The Impact of Computerized Physician Order Entry

Session on Redesigning Work Processes to Improve Patient Safety and Quality

AHRQ Conference, Bethesda MD, September 2007

Ross Koppel, Ph.D. Ross Koppel, Ph.D.

Center for Clinical Epidemiology & BiostatisticsCenter for Clinical Epidemiology & BiostatisticsSchool of Medicine, & Sociology Department School of Medicine, & Sociology Department

University of PennsylvaniaUniversity of Pennsylvaniarkoppel@sas.upenn.edurkoppel@sas.upenn.edu

CPOE BENEFITS

CPOE Eliminates:

handwriting errors

Rx order travel time to pharmacy

CPOE BENEFITS

CPOE Eliminates:

abbreviation errors

transcription errors

CPOE BENEFITS

CPOE eliminates:trailing zero problems 0 0 0 0 0 0 ……

I.T. cost overruns

apothecary measure errors

CPOE BENEFITS

CPOE Facilitates

ID of prescribing MD

integration of CDSS

integration with Pt. record

CPOE BENEFITS (MOSTLY)

CPOE Facilitates

clicking inside the box

clicking outside the box

CPOE BENEFITS

CPOE facilitates:

Analysis of patient and Rx data

CPOE BENFITS!

CPOE Eliminates: Poor judgment

Sound-alike drug choice spelling errors

Skewed efficacy claims

CPOE BENEFITS ?

However….

Some reports of poor

fit between workflow

and CPOE

Can Disaggregate? CPOE Hospital Workflow

Sure…..well?

Yes

Sure…..well?

No

Sure…..well?

Maybe

Sure…..well?

Yes

Example: Order sets

Sure…..well?

No

Example: Order sets

Sure…..well?

Sometimes

Example: Order sets

Of course, Many, many, many good examples

Handwriting-free

Always available

& retrievable

Etc, etc, etc

But some unhappy examples, too

5

4

1

7

3

2

Difficulties Disaggregating

M. Harrison, R. Koppel & S. Bar-Lev. Unintended consequences of information technologies in health care – An interactive sociotechnical analysis . Journal of the American Medical Informatics Association, Sept. 2007.

Interactive Sociotechnical Systems

Cases (1) New HIT changes existing social system

CPOE procedures changes communication between transport teams and emergency room in Children’s hospital (Han)*

* For references, see Harrison et al., JAMIA paper or email us.

Interactive Sociotechnical Systems

Cases (2) Technical & physical infrastructures mediate HIT use -- Interaction of new HIT with existing technical and physical conditions affect HIT-in-use

paper persistence (Campbell, 2006)

computer carts on wheels

Interactive Sociotechnical Systems

Cases (3) Social system mediates HIT use --Interaction of new HIT with the social system affects HIT-in-use

Instead of real-time entry, nurses document meds at end of shift (Koppel et al.; Bar-Lev and Harrison)

Interactive Sociotechnical Systems

Cases (4) HIT-in-use changes social system – Interaction of new HIT with the social system affects HIT-in-use, which then further changes the social system.

Stealth dosing erodes authority of infectious disease fellows (Larosa et al.)

Interactive Sociotechnical Systems

Cases (5) HIT-social system interactions engender HIT redesign --Interaction of new HIT with the social system affects HIT-in-use, which then leads to changes in HIT properties

Physicians resist fixed choice templates, forcing redesign to allow free-text entry for diagnoses (Bar-Lev and Harrison)

Seldom This Clear or True… CPOE Hospital

Conclusion:Yes, No, Sometimes

Many examples: CPOE Workflow

Some examples: CPOE Workflow

Some examples: CPOE Workflow

Most often: CPOE Workflow

Not discussed: Implementing……

MD Acceptance…….

Not discussed:

Customization…..

New versions……

Interactions w/ Vendors…..

CPOE improvements & hospital workflows always emerging

No hospital with CPOE has been struck by a meteor.

Thank you Ross Koppel University of Pennsylvania rkoppel@sas.upenn.edu