Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument

This is a review for Dean F Sitting’s Assessing the Anticipated Consequences of Computer-based Provider Order Entry at Three Community Hospitals Using an Open-ended, Semi-structured Survey Instrument.

Introduction

The purpose of this project was an attempt to determine what “average” clinicians were expecting to occur in organizations that were about to implement Computer-based Provider Order Entry (CPOE) for the first time, or one that was about to experience a significant system upgrade.

Methods

We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately five minutes to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to.

The Survey Sites

Three hospitals were surveyed with each hospital at a slightly different stage in the CPOE implementation pathway. One organization had begun rolling out their CPOE system on one small clinical unit. The second was in the early, pre-CPOE phase of their roll-out. The Third organization with within 2 months of their planned go-live dates.

El Camino Hospital, Mountain View, CA - El Camino Hospital is a 395-bed community hospital serving the Mountain View, CA area; the heart of the “Silicon Valley.” The hospital was upgrading from the first implemented Lockheed system in the 1970’s to the new Eclipses Sunrise system.

Kaiser Permanente, Sunnyside Hospital, Portland, OR—Kaiser Permanente's Sunnyside hospital is a 196-bed community hospital serving Kaiser Permanente, Northwest members in the greater Portland metropolitan area. At the time of this survey, Sunnyside hospital had just “gone live” with phase I (Admission/ Discharge/Transfer, new inpatient pharmacy, hospital billing, and Emergency Department tracking systems, all from Epic Systems) of their in-patient clinical information system rollout and were approximately four months away from the planned hospital-wide roll-out of their CPOE system.

Portland Providence Medical Center, Portland, OR—Portland Providence hospital is a 483-bed, community hospital serving the Portland metropolitan area. At the time of this study survey, they were approximately four months into a CPOE pilot on their rehabilitation unit, with plans to begin a phased roll-out to the rest of the in-patient clinical units over the next two years.

Methods

Following Institutional Review Board approval of the study at Oregon Health & Science University (OHSU), Kaiser Permanente Northwest, and each study site, we created an openended, semi-structured interview survey template that we customized for each organization. This survey was designed to be administered orally to clinicians and take approximately five minutes to complete, although we did not stop any clinician from discussing the topics in greater depth, if they desired. The survey was administered the survey to clinicians within each organization at common gathering places - a true “convenience” sample.

Results

The Survey

A total of 83 clinicians: 31 physicians, 31 nurses, and 21 allied health professionals at the three sites. There were no large differences in the clinical training of the interviewees within professional categories, years of professional experience, age, or gender among the sites. In addition, all of the clinicians at each site were familiar with basic clinical computing features and functions such as patient lookup, clinical results review, email, and Internet access.

When asked how the new system might compare to the current system, almost all respondents were able to articulate multiple perceived advantages, including increased legibility, reduced time to find charts, less paper, improved communication, and an overall improvement in patient safety. Most interviewees were also able to describe multiple disadvantages of the new system including: more difficult to use (i.e., More work/new work from our list of Unintended Adverse Consequences, see Table 1), long learning curve (Never ending demands), more frustrating (Emotions), and worries about technical issues such as downtime procedures (Overdependence on technology).

When asked about the perceived effect of the system on the organization as a whole, many interviewees stated that it would improve the perception of the organization in the community and perhaps save the organization money.

Discussion

Based on our small convenience sample of clinicians at these three community hospital sites, it appears that clinicians recognize that during the transition period, many work processes will take longer and that there will be some new work on their part as they become accustomed to the new system. Many clinicians were worried about how they would take care of patients if/when the system went down. Further, none of the interviewees mentioned that the new system might have a detrimental impact on communication

Summary

The clinicians we interviewed had a realistic view of the impact that CPOE would have on them and their peers. They understood both the upsides and the downsides of CPOE and even seemed to have a long-term perspective, acknowledging that there could be a positive payoff at the end of the long learning curve. They did not indicate that they were aware of many of the unintended consequences of CPOE implementation that we have identified, but they were surprisingly well informed about CPOE in general.