1.  Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors.

Author(s): Ash JS, Berg M, Coiera E

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2004 Mar-Apr;11(2):104-112.

Summary: Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means of achieving it. As researchers conducting separate studies in the United States, the Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their disciplines (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

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2.  Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment

Author(s): Ahmad A, Teater P, Bentley TD, Kuehn L, Kumar RR, Thomas A, Mekhjian HS

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2002 Jan-Feb;9(1):16-24.

Summary: The benefits of computerized physician order entry have been widely recognized, although few institutions have successfully installed these systems. Obstacles to successful implementation are organizational as well as technical. In the spring of 2000, following a four-year period of planning and customization, a nine-month pilot project, and a 14-month hiatus for year 2000, the Ohio State University Health System extensively implemented physician order entry across inpatient units. On implemented units, all orders are processed through the system, with 80% entered by physicians and the rest by nursing or other licensed care providers. The system is deployable across diverse clinical environments, focused on physicians as the primary users, and accepted by clinicians. They believe that the availability of specialty-specific order sets, the engagement of physician leadership, and a large-scale system implementation were key strategic factors that enabled physician-users to accept a physician order entry system, despite significant changes in workflow.

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3.  The Anatomy of Decision Support During Inpatient Care Provider Order Entry (CPOE): Empirical Observations from a Decade of CPOE Experience at Vanderbilt.

Author(s): Miller RA, Waitman LR, Chen S, Rosenbloom ST

Source: Journal of Biomedical Informatics. 2005 Dec;38(6):469-485 Epub 2005 Oct 21.

Summary: The authors describe a pragmatic approach to the introduction of clinical decision support at the point of care, based on a decade of experience in developing and evolving Vanderbilt's inpatient "WizOrder" care provider order entry (CPOE) system. The inpatient care setting provides a unique opportunity to interject CPOE-based decision support features that restructure clinical workflows, deliver focused relevant educational materials, and influence how care is delivered to patients. The specific approach to implementing a given clinical decision support feature within a CPOE system should involve evaluation along three axes: what type of intervention to create; when to introduce the intervention into the user's workflow; and how disruptive, during use of the system, the intervention might be to end-users' workflows. Framing decision support in this manner may help both developers and clinical end-users plan future alterations to their systems when needs for new decision support features arise.

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4.  Computer Physician Order Entry: Benefits, Costs, and Issues

Author(s): Kuperman GJ, Gibson RF

Source: Annals of Internal Medicine. 2003 Jul 1;139(1):31-39.

Summary: Information technology has consistently been identified as an important component for improvement throughout the health care system. Computerized physician order entry (CPOE) is a relatively new technology that allows physicians to enter orders into a computer instead of handwriting them; however, there is no consensus on the best approaches to the challenges it presents. CPOE fundamentally changes the ordering process, which can lead to: a substantial decrease in the overuse, underuse, and misuse of health care services; decrease in costs; shorten length of stay; decrease in medical errors; and improvement of compliance with several types of guidelines. The costs of implementing CPOE are substantial both in terms of technology and organizational process analysis and redesign, system implementation, and user training and support. This technology can yield many significant benefits and is an important platform for future changes to the health care system. Organizational leaders must advocate for CPOE as a critical tool in improving health care quality.

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5.  A Consensus Statement on Considerations for a Successful CPOE Implementation

Author(s): Ash JS, Starvi PZ, Kuperman GJ

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2003 May-Jun;10(3):229-234.

Summary: In May of 2001, 13 experts on computerized provider order entry (CPOE) from around the world gathered at a two-day conference to develop a consensus statement on successful CPOE implementation.  A qualitative research approach, including activities before, during, and after the conference, was used to generate and validate a list of categories and considerations to guide CPOE implementation.  Preconference activities included prior reading for participants to establish a shared knowledge base.  During the conference, participants shared success factors they had discovered during their implementation of CPOE, developed lists of success factors, and prioritized main discussion points.  Postconference activities included creating a "themes document" that reflected participants' consensus on CPOE implementation.  The general considerations before CPOE implementation include: motivation for implementation; CPOE vision, leadership, and personnel; financial costs; integration: workflow, health care process; value to users/decision support systems; project management and staging of implementation; technology; training and support 24x7; learning/evaluation/improvement.