| More work and New work |
• Needs additional educational effort and surveillance by nursing and pharmacy to prevent ADE’s • Orders are more labor intensive; repeat orders are timesaving with the system, though • Most examples of new work that come to mind really are not new, but only new to the person doing it • Prescribers are now responsible for much of the ordering and documenting that used to be done by support staff • People expect the computer to save them time, but there is a learning curve while trying to get to know the system and that creates work • More data can mean that there is more to manage and how to do that effectively becomes an issue. CPOE has made some things definitely faster • Upfront work takes more time which is the downside, but information is there and clearly available for everyone • Time saved overall, but individually some see more work than others |
| Workflow |
• Has different effects on different jobs and people • Especially the physicians • Sequence of workflow is often required to be changed; new steps are added • Same work, different groups performing the tasks • Establishing remote access, many doctors have already checked their labs and work online before coming to work or doing rounds, which makes their floor practices easier |
| System demands |
• It takes an army to help build and maintain X system, assuming you have not hired the vendor to do this work. There are about 50 people who support the X system directly in our IT department and it still is not enough to keep up with the demand • The need for constantly upgrading old computer equipment is a huge issue. It is a constant tug-of-war between the cost of new equipment and the cost of user time and frustration having to use equipment that is slow or in need of repair • Huge undertaking, a lot on the software side, there were cultural issues as well • Demand from the organization exceeding our supply so getting priorities sorted out once you establish the mandatory maintenance allocation is critical • Training and maintenance have been huge • Order sets are the biggest challenge and modification of them once in the working system is very intensive • Weren’t aware that so much support resources would be needed; we way under forecasted • Do not do this unless you can support it! • We’ve tackled the beast with 6 full time workers, each specializing in a particular area |
| Communication |
• People seem to forget how to communicate, even for the most basic, routine matters. They expect the computer to tell them what to do, every step of the way • I think there is less face-to-face communication between providers • It’s always a challenge in a complex environment because the computer makes things invisible; we should educate everyone in what the system can and can’t do to uncover misconceptions and silent communication patterns • People began to assume the system had it so they did not need to tell someone • Initially, they didn’t think they had to talk any more and that isn’t the case! It is much improved over time • Improvement because patient records accessible anywhere |
| Emotions |
• Computer phobics had a hard time; they identified each additional minute the physicians spent because of the system • There have been both strong advocates and strong opponents of the system • Doctors mostly see CPOE as a good tool and beneficial for others • In the beginning, resistance, now no • At first, everyone was upset. But now residents rely on it; they don’t know how to use the paper system • Pick your favorite terms of praise or profanity. They are all used • It’s an inanimate object, so easier to express it toward system than toward a human; people expect computers to be working all the time and when they don’t people are angry • A small but vocal minority hate it • Generational, but mostly favorable • Many reactions on both sides of the fence. Some doctors were upset because they felt like they were being asked to be typists. Others are happy because they can navigate the computer to find the information they need quickly • Some love it and other keep hoping that it will just go away • Most have been willing to adapt and have had positive responses. There was one case where a doctor told the implementation staff that they were ruining his life • Doctors don’t like feeling dumb so when they don’t know how to use the system, they get frustrated and angry |
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| New Kinds of Errors |
• Wrong patient being selected. We now have an extra step to confirm the patient’s identity • Potential, but only a few minor errors so far; paper mistakes only mess up one record, but the computer has the potential to mess up multiple records • People think that computers should catch any errors in the system and therefore don’t examine things as closely • With computers you have to think in black and white and patients are in the gray • Issues have shifted. Medication problems have been reduced significantly, but there are new things like errors of omission • Orders entered on wrong patient, takes away a few cues, location, color, thickness of chart—easy to transpose numbers when typing—this is why decision support is important to safeguard • Desensitized to alerts; do things without challenging the computer • Someone gets numb looking at alert messages and skips by an important one • At points of transfer of care or areas where two systems abut and are not integrated • Lose critical thinking abilities. Don’t question order sets • Physicians have stated in the early phase that they forgot to order things as they were distracted—but over time, they feel absolutely more safe • Insufficient training and system glitches can cause safety issues with higher reliance on machines • Potential for new issues so awareness is vital |
| Power Shifts |
• Was 1 [low] with the paper system, 5 [high] with new system, and down to 1 again after people got used to the new system • Pharmacy feels threatened … doctors are now more in charge of medications like they are meant to be • Ancillary departments have gained much more power over how patient records and patient care are handled • With the ability of the computerized system to force and monitor behaviors, primary care providers have much less control over their workflow • CPOE puts more power into the IS department • You mean the CIO becomes king? • Computer developers need to be careful and just provide the tools, not the rules • Not so much a change in the balance of power, but it does shine a light on how decisions are made in a very public way • Knowledge is power. There are now tracking patterns • Mostly I think physicians have lost power, but I also think this is happening more generally |
| Dependence on the Technology |
• The organization implemented a downtime procedure, but some staff have never had to work with the backup paper systems before • If we lost CPOE, other programs/systems that are programmed to run in parallel would be lost as well • Despite some very well-designed and well-intentioned downtime processes, it is basically managed chaos with a very negative impact on productivity • Downtime is difficult, but even more so is when the system comes back online and they have to manage all the data from paper back into the system and that creates a lot of duplication of the work • Much harder if it’s down more than three hours |
