Richard H. Dykstra

Types of Unintended Consequences Related to Computerized Provider Order Entry

OBJECTIVE To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation. DESIGN An expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites. METHODS Using a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences. RESULTS Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences. CONCLUSION Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

OBJECTIVE To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences. RESULTS Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature. CONCLUSION Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.

Implementing computerized physician order entry: the importance of special people

OBJECTIVE To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. 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 The theme we call Special People is explored here in detail. A taxonomy of types of Special People includes administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users. CONCLUSION The recognition and nurturing of Special People should be among the highest priorities of those implementing computerized physician order entry. Their education and training must be a goal of teaching programs in health administration and medical informatics.

Computerized provider order entry adoption: implications for clinical workflow.

ABSTRACTOBJECTIVETo identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.METHODSWe analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.RESULTSCPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.CONCLUSIONSAs CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.

Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study

BackgroundThe purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S.MethodsGuided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices.ResultsThe team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction.ConclusionsThese ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.

Rapid Assessment of Clinical Information Systems in the Healthcare Setting

OBJECTIVE Recent legislation in the United States provides strong incentives for implementation of electronic health records (EHRs). The ensuing transformation in U.S. health care will increase demand for new methods to evaluate clinical informatics interventions. Timeline constraints and a rapidly changing environment will make traditional evaluation techniques burdensome. This paper describes an anthropological approach that provides a fast and flexible way to evaluate clinical information systems. METHODS Adapting mixed-method evaluation approaches from anthropology, we describe a rapid assessment process (RAP) for assessing clinical informatics interventions in health care that we developed and used during seven site visits to diverse community hospitals and primary care settings in the U.S. SETTING Our multidisciplinary team used RAP to evaluate factors that either encouraged people to use clinical decision support (CDS) systems or interfered with use of these systems in settings ranging from large urban hospitals to single-practitioner, private family practices in small towns. RESULTS Critical elements of the method include: 1) developing a fieldwork guide; 2) carefully selecting observation sites and participants; 3) thoroughly preparing for site visits; 4) partnering with local collaborators; 5) collecting robust data by using multiple researchers and methods; and 6) analyzing and reporting data in a structured manner helpful to the organizations being evaluated. CONCLUSIONS RAP, iteratively developed over the course of visits to seven clinical sites across the U.S., has succeeded in allowing a multidisciplinary team of informatics researchers to plan, gather and analyze data, and report results in a maximally efficient manner.

Identifying Best Practices for Clinical Decision Support and Knowledge Management in the Field

To investigate best practices for implementing and managing clinical decision support (CDS) in community hospitals and ambulatory settings, we carried out a series of ethnographic studies to gather information from nine diverse organizations. Using the Rapid Assessment Process methodology, we conducted surveys, interviews, and observations over a period of two years in eight different geographic regions of the U.S.A. We first utilized a template organizing method for an expedited analysis of the data, followed by a deeper and more time consuming interpretive approach. We identified five major categories of best practices that require careful consideration while carrying out the planning, implementation, and knowledge management processes related to CDS. As more health care organizations implement clinical systems such as computerized provider order entry with CDS, descriptions of lessons learned by CDS pioneers can provide valuable guidance so that CDS can have optimal impact on health care quality.

Founding Fathers Health Corporation: Idealism and the Bottom Line

Founding Fathers Health Corporation (FFHC) is a not-for-profit healthcare organization located in the southeastern region of the United States. It includes a staff model health maintenance organization (HMO), a very successful preferred provider organization (PPO), and thirteen hospitals in three states. Colonist’s First Medical Center (CFMC) is a 460-bed hospital with 1,600 medical staff members and is one of two FFHC hospitals in a large metropolitan area in Virginia. Eighty of the physicians associated with CFMC are part of the staff model HMO, while another 120 are members of practices owned by FFHC. Although it is a very large organization, the culture is consensus-driven and characterized as “polite.” While this makes for a very pleasant work environment, it sometimes stands in the way of frank and open discussion. It is difficult to express strongly emotional or differing ideas or positions because of the backlash that could result from clashing with the polite culture. When a problem arises, there is much frustration in attempting to gain the system’s attention. Although consensus is the goal of decision making, the sheer size and scope of the organization means decisions are often made at anonymous and invisible organizational levels. Many find it difficult to find the person or office responsible for correcting a problem when a grievance arises. A tradition of promoting from within has perpetuated the culture of the “civil tongue”—placing limits on career growth for more outspoken individuals. Recently, however, FFHC has been filling more management positions with candidates from outside the organization.These newcomers are more willing to speak out and challenge the established culture. It remains to be seen whether the organizational culture will tolerate them and the change that they might represent. CFMC has been widely regarded throughout FFHC as an early adopter of electronic medical record (EMR) systems. Although it has had some notable failures in the past, it is moving to overcome its history through the establishment and support of a professional informatics department.The chief information officer (CIO), Ben Arnold, has witnessed two failed implementations in the past 5 years. Betsy Ross, R.N., M.S. with a master’s degree in informatics, has had a long history of patient advocacy. She was hired nearly 4 years ago as chief implementation officer at CFMC, shortly after CFMC suffered an embarrassing failure in a poorly planned implementation of an electronic admitting system at the hospital. Since then, Ross has worked closely with a charismatic physician, Dr. John Adams, who was then the director of medical informatics at CFMC. Together they envisioned