of the root causes of sentinel events in the period 1995–2005 were communication-related. A sentinel event is defined by the Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient's illness.
Relatively little is known about the different aspects of communication in ICUs, and how these different aspects of communication vary among healthcare providers. Furthermore, we do not know how health Information Technology (IT) implementation may impact communication among healthcare providers, and consequently, quality of care and patient safety.
We know that communication is related to quality of care, patient safety and medical errors [7], [8], [9], [10], but we know little about what aspects of communication are important. In one of the early thorough studies that examined different aspects of communication in ICUs, Shortell et al. [11] developed and tested a model (see Fig. 1) to describe the relation between managerial practices and organizational processes and effective performance defined in terms of quality and efficiency of care provided to patients. They hypothesized that “a team-oriented, achievement oriented culture and leaders who set high standards and provide necessary support provide more open, accurate, and timely communication, effective coordination with other units, and more open collaborative problems solving approaches. These, aspects, in turn, produce greater cohesiveness among team members resulting in the delivery of more effective patient care” [11].
In this study we focus on the core of Shortell and colleagues’ model, i.e. the different aspects of communication, and examine how Computerized Provider Order Entry (CPOE) implementation may influence communication patterns. Communication openness involves the extent to which nurses and physicians are able to say what they mean when speaking with each other without fear of repercussion or misunderstanding. Communication accuracy refers to the degree to which physicians and nurses believe in the accuracy of the information conveyed to them by the other party [12]. Communication timeliness refers to the degree to which patient information is related promptly to the people who need the information. Shift/hand-off communication refers to the effectiveness of nurse/physician communication between shifts [11]. Results of the study by Shortell et al. [11] showed that within- and between-group openness, within- and between-group accuracy, timeliness and shift communication are all positively associated with quality of care and negatively with turnover intention of nurses.
Results of the study by Shortell et al. [2] underline how important managerial and organizational factors are. Shortell et al. concluded: “The findings suggest that ICUs that have a team-oriented culture with supportive nursing leadership, timely communication, effective coordination, and with collaborative open problem solving approaches are significantly more efficient in terms of moving patients in and out of the unit. The units also have lower nurse turnover that can result in further cost savings through reduced expenses for recruitment and selection” [2, p. 521].
Apart from the studies by Shortell and colleagues, there are few studies that examine the different aspects of communication and their relation with quality of care in ICUs. Donchin et al. [13] conducted around-the-clock observations to examine human errors in a medical–surgical ICU of a large hospital. Results of the study showed that verbal communication occurred only in 9% of all activities. Most communications were exclusively among physicians or exclusively among nurses. Only in 2% of the recorded activities did physicians communicate verbally with nurses. Interestingly, verbal communications between physicians and nurses were recorded in 37% of the error reports. This percentage is surprisingly high when considering that verbal communications between physicians and nurses were observed only in 2% of activities recorded during the 24-h observations [13].
In a recent study, Manojlovich et al. [14] examined the relationship between nurses’ perceptions of communication between nurses and physicians, characteristics of the work environment and patient outcomes as measured by ventilator-associated pneumonia (VAP), bloodstream infections associated with a central catheter (BSI) and pressure ulcers in 25 ICU units. Manojlovich et al. [14] focused on different aspects of communication: openness; accuracy; timeliness; and understanding, using the ICU Nurse–Physician Questionnaire [11]. Results show that variability in communication understanding was related to VAP and that communication timeliness was inversely related to pressure ulcers. None of the communication aspects was related to BSI.
Carayon et al. [15] assessed the reliability and validity of three of the communication concepts (openness, accuracy and timeliness) developed by Shortell et al. [11] and examined the relationships between these different aspects of communication on the one hand, and unit effectiveness, satisfaction with care provided, job satisfaction, fatigue and tension on the other hand. Results of the study showed that the measures of communication were reliable and valid. Furthermore, openness, accuracy and timeliness were significantly associated with unit effectiveness, satisfaction with care provided, and job satisfaction. Communication openness was also significantly (negatively) correlated with fatigue and tension [15]. Using data from the first round of data collection in our study to examine the impact of CPOE, Hoonakker et al. [16] showed that among ICU nurses, communication openness and accuracy were related to perceived quality of care and patient safety.
To summarize, successful communication is critical in healthcare and is related to outcomes such as quality of care and patient safety, in particular in ICUs. However, we know relatively little about what aspects of communication are important in this process. Further, implementation of CPOE may have negative effects on communication that need to be studied.
CPOE is a key health IT in healthcare. The orders, based on the physician's decisions with regard to a patient's status, initiate and organize the actions carried out by other healthcare professionals such as nurses, pharmacists, radiologists, and laboratory technicians [17]. Research has shown that CPOE may lead to errors [18], [19], [20]. Errors can occur at each step of the order management process: ordering, transcription, dispensing and execution of orders [17], [21], [22]. Specifically, medication ordering has received attention in the literature because medication overuse, misuse, and even underuse can do great harm to the patient [17].
Using a CPOE system, the healthcare decision maker enters orders directly into a computer instead of using paper. Several studies have shown that implementation of CPOE can improve the medication ordering and administration process and reduce medication errors because of the support for information flow and communication between care providers. For example, CPOE implementation has been shown to improve antibiotic ordering patterns [23], [24], [25], [26], [27] and significantly decrease non-intercepted medication errors and potential adverse drug events [23]. Several functionalities of CPOE such as patient specific dosing suggestions, reminder to monitor drug levels, reminders to choose an appropriate drug, checking for drug–drug and drug–allergy interactions, standardized order sets, increased legibility, automated communication with other departments within a hospital, access to patient data and reference information while ordering, and integration of CPOE with other health IT systems, such as the pharmacy application and the nurses’ electronic Medication Administration Record (eMAR) system can improve the medication use process [28].
However, recent studies have shown that implementation of CPOE may undermine the efficiency and safety of the medication process by impeding nurse–physician collaboration and communication [17], [19].
The primary goal of this study is to examine the impact of CPOE implementation on quality of communication in ICUs. We also discuss the results of this study from an international perspective. We use data from three rounds of data collection: 6-months pre-CPOE-implementation (R1), 3-months post-CPOE implementation (R2), and one-year post-CPOE implementation (R3) to examine the impact of CPOE implementation on communication.
The study was performed in four ICUs in a 400-bed rural, tertiary care teaching hospital in the northeast US: the 24-bed adult Intensive Care Unit (AICU), the 18-bed cardiac ICU (CICU), the 38-bed neonatal ICU (NICU) and the 11-bed pediatric ICU (PICU). CPOE was implemented throughout the hospital in October 2007. Related EHR functionalities implemented at the same time included the electronic pharmacy order-management system and electronic medication-administration record (eMAR), along with
Table 1 describes the study population. A greater proportion of nurses were female as compared to providers. On average, nurses were older and had longer tenure than providers; providers had more years of computer experience and more computer expertise than nurses. Providers in the sample more often work in the AICU. There are no statistically significant changes in the study population's characteristics over time.
The primary objective of this study was to examine the effects of CPOE implementation on communication in ICUs. Results of our study show few differences in the quality of communication 6 months before CPOE implementation (R1), 3 months post-CPOE implementation (R2) and one-year post-CPOE implementation (R3). Results show that for nurses, overall, quality of communication decreases 3-months post-CPOE implementation. Especially communication timeliness was significantly lower at R2 than both in
All the authors have made significant contributions in making study concept and design, drafting the content, and revising and final approval of the write-up. Peter Hoonakker and Randi Cartmill have done data collection and data analysis works. With these two authors, Pascale Carayon helped in data collection and Roger Brown was involved with data analysis.
None of the authors has a conflict of interest. Summary points What was already known about the topic: Communication is important for patient safety. Computerized Provider Order Entry (CPOE) can improve the medication ordering and administration process and reduce medication errors because they support better data communication between care providers. Recent studies have shown that implementation of CPOE may undermine the efficiency and safety of the medication process by impeding nurse-physician
This research was made possible by grant R01 HS15274 from the Agency for Healthcare Research and Quality [PI: P. Carayon; co-PI: K. Wood]. This study was also supported by grant 1UL1RR025011 from the Clinical & Translational Science Award (CTSA) program of the National Center for Research Resources in the National Institutes of Health [PI: M. Drezner]. We would like to thank the nurses, nurse practitioners, physicians, and physician assistants in the ICUs for their participation in this study.
Computerized physician order entry (CPOE) is a key health information technology in healthcare [1], in which clinicians directly enter medication and other orders into a computer system instead of using paper [2].
Other methods such as questionnaires or conversation analysis are necessary to evaluate the content and quality of communication among ICU clinicians. In another part of our larger study on EHR implementation in ICUs, we conducted a survey of ICU physicians and nurses and found no long-term negative impact of EHR technology on quality of communication such as perceived timeliness and adequacy [6]. Because data were collected in a single hospital, these findings may not generalize to physician work in other ICUs and hospitals and to other changes in work with other EHR technologies or the same technology given the differences in context.
