Computerized Provider Order Entry

As the number of healthcare organizations beginning to implement clinical information systems grows, the number of unanticipated and unintentional consequences inevitably increases as well.  While existing research suggests that much good can come from clinicians entering orders directly, errors or other unintended consequences related to technology may arise.  Ideal for both clinicians and information technology professionals, Clinical Information Systems: Overcoming Adverse Consequences helps fledgling organizations better prepare for the inevitable challenges and obstacles they will face upon the implementation of such systems.  Based on the research and findings from the Provider Order Entry Team from the Oregon Health & Science University, this book discusses the nine categories of unintended adverse consequences that occurred at many of the leading medical centers during their implementation and maintenance of a state-of-the-art clinical information system. It goes on to present the best practices they identified to help organizations overcome these obstacles.

The United States healthcare system is transitioning from paper-based to computer-based systems. In this process, it is vitally important to focus on optimizing the role of human factors in systems design. This review examines a wide range of cognitive ergonomics and socio-technical systems issues that impact the successful implementation of healthcare information technologies (HIT). We review evidence on the impact of HIT on medication errors, electronic health records and clinical support, copying clinical exams and notes, computerized-provider order entry and clinical decision support system, and bar-code medication administration systems. We examine research on barriers to successful HIT implementation and also on user workarounds of systems’ limitations. The review concludes by summarizing a series of important human factors design considerations that must be considered for successful systems implementation. This information is presented in a manner that should allow HIT system...

Objective: Alerting systems, a type of clinical decision support (CDS), are increasingly prevalent in healthcare, yet few studies have concurrently measured the appropriateness of alerts with provider responses to alerts. Recent reports of suboptimal alert system design and implementation highlight the need for better evaluation to inform future designs. The authors present a comprehensive framework for evaluating the clinical appropriateness of synchronous, interruptive medication safety alerts.
Methods: Through literature review and iterative testing, we developed metrics that describe successes, justifiable overrides, provider non-adherence, and unintended adverse consequences of CDS alerts. We validated the framework by applying it to a medication alerting system for patients with acute kidney injury (AKI).
Results: Through expert review, the framework assesses each alert episode for appropriateness of the alert display and the necessity and urgency of a clinical response. Primary outcomes of the framework include the false positive alert rate, alert override rate, provider non-adherence rate, and rate of provider response appropriateness. Application of the framework to evaluate an existing AKI medication alerting system provided a more complete understanding of the process outcomes measured in the AKI medication alerting system. We confirmed that previous alerts and provider responses were most often appropriate.
Conclusion: The new evaluation model offers a potentially effective method to assess the clinical appropriateness of synchronous interruptive medication alerts prior to evaluating patient outcomes in a comparative trial. More work can determine the generalizability of the framework for use in other settings and other alert types.

The United States healthcare system is transitioning from paper-based to computer-based systems. In this process, it is vitally important to focus on optimizing the role of human factors in systems design. This review examines a wide range of cognitive ergonomics and socio-technical systems issues that impact the successful implementation of healthcare information technologies (HIT). We review evidence on the impact of HIT on medication errors, electronic health records and clinical support, copying clinical exams and notes, computerized-provider order entry and clinical decision support system, and bar-code medication administration systems. We examine research on barriers to successful HIT implementation and also on user workarounds of systems’ limitations. The review concludes by summarizing a series of important human factors design considerations that must be considered for successful systems implementation. This information is presented in a manner that should allow HIT system...

A major portion of patient care planning occurs during the process of writing orders. Computerized order entry can present collections of predefined orders to the user during the ordering process. These order sets are useful for promoting standards of care, and provide one element of structured clinical knowledge to be used by Computerized Provider Order Entry (CPOE) systems at the

To assess the effects of a CPOE system on inter-professional workflow in the medication process. Twenty-three semi-structured interviews with physicians, nurses, and pharmacists were conducted in a Dutch academic hospital. In addition, the handwritten and system-generated documents used daily were collected for analysis. Data was analyzed on the basis of three conceptual themes in the inter-professional workflow: division of tasks, flow of information, and task coordination. The CPOE system reorganized the existing work procedures, affecting the workflow among the three professional groups both advantageously and disadvantageously. The system resulted in the reassignment of tasks and reallocation of areas of expertise in the medication process. Moreover, patients' medication-related information became fragmented in both the paper records and in the electronic records, as well as in different professional domains. The system provided limited support for professional groups to coordinate their tasks temporally. It also made it difficult to build mutual intelligibility upon new changes in the medication plan. To integrate tasks, the professional groups had to bypass the system or add new steps and extra coordinative tasks. We identified several workflow integration issues after the implementation of a CPOE system. Our insights into these issues can help ensure that the system design or redesign properly integrates all tasks, information, and areas of expertise of professional groups into those of the physicians.

Method Prospective collection of all medication order lines during five days in a tertiary care university hospital using computerized physician order entry for drug prescription. All orders were reviewed by a pharmacist. We described the frequency of pharmacy alerts and their ...

A major portion of patient care planning occurs during the process of writing orders. Computerized order entry can present collections of predefined orders to the user during the ordering process. These order sets are useful for promoting standards of care, and provide one element of structured clinical knowledge to be used by Computerized Provider Order Entry (CPOE) systems at the point of care. Since the creation, confirmation and maintenance of order sets is resource intensive, sharing order sets is a useful goal. We describe a standard representation of order sets that supports maintenance, sharing and interoperation of pre-defined order sets. A dialogue within the HL7 community seeks to harmonize this proposal with the Clinical Document Architecture and the HL7 Reference Information Model.

Computerized provider order entry (CPOE) and clinical decision support (CDS) are advocated health care information technologies for improving patient safety through reduction and prevention of medication errors. CPOE and DCS target specific errors in medication processes, particularly in prescribing and ordering. These are of particular importance in pediatrics, because children may be more vulnerable to prescribing errors than adults. Studies of CPOE/CDS performed at academic medical centers have demonstrated their effectiveness in reducing medication process errors in pediatrics, but scant data so far show effects on health outcomes. CPOE/CDS adoption requires significant expertise in health care processes, information technology, and change management. Adoption is a high-cost, high-risk venture with political implications.

One of the challenges associated with the implementation of e-health systems is the effect they have on the temporal landscape (how time is conceived, structured and monitored) of an organisation particularly as it relates to the way that work is prioritised, allocated, synchronised and coordinated. This study aims to identify the impact of the introduction of a new e-health system on key aspects of the temporal and organisational functioning of a hospital pathology service. The study employed qualitative methods including interviews, focus groups and observation sessions. It was carried out in the period of August 2005 to August 2008 across a hospital pathology service in Sydney, Australia during the introduction of a new laboratory information system and electronic ordering system. The results revealed a number of temporal layers which can be defined as organisational (how the service synchronises its work with other settings); clinical (coordination of work to ensure the appropriate laboratory contribution to effective patient care); procedural (allocating work according to scientific and pathologic processes); and informational and electronic (how and what information is communicated and accessed). The introduction of a new e-health system was shown to have a major impact on the temporal landscape of the pathology service. Specific examples of this were revealed in changes to the way the pathology service: (1) tracked and monitored specimens within the laboratory; and (2) communicated and coordinated its work internally and externally. The use of qualitative methods longitudinally provided key insights into the way that temporal factors operate within pathology laboratories and their interrelationship with the performance, distribution and allocation of work.

One of the challenges associated with the implementation of e-health systems is the effect they have on the temporal landscape (how time is conceived, structured and monitored) of an organisation particularly as it relates to the way that work is prioritised, allocated, synchronised and coordinated. This study aims to identify the impact of the introduction of a new e-health system on key aspects of the temporal and organisational functioning of a hospital pathology service. The study employed qualitative methods including interviews, focus groups and observation sessions. It was carried out in the period of August 2005 to August 2008 across a hospital pathology service in Sydney, Australia during the introduction of a new laboratory information system and electronic ordering system. The results revealed a number of temporal layers which can be defined as organisational (how the service synchronises its work with other settings); clinical (coordination of work to ensure the appropriate laboratory contribution to effective patient care); procedural (allocating work according to scientific and pathologic processes); and informational and electronic (how and what information is communicated and accessed). The introduction of a new e-health system was shown to have a major impact on the temporal landscape of the pathology service. Specific examples of this were revealed in changes to the way the pathology service: (1) tracked and monitored specimens within the laboratory; and (2) communicated and coordinated its work internally and externally. The use of qualitative methods longitudinally provided key insights into the way that temporal factors operate within pathology laboratories and their interrelationship with the performance, distribution and allocation of work.