Same system, different outcomes: Comparing the transitions from two paper-based systems to the same computerized physician order entry system

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Abstract

Objective

To compare how nurses in two different paper-based systems perceive the impact of a computerized physician order entry (CPOE) system on their medication-related activities.

Setting

13 non-surgical, adult inpatient wards in a Dutch academic hospital.

Methods

Questionnaire survey of 295 nurses before and 304 nurses after the implementation of a CPOE system. These nurses worked with two different paper-based medication systems before the implementation: ‘Kardex-system’ and ‘TIMED-system’. In the Kardex-system, the structure of the nursing medication work was similar to that of after the CPOE implementation, while in the TIMED-system, it was different. ‘Adaptive Structuration Theory’ (AST) was used to interpret the results.

Results

The response rates were 52.2% (154/295) before and 44.7% (136/304) after the implementation. Kardex-nurses reported more positive effects than TIMED-nurses. TIMED-nurses reported that the computerized system was more inflexible, more difficult to work with, and slower than the TIMED-system. In the TIMED group, the overall mean score of the computerized process was not significantly different from that of the paper-based process. Moreover, nurses in both groups were more satisfied with the post-implementation process than with the pre-implementation process. Nevertheless, none of groups reported a better workflow support in the computerized system when compared to that of the paper-based systems.

Conclusions

Our findings suggest that not only the technology but also large differences between pre- and post-implementation work structure influence the perceptions of users, and probably make the transition more difficult. This study also suggests that greater satisfaction with a system may not necessarily be a reflection of better workflow support.

Introduction

The implementation of a computerized physician order entry (CPOE) system is considered as a pivotal transitional step towards the more effective management of medications [1]. A CPOE system is defined as a computer application where a physician directly enters medical orders. Because nurses are also involved in patient care, they inevitably interact with these systems or their outputs. Studies have shown that a CPOE system can eliminate a number of intermediate steps for nurses. For example, they no longer have to deal with illegible and incomplete hand-written orders, which are a common source of extra workload for nurses [2], [3], [4]. The system, moreover, facilitates order communication to other parties such as the pharmacy, which in turn saves considerable time for nurses [5], [6].

However, something which has recently received considerable attention is the extent to which these systems change the nature of workflow for health professionals, including nurses [7], [8], [9]. In fact, in addition to the literature that reports benefits of CPOE systems, there is a growing number of studies that focus on unintended changes in many aspects of workflow following the implementation [8], [10]. Beuscart-Zephir et al. described the role of nurses in distributed decision making in the medication ordering and administration process [11]. Coleman observed that nurses normally interpret physicians’ intents in their orders [12]. Therefore, if nurses were to be bypassed after implementation of a CPOE system, the system would not be able to handle this interpretation effectively. Both studies criticized the fact that the organizational role of nurse was ignored during the design of CPOE systems [11], [12]. Moreover, in a study of perceived impact of CPOE systems, nurses reported a sense of loss of control over their work [13]. Goorman and Berg argued that at least some of the problems with these systems occur because of the clash between the nursing workflow model embedded in the system and actual nursing practice [14]. This evidence indicates that nurse-related medication activities, and more importantly their organizational role in the medication process, deserve more attention in the design, implementation and evaluation of CPOE systems.

Depending on different work organizations, nurses may be assigned different roles and responsibilities. As the implementation of CPOE systems brings a new work organization along with it, this unavoidably transforms their roles and activities. The study of how nurses perceive this transformation in the transition from a paper-based to a computerized work structure can give insight into how this transition can effectively be managed. In 2001, a computerized medication order entry system was implemented in a Dutch academic hospital. Several different paper-based medication systems were in use before the implementation. To compare the perceived impact of this CPOE system on nursing medication practice, we conducted a before-and-after study in two different paper-based medication systems. In particular, we compared the perceived benefits and/or drawbacks of the computerized system with those of the two different paper-based systems. We also examined nurse satisfaction and perceived workflow support before and after CPOE implementation.

Section snippets

Theoretical background

We used the ‘Adaptive Structuration Theory (AST)’ [15] as a theoretical framework to study the changes that occurred in two different work practices following the CPOE implementation. AST is based on Anthony Giddens’ Structuration Theory [16]. This theory is formulated as “the production and reproduction of the social systems through members’ use of rules and resources in interaction”. DeSanctis and Poole adapted Giddens’ theory to study the interaction of groups and organizations with

Study environment and the CPOE system

This study was conducted at Erasmus University Medical Center (Erasmus MC) in Rotterdam, a 1237-bed academic hospital in the Netherlands. We studied a commercially available computerized medication order entry system named Medicatie/EVS®. To retrieve patient and drug data, Medicatie/EVS communicates with the existing hospital information system (HIS) and patient medical record (Patient 98). This system was first piloted in six wards of two specialties from December 2001 to December 2002. It was

Study design and measurements

Our evaluation was based on questionnaire administered to nurses before and after the CPOE implementation. Design of the questionnaire was based in part on previously published questionnaires for the assessment of user satisfaction with CPOE – such as [18] – and was done in a close collaboration with nursing staff. In addition to demographics, the original questionnaire contained 28–40 questions to measure attitudes regarding the paper-based systems (Kardex and TIMED) and the CPOE system. In

Results

Table 1 provides the demographics of the different study groups. Most nurses were women, practicing nurses, often used computers both at home and at work, and had no prior experience with an electronic prescription system. With regard to demographics, there were no important differences neither between respondents of pre- and post-implementation phases nor between respondents in Kardex units and respondents in TIMED units. Cronbach's Alpha for questions 1.1–5.2 was 0.84 for the paper-based and

Discussion

Our study showed that although the system eliminated the workload of transcription and translation tasks for the TIMED-nurses, they showed a less positive attitude compared with the Kardex-nurses. Nurses in both groups benefited from improved legibility and completeness of medication orders and greater reliability of drug overview after the implementation. TIMED-nurses were sometimes less positive about the new medication process than the pre-implementation process, with the new process being

Conclusion

Implementing CPOE systems reorganizes the medication work. These systems are referred to as transformational technology and nursing practice is not an exception. The pattern of nursing work in general and their roles and responsibilities in particular are all affected. Yet, the perceived impact of the system on nursing practice depends in part on the extent to which the system changes existing work patterns. Use of AST allowed us to explain why the outcome of transition from a paper-based to

Contributions of the authors

HS designed the questionnaire and collected data. ZN and HP designed the study and analyzed data. ZN wrote the early draft of the manuscript. HS was also involved in the comments on the manuscript. WR was involved in analysis of data and critical review and editing of the manuscript. ZN, HP, and JA participated in the development of the concept and critical review of the content. ZN revised different versions of the manuscript. JA scientifically supervised the paper.

Acknowledgements

The authors gratefully acknowledge the time and effort of all head nurses and all of those who completed the questionnaires. We also thank Enrico Coiera, Antoinette de Bont, and Marc Berg for their insightful comments on an earlier version of this paper. The first and the third authors were supported by a grant from the Iranian Ministry of Health and Medical Education while conducting this research.

Summary points

What was known before the study

  • The implementation of CPOE systems changes work

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