In an in-depth study of hospitals using computerized provider order-entry systems, it was found that most institutions with fully implemented CPOE have not been using it that long but are using it intensely—despite the occurrence of eight common unintended consequences, which researchers said can be managed if healthcare teams anticipate and prepare for them.
In a
report in the July issue of the
Journal of the American Medical Informatics Association, those eight unintended consequences were listed in order of their importance, according to a survey of 176 CPOE-using hospitals: issues involving more work or new work, workflow issues, never-ending demands for new software, equipment and training, paper persistence, communication issues, emotional issues, new kinds of errors, changes in power structure and overdependence on technology.
The effect of the consequences can be positive or negative depending on one's point of view, particularly with the consequence of shifts in the institutional power structure.
"What we had seen were physicians definitely feeling they were losing autonomy," said Joan Ash, an associate professor and vice chairwoman of the Oregon Health and Science University School of Medicine's department of medical informatics and clinical epidemiology. "But the people answering our questions didn't think power shifts were going on—or, at least, they didn't feel that they were that important. Maybe the people who were answering questions didn't feel the shift because they were gaining power, and perhaps it's harder to realize you're gaining—instead of losing—power."
Ash and a team of researchers spent a total of 390 hours between August 2004 and April 2005 observing clinicians using CPOE at five institutions and identified the eight unintended consequences. They then attempted to survey 113 Veterans Affairs Department hospitals and the 448 acute-care hospitals listed in a database compiled by HIMSS Analytics (a subsidiary of the Healthcare Information and Management Systems Society) as hospitals reporting having CPOE in place and asked respondents to judge the importance of the eight unintended consequences.
"I think we made a herculean effort," Ash said. "Many sites that claim to have CPOE really don't. I don't think they knowingly tried to mislead; I think there was a lot of wishful thinking."
In all, the researchers made contact with 265 institutions and found that 89 did not have CPOE in place. (Also, 34 other hospitals were found to have policies of not participating in surveys and were added to the list of nonrespondents.) Respondents were asked how important each of the eight unintended consequences were to their institution on a zero-to-five scale.
Ash said that she was surprised by the low level of importance respondents gave the new kinds of errors and the consequences of power shifting, because the researchers detected those "loud and clear and many times over" during their field observations.
In particular, she said "juxtaposition errors" were common and these included instances where providers entered numbers on the wrong patient or ordered the wrong medication because they clicked on the wrong box.
"We've seen this everywhere we were but our informants didn't think they were important," Ash said.
The oldest CPOE system in the survey had been in use since 1972, so Ash said that she was somewhat surprised to learn that the median length of time the hospitals had been using CPOE was only five years. She was also surprised to see how widely CPOE functions like clinical decision support were being used.
"That was a surprise, that a) the systems were so young, and b) that they're being so deeply used," she said. "For people in informatics, that's good news."
Also, the fact that CPOE can lead to communication problems, or what Ash termed the "illusion of communication," was something of a revelation.
"Certainly, handwriting is no longer an issue with CPOE," she said. "But many say it can undermine communication because physicians don't talk to other members of the healthcare team when entering orders."
Ash said another problem was people assuming that others had seen and knew exactly what had been entered in the record when they had not.
"I do the same thing with e-mails," she said. "I send one and assume the other person received it."
The
JAMIA report included survey respondents' comments on the individual consequences. For the emotional-issue consequence, the comments reflect the intensity of the feelings people had for the CPOE system their institution was rolling out.
"Pick your favorite terms of praise or profanity," said one respondent. "They are all used."
"A small but vocal minority hate it," wrote another.
"A doc threw a computer at me!" reported a respondent. "The screaming is slowly improving after three to four years of meetings."
Because the report highlights problems with CPOE, Ash said she has received some negative feedback and has been accused of writing a "doom and gloom" report.
She, however, prefers to think of the report as "optimistic," because it tells people what to watch for and warns them about the need for being prepared with mitigating strategies.
For physicians who feel their authority slipping away, for example, Ash recommends making sure these doctors get seated on advisory boards and supervisory panels overseeing the CPOE implementation.
"The optimism comes from ... things that can be done to mitigate all of these unintended consequences," she said. "It's far from hopeless."
Delbanco
|
One of the most visible supporters of CPOE has been the Leapfrog Group
coalition of major employers, and Leapfrog Chief Executive Officer Suzanne Delbanco said that the consequences mentioned in the report have been known to exist since her organization's inception seven years ago.
"There's no question that implementing computerized physician order entry effectively is challenging," Delbanco said. "We know when it's done well, it's still the gold standard when it comes to reducing serious medical errors."
While the
JAMIA article refers to CPOE as "computerized
provider order entry," Delbanco insists on calling it "computerized
physician order entry."
"Leapfrog is not interested that a physician gives an order orally or in chicken scratch to another provider to enter," she said, explaining that the value to the patient that
CPOE provides is instant feedback to the doctor in terms of alerts or clinical decision support.
Two main strategies that Leapfrog suggests to mitigate unintended consequences is to have the physicians who will be using CPOE involved in the selection and design of the system and to accept that CPOE will slow down or change workflow and "find efficiencies elsewhere."
"We've more clearly identified what the hurdles are—it doesn't mean the hurdles aren't there," she said.
Delbanco also was not surprised to learn that many hospitals who report having CPOE did not actually have a functioning system in place.
"How people define 'computerized physician order entry' does vary tremendously," she said. "Buying the software is the easy part, actually installing it and having the physicians use it is what will benefit patients."
As of the end of June, of the 1,239 hospitals that responded to a Leapfrog
survey, 124 met the organization's criteria for having a full implementation of CPOE and 54 more committed to being at that level by 2008.
Last year, about 7.3% of the hospitals met the full criteria, so this year's total of around 10% was one of the first significant increases in the last few years, Delbanco said, adding that it was also significant that CPOE has reached "the land of double digits" as CPOE use hovered very low to the ground in the first years of the Leapfrog survey between 2% and 3%.
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