Computerized physician order entry (CPOE) system ... - share
Computerized physician order entry (CPOE) system ... - share Computerized physician order entry (CPOE) system ... - share
J.E. van Doormaal et al.CPOE: expectations and experiencesNumber of respondents161412108642PhysiciansNursesFigure 2 Overall attitude of physicians/nurses towards computerized physicianorder entry system (CPOE).0Fine (no needfor changes)Moderate(there are stillsome bugs)NeutralHasconstraintsDoes not meettherequirementsTable 2 Expectations and experiences with computerized physician order entry system (CPOE)PhysiciansNursesBy the introduction of CPOE ...Expectations*(n = 10) (%)Experiences*(n = 8) (%)P value †Expectations*(n = 23) (%)Experiences*(n = 19) (%)P value †Positive statementsFewer errors in prescribing 100 75 0.09 83 68 0.28A new medication order is sooner known to the nurses 40 50 0.67 26 42 0.27A better overview of patients’ medication use 90 88 0.87 61 37 0.12A good support for preventing of drug–drug interactions 80 50 0.18 96 74 0.04More clear which medication/dosage the patient should get – ‡ – ‡ – 87 84 0.80The system is user-friendly enough to prescribe in an – ‡ 88% – – ‡ – ‡ –efficient wayNegative statementsMany (colleague) physicians do not handle the system well, 30 50 0.39 44 74 0.05which causes problemsMany (colleague) nurses do not handle the system well, 50 13 0.09 48 32% 0.29which causes problemsPrescribing takes a lot of time 70 13 0.02 – ‡ – ‡ –There are still many technical glitches 80 63 0.41 87 47 0.01*Expressed as percentage agreeing [positive is defined as scores 4 and 5 on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree)].†P values refer to chi-squared tests for nominal variables.‡Not asked.This was found both before (expectations) and after (experiences)the implementation of CPOE. Less technical glitches were experiencedthan expected, although these glitches are still consideredto be a problem.Physicians and nursesNo significant differences between the views of physicians andnurses were identified except for the overview they had of patients’medication use in CPOE which nurses experienced as not good incontrast to the physicians who experienced it as good.No significant differences were identified in the sum score ofpositive views towards CPOE (mean of the number positiveanswered items) before and after the implementation for physicians(mean before = 4.80, mean after = 5.25, P = 0.46) and fornurses (mean before = 4.74, mean after = 4.53, P = 0.63). Therewere also no differences between professions in their overall positiveexpectations (mean physicians = 4.80, mean nurses = 4.74,P = 0.91) nor in their overall positive experiences (mean physicians= 5.25, mean nurses 4.53, P = 0.20).The respondents in both hospitals were satisfied with theimplementation process, despite the different approaches used(Table 3). Most of the physicians and nurses reported to be sufficientlyprepared to start working with the system. Most professionalspresent during the implementation process were satisfiedwith the availability and the available support of the implementationteam.In Box 1 the most frequently mentioned advantages and disadvantagesof CPOE are listed. According to the respondents thesystem improved the efficiency of the medication process andimproved the readability of the prescriptions. However, there werestill many technical glitches.© 2010 Blackwell Publishing Ltd 741
CPOE: expectations and experiencesJ.E. van Doormaal et al.Table 3 Experiences with the implementation processPhysicians (n = 8) Nurses (n = 19)You were sufficiently prepared to work with the system? 75%* 90%*Only for persons who were working at the ward during the implementation (n = 4) (n = 18)There was enough support from the implementation team during the implementation phase. 100%* 94%*The implementation team was sufficiently available to give support. 100%* 94%**Expressed as percentage agreeing (positive is defined as scores 4 and 5 on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).Box 1 Most listed advantages and disadvantages of CPOEAdvantagesDisadvantages‘System gives a good overview of used medication’ (13 times)‘System is efficient’ (13 times)‘Readability is improved’ (11 times)‘Fewer medication errors than before’ (9 times)‘Introduction of CPOE results in better logistics’ (only UMCG) (7 times)‘Clinical decision support is incorporated’ (6 times)‘Still many technical glitches’ (9 times)‘Dependence on physicians’ (only nurses) (6 times)‘System does not give a good overview of used medication’ (6 times)‘Too many irrelevant drug–drug interactions’ (3 times)‘It is a slow system’ (3 times)‘Logistics got worse’ (only TSh) (2 times)DiscussionPhysicians and nurses were more positive about CPOE than thepaper-based medication ordering system. They were also satisfiedwith the way the system was implemented. In general, their ideasabout CPOE before implementation were comparable to theirexperiences. Even before implementation, a high degree of acceptanceof CPOE existed on the work floor which undoubtedlyfacilitated the actual implementation and adoption. Coupled withthe view of professionals that the paper-based system was outdated,this provides good conditions for change [12]. At the sametime we have to bear in mind that the use of CPOE was decided atthe top of the organization and once implemented there was nochoice at the work floor whether to use CPOE or not.The most surprising difference between expectations and experiencesis with respect to the time investment of prescribing. Prescribingby use of CPOE took less time than the physiciansthought it would take. This is in contrast to earlier studies showingthat physicians were annoyed with the additional time required forcomputerized prescribing in comparison with the handwritten wayof prescribing [13,14]. Our more positive findings may beexplained by the more user-friendly interfaces that are being usednowadays in comparison with the systems in the 1990s describedin earlier studies.In contrast to physicians, nurses were negative about the overviewthey had of patients’ medication use in CPOE. According tothem these overviews were not clear. This is certainly a point ofinterest, because it affects the work process of nurses in a negativeway and it can lead to medication errors. Furthermore, the nurseswere negative about the way physicians handled CPOE. This maybe caused by a change in the way nurses and physicians collaboratesince the introduction of CPOE as has been described elsewhere[8,15]. It is known that in paper-based systems, nursesand physicians interact more easily and efficiently with respectto patient’s condition and medication [8]. In the CPOEsystem such interaction is less easy because it separates thework of physicians from that of nurses; the prescribing phase takesplace behind a computer with less feedback or information fromnurses. Nurses become more dependent on the way physiciansprescribe and they have less opportunity to correct physicians’actions.This study showed that the decision support on drug–drug interactionsin CPOE needs more attention. Because in the paper-basedsystem there was limited decision support during the prescribingphase, nurses’ and physicians’ expectations about decision supportwere high. However, these expectations were not met. The mainreason is the generation of too many safety alerts which are notappropriate for the hospital setting. Improvement is needed before‘alert fatigue’ occurs, which can lead to ignorance of importantalerts besides the unimportant ones [16]. Future research shouldinvestigate what the best approach is, as turning off alerts hospitalwidecan be problematic because of differences in clinical relevancefor the various medical specialties and differences inknowledge [17].Despite the difference in strategies for implementing CPOEbetween both hospitals, physicians and nurses from both hospitalswere satisfied with the duration and quantity of the support givenby the implementation team. This suggests that both strategieswere adequate approaches to implement CPOE, at least well fittedin their context.The main limitation of this study is the difference in studysample before and after the implementation of CPOE, i.e. fewrespondents were interviewed twice. Another limitation is the useof a convenience sample instead of a randomized sample. It ispossible that our respondents were more willing to participatethan other users because they had a clear view towards CPOE,whether positive or negative. A strength of our study is thesetting of two hospitals (a university and a teaching hospital)with two different CPOE systems. This enhances the generalizabilityof our results.Despite the positive experiences with CPOE, the system doesnot function optimally yet. Based on the results of this study a742© 2010 Blackwell Publishing Ltd
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J.E. van Doormaal et al.<strong>CPOE</strong>: expectations and experiencesNumber of respondents161412108642PhysiciansNursesFigure 2 Overall attitude of <strong>physician</strong>s/nurses towards computerized <strong>physician</strong><strong>order</strong> <strong>entry</strong> <strong>system</strong> (<strong>CPOE</strong>).0Fine (no needfor changes)Moderate(there are stillsome bugs)NeutralHasconstraintsDoes not meettherequirementsTable 2 Expectations and experiences with computerized <strong>physician</strong> <strong>order</strong> <strong>entry</strong> <strong>system</strong> (<strong>CPOE</strong>)PhysiciansNursesBy the introduction of <strong>CPOE</strong> ...Expectations*(n = 10) (%)Experiences*(n = 8) (%)P value †Expectations*(n = 23) (%)Experiences*(n = 19) (%)P value †Positive statementsFewer errors in prescribing 100 75 0.09 83 68 0.28A new medication <strong>order</strong> is sooner known to the nurses 40 50 0.67 26 42 0.27A better overview of patients’ medication use 90 88 0.87 61 37 0.12A good support for preventing of drug–drug interactions 80 50 0.18 96 74 0.04More clear which medication/dosage the patient should get – ‡ – ‡ – 87 84 0.80The <strong>system</strong> is user-friendly enough to prescribe in an – ‡ 88% – – ‡ – ‡ –efficient wayNegative statementsMany (colleague) <strong>physician</strong>s do not handle the <strong>system</strong> well, 30 50 0.39 44 74 0.05which causes problemsMany (colleague) nurses do not handle the <strong>system</strong> well, 50 13 0.09 48 32% 0.29which causes problemsPrescribing takes a lot of time 70 13 0.02 – ‡ – ‡ –There are still many technical glitches 80 63 0.41 87 47 0.01*Expressed as percentage agreeing [positive is defined as scores 4 and 5 on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree)].†P values refer to chi-squared tests for nominal variables.‡Not asked.This was found both before (expectations) and after (experiences)the implementation of <strong>CPOE</strong>. Less technical glitches were experiencedthan expected, although these glitches are still consideredto be a problem.Physicians and nursesNo significant differences between the views of <strong>physician</strong>s andnurses were identified except for the overview they had of patients’medication use in <strong>CPOE</strong> which nurses experienced as not good incontrast to the <strong>physician</strong>s who experienced it as good.No significant differences were identified in the sum score ofpositive views towards <strong>CPOE</strong> (mean of the number positiveanswered items) before and after the implementation for <strong>physician</strong>s(mean before = 4.80, mean after = 5.25, P = 0.46) and fornurses (mean before = 4.74, mean after = 4.53, P = 0.63). Therewere also no differences between professions in their overall positiveexpectations (mean <strong>physician</strong>s = 4.80, mean nurses = 4.74,P = 0.91) nor in their overall positive experiences (mean <strong>physician</strong>s= 5.25, mean nurses 4.53, P = 0.20).The respondents in both hospitals were satisfied with theimplementation process, despite the different approaches used(Table 3). Most of the <strong>physician</strong>s and nurses reported to be sufficientlyprepared to start working with the <strong>system</strong>. Most professionalspresent during the implementation process were satisfiedwith the availability and the available support of the implementationteam.In Box 1 the most frequently mentioned advantages and disadvantagesof <strong>CPOE</strong> are listed. According to the respondents the<strong>system</strong> improved the efficiency of the medication process andimproved the readability of the prescriptions. However, there werestill many technical glitches.© 2010 Blackwell Publishing Ltd 741
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