Ross Koppel, Ph.D. Center for Clinical Epidemiology & Biostatistics School of Medicine, & Sociology Department

1. The Impact of Computerized Physician Order EntrySession on Redesigning Work Processes to Improve Patient Safety and QualityAHRQ Conference, Bethesda MD, September 2007 Ross Koppel, Ph.D. Center for Clinical Epidemiology & Biostatistics School of Medicine, & Sociology Department University of Pennsylvania rkoppel@sas.upenn.edu

2. CPOE BENEFITS CPOE Eliminates: handwriting errors Rx order travel time to pharmacy

3. CPOE BENEFITS CPOE Eliminates: abbreviation errors transcription errors

4. CPOE BENEFITS CPOE eliminates: trailing zero problems 0 0 0 0 0 0 …… I.T. cost overruns apothecary measure errors

5. CPOE BENEFITS CPOE Facilitates ID of prescribing MD integration of CDSS integration with Pt. record

6. CPOE BENEFITS(MOSTLY) CPOE Facilitates clicking inside the box clicking outside the box

7. CPOE BENEFITS CPOE facilitates: Analysis of patient and Rx data

8. CPOE BENFITS! CPOE Eliminates: Poor judgment Sound-alike drug choice spelling errors Skewed efficacy claims

9. CPOE BENEFITS? However…. Some reports of poor fit between workflow and CPOE

10. Can Disaggregate? • CPOE Hospital Workflow

11. Sure…..well? Yes

12. Sure…..well? No

13. Sure…..well? Maybe

14. Sure…..well? Yes Example: Order sets

15. Sure…..well? No Example: Order sets

16. Sure…..well? Sometimes Example: Order sets

17. Of course, Many, many, many good examples Handwriting-free Always available & retrievable Etc, etc, etc

18. But some unhappy examples, too 5 4 1 7 3 2

19. Difficulties Disaggregating • M. Harrison, R. Koppel & S. Bar-Lev. Unintended consequences of information technologies in health care – An interactive sociotechnical analysis . Journal of the American Medical Informatics Association, Sept. 2007.

20. Interactive Sociotechnical Systems

21. Cases (1) New HIT changes existing social system CPOE procedures changes communication between transport teams and emergency room in Children’s hospital (Han)* * For references, see Harrison et al., JAMIA paper or email us.

22. Interactive Sociotechnical Systems

23. Cases (2) Technical & physical infrastructures mediate HIT use -- Interaction of new HIT with existing technical and physical conditions affect HIT-in-use • paper persistence (Campbell, 2006) • computer carts on wheels

24. Interactive Sociotechnical Systems

25. Cases (3) Social system mediates HIT use --Interaction of new HIT with the social system affects HIT-in-use • Instead of real-time entry, nurses document meds at end of shift (Koppel et al.; Bar-Lev and Harrison)

26. Interactive Sociotechnical Systems

27. Cases (4) HIT-in-use changes social system – Interaction of new HIT with the social system affects HIT-in-use, which then further changes the social system. Stealth dosing erodes authority of infectious disease fellows (Larosa et al.)

28. Interactive Sociotechnical Systems

29. Cases (5) HIT-social system interactions engender HIT redesign --Interaction of new HIT with the social system affects HIT-in-use, which then leads to changes in HIT properties Physicians resist fixed choice templates, forcing redesign to allow free-text entry for diagnoses (Bar-Lev and Harrison)

30. Seldom This Clear or True… CPOEHospital

31. Conclusion: Yes, No, Sometimes Many examples: CPOE Workflow Some examples: CPOE Workflow Some examples: CPOE Workflow Most often: CPOE Workflow

32. Not discussed: • Implementing…… • MD Acceptance…….

33. Not discussed: • Customization….. • New versions…… • Interactions w/ Vendors…..

34. CPOE improvements & hospital workflows always emerging No hospital with CPOE has been struck by a meteor.

35. Thank you • Ross Koppel • University of Pennsylvania • rkoppel@sas.upenn.edu