The organisational and communication implications of electronic ordering systems for hospital pathology services

Computerised Provider Order Entry (CPOE) systems provide clinicians with the ability to electronically enter hospital orders for laboratory tests and services. CPOE is able to integrate with hospital information systems and provide point of care decision support to users thereby making a potentially significant contribution to the efficiency and effectiveness of care delivery. The evidence of the impact of CPOE systems on pathology services is not extensive and insufficient attention has been paid to their effect on organisational and communication processes. This thesis aimed to investigate the implications of CPOE systems for pathology laboratories, their work processes and relationships with other hospital departments, using comparative examinations to identify the tasks they are involved in and the particular needs the laboratories expect to be filled by the new system. This longitudinal study of a CPOE system was carried out over three years using multiple cases from a hospital pathology service based at a large Sydney teaching hospital. Multi-methods using quantitative and qualitative data were employed to achieve triangulation of data, theory and methods. The findings provide evidence of a significant 14.3% reduction of laboratory turnaround times from 42 to 36 minutes when laboratory data for two months were compared before and after CPOE implementation. The findings also reveal changes in the pattern and organisation of information communication, highlighting transformations in the way that work is planned, negotiated and synchronised. These findings are drawn together in a comprehensive organisational communication framework that is highly relevant for developing a contingent and situational understanding of the impact of CPOE on pathology services

A Study of Critical Value Notification in the Outpatient Setting: The Relationship Between Physician Response and Patient Outcomes

Critical values are laboratory values that represent a life-threatening condition for which there is a treatment available. Laboratories make immediate notifications to ordering providers when critical values are identified so that they may quickly act to initiate a treatment for their patient. The majority of laboratories apply the inpatient critical value list to the outpatient setting, although there are many differences between an acutely ill inpatient population and an ambulatory outpatient population. The goal of this study was to determine if providers responded to the critical values in the outpatient setting and to determine if there was a difference in outcome indicators when providers responded to notifications and when they did not respond to notifications. Data for 673 critical value notifications for PT/INR, Digoxin, and Glucose results were collected from Riverside Health System’s five laboratories. Analysis suggested that the inpatient critical value lists and thresholds may not be appropriate to apply to the outpatient setting. In this study of 637 critical value notifications, providers chose not to respond to 25.7% of critical value notifications. Providers were more likely to respond to PT/INR and Digoxin critical value notifications that glucose critical value notifications. None of the cases for either of the three tests that went without a provider response resulted in death or serious harm to a patient, indicating that the critical value thresholds do not meet the definition of a critical value in the outpatient setting. In the future, laboratories should explore the utilization of a different critical value list and thresholds for the outpatient setting based upon patient outcomes

The use of health information technology in the follow-up of patient test results: an exploration of the experiences and views of primary care staff in the North East of England

Background Computerisation in general practices in the UK over the last 30 years has enabled paperless clinical record keeping but the process of ordering tests and receiving results electronically from hospital systems has been a relatively recent development. The Integrated Clinical Environment System (ICE) provides an electronic link between general practices and hospital-based facilities, facilitating the timely transfer of test results across healthcare boundaries. Whilst the existing literature covers the technical aspects of such systems, there is a paucity of information about how these systems function in real life and what views healthcare staff have of using them. Aims and Objectives This research sought to ascertain the experiences and views of health care staff in general practice about their use of health information technology (HIT) systems for the ordering, processing and follow-up of test results. The research described the test ordering processes and the subsequent actions taken by healthcare professionals. It provided an understanding of different staff roles in this process, including what obstacles GPs and administrative staff faced and their views on the possible subsequent impact these obstacles had on patient care. The human element in the process of requesting and dealing with test results has not been previously described in detail. Methodology The programme of work comprises, in the first section, a narrative and systematic review of the literature, initially from the UK and then, because of a paucity of data, the global setting, on using HIT to order and act on test results. This was followed by a description of the established Donabedian model for evaluating healthcare processes through the stages of structure, process and outcome, with a description of how these components applied to this research. The third section of the thesis consisted of empirical qualitative research project involving semi-structured interviews with 18 staff members from 13 general practices within the North East of England, to ascertain and explore their experiences, views and perceptions around using HIT systems for the follow-up of test results. A conceptual framework was generated by which these data were labelled and sorted. The analysis process involved identifying recurring themes and concepts. Results The reviews indicated that users found the HIT systems easy to use and felt that these systems improved their efficiency compared with the previous paper-based systems, which was confirmed in this study. A new finding, reflecting aspects of the literature, was that results’ management was also perceived to be associated with increased workload, sometimes due to receiving multiple warning alerts about abnormal findings and because of results received from tests done elsewhere. A further, new finding, was the blurring of responsibility and duties about who should review, interpret and act on certain test results received. This task was sometimes left to administrative staff, whose role was to file ‘normal’ results but often found themselves in a position of not knowing whether such results had clinical significance. This factor appeared to be related to GP workload and the delegation of tasks. Participants also felt that the numbers of tests ordered and received had increased, an issue highlighted recently in the literature. There also appeared to be an increasing level of dis-continuity in the clinical care provided in practices, related in part to the use of locum and sessional doctors. Tests ordered were not necessarily designated for follow-up by a specific doctor. These factors may also be contributing to the increasing number of tests ordered. Conclusions and Discussion This study found that whilst the new HIT systems for tests have been associated with ease of use and efficiency in the transfer and availability of results, there appears to be a number of challenges in processing and actioning these results. Applying the Donabedian model for evaluating healthcare processes through the stages of structure, process and outcome shows how the components of the differing procedures have potential drawbacks and could contribute to compromised patient care. This is largely related to the changing structures of general practice whereby continuity of care can be a problem. There appeared to be no standardised procedures for dealing with tests and a standardised approach might be a necessary way forward. This work revealed the importance of human factors in the structure and process of tests results’ management, and how clarification of responsibilities and maintenance of continuity of care are crucial elements in delivering high quality care

The effect of computerisation on the quality of care in Australian general practice

This thesis describes a study of the utilisation of computers by individual general practitioners (GPs) in Australia, and compares the practice behaviour of GPs who use a computer as a clinical tool, either by prescribing, ordering tests, or storing patient data in an electronic medical record format, with those who do not use a computer for these functions. A survey of individual GP’s use of computers was conducted among 1,336 GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) program between October 2003 and March 2005. The GPs were then assigned to groups according to their clinical use (or not) of a computer, and were compared on a range of variables including the characteristics of the GPs themselves, their practices, their patients, the morbidity they managed for their patients, and the managements they provided. Their behaviour was also compared, using a set of quality indicators designed for use with the BEACH data, and applicable in a primary care setting, to determine whether the clinical use of a computer has an affect on the quality of care GPs provide to their patients. Finally, GPs who use clinical software with embedded pharmaceutical advertising were compared with GPs not exposed to advertisements via this media, to determine whether such advertising influences the prescribing behaviour of GPs to favour advertised brands. From 44 quality indicators examined, clinical computer users performed ‘better’ on four and ‘worse’ on four. For the remaining 36 they exhibited no difference. Exposure to pharmaceutical advertising embedded in clinical software did not influence the prescribing behaviour of the GPs so exposed. Despite the belief espoused in the literature that computer use will improve the quality of patient care, I have found no evidence to demonstrate that the use of a computer for clinical activity has (as yet) affected, either positively or negatively, the quality of care GPs provide to their patients. The current push to computerise general practice will mean that this method of assessment will be difficult to replicate in the future, given the absence of control groups. Other research methods will need to be developed

Health information technology (HIT) in small and medium sized physician practices: examination of impacts and HIT maturity

Small and medium sized physician practices (SMPP) are medical practices that consist of a staff of less than 10 physicians. Nearly 60% of the US physicians work in SMPP and face more barriers to HIT adoption and implementation than their larger counterparts. The dissertation is on the use and impact of Health Information Technology (HIT) on SMPP. The dissertation will also explore the effects of IT maturity on health care organizations’ abilities to impact outcomes. It will examine how SMPP have grown through the use of IT and how this has impacted the organization’s use of HIT. While previous work has observed some organizational impacts of HIT, they have only studied a single phenomenon that had been impacted and not how the organization as a whole is impacted. While researchers have found that organizations with higher IT maturity tend to show better operational and financial performance, very little prior studies have shown the impact of HIT maturity on SMPP. The dissertation’s goal is to answer the following questions: 1. How does HIT usage influence the organizational impacts on Small and Medium Sized Physician Practices? 2. How does the SMPP’s HIT maturity influence these impacts? To answer these questions, the dissertation used a framework derived from DeLone and McLean’s (1992, 2003) IS Success Model and the IT Value Hierarchy (Urwiler & Frolick, 2008). The dissertation employed a multiple case study approach by collecting and analyzing data from various members of five different SMPP. The dissertation found that the process of HIT documentation had a major influence on the SMPP. While it has a positive impact on the patient’s Quality of Care, it has a negative impact on Productivity and User Satisfaction. While prior HIT research found that communication was a final outcome of HIT use, this dissertation found that communication is a mitigating factor influencing organizational impacts

COMBINING HUMAN FACTORS AND DATA SCIENCE METHODS TO EVALUATE THE USE OF FREE TEXT COMMUNICATION ORDERS IN ELECTRONIC HEALTH RECORDS

Medication errors are a leading cause of death in the United States. Electronic Health Records (EHR) along with Computerized Provider Order Entry (CPOE) are considered promising ways to reduce these errors. However, EHR systems have not eliminated medication errors. Moreover, in some cases they have facilitated errors due to issues such as poor usability and negative effects on clinical workflows. The use of unexpected free text within a CPOE system can serve as a marker that the system does not adequately support clinical workflow. Prior studies have looked at the use of free text within medication orders, but the inclusion of medication related information in communication for non-medication orders (CNMOs), a type of free text order, has not been adequately studied. This mixed-methods study identified the prevalence, nature and reasons for the inclusion of medication related information in CNMOs using a large sample of CNMOs placed at a mid-Atlantic hospital system in 2017, and via interviews with physicians. The study found that more than 42% of CNMOs contain medication related information. Moreover, the use of CNMOs varied significantly across provider types, hospital locations, patient settings and other factors. The study found 10 themes that might cause providers to adopt such workarounds, including missing functionality and poor usability. The viii study also identified several general challenges in communicating medication information in the EHR, and potential solutions to mitigate these challenges. This dissertation also demonstrates how natural language processing could be used to identify medication related CNMOs

An Integrated Lean Supply Chain Framework for U.S. Hospitals

We apply a lean supply chain framework to the healthcare industry in the U.S., drawing support from lean systems philosophy. We conceptualize a view of the U.S. healthcare ecosystem that places a hospital and its admitted patients at the center and describes how all entities inside and outside the hospital work can implement lean principles to improve patients\u27 quality care. This application depicts how a holistic consideration of hospital resources available in both the internal and external supply chain would increase the optimal use of such resources and ultimately serve patients. We offer propositions suggesting that an integrated supply chain perspective would be helpful for delivering high quality of care to patients admitted to the hospital. This perspective suggests that hospitals need to streamline the three types of flows– physical product, information and financial–with elements in the internal supply chain and maintain collaborative relations with entities in their external supply chain. We discuss theoretical and practical implications of our research

An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area