Taxonomy of delays in the implementation of hospital computerized physician order entry and clinical decision support systems for prescribing:a longitudinal qualitative study

BACKGROUND: Implementation delays are common in health information technology (HIT) projects. In this paper, we sought to explore the reasons for delays in implementing major hospital-based HIT, through studying computerized physician order entry (CPOE) and clinical decision support (CDS) systems for prescribing and to develop a provisional taxonomy of causes of implementation delays. METHODS: We undertook a series of longitudinal, qualitative case studies to investigate the implementation and adoption of CPOE and CDS systems for prescribing in hospitals in the U.K. We used a combination of semi-structured interviews from six case study sites and two whole day expert roundtable discussions to collect data. Interviews were carried out with users, implementers and suppliers of CPOE/CDS systems. We used thematic analysis to examine the results, drawing on perspectives surrounding the biography of artefacts. RESULTS: We identified 15 major factors contributing to delays in implementation of CPOE and CDS systems. These were then categorized in a two-by-two delay classification matrix: one axis distinguishing tactical versus unintended causes of delay, and the second axis illustrating internal i.e., (the adopting hospital) versus external (i.e., suppliers, other hospitals, policymakers) related causes. CONCLUSIONS: Our taxonomy of delays in HIT implementation should enable system developers, implementers and policymakers to better plan and manage future implementations. More detailed planning at the outset, considering long-term strategies, sustained user engagement, and phased implementation approaches appeared to reduce the risks of delays. It should however be noted that whilst some delays are likely to be preventable, other delays cannot be easily avoided and taking steps to minimize these may negatively affect the longer-term use of the system

Treatment of primary advanced and recurrent endometrial carcinoma with a combination of carboplatin and paclitaxel - long-term follow-up

There is no generally accepted standard chemotherapy in treatment of advanced and recurrent endometrial carcinoma. Cisplatin and doxorubicin with or without cyclophosphamide are widely used. Response rates have improved with combination chemotherapy compared with single-agent therapy. A platinum analog seems to be an important part of the chemotherapy regimen. Since few patients are cured from their disease and since the duration of response is short, further improvement of this therapy is warranted. During the past years, the taxanes (paclitaxel) are being added to prior evaluated regimens and not only improved response rates are reported but also increased toxicity is observed. In a prospective, phase II, multicenter study, carboplatin (area under the curve = 5) and paclitaxel (175 mg/m(2)) were evaluated in treatment of primary advanced and recurrent endometrial carcinoma. In total, 66 patients were recruited during the years 2000-2004. Eighteen primary advanced tumors and 48 recurrences were treated. All histologic types and tumor grades were allowed. The median follow-up was 57 months (range 37-69 months). The overall response rate was 67% (95% CI 55-78). The complete response rate was 29% and the partial response rate 38%. Primary advanced and recurrent tumors as well as endometrioid and nonendometrioid tumors showed similar response rates. The median response duration was 14 months. The 1- and 3-year survival rates were 82% and 33%, respectively. The main toxicities were hematologic and neurologic (sensory neuropathy). The response rates were encouraging, superior to prior platinum-containing regimens, but response duration and the long-term survival rate were still short. The neurologic toxicity was frequent and was a substantial problem in this series of patients. Further research is highly needed to improve the treatment of advanced and recurrent endometrial cancer

Feedback in the ERP value-chain: what influence has thoughts about competitive advantage

Different opinions about whether an organization gains a competitive advantage (CA) from an enterprise resource planning (ERP) system exist. However, this paper describes another angle of the much reported competitive advantage discussion. The basic question in the paper concerns how thoughts about receiving competitive advantage from customizing ERPs influences feedback in ERP development. ERP development is described as having three stakeholders: an ERP vendor, an ERP partner or re-seller, and the ERP end-user or client. The question asked is: What influence has thoughts about receiving competitive advantage on the feedback related to requirements in ERP development? From a set of theoretical propositions eight scenarios are proposed. These scenarios are then illustrated from interviews with stakeholders in ERP development. From an initial research, evidence for six of these eight scenarios was uncovered. The main conclusion is that thoughts about competitive advantage seem to influence the feedback, but not really in the way that was initial assumed. Instead of, as was assumed, having a restrict view of providing feedback stakeholders seems to be more interested in having a working feedback loop in the ERP value-chain making the parties in a specific value-chain more interested in competing with other parties in other ERP valuechains