Computerized Provider Order Entry—What are health professionals concerned about? A qualitative study in an Australian hospital

Abstract

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.

Introduction

Computerized Provider Order Entry (CPOE) systems are widely recognized as a critical component of the future electronic health record for accessing and sharing information across health care settings, and making delivery of patient care safer [1]. Defined by their ability to provide doctors, or other authorised clinicians with the facility to enter orders (e.g. laboratory, medication, imaging, etc.) directly into computers, CPOE systems open up possibilities for improving the efficiency, effectiveness and quality of health care systems [2]. Despite the considerable potential of CPOE systems, their adoption in the US and internationally has been slow [3]. Research has pointed to the possibility of these systems to have unexpected and detrimental effects on workload, hospital culture and relationships, with implications for the delivery of patient care [4], [5], [6], [7], [8], [9], [10]. The successful implementation of a CPOE system requires a range of inputs from a wide variety of professionals including clinical groups, health care managers and service planners. What are their views in the lead-in to CPOE implementation?

A key theoretical consideration centres on the underlying processes associated with new information and communication technology (ICT) systems and how their stability over time depends on the way that users approach and deal with these processes. According to McLaughlin, the value of technology has to be built by users over time as they make sense of and embed it into their local settings [11]. Orlikowski et al. describe this as a transformational development involving ongoing and explicit adaptation of information technology (IT) systems in their changing contexts [12], [13]. Such technology-use mediation incorporates the pre-conceptions, concerns and worries about the value of the new system. The identification of pre-existing barriers and obstacles, and the investigation of the diverse concerns and perceptions of different groups, are crucial steps in implementing change [14], [15]. A valuable example of physicians’ perceptions prior to implementation of a drug prescribing support system is provided by Bastholm Rahmner et al. who reported an inconsistency between physicians’ views that access to patient history would be a major potential benefit, and the inability of the new system to provide this information [16].

The dominant approach to the evaluation of ICT systems such as CPOE has viewed implementation as a largely rational process based upon clearly defined criteria [17]. This approach aspires to provide step-by-step guidance in order to maximise hospital preparedness for employing these systems. But even the more strongly researched and influential of CPOE readiness assessment tools such as that produced by Stablein et al. [18] underscore the complex and difficult tasks involved with CPOE implementation. There are few processes and departments or disciplines which remain untouched by the many changes caused by CPOE. Implementation of these systems crosses cultural and professional boundaries and barriers. Alternative approaches to evaluation have been developed using behavioural models with a greater emphasis on the impact of human factors, emotions and even self-interest [4], [19], [20].

Studies using a wide range of qualitative and theoretical methods to investigate the impact of CPOE have become more numerous. They have added an important dimension to improving our understanding of the complexities and challenges of implementation. In large part these studies have sought to deal with the “why” and “how” questions relevant to understanding the difficulties involved with CPOE systems [21]. Many of them have contributed to challenging pre-existing assumptions about implementation [22], [23] or revealed important unanticipated consequences of the system [24].

The aim of this study was to identify the main concerns of a broad section of hospital personnel (doctors, nurses, managers, pharmacists and senior executives) prior to the implementation of an electronic medication management system. This commercial system comprises prescribing and direct drug administration functionalities with an electronic medication chart. The study represents a before study which investigates an often-neglected dimension to ICT evaluation, namely the pre-implementation inclinations and concerns of a range of different hospital staff about new ICT systems. There are few studies which have considered the perspectives of users prior to implementation, particularly those in situ users who will be instrumental in adopting and using CPOE, and who can therefore make or break the implementation. Their pre-conceptions can have a significant mediating effect on the implementation process. Understanding the nature and cause of the concerns can greatly help to inform strategies to overcome difficulties and potential hurdles including those from unintended consequences. Further, there is limited information about the differences in the concerns of clinicians and managers regarding ICT implementation to determine whether different strategies may be required for these groups. In the end this understanding can contribute to a better appreciation of the dynamics of computer use in work practices [25]. These data also provide a valuable reference point which can be used to monitor and follow up the impact of the system and to assess whether (and how) the challenges of implementation were met [26].