Unintended transformations of clinical relations with a computerized physician order entry system

1. Introduction 

This study pays special attention to the technique and role of a computerized order entry system (CPOE) in the work processes of medication at two wards of internal medicine in a middle-sized Danish hospital. From the view of health care management, “the cockpit crew” [1], CPOE systems are expected to reduce errors and medical costs, give better quality and continuity of care and improve cooperation between health care professionals [2]. The aim of the qualitative study presented here, though, is to bring in the view of the “fire brigade” [1], the clinicians responsible for the medication outcome, and to support their articulation of experiences as the primary users of the system. These articulations might, in spite of their local, qualitative origin, be of interest to other implementers and developers of CPOE systems, as learning on design, change management and the nature of clinical work [3], [4] seem to be the imperative of improving information systems in health care. Classen et al. state that evaluation of CPOE installation in individual organizations is more pressing than ever [5, p. 51]. “All organizations will need to perform ongoing evaluation of their CPOE applications and their electronic health record (EHR) if the potential benefits of these technologies are to be actually realized” [6, p. 53]. Georgiou et al. concluded that further research is needed, especially as “(f)ew data are available regarding the impact of CPOE on patient outcomes” [6, p. 514]. Pragmatic discussions on health care improvements from CPOE call for more attention to detail and appropriate support to clinicians’ workflow [7]. The following ethnographic study illuminates usability and utility problems of clinicians interacting with CPOE in real life settings.

2. Materials and method 

The object of study is the medication process with a CPOE system in two Danish internal medical wards. Qualitative methods have been used for in-depth analysis of 48h observation, six semi-structured interviews with primary users (two physicians and four nurses) and an analysis of the user interface and of other documents. Based on the observations, three use scenarios for central events in the medication process were constructed. The actants were among others drugs, physicians, nurses and the CPOE system. The CPOE system, at this stage of development, is only handling the “bookkeeping” of medication. It is not offering any decision support, and is developed by a professional vendor (Systematic Software Inc., Aarhus, DK) in close cooperation with the responsible Health Maintenance Organization (HMO) (Aarhus County, DK), who have supplied clinicians to the development project. At the time of the study, the CPOE had been in use for 8 months in the participating hospital wards, replacing a paper medication scheme, called MOS. Other actants were the pharmacy system (electronic Danish Physicians Desk Reference (PDR)), handbooks on medication, PC tables, other staff groups and techniques.

3. Results 

The following shows how the CPOE system participates in the transformation of three central relations for enacting right medication, i.e. between doctor and patient treatment when prescribing and ordering drugs, between doctor and nurse and their collaboration around ordering and decisions on proper dosage for the patient, and in the coordination between hospital and future situations of treatment. These transformations point to unintended consequences that cannot alone, though, be reduced to either the system or social factors but are in many ways sensible outcomes of concrete situations of interaction. The use scenarios showed that the system's success or failure in use could not be assessed isolated from the environment in which it participates. The social culture and the materiality of space and things challenge the use of the CPOE system.

3.1. Transformation of prescription (2) and drug order (3) on doctor's rounds 

On doctor's rounds ‘a detour’ [6] or work around occurred in making prescriptions and entering orders in the system. This was due to long walking distances between the patients’ beds and the stationary dictaphone in the hallway for making prescriptions in the patient's medical record and subsequently, a clumsy PC table with the otherwise portable CPOE (Fig. 1). The doctor would therefore memorize three or four patients at a time before (s)he would, first, dictate the patients’ diagnoses, indications and prescriptions for the patients’ records and then enter the drug orders in the system. In other words, the space and distance between hospital beds, PC tables and a stationary dictaphone decide what is accessed, when, in what order and how. The CPOE may be, therefore, technically ubiquitous in the sense that it provides users with global access to patients’ medication across hospital wards and other health care institutions in the county. Though in its local use other actants such as the stationary dictaphone, the clumsy mobile PC table (Fig. 1), the endurance of the laptop computers and the walking distance between the different interactions of talking to the patient, dictating the diagnosis for the patient record and prescribing medicine for treatment in the CPOE, play a decisive role in how and what medicine is actually performed. Alas, the best working conditions for the users were at the stationary PCs in the ward office away from the patients and the drug storage.

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Fig. 1. PC table and patient paper records of both nurses and doctors.

3.1.1. The figuration of a collective e-patient for drug orders 

The term ‘figuration’ means the formation and appearance of another meaning and identity in the given context [11]. In this case, a more ‘collective e-patient’ appeared in the physician's way of coordinating doctor's rounds, with the activities of recording diagnostic information on the dictaphone for the patient record and ordering prescriptions in the CPOE. The physician would start/continue treatment of the individual patient on the background of an encounter of three or four patients at a time, before (s)he would do the drug orders collectively. The health care treatment and trust relation between the human actants, therefore, to a higher degree depends on the doctor's memory and ability to keep the different patients’ diagnoses, prescriptions, other treatments and plans of action apart.

4. Discussion 

The role of CPOE systems in fostering new errors as well as reducing old ones is known [3], [12] and forms the debate on IT development in health care as such [1], [5], [6], [7], [12], [13], [14], [15]. The point seems to be that, despite disappointments in improving the quality of health care with information technology, HIT [16], including CPOE systems, is indispensable to modern health care. It also follows that the complexities of health care make flawless systems a priori impossible [7], [16], [17]. Arguing along the line of either the system [18] or system developers/organization [19] being solely responsible for the user's resistance is a modernistic conception of rationality [20], that cannot grasp the transformative character of IT implementation on communication and sense-making. Instead, more iterative design processes that include the domain knowledge of the end-users [4], [7], [16], [20] are required. Interdisciplinary research in human–computer interaction in hospital settings can inform on more clinical sensitive and iterative design processes [1], [5], [6], [15], [16]. Here, quality of health care depends heavily on the inclusion of the end-users’ domain knowledge in more iterative design processes [7], [17], [21]. The argument is that transformations of medication processes, also outlined above, touch upon many actants that all have responsible roles to play in the overall goal of medication, i.e. the right – and safe – treatment of individual patients. ‘Errors’ are, therefore, not an impediment to HIT-mediated health care, but can be seen as something to learn from [22] when new understandings and solutions are equally integrated into the system design and work processes.

This study confirms numerous usability problems that also affect the overall quality of health care and is of consequence to professionals. One important issue concerns the technical maturity in relation to stability and functionalities, and the CPOE system in this study is fairly unripe. Another important issue is the rationality of the system as reflecting different understandings of work division. In this study, the deconstruction of the formal user rights and of the individualized logon to a clinical team user, working under the rights and responsibilities of a physician, showed a lack of correspondence between work division inscribed in the system, and the actual use of the system for medication work. This ‘gap’ between formal understandings of what nurses and doctors are trained and licensed to do, inscribed in the software, and how these roles are played out as teamwork to smooth the process in a real clinical setting, stays open, and has not yet been bridged. Among the Danish public, this issue is in general discussed as either a technical problem of making a faster and unbreakable login [23], a jurisdictional problem of health care authorities to secure and punish misuse of patient data more firmly [24], or as problems of the hegemony of the clinical professions. The authority and right of the physician to delegate tasks, and the duty of the nursing profession to protect care obligations from new tasks and workloads are diluted. These issues point to implementation problems that transcend the knowledge domain of the vendor and hospital owners, as they touch upon power relations and core duties and responsibilities of health care professionals. Additionally, it can therefore be asked who is responsible, or can be made responsible, for these transformations of core relations in patient treatment with the CPOE systems.

5. Conclusion 

Expectations of more quality and continuity in health care from simply implementing vendor-built CPOE systems are naive and bound to be disappointed. ‘Rational medication’ can never be detached from local interactions between wide ranges of actants. System design and implementation has to take the pragmatic rationalities of concrete tempo-spatial interaction into consideration and negotiation. The presented study points to critical situations of enacting medication with CPOE, that demands more flexible functionalities, vendors adherence to general recommendations for human–computer interaction, more attention to change management by the project organization, but also to political and ethical issues on among whom and how responsibilities for health care are to be shared.