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. [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)?



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


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


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.


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.


  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.