The effect of physicians' long-term use of CPOE on their test management work practices

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The objective of this study was to explore physicians’ work practices in relation to their long-term use of a computerized physician order entry system (CPOE). It was a cross-sectional qualitative study conducted in the Emergency Department (ED) and the hematology ward of two large Australian teaching hospitals. Hospital A had used a computerized system to order and view all laboratory and radiology tests for over 10 years. For 7 years Hospital B had used only computerized viewing of laboratory and radiology tests. Hospital B had continued to order all tests manually.

Study data was collected by non-participatory observers and by unstructured field interviews, using a case study protocol. Two data sets were analyzed: observation and interview notes, and reflections on observations and interviews.

There were 3 themes relating to physicians’ work practices associated with the use of CPOE. They were: 1) the effect of the hospital and clinical environment; 2) changes to work practices; 3) physicians’ management of clinical information. Some examples supporting these themes follow.

The first theme was “effect of the hospital and clinical environment”. The authors found that the ED and the hematology wards were much different clinical environments. The ED often treated patients who presented with acute problems, often necessitating prompt treatment on an individual basis. This was in contrast to the hematology ward, where often patients were treated for chronic disease. Many of these patients were treated as a group with the same or similar orders, since they tended to have similar clinical problems. The authors conclude that clinical information system teams must take this diversity in workflow patterns into account when they implement new systems.

Linked to the first theme is the second theme, “changes to work practices”. As an example, this particular computer system did not have clinical decision support but it did have prompts to alert users to order tests which he/she may not have considered. Many physicians found this to be useful and followed up on the prompts, thus changing some of their work practices.

The third theme was “physicians’ management of clinical information”. Many physicians used both paper and computerized information in the course of their workday. As a result, there was often duplication of information. The authors felt that there should be a focus on the users of the system, so that technology would improve rather than duplicate the work practice of the users, with the end-result being improved patient care.

The conclusion was that hospitals need to understand and analyze physicians’ test management work practices prior to and during implementation of CPOE to accommodate their diverse ways of working with computerized information systems. In the mixed-media environment, physicians’ use of manual and computerized information systems for sourcing and recording information had an impact on efficiency and patient safety.

Comments: This was an interesting observational study, in which the authors identified some of the problems associated with electronic medical records and information retrieval. Their conclusions are relevant to clinical practice today in this country.

Teresa Mason