Linda W. P. Peute

Anatomy of a failure: A sociotechnical evaluation of a laboratory physician order entry system implementation

OBJECTIVE To investigate the human, social and organizational issues surrounding a Computerized Physician Order Entry system for Laboratory ordering (CPOE-L) implementation process and to analyze their interrelated effects on the system implementation failure in an academic medical setting. Second, to provide lessons learned and recommendations on to how to manage challenges of human, social and organizational nature surrounding CPOE-L implementations. METHODS The themes surrounding CPOE introduction were identified by a heuristic analysis of literature on CPOE implementations. The resulting set of themes was applied as a reference model for 20 semi-structured interviews conducted during the CPOE-L implementation process with 11 persons involved in the CPOE-L project and in reviewing all CPOE-L related project documentation. Data was additionally gathered by user questionnaires, by user discussion rounds and through an ethnographical study performed at the involved clinical and laboratory departments. In analyzing the interview transcripts, project documentation and data from user questionnaires and discussion rounds a grounded theory approach was applied by the evaluation team to identify problem areas or issues deserving further analysis. RESULTS Outlined central problem areas concerning the CPOE-L implementation and their mutual relations were depicted in a conceptual interpretative model. Understanding of clinical workflow was identified as a key theme pressured by organizational, human and social issues ultimately influencing the entire implementation process in a negative way. Vast delays in CPOE introduction, system immaturity and under-functionality could all be directly attributed to a superficial understanding of workflow. Consequently, final CPOE integration into clinical and laboratory workflows was inhibited by both end-users as well as department managers and withdrawal of the CPOE-L system became inevitable. CONCLUSION This case study demonstrates which human, social and organizational issues relevant to CPOE implementation cumulatively led to a failure outcome of the CPOE-L pilot introduction. The experiences and considerations described in this paper show important issues for CPOE systems to be successfully introduced and to be taken into account in future CPOE implementations. Understanding and consideration of (clinical) workflow aspects by project managers and the involved clinical organization is of extreme importance from the very start of a CPOE implementation process.

Factors influencing implementation success of guideline-based clinical decision support systems: A systematic review and gaps analysis

OBJECTIVE To provide an integrated and differentiated understanding of factors influencing guideline-based CDSS implementation and illustrate the gaps in the current literature. MATERIALS AND METHODS A systematic literature review and in-depth exploration of factors impeding or facilitating successful implementation of guideline-based CDSS supporting physicians in clinical decision-making was performed. Factors were identified thematically by textual analysis of the included publications and were individually mapped to the human, organization and technology-fit (HOT-fit) framework for evaluating implementations of health information systems. RESULTS A total of 421 factors were found in 35 included publications from a total of 3676 publications. The mapping of factors concerning CDSS implementation on the HOT-fit framework revealed gaps in each domain of the framework and showed that research has mainly focused on human and technology factors and less on organizational factors. CONCLUSIONS Future research within the field of guideline-based CDSS should focus on evaluating implementations through the use of socio-technical models to study guideline-based CDSS system implementations from a multidimensional view. Furthermore, research is needed to explore whether use of these models during the planning phases of a CDSS project is useful in anticipating and preventing implementation barriers from occurring and exploiting facilitators to a successful implementation of the system.

A Concise and Practical Framework for the Development and Usability Evaluation of Patient Information Websites

BACKGROUND The Website Developmental Model for the Healthcare Consumer (WDMHC) is an extensive and successfully evaluated framework that incorporates user-centered design principles. However, due to its extensiveness its application is limited. In the current study we apply a subset of the WDMHC framework in a case study concerning the development and evaluation of a website aimed at childhood cancer survivors (CCS). OBJECTIVE To assess whether the implementation of a limited subset of the WDMHC-framework is sufficient to deliver a high-quality website with few usability problems, aimed at a specific patient population. METHODS The website was developed using a six-step approach divided into three phases derived from the WDMHC: 1) information needs analysis, mock-up creation and focus group discussion; 2) website prototype development; and 3) heuristic evaluation (HE) and think aloud analysis (TA). The HE was performed by three double experts (knowledgeable both in usability engineering and childhood cancer survivorship), who assessed the site using the Nielsen heuristics. Eight end-users were invited to complete three scenarios covering all functionality of the website by TA. RESULTS The HE and TA were performed concurrently on the website prototype. The HE resulted in 29 unique usability issues; the end-users performing the TA encountered eleven unique problems. Four issues specifically revealed by HE concerned cosmetic design flaws, whereas two problems revealed by TA were related to website content. CONCLUSION Based on the subset of the WDMHC framework we were able to deliver a website that closely matched the expectancy of the end-users and resulted in relatively few usability problems during end-user testing. With the successful application of this subset of the WDMHC, we provide developers with a clear and easily applicable framework for the development of healthcare websites with high usability aimed at specific medical populations.