Paul N. Gorman

Computerized Physician Order Entry in U.S. Hospitals: Results of a 2002 Survey

OBJECTIVE To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it. DESIGN Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997. MEASUREMENTS AVAILABILITY computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer. RESULTS The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51-90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way. CONCLUSION Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.

Information needs of physicians

Quantitative estimates of physician information need reported in the literature vary by orders of magnitude. This article offers a framework for explicitly defining the types of information that clinicians use and the various states of information need on which different studies have focused. Published reports seem to be in agreement that physicians have many clinical questions in the course of patient care, but most of their questions are never answered. Examination of the clinical questions themselves reveals that they tend to be highly complex, embedded in the context of a unique patients story. The heavy reliance of physicians on human sources of information has implications for the nature of their information needs, including the narrative structure of their knowledge and the need for more than information alone when solving clinical problems. Evaluation of clinical information systems must move beyond measures of the relevance of retrieved information to assessing the extent to which information systems help practitioners solve the clinical problems they face in practice.

A Cross-site Qualitative Study of Physician Order Entry

OBJECTIVE To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals. DESIGN A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data. MEASUREMENTS Patterns and themes concerning perceptions of POE were identified. RESULTS Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions. CONCLUSION An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.

Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

OBJECTIVE Computerized physician documentation (CPD) has been implemented throughout the nations Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC. DESIGN A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital. MEASUREMENTS Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing. RESULTS Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care. CONCLUSION CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.

Distributed cognition: An alternative model of cognition for medical informatics

BACKGROUND Medical informatics has been guided by an individual-centered model of human cognition, inherited from classical theory of mind, in which knowledge, problem-solving, and information-processing responsible for intelligent behavior all derive from the inner workings of an individual agent. OBJECTIVES AND RESULTS In this paper we argue that medical informatics commitment to the classical model of cognition conflates the processing performed by the minds of individual agents with the processing performed by the larger distributed activity systems within which individuals operate. We review trends in cognitive science that seek to close the gap between general-purpose models of cognition and applied considerations of real-world human performance. One outcome is the theory of distributed cognition, in which the unit of analysis for understanding performance is the activity system which comprises a group of human actors, their tools and environment, and is organized by a particular history of goal-directed action and interaction. CONCLUSION We describe and argue for the relevance of distributed cognition to medical informatics, both for the study of human performance in healthcare and for the design of technologies meant to enhance this performance.

Perceptions of Physician Order Entry: Results of a Cross-Site Qualitative Study

OBJECTIVE To identify perspectives of success factors for implementing computerized physician order entry (POE) in the inpatient setting. DESIGN Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. RESULTS A taxonomy of ten high level themes was developed, including 1) separating POE from other processes, 2) terms, concepts, and connotations, 3) context, 4) tradeoffs, 5) conflicts and contradictions, 6) collaboration and trust, 7) leaders and bridgers, 8) the organization of information, 9) the ongoing nature of implementation, and 10) temporal concerns. CONCLUSION The identified success factors indicate that POE implementation is an iterative and difficult process, but informants perceive it is worth the effort.

Information needs in primary care: a survey of rural and nonrural primary care physicians.

OBJECTIVE To compare the self-reported information needs of rural and nonrural primary care physicians. DESIGN AND PARTICIPANTS Mail survey of active non-academic primary care physicians. DATA COLLECTION A 60 item questionnaire regarding 1) demographic and practice setting data; 2) medical information needs; 3) medical knowledge resource availability and use; and 4) physician information seeking behavior. MAIN RESULTS The response rate was higher among rural than non-rural physicians (55% vs. 42%, p< 0.001) and among Family Physicians than others (Family Medicine 53%, Internal Medicine 43%, Pediatrics 48%, p=0.015.) Rural physicians reported working more hours per week (45.3 vs. 42.7, p=0.033,) and seeing more patients per day (24.6 vs. 22.3, p=0.005) than their nonrural counterparts. Both groups reported a median of about 1 question for every 10 patients they see, with great variance among responses. Both groups reported pursuing answers to about 57% of their questions, and finding answers to about 70% of those they pursue. Knowledge resource preferences of the two groups were similar. Both groups reported frequent use of consultants, drug compendia, colleagues, and textbooks, and little use of library- or computer-based sources. Compared to nonrural physicians, rural physicians reported less frequent use of consultants, colleagues, librarians, and bound journals. These differences were small, and paralleled differences in availability. The two groups had equal access to textbooks and drug compendia, but for rural physicians, other resources were locally available significantly less often. CONCLUSIONS Rural and nonrural primary care physicians reported equal information needs, similar information seeking, and similar resource preferences. Rural physicians reported less access to some information resources, but little difference in use of resources. Further studies are needed to determine how these differences impact rural practitioners and their patients.

Outcomes From Health Information Exchange: Systematic Review and Future Research Needs

Background Health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations, has been promoted to improve the efficiency, cost-effectiveness, quality, and safety of health care delivery. Objective To systematically review the available research on HIE outcomes and analyze future research needs. Methods Data sources included citations from selected databases from January 1990 to February 2015. We included English-language studies of HIE in clinical or public health settings in any country. Data were extracted using dual review with adjudication of disagreements. Results We identified 34 studies on outcomes of HIE. No studies reported on clinical outcomes (eg, mortality and morbidity) or identified harms. Low-quality evidence generally finds that HIE reduces duplicative laboratory and radiology testing, emergency department costs, hospital admissions (less so for readmissions), and improves public health reporting, ambulatory quality of care, and disability claims processing. Most clinicians attributed positive changes in care coordination, communication, and knowledge about patients to HIE. Conclusions Although the evidence supports benefits of HIE in reducing the use of specific resources and improving the quality of care, the full impact of HIE on clinical outcomes and potential harms are inadequately studied. Future studies must address comprehensive questions, use more rigorous designs, and employ a standard for describing types of HIE. Trial Registration PROSPERO Registry No CRD42014013285; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42014013285 (Archived by WebCite at http://www.webcitation.org/6dZhqDM8t).

Investigating physician order entry in the field: Lessons learned in a multi-center study

The progress of studies by this team of researchers concerning computerized physician order entry (POE), beginning with a mail survey and moving to qualitative multi-center studies, is reviewed, with emphases on lessons learned and future directions. While mail surveys were appropriate to answer initial research questions about diffusion of POE in the U.S., multiple qualitative methods became the methods of choice for answering more complex questions. Results of the latter include articulation of multiple perspectives on both positive and negative aspects of POE and a description of what may be important for successful implementation of POE in the future. The present economic environment of hospitals may be inhibiting widespread diffusion of POE, not only because of the direct cost, but also indirectly by affecting relations with practitioners. Analysis of successful past implementations can provide guidance when the time is right.

Applying task analysis to describe and facilitate bioinformatics tasks

OBJECTIVE To document bioinformatics tasks currently per-formed by researchers in genomics and proteomics in an effort to recognize unmet informatics needs and challenges, identify system features that would enhance the performance of those tasks, and inform the development of new bioinformatics tools. DESIGN A cross-sectional study of bioinformatics tasks performed by OHSU investigators involved in genomics and proteomics research was conducted using task analysis techniques. RESULTS Four major categories emerged from 22 bioinformatics tasks reported by 6 research laboratories. These were: 1) gene analysis, 2) protein analysis, 3) biostatistical analysis, and 4) literature searching. Analysis of the data also raised the following challenging issues: 1) lack of procedural documentation, 2) use of home-grown strategies to accomplish goals, 3) individual needs and preferences, and 4) lack of awareness of existing bioinformatics tools. CONCLUSION Task analysis was effective at documenting bioinformatics tasks performed by researchers in the fields of genomics and proteomics, at identifying potentially desirable system features and useful bioinformatics tools, and at providing a better understanding of some of the unmet needs and challenges faced by these researchers.