computerized physician order entry systems: impact on physician-nurse cooperation marie-catherine...

Computerized Physician Order Entry systems: impact on physician-nurse cooperation

Marie-Catherine Beuscart-Zéphir*, Françoise Anceaux**

*EVALAB, Faculty of Medicine & University Hospital, Lille, France**Percotec-LAMIH, CNRS UMR 8530, University of Valenciennes, France

PERCOTEC

EVALAB Faculté de médecine–CHRU de Lille

PERCOTEC-LAMIH UVHC-CNRS

Background

• Medication ordering, dispensing & administration is a key healthcare process in the hospital setting

• But it is unfortunately not as safe as one could expect (cf. « To err is human »)– 44000 to 98000 deaths /year due to medical

errors in US hospitals– 7000 deaths related to medication errors,

increased hospital cost amounts to $2 billion



• Computerized Physician Order Entry (CPOE) systems proved efficient in preventing and actually reducing medication errors and Adverse Drug Events

• But they remain difficult to implement, mostly because of physicians’ reluctance to use them

• Recent survey from US Pharmacopeia demonstrated a slow but steady increase of medication errors in the hospitals using CPOE systems during last two years



Difficulties

• Increased workload and additional time for the physicians

• Organizational changes

• Poor usability

• Negative impact on Doctor-Nurse cooperation



Two complementary studies

• 1st study: comparative analysis of paper-based and computer-based work situations combined with a usability assessment of the HCI

• 2nd study: detailed cognitive analysis of the cooperative activities and of the individual and shared representations underlying the management of the tasks and the control of the medication process



Focus of the 1st study

• Analysis of Doctor-Nurse communication and cooperation comparing paper-based and CPOE situations

• Usability engineering approach:– Analysis of users’ individual and collective activity

– Usability assessment of the Human Computer Interface

• Focus on the medication administration functions:– Documentation of the time for administration in the

physicians’ orders

– Nurses’ understanding of the physicians’ orders



Content of a medication order

• Name of the drug - Lasix, Medrol, …• Pharmaceutical form - pill, powder, cream, …• Route - oral, IV, …• Concentration - 20mg, 40mg, …• Dose / Quantity – 2 tablets, 75mg, • Frequency - 3 times / day• Duration - during 5 days• Time for administration – 8am- 12 - 6pm• Conditions - if pain



Context of the study

Three observation sites

• University hospital of Lille:– 3000 bed-capacity hospital

– Paper based situation

– Nephrology and neuro-surgery

• General public hospital (Denain, north of France):– 413 bed-capacity hospital

– Paper-based situation

– surgery, respirology and convalescents (rehab)

• Georges Pompidou University hospital (Paris)– 825 bed-capacity hospital

– CPOE situation: immunology and nephrology

– Medasys DxC@re®



Methods



Methods (1): activity analysis

• Semi-structured and structured interviews of the target users (physicians and nurses)

• Continuous observations, audio recording

• Document analysis (written orders)

• Self confrontation interviews (users review the records of their own activity and explain their thought processes)



Methods (2): usability assessment

Usability assessment of the CPOE functions of DxC@re®:

• Usability inspection (3 independent evaluators, ergonomic criteria)

• On-site usability tests (real activity, portable labs)



Site 1

(University hospital, Lille)

Site 2

(Denain general hospital)

Site 3

(G. Pompidou University hospital)

Usability lab

Task and activity analysis

•Paper-based

•80 hours observation

•Document analysis

•Paper-based


•Document analysis

•CPOE situation


Usability assessment

•Usability test

•DxC@re CPOE

•16 hours videotaped

•Usability inspection



Results (1) Activity analysis Description of the work situations

Paper-based situation (sites 1 & 2)The nurse accompanies the physician on his medical round

may ask questions about drugs administration, may suggest changes in the treatment, transcribes the orders, passes the file to the physician for signature

handles the patient record, summarizes the patient’s case, answers the physician’s questions, hands him the required documents

interviews the patient, performs the clinical exam, assesses the situation, makes a decision, dictates the orders to the nurse

Paper-based situation (sites 1 & 2)

After the rounds, the nurse copies (transcribes) the orders on her Medication Administration Record (MAR)

Computer-based (CPOE) situation (site 3)The nurse does not accompany the physician for his medical round

The physician gets the necessary medical and therapeutic information from the EPR

He interviews the patient, performs the clinical exam, assesses the situation, makes a decision about each item of the therapeutic treatment, enters each order on the computer using the CPOE

The SYSTEM (CPOE) automatically populates the nurses’ Medication Administration Record



Documentation of the time for administration in the MAR

• CPOE situation:– The physician is constrained to enter precise orders,

including precise time for the administration– The system automatically updates the nurses’ MAR– The nurse has nothing to do

• Paper situation– The nurse has to transcribe the orders in her MAR

• Question: what is the available information / time for administration in the physician’s orders?



ResultsActivity analysis:

Qualitative and quantitative analysis of paper-based orders



Analysis of the written orders• Focus on oral route orders (n = 671)

Respirology: n = 152; Surgery: n = 78; Convalescents (rehab): n = 441

• Analysis of the documentation of time for administration

• Orders written by the doctors vs. by the nurses: no difference

To copy

Nurse’s task & responsibility

FrequencyExamplesAdministration plan

(24h period)

1%(n=7)

•50 mg at 10 am.

•2 pills at 2 pm.Exact time for administration

Paper-based situation

Administration plan

(24h period)Examples Frequency


Exact time for administration

•50 mg at 10 am.

•2 pills at 2 pm.

1%(n=7)

To copy

Approximate time for administration

•Morning, Noon, Evening

•At bedtime

•If diarrhea

•If pain

24%(n=163)

To specify the precise time for administration


Administration plan

(24h period)Examples Frequency


Exact time for administration

•50 mg at 10 am.

•2 pills at 2 pm.

1%(n=7)

To copy

Approximate time for administration

•Morning, Noon, Evening

•At bedtime

•If diarrhea

•If pain

24%(n=163)

To specify the precise time for administration

No information / administration

schedule

•2 pills / Day

•25 mg every 2 days

75%(n=501)

To make the decision / time for administration




Activity analysis: model of the activity

Medication ordering and administration process

Therapeutic decisionMedication ordering

Planning of medication administration

Drug administration





Drug administration

Makes thedecision

Gives the order: name & dosage

Schematic decision:

abstract plan





Drug administration

Makes thedecision


Schematic decision:

abstract plan

The nurse listens to the doctor-patient dialog, answers questions, asks questions





Drug administration

Makes thedecision


Schematic decision:

abstract plan

Specified plan (exact time-scheduling)

Administers the drug & documents administration






Drug administration

Schematic decision:

abstract plan

Specified plan (exact time-scheduling)



Cooperativeactivities

DistributedDecisionmaking


Makes thedecision





Drug administration

Common frame of Reference: CoFORSynchronous cooperation

The doctor-nurse dialog supports the elaboration and maintenance of a Common Frame of Reference

Coordination of actions = physician + nurse responsibility





Drug administration

Makes thedecision

Formulates the order: name & dosage

Schematic decision:

abstract plan

Specific plan (exact time-scheduling)


The nurse may ask questions of the doctor when he is available

Computer-based situation




Drug administration

Makes thedecision

Formulates the order: name & dosage

Schematic decision:

abstract plan

Specific plan (exact time-scheduling)


The nurse may ask questions of the doctor when he is available


Cooperativeactivities

DistributedDecisionmaking




Drug administration

No synchronous Doctor-Nurse dialogNo COFOR management

Coordination of actions = CPOE


Coordination of actions = CPOE

•How well does the system support the coordination of actions?•Does it help the users to understand each others actions and intentions?



Results (2) Usability assessment

Order entry: time for administration …

Selection of the pre-set schedule « morning, noon, evening, and bedtime » is automatically transcribed in « 8, 12, 18 and 21 h » in the time table (configuration depending on the time of the nurses rounds in the department)

Second solution: the physician clicks in the desired time slots and documents the dose to be delivered at that time



Examples of problems / administration planning

• There is a problem of erroneous guidance with the time-table (ambiguous display)

• Information / times of administration can be ambiguous in the MAR

During the test, the physicians sometimes entered the wrong timings in the time table; they didn’t know what the grayish slots meant



Examples of problems / administration planning

• There is a problem of erroneous guidance with the time-table (ambiguous display)

• Information / times of administration can be ambiguous in the MAR

During the test, the nurses interpreted the orders and made assumptions. When confronted with « bizarre » timings, the nurses made the corrections in their Medication Administration Record without asking the physician



Conclusion of the 1st study



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Fréquence :

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Questions and problems• The cognitive task and activity analysis

uncovered important underlying variables– Synchronous or asynchronous cooperation– Distributed or individual decision making– Individual and / or shared representations of the

medication decision process

• Impact on:– The control of the medication process– The prevention of new risks in the process



Focus of the second study

• Individual and shared representations underlying (supporting) the management of the tasks and the control of the medication process:– Content of the Common Frame of Reference?

• Important variable: type of cooperation, synchronous vs. asynchronous– Preliminary results in the paper-based synchronous

situation



Analysis of physician – nurse dialogs:verbal protocol analysis



Methods

• Detailed observation of the physician-nurse dialog during the medical rounds– Audio-taped, detailed observation grid

• Transcription: detailed verbal (& behavioral) protocols

• Protocol analysis: coding scheme

• Analysis of the coded communication units



Protocol analysis

• A coding scheme is necessary to code the cooperation units in the doctor-nurse dialogs recorded during the medical rounds

• This analysis relies on a model of cognitive architecture of cooperation (Millot & Hoc 97; Hoc 2001)



Cognitive architecture of cooperation

• On a cognitive point of view, cooperation can be described as the management of interferences

• Interference: the effects of the action(s) of one agent are relevant for the goals of another agent, either to favor it (positive interference) or to threaten it (negative interference) (Castelfranchi 98; Hoc 2001)

• Interference management requires the sharing of task representations, of partners’ activities, and of the goal to be reached.

• The COmmon Frame Of Reference (COFOR) is the shared representation that supports interference management

Cooperation cognitive architecture (Hoc, Helie & Loiselet, 2000)

Meta Cooperation

Cooperationin planning

Cooperationin action

Cooperation cognitive architecture (Hoc, Helie & Loiselet)

Meta Cooperation


Cooperationin action Interference management (coordination of actions)


Meta Cooperation



Agent A’s Current Representation

Interference management (coordination of actions)


Meta Cooperation




Agent B’s Current Representation



Meta Cooperation



COFORElaboration Maintenance



CommonFrame ofReference



Meta Cooperation




Anticipative management of interferences

When local management is not efficient or sufficient






Meta Cooperation



Elaboration of compatible

representations

Elaboration of a mental model of self and a mental

model of others

Elaboration of a common code ofcommunication


Anticipative management of interferences

When local management is not efficient or sufficient







Verbal protocol analysis: example of coding of verbal exchanges during the

medical round

Nurse : 25, we can leave him on that Physician : no, we’re going to stop it entirelyNurse : it’s up to you.

Physician : OK,your temperature did’nt go up again?Patient : NoNurse : Since we stopped the Claforan, he’s doing betterPhysician : yeah, yeah

(he picks up the temperature chart from the foot of the bed) Physician : artificial tears, vitamin A, Medrol, Omeprazole…ok.

Nurse : and the Médrol does he still need it? We’re at post-op day ... I can’t remember

Nurse : What dose was he on??Physician : (he picks up the temperature chart from the foot of the bed )

50, post-op day 10 we can stop it

Physician : Did we get an inflammation order set with a CRP?Nurse : yesterday

Physician : yesterday…(the nurse hands him the results and he reads them) Physician : He’s getting Medrol, eh?Nurse : mmmm

Physician : CRP below 3

Physician : yeah, but if we stop it ... Yeah, you’re right

COFOR Management

maintenance

elaboration











COFOR Management

maintenance

elaboration











Interference detection

Interference creation

COFOR Management

maintenance

elaboration











Interference detection

Interference resolution

Interference creation



• This typical excerpt demonstrates – the importance of COFOR management in the

dialogs– The important part played by the nurse in the

medication decision making



Preliminary results

• Two rounds, 30 patients (11 + 19), 1h53mn recorded

• Total number of communication units: 790

• Total number of physician-nurse communication units: 417



Distribution of cooperation units for both actors (physician / nurse)

010

2030

4050

6070

8090

100

Cooperation in action cooperation in planning

Type of cooperation

%

Physician

Nurse



distribution of Physician Nurse cooperation units

0

5

10

15

20

25

Requirementfor

information

Answer /requirement

forinformation

Transmissionof information(comments onone's actions)

Decisionmaking(order)

Suggestion

Functions of communication units

%

Physician

Nurse



Discussion, conclusion



Impact for the design of CPOE systems

• Normative model: the physician is responsible for the decision making and for medication ordering he is solely responsible for orders entry

• Observed activity in the paper-based situations (5 departments, 2 hospitals): the nurses play an important part in the decision making part of the process, they are often in charge of orders entry



• Not only a design issue: also an organizational issue and a safety issue

• Can we (must we) imagine systems implementing a cooperative model of the medication ordering process and supporting a distributed decision making process?

Impact for the design of CPOE systems



• The physician and the nurse are in charge – of the coordination of their actions – of the control of the process.

• They share part of their individual representations, and their control of the process overlap.

• The nurse can control the whole process at a high level (tactical survey)

Paper-Based situation




Medication

Planning ordering administration

Physician’s control

of the processNurse’s control of

the processShared control



• The system is in charge – of the coordination of the actions – of the overall control of the medication ordering

and administration process.

• This control and the actions performed by the system are not always visible to the users.

• The nurse controls a smaller part of the process, only on an operational level.

CPOE situation

Medication

Planning ordering administration

Physician’s control

of the processNurse’s control of

the process

CPOE’s Control of the

process



Next steps

Paper-based CPOE

Synchronous cooperationCommon rounds

FrequentAnalysis in process

??????

Asynchronous cooperation

No common rounds

Less frequentAnalysis in process

FrequentAnalysis in process



Thank you for your attention

Questions?



Documents analysis

• Extensive quantitative and qualitative analysis of a sample of 818 written orders– site 1 Neurosurgery, 109 orders for 20 patients

mean length of stay = 6 days– site 2 Respirology 292 orders, 42 patients,

mean length of stay = 9 days– and site 2 Convalescents 417 orders, 38

patients, mean length of stay = 17 days



• Name of the drug - Lasix, Medrol, …• Pharmaceutical form - pill, powder, cream, …• Route - oral, IV, …• Concentration - 20mg, 40mg, …• Dose / Quantity – 2 tablets, 75mg, • Frequency - 3 times / day• Duration - during 5 days• Time for administration – 8am- 12 - 6pm• Conditions - if pain

Percentage of available data elements in 818 medication orders (oral route)

0 20 40 60 80 100

ca

teg

ori

es

of

av

aila

ble

da

ta e

lem

en

ts

percentages

Site 2 Convalescents

Site 2 Respirology

Site 1 Neurosurgery



Patterns of missing information

Total Daily Dose 0 0 0 1 0 1 1Concentration of medication per tablet 0 0 0 0 0 1 1Total number of tablets per day 0 0 1 0 1 1 1Number of tablets per administration 0 0 0 0 1 0 1Frequency of administration 0 1 0 0 1 0 1Patterns P1 P3 P4 P5P2

Legend: 0 = missing data; 1 = available data



Distribution of the patterns within the 818 orders from the three departments of the two hospitals

0

5

10

15

20

25

30

35

40

P1 P2 P3 P4 P5

Patterns

%

Neuro surgery

Respirology

Convalescents



Self Confrontation interviews (Nurses)

• Exploratory study: 2 nurses, Neurosurgery• Confronted with orders representing patterns

1 tà 4• Asked to explain how they would carry out

the orders (what, and when) and on which knowledge they would rely on to fill in the missing data

• Content analysis: 217 information units identified and categorized

Cooperation level

Categories of knowledge ExamplesObserved frequency

Meta-cooperation

Knowledge on her own competencies

“I haven’t enough information to execute this order” 8%

Knowledge on nurses strategies “A nurse would have to phone the doctor” 10%

Knowledge on partners “The anaesthetist always documents his orders this way” 10%

Cooperation in planning

Knowledge on the patient’s case and his particular context

“He [the patient]’s already on medication at home, he needs his usual meds” 13%

Knowledge on the medical decision making

“This treatment depends on two parameters, when they are met, we may suggest a shift from the intravenous to the oral route”

2%

Contextual knowledge, exceptions: when rules don’t apply

“The patient is NPO [fasting] so should not get it [the medication] orally, but the anaesthetist explicitly ordered it, so it’s OK”

6%

Knowledge on medication: usual dosage, rules of administration

“It is always one dose in the morning”

“It is always 100 mg pills that we divide in two or four”

31%

Knowledge on orders documentation: usual codes for notation and transcribing

“We would have written it in the MAR”

20%



Distribution of the categories of knowledge necessary to administer medication orders according to two patterns of

missing data

0 10 20 30 40 50 60 70

K / own competencies

K / nurses strategies

K / partners

K / patient's case

K / medication

K / writing & transcribing codes

Exceptions

Pattern

s

%

P4

P1

Pattern 1: « lasix »; Pattern 4: « Lasix 20mg, 2 X Day »