The Implementation of Computer Physician Order Entry, Research Paper Example

Introduction

The implementation of Computerized Physician  Order Entry is transforming healthcare system and cannot but affect the deliverers of healthcare in multiple ways, both predicted and unexpected. The main aim of CPOE introduction was to reduce the daunting number of medical errors extensively brought into light by a famous publication of To Err is Human (Institute of Medicine, 1999). The numerical data presented in the publication (an estimated 50,000 to 100,000 annual deaths attributable to medical errors) attracted national attention and induced some of America’s largest corporations to create an organization (the Leapfrog) which stimulated providers to adopt three practices which were believed to reduce errors: evidence-based referrals, intensivists in ICUs, and CPOE. However, not many hospitals leapt at the first opportunity to install CPOE. First of all, it was at first regarded as “an admission of guilt” (Bauer, 2004). In other words, to install CPOE was supposed to mean the hospital was admitting that many patients in it suffered from medical errors, often fatal. Other concerns included financial issues and staff turnover that was to be triggered by CPOE.

In 2002, only 5 percent of all hospitals reported having automated order entry despite the extensive promotion campaigns launched by academicians and policy analysts. In 2004, there was an increase in the interest to and appreciation of CPOE (Bauer, 2004). A series of annual IT surveys held by the journal Modern Healthcare showed that in 2005 there were 43 percent of hospitals who said they had a CPOE system either in operation or being implemented and 49 percent in 2006. Out of the rest 51 percent in the 2006 survey, 56 percent of respondents said they planned to implement a CPOE system within 12 months, which was up from 38% the previous year. In the 2005 survey, most hospitals who did not have CPOE explained it by the lack of finance. In 2006, however, the most popular reason given was that the hospital had other budget priorities, not cost per se (Conn, 2007).

The Leapfrog statistics are less optimistic, but they also indicate a significant upward trend. The difference in the survey results can be explained by the fact that the Leapfrog survey is stricter and measures not only the availability of CPOE in a hospital but also the compliance of the system with the Leapfrog standards. In Leapfrog’s estimation, 3.6 percent reported compliance at the end of 2003, 5.7 percent in 2005 and 8 percent in 2007 (Conn, 2007).

The experience of using CPOE allows to identify some problem areas as well as benefits of the system. The tendency for the increase means it is essential to study the nature of new interaction between healthcare providers, patients and technology and make justified conclusions before deciding whether to install CPOE in individual cases.

Traditionally, nurses have played the major role in the interaction between physicians and patients. With the implementation of automated order entry, the role of nurses has become more complex and even more critical. It can be claimed without reservations that the success of CPOE implementation depends greatly on the nurses, their skill and acceptance of the system (Ghosh, Norton, and Skiba, 2006). The nurses are at the heart of cross-disciplinary workflow processes that are immediately impacted through CPOE implementation. Nurses take a holistic view of patient care, care process, workflow analysis and change management (Ghosh, Norton, and Skiba, 2006). It is they who are to be the key catalysts in the transformation of care processes which occur as a result of CPOE implementations. The nurses’ willingness to communicate and collaborate depends on the changes brought about in the nursing profession by CPOE. These changes fall into several groups, such as physician-nurse interaction, patient-nurse interaction, new skills required from nurses, new professions created by CPOE implementations, new hospital environment.

Researching CPOE implementation and its effects on healthcare is complicated by the fact that the success of the implementation depends also on the nature of a hospital. According to Jane Metzger, research director for First Consulting Group in Boston, hospitals that are best positioned to adopt CPOE quickly are ones with clinical information systems implemented from a vendor that offers CPOE. Moreover, Metzger mentions that the success is very individual and solutions do not appear universal (Campbell, 2004).

The research Principles for a Successful Computerized Physician Order Entry Implementation by J. Ash, L. Fournier et al. suggests a system of principles based on the Multiple perspective Approach by Linstone (Linstone, 1984) adapted for CPOE implementation process. The principles are divided into Computer Technology, Personal, Organizational, and Environmental, thus the system creates the mnemonic CPOE. This framework appears effective and we will use it as the backbone for our research proposal. Computer technology principles comprise temporal concerns, meeting information needs and technology needs, multidimensional integration and costs. Personal principles are the value to users and tradeoffs, essential people, and training and support. Organizational Principles include foundational underpinnings, collaborative project management, terms, concepts and connotations, and improvement through evaluation and learning. Finally, motivation and context belong to environmental principles (Ash et al., 2003).

Purpose of the Study

• The purpose of this study is to identify the effects of CPOE implementation on the registered nurses’ bedside care.
• Specifically, the study will address the following questions:
• In what way does CPOE implementation change the hospital workflow for nurses?
• Do the changes make the nurses appreciative of CPOE implementation?
• How does nursing changed by the implementation of CPOE influence patient outcomes?

Definitions

CPOE implementation is the process of introducing Computerized Physician Order Entry (electronic entry of physician instructions for the treatment of (hospitalized) patients transmitted over a computer network to the medical staff) in hospitals.

Registered Nurse is a healthcare professional who implements nursing practice through the use of the nursing process in cooperation with other healthcare professionals.

Bedside Care is medial assistance and emotional support provided on a regular basis to hospitalized patients.

Hospital Workflow is the process of functioning of a hospital which includes delivering medical care to patients, personnel and technology occupied in the process, collaboration and project management, administrative issues etc.

Nursing is a healthcare profession which involves giving detail-oriented care to individuals, families, and communities in maintaining and recovering optimal health and functioning.

Patient Outcomes are results of medical intervention and care for patients. The preferable outcomes include full recovery, alleviating symptoms etc.

Literature Review

In order to make a research proposal for the identification of the effects of CPOE implementation on registered nurses’ bedside care, we studied a number of research articles that the necessary insights and basis for our research. The sources may be roughly grouped in the following classes: the sources which mainly provide numerical data, the sources which analyze the changes in the working environment brought about through the implementation of CPOE and are mainly based on surveys and opinion palls, and the sources which offer tools to structure the findings.

For numerical data, we used the following sources.

Inpatient Computerized Provider Order Entry. Findings from the AHRQ Health IT Portfolio. This study prepared by AHRQ National Resource Center for Health Information Technology pictures the scope of CPOE application and writes about aspirations and funding provided for the nationwide implementation of CPOE. It goes into detail about grants for CPOE installation over the USA.

A survey conducted by Modern Healthcare and presented by J. Conn (2007) provides comprehensive statistics of the application of CPOE over the last decade. Conn focuses on both the results of a series of annual studies organized by Modern Healthcare and the results of the surveys of the Leapfrog – an organization created with the aim to promote the use of CPOE. This statistics are presented in the introduction.

J.Bauer, PhD, a nationally recognized medical economists, analyzes the statistics in his work Why CPOE Must Become SOP and explains the motives for the slow speed at which hospitals are adopting CPOE and the recent increase in the number of implementations.

1. Campbell in CPOE: Promise and Progress concentrates on the statistics of the Leapfrog and describes some measures to support the integration of CPOE. She also touches upon financial aspects of CPOE implementation saying that it “can cost anywhere from $500,000 to $15 million, depending upon the size of the hospital and the status of its existing information system” (Campbell, 2007).

For the listing and analyses of benefits and negative aspects of CPOE implementation, the following articles were consulted.

Aarts J., Ash J., Berg M. (2007). Extending the Understanding of Computerized Physician Order Entry: Implications for Professional Collaboration, Workflow and Quality of Care. This research is closely related to our work as it studies the effects of CPOE on the professional environment, workflow and the quality of healthcare. It is based on the interviews with professionals engaged in CPOE implementation. The study revealed a multidimensional nature of CPOE. The authors found that measuring the impact of CPOE on the quality of care is challenging and depends greatly on how orders are created and processed and how well is CPOE integrated in the workflow. The study indicated a special risk area associated with hand-offs in the workflow.

Ash, J.S., Sittig, D.F., Seshadri, V., Dykstra, R.H., Carpenter, J.D., Stavri, P.Z. (2005). Adding Insight: A Qualitative Cross-Site Study of Physician Order Entry.

This study reviews the results of a 7-year qualitative study of CPOE implementation in successful hospitals. The study is invaluable because it is dedicated to identifying success factors for implementing CPOE and appears very practical in terms of the growth in CPOE implementation. The authors elaborated on the research strategies in the field and worked out the twelve principles of CPOE estimation which we chose as a framework for our research.

Ash, J.S., Stavri, P.Z., Dykstra, R.H., Fournier, L. (2004). Implementing Computerized Physician Order Entry: The Importance of Special People.

This research is closer to our immediate theme as it investigates the role of people on the successful implementation of CPOE. The research introduces the term Special People implying “administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users”,  (Ash et al., 2004). The authors are convinced that recognition and nurturing of Special People should be at the heart of CPOE implementation campaigns. Moreover, they feel that health administration and medical informatics must concentrate on educating and training the staff to prepare it for the challenge.

Bates, D.W. (2005). Computerized Physician Order Entry and Medication Errors: Finding a Balance.

This research focuses on the extent to which CPOE copes with its primary goal ­– reducing and eliminating the number of medication errors. It appears that although some of the errors can be perfectly avoided with the help of CPOE (errors associated with timing and access, for instance), new errors stem directly from CPOE usage (mainly technology handling issues). A group of errors is still unaffected with CPOE (diagnosis and prescription errors). The research is necessary for us to estimate patient outcomes.

Berger, R.G., Kichak, J.P. (2004). Computerized Physician Order Entry: Helpful or Harmful?

The authors doubt the benefits of CPOE implementation. They say that the promise of CPOE implementation stems mainly from the shocking article of the Institute of Medicine To Err Is Human (1999) which revealed the number of fatal medical errors and is based on the presumption that the situation cannot be worse. However, the authors insist on the increased risk of adverse drug events associated with the implementation of CPOE, despite claims to the contrary. They also emphasize the problem of affordability and financial prioritizing in the aspect of CPOE implementation.

Beuscar-Zephir, M.C., Pelayo, S., Anceaux, F., Meaux, J-J., Degroisse, M., Degoulet, P. (2005). Impact of CPOE on Doctor-Nurse Cooperation for the Medication Ordering and Administration Process.

This study focuses on one of the key aspects of our research – physician-nurse communication in respect to CPOE implementation. The research compared the work situations in a hospital which is still using paper-baser orders, a hospital which is currently implementing CPOE, and a hospital which has patient care information system installed. The results for the paper-based situation indicated synchronous physician-nurse cooperation with a distributed decision-making relying mostly on verbal communication. Paper order sheets fail to support the documentation task and are weakly structured. The computer situation allows physicians and nurses to work asynchronously, their actions are coordinated by the system. Although data is thoroughly documented, misinterpretations occur sometimes. Some problems derive from usability flaws of the human computer interface. The authors suggest usability improvement of CPOE and give some recommendations as to organizing doctor-nurse communication.

Callen, J., Braithwaite, J., Westbrook, J.I. (2007). Cultures in Hospitals and their Influence on Attitudes to, and Satisfaction with, the Use of Clinical Information Systems.

This study concentrates on the correlation between working environment in a hospital and the success of CPOE system. The authors found a relationship between work culture and the attitudes of healthcare deliverers to CPOE. The personnel of hospitals with constructive culture were more likely to express positive attitudes towards CPOE, whereas those in the aggressive/defensive hospitals were more likely to be negative. The practical aspect unfolded by the research is importance of considering the initial hospital culture before prognosis the success of CPOE implementation.

Coleman, R.W. (2004). Translation and Interpretation: The Hidden Processes and Problems Revealed by Computerized Physician Order Entry Systems.

This research highlights the benefits of CPOE implementation claiming that even the most primitive CPOE variants can reduce medication error rates, improve the quality of healthcare and in the long run even decrease the costs. According to the author, the main advantage of CPOE lies in the fact that it facilitates the routine tasks of decryption, triage, transcription, and transmission. However, translation of physician intent into actual orders and sophisticated interpretations require more advanced computer systems.

Ghosh, T., Norton, M., Skiba, D. (2006). Communication, Coordination and Knowledge Sharing in the Implementation of CPOE: Impact on Nursing Practice.

This study gives us valuable insights into the effects of CPOE on nursing practice. The authors conducted a series of key informant interviews with nursing leaders using multiple interview formats. Nurses feel that it is critical for them to take part in design and implementation planning so that their concerns would be considered. They become powerful allies in facilitating CPOE adoption among physicians if they can articulate the benefits such as legibility and improved communication to patient care. The planning team must take time to define nursing processes in actualizing physician order that are rendered obsolete by CPOE and new processes which are involved in CPOE operation to give the nurses a clear picture of advantages and disadvantages. It is essential that the process be collaborative and balanced.

Guappone, K.P., Ash, J.S., Sittig, D.F. (2008) Field Evaluation of Commercial Computerized Provider Order Entry Systems in Community Hospitals.

This study focuses on human computer interface usability. The authors attribute low user acceptance of CPOE mainly to technological problems. They suggest that field usability testing should be “considered in all institutions implementing CPOE or other clinical computer applications as a means of improving the usability and acceptance of those systems” (Guappone et al., 2008).

Kaushal, R., Bates, D.W. (2004). Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs).

This study is very important for us because it gives numerical data on medication errors after the implementation of CPOE. The figures presented in the research are 55 percent decrease in serious medication errors and 17 percent decrease in preventable adverse drug events as a secondary outcome which is not regarded statistically significant. The types of errors unaffected by the implementation of CPOE include missed dose errors and non-intercepted serious medication errors.

Kuperman, G.J., Gibson, R.F. (2004). Computer Physician Order Entry: Benefits, Costs, and Issues.

This study focuses mainly on the reduction of medical errors and financial aspects of CPOE implementation. However, it marks some important features concerning the acceptance of CPOE by the personnel. The authors insist that CPOE should not be the first computerized clinical system attempted by an organization since mastering it often appears challenging for both physicians and nurses. Many physicians are reported to have expressed concern about the time burden of ordering with CPOE. They would rather prefer direct communication with the nurses. The authors encourage healthcare providers to overcome the teething problems of CPOE implementation and enjoy the increased efficiency it can offer.

Pirnejad, H., Niazkhani, Z., Sijs, H., Berg, M., Bai, R. (2008). Impact of a Computerized Physician Order Entry System on Nurse-Physician Collaboration in the Medication Process.

This study evaluates the effects of CPOE on physicians and nurses collaboration. The attitudes of nurses towards the effectiveness of the paper-based system in comparison to the computer-based system were estimated with the help of questionnaires. Only 52 percent of the nurses considered computer systems effective, while 54 percent supported paper-based system. Specifically, the nurses said that while CPOE improved the main non-supportive features of paper-based system, it lacked the main supportive features of it. The research revealed that the nurses mostly suffered from synchronization and feedback mechanisms impaired by the introduction of CPOE systems.

Sittig, D.F., Krall, M., Kaalaas-Sittig, J., Ash, J.S. (2005). Emotional Aspects of Computer-based Provider Order Entry: A Qualitative Study.

This qualitative study is devoted to the emotions surrounding CPOE implementation and use. It is based on a secondary analysis of several previously collected qualitative data sets from interviews and observations of over 50 individuals. Although the research found out examples of positive and neutral emotions, negative ones prevailed. The authors attribute low acceptance of CPOE among physicians and nurses to imperfect computer interface and faulted implementation strategies.

Finally, the last group of sources gives us the research instrumentation for constructing research design.

Ash, J.S., Fournier, L., Stavri, Z., Dykstra, R. (2004). Principles for a Successful Computerized Physician Order Entry Implementation.

This is the research in which the principles of estimating CPOE implementation mentioned in the Introduction were presented. The principles fall into four categories: computer technology, personal, organizational and environmental. The research is based on observing four hospitals with successful CPOE implementations (having over 80 percent of orders entered this way). The main methods were ethnographic observation and interviews. The interviews were primarily oral history interviews with administrators, physicians and nurses.

Linstone, H. A. (1984). Multiple Perspectives for Decision Making: Bridging the Gap Between Analysis and Action.

In this work, a general framework was developed to be later used by J.S. Ash et al for a specific framework of CPOE implementation principles.

This theoretical model describes the nature of hospital interaction influenced by the implementation of CPOE. The interaction between nurses and patients has not been marked as a problem area in the researches this work is based on. However, the collaboration between physicians and nurses is reported to have impaired. Also, many problems have arisen in the field of computer-human interaction both on the parts of physicians and nurses. Problematic interaction is marked with red arrows in contrast to black errors which mark effective interaction.

The operational model that follows presents the aspects of the comprehensive research of the effects of CPOE implementation on nursing to be conducted and ways to measure them. As can be seen, the research mostly relies on oral interviews and questionnaires to be analyzed afterwards.

Protection of Participants’ Rights

All the participants in the research will be granted full safeguard of their rights, safety, and well-being by the IRB. The IRB will be composed of scientists, non-scientists and community representatives. First, the IRB will review the research proposal for the issues involving human subjects. The IRB will also specify the intent of the research and publicity it can gain. They also will make sure whether the outcome of the study will be reported as a means to disseminate knowledge and advance the field. Since the research is to involve only interviews and is no way connected with medical experimenting, the IRB will only need to make sure confidentiality of data is maintained. According to IRB practice and regulation, no consents should be obtained from the participants in this case.

Tool Description

The research is to estimate the quality of nursing care as affected by CPOE implementation. The quality of care includes the difficulties faced by the nurses, the skills they have to master as well as their motivation and environment in which they work. It is presumably most effective to obtain the information directly from nurses. In this respect, we choose oral interviews as the main method of collecting data. On completing the interviews, we will use qualitative data research software such as XSIGHT, a widely recognized tool for qualitative research analysis, to help us process the data.

To measure the patient outcomes, which are an integral part of the notion of quality of healthcare, we can turn to available statistics for each organization.

Research Design

As the first issue of concern is CPOE implementation, we must first define the extent to which CPOE is used in a particular hospital. As very few hospitals have 100 percent of their order automated, a figure of 80 percent would be enough to regard the institution as using CPOE. This information is easily obtained from any official source on the hospital, including hospital administration.

The statistics for patient outcomes may be less accessible. However, since the research is first of all aimed at nursing, we may rely on the opinions of interviewed nurses about the effectiveness of CPOE systems.

Nurses are to be interviewed according to the pattern presented in the operational scheme. Beforehand, the nurses must be made aware of their rights protected by IRB and full confidentiality of their accounts.

After that, the information is to be processed as has been described above and a report must follow to lay out the findings on the influence of CPOE on the nurses’ bedside care.

The internal validity of the research may be threatened by the imperfect system of patient outcomes identification based on the nurses’ accounts. More reliable statistical data is desirable.

Population and Sample

The population involved in the research is registered nurses working with CPOE on regular basis. For this research, a random selection of participants is preferable. If we interview only nursing leaders, the sample would not be completely representative of the survey population since leaders are likely to be less involved in primary nursing care and to be more engaged in administrative work and we are interested in the effects of CPOE implementation on direct practitioners. However, even the random selection does not guarantee complete representation of target population by the survey population. The reason for it is high dependability of the success of CPOE implementation on the overall nature of hospital and the individual nature of solutions – the factors which have been mentioned above.

Data Collection

The data will be collected through direct interviewing of registered nurses working with CPOE by the researchers. While it is necessary to give the research team recommendations on how to conduct interviews, the participants need no training and should only be encouraged to answer openly.

Summary

In conclusion, we would like to say that this research can give valuable insights in the effects of CPOE implementation on nursing care due to its comprehensive nature. It not only measures specific areas like physician-nurse collaboration, but is designed to estimate computer-nurse interaction and the effects on general hospital environment. The study is very important in the view of the increasing use of CPOE as it will help to develop effective policies that will not allow the new practice to appear counterproductive.

References

AHRQ National Resource Center for Health Information Technology. Inpatient Computerized Provider Order Entry. Agency for Healthcare Research and Quality. Retrieved April 14, 2009, from http://healthit.ahrq.gov/images/jan09cpoereport/cpoe_issue_paper.htm

Aarts J., Ash J., Berg M. (2007). Extending the Understanding of Computerized Physician Order Entry: Implications for Professional Collaboration, Workflow and Quality of Care. International Journal of Medical Informatics, 76, supplement 1, S4-S13.

Ash, J.S., Fournier, L., Stavri, Z., Dykstra, R. (2004). Principles for a Successful Computerized Physician Order Entry Implementation. American Medical Informatics Association Annual Symposium Proceedings Archive. Retrieved April 14, 2009, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14728129

Ash, J.S., Sittig, D.F., Seshadri, V., Dykstra, R.H., Carpenter, J.D., Stavri, P.Z. (2005). Adding Insight: A Qualitative Cross-Site Study of Physician Order Entry. International Journal of Medical Informatics, 74 (7-8), 623-628.

Ash, J.S., Stavri, P.Z., Dykstra, R.H., Fournier, L. (2004). Implementing Computerized Physician Order Entry: The Importance of Special People. International Journal of Medical Informatics, 69 (2-3), 235-250.

Bates, D.W. (2005). Computerized Physician Order Entry and Medication Errors: Finding a Balance. Journal of Biomedical Informatics, 38 (4), 259-261.

Bauer, J.C. (2004).  Why CPOE Must Become SOP. Journal of Healthcare Information Management, 18 (1), 9-10.

Berger, R.G., Kichak, J.P. (2004). Computerized Physician Order Entry: Helpful or Harmful? Journal of the American Medical Informatics Association, 11 (2), 100-103.

Beuscar-Zephir, M.C., Pelayo, S., Anceaux, F., Meaux, J-J., Degroisse, M., Degoulet, P. (2005). Impact of CPOE on Doctor-Nurse Cooperation for the Medication Ordering and Administration Process. International Journal of Medical Informatics, 74 (7-8), 629-641.

Callen, J., Braithwaite, J., Westbrook, J.I. (2007). Cultures in Hospitals and their Influence on Attitudes to, and Satisfaction with, the Use of Clinical Information Systems. Social Science and Medicine, 65 (3), 635-639.

Cambell, S., CPOE: Promise and Progress. Physicians Practice. Retrieved April 13, 2009, from http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/373/page/2.htm

Coleman, R.W. (2004). Translation and Interpretation: The Hidden Processes and Problems Revealed by Computerized Physician Order Entry Systems. Journal of Critical Care, 19 (4), 279-282.

Conn, J. (2007). CPOE Adoption Slowly Gaining Ground: Survey. Modern Healthcare. Retrieved April 12, 2009, from http://www.modernhealthcare.com/article/20070319/FREE/70319001

Ghosh, T., Norton, M., Skiba, D. (2006). Communication, Coordination and Knowledge Sharing in the Implementation of CPOE: Impact on Nursing Practice. American Medical Informatics Association Annual Symposium Proceedings Archive. Retrieved April 14, 2009, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839469

Guappone, K.P., Ash, J.S., Sittig, D.F. (2008) Field Evaluation of Commercial Computerized Provider Order Entry Systems in Community Hospitals. American Medical Informatics Association Annual Symposium Proceedings Archive. Retrieved April 12, 2009, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18998909

Kaushal, R., Bates, D.W. (2004). Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs). Agency for Healthcare Research and Quality. Retrieved April 14, 2009, from http://www.ahrq.gov/clinic/ptsafety/chap6.htm

Kuperman, G.J., Gibson, R.F. (2004). Computer Physician Order Entry: Benefits, Costs, and Issues. Annals of Internal Medicine. Retrieved April 13, 2009, from http://www.annals.org/cgi/content/full/139/1/31

Linstone, H. A. (1984). Multiple Perspectives for Decision Making: Bridging the Gap Between Analysis and Action. New York: North Holland

Pirnejad, H., Niazkhani, Z., Sijs, H., Berg, M., Bai, R. (2008). Impact of a Computerized Physician Order Entry System on Nurse-Physician Collaboration in the Medication Process. International Journal of Medical Informatics, 77 (11), 735-744.

Sittig, D.F., Krall, M., Kaalaas-Sittig, J., Ash, J.S. (2005). Emotional Aspects of Computer-based Provider Order Entry: A Qualitative Study. Journal of the American Medical Informatics Association, 12 (5), 561-567.

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