The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

STUDY OBJECTIVE: We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). METHODS: We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. RESULTS: We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). CONCLUSION: There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care.

An ICU clinical information system - clinicians' expectations and perceptions of its impact.

The Intensive Care Unit (ICU) is an information intense environment where Clinical Information Systems (CISs) can greatly impact patient care and the workload of clinicians. With the introduction of an ICU CIS imminent across New South Wales hospitals, we aimed to understand how ICU clinicians perceived a new system would impact on work practices in Australian ICUs, as much of the current evidence is generated from overseas. We conducted interviews with 66 doctors and nurses in 3 ICUs without a CIS. Many had positive perceptions regarding the impact of its introduction, though others were more guarded and unsure. Clinicians believed information access to patient would improve, communication processes could potentially change and there was potential for work processes to be more efficient. It was expected that ward rounds and handover would be less disrupted with all information available at the bedside or at the handover setting. There were mixed responses about whether a CIS would save time and how it would influence patient care, though the majority believed a CIS would improve safety by providing a means for increasing accountability and reducing medication errors. Concerns were raised about the transition from paper to a CIS and the training required. This information provides valuable evidence in the Australian setting regarding clinicians' expectations of a new ICU CIS to assist with future implementations. It also provides baseline data as a foundation for future research once the CIS is implemented. It is clear that robust quantitative studies are required to gain a detailed understanding of how a new CIS will impact clinicians' work processes and that appropriate training is crucial for full benefits to be achieved.

How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals.

BACKGROUND: Time nurses spend with patients is associated with improved patient outcomes, reduced errors, and patient and nurse satisfaction. Few studies have measured how nurses distribute their time across tasks. We aimed to quantify how nurses distribute their time across tasks, with patients, in individual tasks, and engagement with other health care providers; and how work patterns changed over a two year period. METHODS: Prospective observational study of 57 nurses for 191.3 hours (109.8 hours in 2005/2006 and 81.5 in 2008), on two wards in a teaching hospital in Australia. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied. Proportions of time in 10 categories of work, average time per task, time with patients and others, information tools used, and rates of interruptions and multi-tasking were calculated. RESULTS: Nurses spent 37.0%[95%CI: 34.5, 39.3] of their time with patients, which did not change in year 3 [35.7%; 95%CI: 33.3, 38.0]. Direct care, indirect care, medication tasks and professional communication together consumed 76.4% of nurses' time in year 1 and 81.0% in year 3. Time on direct and indirect care increased significantly (respectively 20.4% to 24.8%, P < 0.01;13.0% to 16.1%, P < 0.01). Proportion of time on medication tasks (19.0%) did not change. Time in professional communication declined (24.0% to 19.2%, P < 0.05). Nurses completed an average of 72.3 tasks per hour, with a mean task length of 55 seconds. Interruptions arose at an average rate of two per hour, but medication tasks incurred 27% of all interruptions. In 25% of medication tasks nurses multi-tasked. Between years 1 and 3 nurses spent more time alone, from 27.5%[95%CI 24.5, 30.6] to 39.4%[34.9, 43.9]. Time with health professionals other than nurses was low and did not change. CONCLUSIONS: Nurses spent around 37% of their time with patients which did not change. Work patterns were increasingly fragmented with rapid changes between tasks of short length. Interruptions were modest but their substantial over-representation among medication tasks raises potential safety concerns. There was no evidence of an increase in team-based, multi-disciplinary care. Over time nurses spent significantly less time talking with colleagues and more time alone.

Innovation in intensive care nursing work practices with PACS.

Doctors are the main users of x-rays and other medical images in hospitals and as such picture archive and communication systems (PACS) have been designed to improve their work processes and clinical care by providing them with faster access to images. Nurses working in intensive care units (ICUs) also access images as an integral part of their work, yet no studies have examined the impact of PACS on the work of intensive care nurses. Our study aimed to examine whether and how ICU nurses view and use images and whether access to PACS promotes innovation in work practices. We interviewed (n=49) and observed (n=23) nurses in three Australian metropolitan teaching hospital ICUs with varying degrees of PACS implementation. Our study found that nurses with access to PACS were able to independently and easily access images, did so more frequently when required, and perceived that this had the potential to positively impact upon patient safety. Those without PACS usually viewed images more traditionally as part of a ward round. The introduction of PACS to ICU settings promotes changes in nursing work practices by providing nurses with the ability to act more autonomously, with the potential to enhance patient care.

Does PACS facilitate work practice innovation in the intensive care unit?

Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to clinicians at the point-of-care, supporting quicker decision-making. PACS has the potential to have a significant impact in the Intensive Care Unit (ICU) where critical decisions are made on a daily basis, particularly during ward rounds. We aimed to examine how accessing image information is integrated into ward rounds and if the presence of PACS produced innovations in ward round practices. We observed ward rounds and conducted interviews with ICU doctors at three hospitals with differing levels of PACS availability and computerization. Imaging results were infrequently viewed by clinicians during ward rounds in two ICUs: one without PACS and one which had both PACS and bedside computers. In the third ICU, where PACS was only available at a central workstation, images were frequently viewed throughout the daily round and integrated into decisions about patient care. The presence of bedside computers does not automatically result in innovations to work practice. Despite the ability to utilize PACS at the bedside to support decision-making, use was varied. Research to understand how the complexities and context of the ICU contribute to work practice innovation and why practice changes differ is required.

Understanding communication networks in the emergency department.

BACKGROUND: Emergency departments (EDs) are high pressure health care settings involving complex interactions between staff members in providing and organising patient care. Without good communication and cooperation amongst members of the ED team, quality of care is at risk. This study examined the problem-solving, medication advice-seeking and socialising networks of staff working in an Australian hospital ED. METHODS: A social network survey (Response Rate = 94%) was administered to all ED staff (n = 109) including doctors, nurses, allied health professionals, administrative staff and ward assistants. Analysis of the network characteristics was carried out by applying measures of density (the extent participants are concentrated), connectedness (how related they are), isolates (how segregated), degree centrality (who has most connections measured in two ways, in-degree, the number of ties directed to an individual and out-degree, the number of ties directed from an individual), betweenness centrality (who is important or powerful), degree of separation (how many ties lie between people) and reciprocity (how bi-directional are interactions). RESULTS: In all three networks, individuals were more closely connected to colleagues from within their respective professional groups. The problem-solving network was the most densely connected network, followed by the medication advice network, and the loosely connected socialising network. ED staff relied on each other for help to solve work-related problems, but some senior doctors, some junior doctors and a senior nurse were important sources of medication advice for their ED colleagues. CONCLUSIONS: Network analyses provide useful ways to assess social structures in clinical settings by allowing us to understand how ED staff relate within their social and professional structures. This can provide insights of potential benefit to ED staff, their leaders, policymakers and researchers.

Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study.

BACKGROUND: Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care. DESIGN: A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care. DISCUSSION: A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.

The development, design, testing, refinement, simulation and application of an evaluation framework for communities of practice and social-professional networks.

BACKGROUND: Communities of practice and social-professional networks are generally considered to enhance workplace experience and enable organizational success. However, despite the remarkable growth in interest in the role of collaborating structures in a range of industries, there is a paucity of empirical research to support this view. Nor is there a convincing model for their systematic evaluation, despite the significant potential benefits in answering the core question: how well do groups of professionals work together and how could they be organised to work together more effectively? This research project will produce a rigorous evaluation methodology and deliver supporting tools for the benefit of researchers, policymakers, practitioners and consumers within the health system and other sectors. Given the prevalence and importance of communities of practice and social networks, and the extent of investments in them, this project represents a scientific innovation of national and international significance. METHODS AND DESIGN: Working in four conceptual phases the project will employ a combination of qualitative and quantitative methods to develop, design, field-test, refine and finalise an evaluation framework. Once available the framework will be used to evaluate simulated, and then later existing, health care communities of practice and social-professional networks to assess their effectiveness in achieving desired outcomes. Peak stakeholder groups have agreed to involve a wide range of members and participant organisations, and will facilitate access to various policy, managerial and clinical networks. DISCUSSION: Given its scope and size, the project represents a valuable opportunity to achieve breakthroughs at two levels; firstly, by introducing novel and innovative aims and methods into the social research process and, secondly, through the resulting evaluation framework and tools. We anticipate valuable outcomes in the improved understanding of organisational performance and delivery of care. The project's wider appeal lies in transferring this understanding to other health jurisdictions and to other industries and sectors, both nationally and internationally. This means not merely publishing the results, but contextually interpreting them, and translating them to advance the knowledge base and enable widespread institutional and organisational application.

Mobile and fixed computer use by doctors and nurses on hospital wards: multi-method study on the relationships between clinician role, clinical task, and device choice.

BACKGROUND: Selecting the right mix of stationary and mobile computing devices is a significant challenge for system planners and implementers. There is very limited research evidence upon which to base such decisions. OBJECTIVE: We aimed to investigate the relationships between clinician role, clinical task, and selection of a computer hardware device in hospital wards. METHODS: Twenty-seven nurses and eight doctors were observed for a total of 80 hours as they used a range of computing devices to access a computerized provider order entry system on two wards at a major Sydney teaching hospital. Observers used a checklist to record the clinical tasks completed, devices used, and location of the activities. Field notes were also documented during observations. Semi-structured interviews were conducted after observation sessions. Assessment of the physical attributes of three devices-stationary PCs, computers on wheels (COWs) and tablet PCs-was made. Two types of COWs were available on the wards: generic COWs (laptops mounted on trolleys) and ergonomic COWs (an integrated computer and cart device). Heuristic evaluation of the user interfaces was also carried out. RESULTS: The majority (93.1%) of observed nursing tasks were conducted using generic COWs. Most nursing tasks were performed in patients' rooms (57%) or in the corridors (36%), with a small percentage at a patient's bedside (5%). Most nursing tasks related to the preparation and administration of drugs. Doctors on ward rounds conducted 57.3% of observed clinical tasks on generic COWs and 35.9% on tablet PCs. On rounds, 56% of doctors' tasks were performed in the corridors, 29% in patients' rooms, and 3% at the bedside. Doctors not on a ward round conducted 93.6% of tasks using stationary PCs, most often within the doctors' office. Nurses and doctors were observed performing workarounds, such as transcribing medication orders from the computer to paper. CONCLUSIONS: The choice of device was related to clinical role, nature of the clinical task, degree of mobility required, including where task completion occurs, and device design. Nurses' work, and clinical tasks performed by doctors during ward rounds, require highly mobile computer devices. Nurses and doctors on ward rounds showed a strong preference for generic COWs over all other devices. Tablet PCs were selected by doctors for only a small proportion of clinical tasks. Even when using mobile devices clinicians completed a very low proportion of observed tasks at the bedside. The design of the devices and ward space configurations place limitations on how and where devices are used and on the mobility of clinical work. In such circumstances, clinicians will initiate workarounds to compensate. In selecting hardware devices, consideration should be given to who will be using the devices, the nature of their work, and the physical layout of the ward.

Multimethod evaluation of information and communication technologies in health in the context of wicked problems and sociotechnical theory.

OBJECTIVE: Few research designs look at the deep structure of complex social systems. We report the design and implementation of a multimethod evaluation model to assess the impact of computerized order entry systems on both the technical and social systems within a health care organization. DESIGN: We designed a multimethod evaluation model informed by sociotechnical theory and an appreciation of the nature of wicked problems. We mobilized this model to assess the impact of an electronic medication management system via a three-year program of research at a major academic hospital. MEASUREMENTS: Model components include measurements relating to three dimensions of system impact: safety and quality, organizational culture, and work and communication patterns. RESULTS: Application of the evaluation model required the development and testing of purpose-built measurement tools such as software to collect multidimensional work measurement data. The model applied established research methods including medication error audits and social network analysis. Design features of these tools and techniques are described, along with the practical challenges of their implementation. The distinctiveness of doing research within a unique paradigm of complex systems, explicating the wickedness and the dimensionality of sociotechnical theory, is articulated. CONCLUSION: Designing an effective evaluation model requires a deep understanding of the nature and complexity of the problems that information technology interventions in health care are trying to address. Adopting a sociotechnical perspective for model generation improves our ability to develop evaluation models that are adaptive and sensitive to the characteristics of wicked problems and provides a strong theoretical basis from which to analyze and interpret findings.

A comparison of self-reported and observational work sampling techniques for measuring time in nursing tasks.

OBJECTIVES: To compare self-reported and observational work sampling techniques when applied to ward-based nurses. METHODS: A self-reported work sampling study was undertaken with nine registered nurses in an Australian teaching hospital over 8.5 weeks, followed by an observational work sampling study conducted over 4.5 weeks. Both studies used a random reminder method and a multidimensional work task classification. Field notes were also recorded and analysed. RESULTS: 3910 data points were collected, 667 during the self-report study and 3243 in the observational study. The two techniques yielded significant differences in work patterns of registered nurses. The observational study showed that compared with the self-reported study, patient care (40% versus 33%, P <0.000) and ward-related activities (7% versus 3%; P <0.001) were recorded significantly more frequently, and documentation less frequently (8% versus 19%; P <0.000). Both the techniques generated similar proportions of time spent in breaks (12%), medication tasks (13%) and clinical discussion (15%). The self-report technique was poorly accepted by nursing staff. The observational technique was well accepted and data collection was more effcient. CONCLUSIONS: The self-report work sampling technique is not a reliable method for obtaining an accurate reflection of the work tasks of ward-based nurses. The observational technique was preferred by nurses, and despite concern regarding a potential Hawthorne effect, this was not substantiated.

The medication advice-seeking network of staff in an Australian hospital renal ward.

Electronic medication systems may impact communication in hospital wards. To identify the ways in which communication patterns may be altered it is necessary to compare processes both before and after system introduction. This paper reports the use of a social network approach to examine the medication advice-seeking network of an Australian hospital renal ward before the introduction of an electronic medication management system. A social network questionnaire was completed by 96% of staff members (doctors, nurses, allied health professionals and administrative staff) on the ward (n=45). Survey data were analysed to produce a sociogram to display the medication advice-seeking network of the staff in the ward. The results showed that there was a relatively low level of advice-seeking about medication-related decisions and tasks. Most communication occurred within professional groups. Several key individuals were pivotal in providing advice both within and across professional groups.

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates.

OBJECTIVES: To measure the weekly medication advice-seeking networks of hospital staff, to compare patterns across professional groups, and to examine these in the context of prescribing error rates. METHOD: A social network analysis was conducted. All 101 staff in 2 wards in a large, academic teaching hospital in Sydney, Australia, were surveyed (response rate, 90%) using a detailed social network questionnaire. The extent of weekly medication advice seeking was measured by density of connections, proportion of reciprocal relationships by reciprocity, number of colleagues to whom each person provided advice by in-degree, and perceptions of amount and impact of advice seeking between physicians and nurses. Data on prescribing error rates from the 2 wards were compared. RESULTS: Weekly medication advice-seeking networks were sparse (density: 7% ward A and 12% ward B). Information sharing across professional groups was modest, and rates of reciprocation of advice were low (9% ward A, 14% ward B). Pharmacists provided advice to most people, and junior physicians also played central roles. Senior physicians provided medication advice to few people. Many staff perceived that physicians rarely sought advice from nurses when prescribing, but almost all believed that an increase in communication between physicians and nurses about medications would improve patient safety. The medication networks in ward B had higher measures for density, reciprocation, and fewer senior physicians who were isolates. Ward B had a significantly lower rate of both procedural and clinical prescribing errors than ward A (0.63 clinical prescribing errors per admission [95%CI, 0.47-0.79] versus 1.81/ admission [95%CI, 1.49-2.13]). CONCLUSIONS: Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation.

Changes in nurses' work associated with computerised information systems: Opportunities for international comparative studies using the revised Work Observation Method By Activity Timing (WOMBAT).

An important step in advancing global health through informatics is to understand how systems support health professionals to deliver improved services to patients. Studies in several countries have highlighted the potential for clinical information systems to change patterns of work and communication, and in particular have raised concerns that they reduce nurses' time in direct care. However measuring the effects of systems on work is challenging and comparisons across studies have been hindered by a lack of standardised definitions and measurement tools. This paper describes the Work Observation Method by Activity Time (WOMBAT) technique version 1.0 and the ways in which the data generated can describe different aspects of health professionals' work. In 2011 a revised WOMBAT version 2.0 was developed specifically to facilitate its use by research teams in different countries. The new features provide opportunities for international comparative studies of nurses' work to be conducted.

Social network analysis of medication advice-seeking interactions among staff in an Australian hospital.

PURPOSE: To examine the medication advice-seeking network of staff in a hospital ward. METHODS: Social network analysis was carried out in a renal ward of an Australian metropolitan teaching hospital. The medication advice-seeking interactions of doctors, nurses, allied health professionals (including a pharmacist) and a ward clerk were examined using data from questionnaires administered to staff. The questionnaire listed all staff who worked in the ward and sought information from respondents regarding their interactions with each staff member. Data were analysed using social network software, UCINET. Analyses performed included geodesic distance, network density, strength of ties, reciprocation of relations, and centrality of individuals. NetDraw was used to produce social network diagrams. RESULTS: A very high response rate of 96% was achieved with 45 of 47 staff returning the questionnaire. On average, there is little interaction between each of the staff members in the medication advice-seeking network, with even less interaction between staff from different professional groups. Nurses are mainly located on one side of the network and doctors on the other. However, the pharmacist is quite central in the medication advice-seeking network as are some senior nurses and a junior doctor. CONCLUSIONS: When hospital clinical staff seek medication advice from other members of a ward it tends to be sought from those in their profession. However key individuals in the ward are relied upon for the provision of medication advice by staff from all professions. Social network analysis can be used to examine the complex medication advice-seeking interactions amongst staff in a hospital ward, providing useful quantitative baseline data against which to compare the effect of interventions, such as an electronic medication system, on interactions.

Computerized Provider Order Entry--what are health professionals concerned about? A qualitative study in an Australian hospital.

PURPOSE: To identify the main concerns of a broad range of hospital staff about the implementation of a new Computerized Provider Order Entry (CPOE) system for medication management. METHODS: The study was conducted in a large Australian teaching hospital using semi-structured interviews (n=20) and focus groups (six focus groups involving a total of 30 participants) from a broad section of health professionals including doctors, nurses, managers, pharmacists and senior health executives. Systematic concurrent analysis of the data was undertaken by a team of researchers. RESULTS: We identified 20 recurrent themes related to nine areas of shared concern including work practices, software/hardware, relationships/communication, education and training, inexperienced staff and de-skilling. A higher level of analysis identified four interrelated constructs that highlight what people are concerned about: (1) Will it help? (2) Will it work? (3) Will we cope? (4) Will it impair existing interaction? LIMITATIONS: The research provides a snapshot overview of perceptions from a range of hospital personnel in the lead up to CPOE implementation. Generalizability is limited by the size of the sample and the contextual circumstances of the hospital being studied. DISCUSSION: This work contributes valuable evidence about an often-neglected dimension in the evaluation of computer systems in hospitals, namely the pre-implementation concerns of staff. These pre-conceptions can have a significant effect on how technology is implemented and utilised. Acknowledging and addressing people's concerns can contribute to the establishment of durable channels of negotiation and communication. Further research informed by the findings of this study will help advance this process.