Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed evaluation.

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.

Impact of CPOE on mortality rates--contradictory findings, important messages.

OBJECTIVE: To analyze the seemingly contradictory results of the Han study (Pediatrics 2005) and the Del Beccaro study (Pediatrics 2006), both analyzing the effect of CPOE systems on mortality rates in pediatric intensive care settings. METHODS: Seven CPOE system experts from the United States and Europe comment on these papers. RESULTS: The two studies are not contradictory, but almost non-comparable due to differences in design and implementation. They demonstrate the range of outcomes that can be obtained from introducing informatics applications in complex health care settings. Implementing informatics applications is a sociotechnical activity, which often depends more on the organizational context than on a specific technology. As health informaticians, we must not only learn from failures, but also avoid both uncritical scepticism that may arise from drawing overly general conclusions from one negative trial, as much as uncritical optimism from limited successful ones. CONCLUSION: The commentaries emphasize the need to promote systematic studies for assessing the socio-technical factors that influence the introduction of increasingly sophisticated informatics applications within complex organizations. The emergence of evidence-based health informatics will be based both on evaluation guidelines and implementation guidelines, both of which increase the chances of successful implementation. In addition, well-educated health informaticians are needed to manage and guide the implementation processes.

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.

Order creation and communication in healthcare.

OBJECTIVES: The aim of this paper is to examine the adequacy of the concept of Physician Order Entry (POE) as a model for clinical systems, and to suggest an alternative understanding of the order creation and communication process. METHODS: The study is based on an interpretative analysis of POE as a model for clinical systems and the results of our recent fieldwork. RESULTS: Observations from our recent fieldwork suggest that orders, like patient care in general, emerge from interactions among patients, physicians, nurses, family members, and others, employing a variety of technologies and information resources in the process. Orders as we have observed them originate, are negotiated, and are carried out in a dynamically evolving group with fluctuating membership and shifting role responsibilities. Furthermore, orders by themselves represent only a partial picture of what is done for the patient. CONCLUSION: We argue that information systems are more likely to be helpful if they accommodate and facilitate POE as a multidisciplinary collaboration effort and fit better into the larger system of patient care.

A diffusion of innovations model of physician order entry.

OBJECTIVE: To interpret the results of a cross-site study of physician order entry (POE) in hospitals using a diffusion of innovations theory framework. METHODS: Qualitative study using observation, focus groups, and interviews. Data were analyzed by an interdisciplinary team of researchers using a grounded approach to identify themes. Themes were then interpreted using classical Diffusion of Innovations (DOI) theory as described by Rogers [1]. RESULTS: Four high level themes were identified: organizational issues; clinical and professional issues; technology implementation issues; and issues related to the organization of information and knowledge. Further analysis using the DOI framework indicated that POE is an especially complex information technology innovation when one considers communication, time, and social system issues in addition to attributes of the innovation itself. CONCLUSION: Implementation strategies for POE should be designed to account for its complex nature. The ideal would be a system that is both customizable and integrated with other parts of the information system, is implemented with maximum involvement of users and high levels of support, and is surrounded by an atmosphere of trust and collaboration.

Multiple perspectives on physician order entry.

OBJECTIVE: Describe the complex interplay of perspectives of physicians, administrators, and information technology staff regarding computerized physician order entry (POE) in hospitals. METHODS: Linstone's Multiple Perspectives Model provided a framework for organizing the results of a qualitative study done at four sites. Data from observation, focus groups, and formal and informal interviews were analyzed by four researchers using a grounded approach. RESULTS: It is not a simple matter of physicians hating POE and others loving it. The issues involved are both complex and emotional. All groups see both positive and negative aspects of POE. CONCLUSION: The Multiple Perspectives Model was useful for organizing a description to aid in understanding all points of view. It is imperative that those implementing POE understand all views and plan implementation strategies accordingly.

Perceptions of house officers who use physician order entry.

OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process.

Factors affecting the diffusion of online end user literature searching.

OBJECTIVES: The aim of this study was to identify factors that affect diffusion of usage of online end user literature searching. Fifteen factors clustered into three attribute sets (innovation attributes, organizational attributes, and marketing attributes) were measured to study their effect on the diffusion of online searching within institutions. METHODS: A random sample of sixty-seven academic health sciences centers was selected and then 1,335 library and informatics staff members at those institutions were surveyed by mail with electronic mail follow-up. Multiple regression analysis was performed. RESULTS: The survey yielded a 41% response rate with electronic mail follow-up being particularly effective. Two dependent variables, internal diffusion (spread of diffusion) and infusion (depth of diffusion), were measured. There was little correlation between them, indicating they measured different things. Fifteen independent variables clustered into three attribute sets were measured. The innovation attributes set was significant for both internal diffusion and infusion. Significant individual variables were visibility for internal diffusion and image enhancement effects (negative relation) as well as visibility for infusion (depth of diffusion). Organizational attributes were also significant predictors for both dependent variables. No individual variables were significant for internal diffusion. Communication, management support (negative relation), rewards, and existence of champions were significant for infusion. Marketing attributes were not significant predictors. CONCLUSIONS: Successful diffusion of online end user literature searching is dependent on the visibility of the systems, communication among, rewards to, and peers of possible users who promote use (champions). Personal image enhancement effects have a negative relation to infusion, possibly because the use of intermediaries is still seen as the more luxurious way to have searches done. Management support also has a negative relation to infusion, perhaps indicating that depth of diffusion can increase despite top-level management actions.

Physician order entry in U.S. hospitals.

OBJECTIVE: Determine the percent of U.S. hospitals where computerized physician order entry (POE) is available and the extent of its use. METHODS: A survey was sent to a systematic sample of 1,000 U.S. hospitals asking about availability of POE, whether usage is required, percent of physicians using it, and percent of orders entered by computer. RESULTS: About 66% do not have POE available. Of the 32.1% that have it completely or partially available, 4.9% require its usage, over half report usage by under 10% of physicians, and over half report that fewer than 10% of orders are entered this way. Analysis of comments showed that many hospitals have POE available for use by non-physicians only, but that they hope to offer it to physicians after careful planning. CONCLUSION: Most U.S. hospitals have not yet implemented POE. Complete availability throughout the hospital is rare, very few require its use, low percentages of physicians are actual users, and low percentages of orders are entered this way. On a national basis, computerized order entry by physicians is not yet widespread.

Factors affecting the diffusion of the Computer-Based Patient Record.

A survey of the perceptions of 629 informatics experts representing 67 institutions with accredited schools of medicine was used to identify factors most important in implementing the Computer-Based Patient Record. A model outlined three theoretical factors: Innovation Attributes (attributes inherent in the CPR itself); Organizational Attributes; and Boundary-Spanning Attributes (related to marketing efforts). The model was explored using multiple regression techniques to delineate the relative importance of 15 variables within the three sets of factors and their effect on two measures of diffusion. The two dependent variables were internal diffusion, or spread of usage of the CPR, and infusion, or depth of usage. Data from the 144 respondents indicate that for diffusion, the organizational variables of "decision making" and "planning" had a significant impact, although the relation between "planning" and diffusion was negative. For infusion, the Innovation Attributes variable "visibility" was significant. The major implication is that successfully encouraging usage of the CPR entails attention and resources devoted to managing the organizational aspects of implementation.

Crimean-congo hemorrhagic fever, Thogoto, dugbe, and Jos viruses isolated from ixodid ticks in Ethiopia.

From 1974 through 1976, U.S. Naval Medical Research Unit No. 5 isolated 25 strain of tick-borne virus in infant mice from 410 pools containing over 6,000 ticks, and one strain from a bird and one strain from a rodent collected in central and southern Ethiopia. Of these, 17 were identified as known viruses previously found in West Central and East Africa. There were 8 strains of Jos virus from Amblyomma ticks; 7 strains of Dugbe virus from a bird, a rodent and from ticks; 1 strains of Crimean-Congo hemorrhagic fever virus and 1 strain of Thogoto virus from ticks.

Blood parasites of Ethiopian birds. 1. General survey.

Five thousand and forty-six smears from 352 species of birds in Ethiopia were examined for blood parasites in an attempt to provide base-line data, to indicate fruitful areas for further study, on avian hematozoa. The prevalence of infection and the parasites found, with particular reference to Plasmodium, are discussed. At least 22 parasite species were recognized.