A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

Physicians' and Nurses' Opinions about the Impact of a Computerized Provider Order Entry System on Their Workflow

INTRODUCTION: In clinical practices, the use of information technology, especially computerized provider order entry (CPOE) systems, has been found to be an effective strategy to improve patient care. This study aimed to compare physicians' and nurses' views about the impact of CPOE on their workflow. METHODS: This case study was conducted in 2012. The potential participants included all physicians (n = 28) and nurses (n = 145) who worked in a teaching hospital. Data were collected using a five-point Likert-scale questionnaire and were analyzed using SPSS version 18.0. RESULTS: The results showed a significant difference between physicians' and nurses' views about the impact of the system on interorganizational workflow (p = .001) and working relationships between physicians and nurses (p = .017). CONCLUSION: Interorganizational workflow and working relationships between care providers are important issues that require more attention. Before a CPOE system is designed, it is necessary to identify workflow patterns and hidden structures to avoid compromising quality of care and patient safety

Refining Computerized Physician Order Entry Initiatives in an Adult Intensive Care Unit

Computerized physician order entry (CPOE) is used in healthcare organizations to improve workflow processes and transcription, as well as to prevent prescribing errors. Previous research has indicated challenges associated with CPOE for end-users that predispose patients to unsafe practices. Unsafe CPOE practices can be detrimental within the intensive care unit (ICU) setting due to the complexity of nursing care. Consequently, end-user satisfaction and understanding of CPOE and electronic health record (EHR) functionality are vital to avoid error omissions. CPOE initiatives should be refined post system implementation to improve clinical workflow, medication processes, and end-user satisfaction. The purpose of this quality improvement project was to refine CPOE system initiatives and develop an e-learning educational module to facilitate end-user understanding of and satisfaction with CPOE. The Iowa model of evidence-based practice, Lean methodology, and Provider Order Entry User Satisfaction and Usage Survey (POESUS) were used to guide the study. An e-learning module was implemented to increase staff understanding of the newly implemented CPOE system, and a plan was provided for ongoing data collection and investigation of end-user satisfaction and medication inadequacies with the CPOE system. A mixed-method design was recommended to key stakeholders to identify the impact of the e-learning course and refined CPOE initiatives on both end-user satisfaction and patient outcomes in the medical-surgical ICU. Findings from the study informed the impact of e-learning educational modules with CPOE system implementation. Those in organizations implementing advanced technology such as CPOE and EHR systems in critical care settings will find this paper of interest

Doctor of Philosophy

dissertationComputerized provider order entry (CPOE) is a component of electronic health records (EHR) that has been touted as a crucial means to support healthcare quality and efficiency. The costs of EHR implementation can be staggeringly high, and little literature exists to verify the hypothesized benefits of CPOE and EHRs. The purpose of this study, based on Coyle and Battle's adaptation of the classic Donabedian quality improvement framework, was to evaluate system-wide outcomes after CPOE implementation in a large academic setting. The specific aims were to describe the association between CPOE implementation and (1) mortality rate and (2) length of stay (LOS), controlling statistically for antecedent, structure, and process variables. The study used hierarchical linear modeling to analyze clinical and administrative data from 2.5 years before and 2.5 years after CPOE implementation. Aim 1 analysis included 104,153 hospital visits and aim 2 analysis included 89,818 visits. Two models were created for each analysis, (a) a model with individual patient care units as the unit of analysis and (b) a model with units aggregated by type. LOS decreased 0.9 days per visit in all models. Mortality decreased 1 to 4 deaths per 1000 visits, depending on the model; or 54 to 216 patient lives saved in the postimplementation period. Significant antecedents were patient demographics, insurance type, and scheduled versus emergency admission; structure variables included patient care unit, private room, and palliative care; and process variables included nursing care iv hours and the number of orders placed. Mortality models were variable by patient care unit, and strongly influenced by confounders such as rapid response team or code activation, suggesting the importance for future studies to account for those influences. CPOE was statistically associated with clinically significant improvements in the system-wide outcomes. Controlling statistically for antecedent, structure, and process variables, the analysis found that after the implementation of CPOE, there was a decrease in mortality and LOS. Future studies need to determine how CPOE implementation impacts nursing performance and how CPOE influences the effect of new physician resident arrival on patient outcomes

Master of Science

thesisCampylobacteriosis is a foodborne and waterborne zoonotic gastrointestinal illness and the most common cause of acute gastroenteritis worldwide. In the United States Campylobacter infections are second only to Salmonella as the most common cause of gastroenteritis, accounting for an estimated 2.4 million symptomatic infections annually. It is estimated that the total cost of foodborne illness in the United States is $152 billion of which$18.8 billion is attributed to Campylobacter. Diagnosis can be challenging because the organism is difficult to isolate, grow, and identify. Clinical manifestation of Campylobacter is indistinguishable from other enteric pathogens; (Salmonella, Shigella, Yersinia, Clostridium difficile, and E. coli 0157:H7 and other enterohemorrhagic E. coli) therefore, a presumptive diagnosis cannot be made putting them at risk for untreated infection. There are a growing number of diagnostic methods available for detection and/or isolation of Campylobacter species from stool, but there is currently no national or state public health testing guidelines. Eight assays were evaluated for performance in the detection of Campylobacter species in stool. The assays are comprised of four culture medias (CVA, CSM, Cefex, and mCCDA); three EIA/ELISA kits (ImmunoCard STAT! Campy, Premier Campy and ProSpecT Campy); and one molecular method (FilmArray GI panel). The FilmArray GI panel due to its ability to detect viable and nonviable organism was used as the gold standard. To verify the gold standard was accurate all positive FilmArray samples were analyzed by DNA sequencing. The sensitivity and specificity, respectively, of each assay are as follows: CVA 87.8%, 100%; CSM 87.8%, 100%; Cefex 87.8%, 100%; mCCDA 78.0%, 100%; ImmunoCard STAT! Campy 31.7%, 65.2%; Premier Campy 80.5%, 26.1%; and the ProSpecT Campy 75.6%, 82.6%. In contrast the FilmArray produces a sensitivity and specificity of 100% when compared to culture. Furthermore the FilmArray GI panel takes the least amount of time to produce a result, 1 hour compared to 48-72 hours for culture. In conclusion, the FilmArray GI panel is the most sensitive, specific, rapid, cost effective, and objective method for the detection of Campylobacter species in stool. Molecular assays such as the FilmArray GI panel should replace traditional culture techniques in the microbiology lab

Survey of information technology in Intensive Care Units in Ontario, Canada

<p>Abstract</p> <p>Background</p> <p>The Intensive Care Unit (ICU) is a data-rich environment where information technology (IT) may enhance patient care. We surveyed ICUs in the province of Ontario, Canada, to determine the availability, implementation and variability of information systems.</p> <p>Methods</p> <p>A self-administered internet-based survey was completed by ICU directors between May and October 2006. We measured the spectrum of ICU clinical data accessible electronically, the availability of decision support tools, the availability of electronic imaging systems for radiology, the use of electronic order entry and medication administration systems, and the availability of hardware and wireless or mobile systems. We used Fisher's Exact tests to compare IT availability and Classification and Regression Trees (CART) to estimate the optimal cut-point for the number of computers per ICU bed.</p> <p>Results</p> <p>We obtained responses from 50 hospitals (68.5% of institutions with level 3 ICUs), of which 21 (42%) were university-affiliated. The majority electronically accessed laboratory data and imaging reports (92%) and used picture archiving and communication systems (PACS) (76%). Other computing functions were less prevalent (medication administration records 46%, physician or nursing notes 26%; medication order entry 22%). No association was noted between IT availability and ICU size or university affiliation. Sites used clinical information systems from15 different vendors and 8 different PACS systems were in use. Half of the respondents described the number of computers available as insufficient. Wireless networks and mobile computing systems were used in 23 ICUs (46%).</p> <p>Conclusion</p> <p>Ontario ICUs demontrate a high prevalence of the use of basic information technology systems. However, implementation of the more complex and potentially more beneficial applications is low. The wide variation in vendors utilized may impair information exchange, interoperability and uniform data collection.</p