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

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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. 
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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. <ref name="Zahra 2009">. 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/</ref>
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Alan F. Rose, Jeffrey L. Schnipper, Elyse R. Park, Eric G. Poon, Qi Li, and Blackford Middleton application of qualitative guidelines in the assessment and improvement of EMR usability. <ref name="Zahra 2007">. 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/</ref>
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== Research question ==
 
== Research question ==
  
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Are studies based on qualitative data efficacious in helping improve the [[usability]] of [[EMR|electronic health records (EMR)]] and if so what design solutions can be recommended?
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What are some advantages and disadvantages in inpatient clinical workflow which have been documented through [[CPOE]] integrated in [[EMR|electronic health records (EMR)]]?
  
 
== Methods ==
 
== Methods ==
  
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=== Environment ===
 
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Two separate qualitative studies that attempted to identify user task flows with an existing EMR, to better understand the environment in which these tasks are performed, and to determine how overall usability can be improved.
 
  
 
=== Design ===
 
=== Design ===
  
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Each of the qualitative studies focused on users of the Longitudinal Medical Record (LMR), a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval.  Then the following three forms of evaluation were applied:
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A literature review was conducted in the PubMed and Cochrane library(see [[Searching for Evidence]]) for journal articles, conference proceedings, and summaries.  MeSH terms (see [[Unified Medical Language System (UMLS)]] and keywords were used to identify CPOE evaluations published in the English language between Jan 1990 and Jun 2007.
  
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* '''Task Analysis''': Task analysis clarifies the objectives of each task, which tasks are most important to users, and which tasks depend on other tasks
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The following criteria were used to narrow the searches:
  
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* '''Focus Groups''': Focus groups are an informal and relatively unstructured exercise that can help assess user needs and feelings both before and after system design
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# Evaluated the effects of [[CPOE]] on realistic or simulated workflow of care providers
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# Study must be carried out in inpatient settings
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# Reported on either quantitative or qualitative studies
  
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* '''Collaboration''': Task analysis and focus group studies were conducted independently of each other with an agreement between their respective administrators to collaborate and identify common themes during the data analysis phase. This resulted in a joint effort to systematically compare the results of our inspection and propose solutions for enhancing LMR’s usability
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Once the potential studies had been identified, they were analyzed based on a conceptual model and one which  met the following criteria:
  
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=== Measurements ===
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# Workflow of individual providers versus co-working providers
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# Workflow with homegrown versus commercial systems
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Each of the qualitative studies focused on users of the Longitudinal Medical Record, a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval.
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== Results ==
 
== Results ==
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=== Main results ===
 
=== Main results ===
  
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The two qualitative studies showed that there were a lot of consistencies in issues with usability of LMR.  Deficiencies were identified specifically with regard to the following aspects:
 
  
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'''Navigation'''
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The review identified 51 publications: 31 journal articles, 32–62 16 proceedings papers, 63–78 and four proceedings abstracts.
  
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Both studies qualified the navigation aspect as "awkward" and subjectively used too many clicks to get data entered or retrieved.  Too many popup menus were offered which crowded the screen.  Physicians created workarounds by opening up multiple browsers which was not ideal as it was time-consuming and consumed the system's resources, slowing down the computer.   
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A compilation of the benefits of [[CPOE]] include the following:
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# Remote access to enter orders or view their status
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# Access to knowledge sources, decision support, order sets, graphical display of data
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# Clerks, nurses, and pharmacists spent less time per day on the medication process after the implementation
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# Physicians had more time to talk with patients after the implementation
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# Substantial decrease in the drug turnaround time, varying from 23 to 92%
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A compilation of the negative effects included the following:
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*1.  More time was spent on ordering after the implementation
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*2.  [[Usability]] limitations and their effects on workflow
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*3.  Ineffective interface between different departmental information systems can cause interruptions for providers working in different departments
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*4.  Pattern of responsibilities for providers also changes after [[CPOE]] implementation
  
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* '''Information Design''' The presentation of the screens created issues.  The Results Manager’s usage of color and low contrast with data objects that are in their “selected” state made it difficult to read or identify the information quickly.  In addition, there was a poor balance of displaying what the provider needed with what was available in "one click away" from the current screen.
 
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* '''Customization''' Comments regarding customization were targeted primarily toward the letter-writing feature in Results Manager. Many physicians often used their own letters and found the pre-defined letter templates of Results Manager to be inadequate for all their workflow needs.
 
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* '''Workflow''' The participants came from a variety of workflow backgrounds.  Some blocked off time at the end of the day to enter notes, while others entered at the end of each patient visit.  The biggest complaint from workflow again came from navigational issues--specifically the popup menus which slowed productivity.
 
  
 
== Conclusion ==
 
== Conclusion ==
  
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Through a thorough examination of two studies, it can be shown that qualitative research can help focus attention on user tasks and goals and identify patterns of care. Findings from both studies found consistency with regards to issues with the organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues.
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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.
  
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== Commentary ==
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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.
  
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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.
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== Commentary ==
  
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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
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Healthcare is a complex activity system of specialized and non-specialized workers, their tools, and their environment. Healthcare work involves continuous interaction among different elements and trade-offs between multiple goals, preferences, values, incentives, and motivations in the course of care processes.
  
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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. 
 
  
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== Related papers ==
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A conceptual model for CPOE was created and had the following elements.  The aspects of clinical workflow therefore can be categorized into four elements:
  
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* 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]]
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# Structuring of clinical tasks
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# Coordinating of task performance
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# Enabling of the flow of information to support task performance
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# Monitoring
  
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The resulting model enabled the reviewers to examine the interplay between the social context of healthcare work and CPOE systems.  This research study which was a cohort of multiple studies helped create these elements and can create a structure to evaluate CPOE systems.
  
 
== References ==
 
== References ==

Latest revision as of 22:38, 7 May 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(see Searching for Evidence) for journal articles, conference proceedings, and summaries. MeSH terms (see Unified Medical Language System (UMLS) 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, they 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

Healthcare is a complex activity system of specialized and non-specialized workers, their tools, and their environment. Healthcare work involves continuous interaction among different elements and trade-offs between multiple goals, preferences, values, incentives, and motivations in the course of care processes.


A conceptual model for CPOE was created and had the following elements. The aspects of clinical workflow therefore can be categorized into four elements:

  1. Structuring of clinical tasks
  2. Coordinating of task performance
  3. Enabling of the flow of information to support task performance
  4. Monitoring

The resulting model enabled the reviewers to examine the interplay between the social context of healthcare work and CPOE systems. This research study which was a cohort of multiple studies helped create these elements and can create a structure to evaluate CPOE systems.

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/
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