Difference between revisions of "The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review"

Revision as of 18:46, 16 February 2015

This is a review for a study done by Zahra Niazkhani, MD, MS,Hab ibollah Pirnejad, MD, MS, PhD, Marc Berg, MD, MA, PhD, and Jos Aarts, PhD which helps summarize CPOE workflow advantage and disadvantages in published literature between 1990 and 2007. ^[1]

Research question

What are some advantages and disadvantages in inpatient clinical workflow which have been documented through CPOE integrated in electronic health records (EMR)?

Methods

Design

A literature review was conducted in the PubMed and Cochrane library for journal articles, conference proceedings, and summaries. MeSH terms and keywords were used to identify CPOE evaluations published in the English language between Jan 1990 and Jun 2007.

The following criteria were used to narrow the searches:

• (1) Evaluated the effects of CPOE on realistic or simulated workflow of care providers

• (2) Study must be carried out in inpatient settings

• (3) Reported on either quantitative or qualitative studies

Once the potential studies had been identified, there were analyzed based on a conceptual model and one which met the following criteria:

• (1) Workflow of individual providers versus co-working providers
• (2) Workflow with homegrown versus commercial systems

Results

Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.

Main results

The review identified 51 publications: 31 journal articles, 32–62 16 proceedings papers, 63–78 and four proceedings abstracts.

A compilation of the benefits of CPOE include the following:

• 1. Remote access to enter orders or view their status
• 2. Access to knowledge sources, decision support, order sets, graphical display of data
• 3. Clerks, nurses, and pharmacists spent less time per day on the medication process after the implementation
• 4. Physicians had more time to talk with patients after the implementation
• 5. Substantial decrease in the drug turnaround time, varying from 23 to 92%

A compilation of the negative effects included the following:

• 1. More time was spent on ordering after the implementation
• 2. Usability limitations and their effects on workflow
• 3. Ineffective interface between different departmental information systems can cause interruptions for providers working in different departments
• 4. Pattern of responsibilities for providers also changes after CPOE implementation

Conclusion

Clinical workflow is highly contingent and collaborative. Many in situ contextual factors such as the kind of specialties, the time through a day and so forth may have an influence on it. Based on the contextual factors, providers may decide to rearrange the order of activities or redelegate certain responsibilities among themselves. 83 When put in practice, the formal, predefined, stepwise, and role-based models of workflow underlying CPOE systems may show a fragile compatibility with the contingent, pragmatic, and co-constructive nature of workflow. This in turn can cause an interruption in workflow and challenge the integration of these systems into daily practice.

In conclusion, more multi-method research is needed to explore CPOE's multidimensional and collective impact on especially collaborative workflow. This review may inform designers, implementers, and evaluators how to pay closer attention to the collective, multidimensional, and contextual impact of CPOE systems on clinical workflow.

Commentary

Usability engineering can play a valuable role in assisting product design teams, unfortunately it has not been a routine part of designing clinical computing systems. Upon interviewing many of the test subjects who evaluated the EMR system, some identified system speed to be the primary determinant of user satisfaction, but most felt that usability principles and not speed or technology alone was necessary for the success of the EMR. Although usability is a broad term, it can be narrowed to two groups via various theories of human cognition and visual sensory perception.

First, it relates to navigation and system content. This is where efficiency of the EMR comes into play in defining usability. When efficiency slows down, the physician blames system speed, however technology is not the issue, rather often its the myriad of details and popup menus which create an overload in visual sensation. The fact that often the users created workarounds by opening multiple browsers reinforced this conclusion. Navigation and system content needs to be designed around user workflow--not a one size fits all. Different practice styles from various specialties and personalities come into play.re is

Second, information design is an important aspect of usability. Cognitive load theory defines the amount of "mental energy" needed to process the information or task in front of the user. There is a direct relationship between cognitive load and the amount of information present. Visualization also affects cognitive load as when too many screen elements come close together, the processing of information becomes slowed. Resolution can decrease efficiency if contrast or colors are not ideal and can mask the visual hierarchy.

Related papers

• Another one of B. Middleton's papers: Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA

References

1. ↑ . Creating The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow:A Literature Review. Journal of American Medical Informatics Association. 2009 July; 16(4): 539-549; 38(1): 51-60. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705258/