Download PDF
Methods Inf Med 2023; 62(01/02): 040-048
DOI: 10.1055/s-0042-1758631
Original Article

Workflow, Time Requirement, and Quality of Medication Documentation with or without a Computerized Physician Order Entry System—A Simulation-Based Lab Study

Viktoria Jungreithmayr
1   Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
2   Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
,
Walter E. Haefeli
1   Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
2   Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
,
Hanna M. Seidling
1   Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
2   Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
,
and Implementation Team › Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background The introduction of a computerized physician order entry (CPOE) system is changing workflows and redistributing tasks among health care professionals.

Objectives The aim of this study is to describe exemplary changes in workflow, to objectify the time required for medication documentation, and to evaluate documentation quality with and without a CPOE system (Cerner® i.s.h.med).

Methods Workflows were assessed either through direct observation and in-person interviews or through semistructured online interviews with clinical staff involved in medication documentation. Two case scenarios were developed consisting of exemplary medications (case 1 = 6 drugs and case 2 = 11 drugs). Physicians and nurses/documentation assistants were observed documenting the case scenarios according to workflows established prior to CPOE implementation and those newly established with CPOE implementation, measuring the time spent on each step in the documentation process. Subsequently, the documentation quality of the documented medication was assessed according to a previously established and published methodology.

Results CPOE implementation simplified medication documentation. The overall time needed for medication documentation increased from a median of 12:12 min (range: 07:29–21:10 min) without to 14:40 min (09:18–25:18) with the CPOE system (p = 0.002). With CPOE, less time was spent documenting peroral prescriptions and more time documenting intravenous/subcutaneous prescriptions. For physicians, documentation time approximately doubled, while nurses achieved time savings. Overall, the documentation quality increased from a median fulfillment score of 66.7% without to 100.0% with the CPOE system (p < 0.001).

Conclusion This study revealed that CPOE implementation simplified the medication documentation process but increased the time spent on medication documentation by 20% in two fictitious cases. This increased time resulted in higher documentation quality, occurred at the expense of physicians, and was primarily due to intravenous/subcutaneous prescriptions. Therefore, measures to support physicians with complex prescriptions in the CPOE system should be established.

Keywords

Computerized physician order entry - lab study - medication documentation process - documentation quality - tertiary care

* Implementation Team, Heidelberg University Hospital. Centre of Information and Medical Technology: Centre of Information and Medical Technology: Cornelia Apfel, Janina Bittmann, Markus Fabian, Alexandra Kapschack, Caroline Kay, Ulrike Klein, Silvia Kugler, Martin Löpprich, Oliver Reinhard, Miriam Rieth, Lucienne Scholz, Hendrik Stiefermann, Birgit Zeeh; Center for Orthopedics, Trauma Surgery and Spinal Cord Injury: Claudia Benkert, Ulf Brunnemer, Andreas Geisbüsch, Rüdiger Gellings, Sébastien Hagmann, Cornelia Hensel, Moritz Innmann, Simone Klingebiel, Claudia Kobus-Schubach, Christian Merle, Marcus Österreicher, Rilana Schuster, Brigitte Simon, Silke Weber; Department of Internal Medicine: Lars Kihm, Stefan Kopf, Anja Liemann, Johanna Zemva; Department of Radiation Oncology: Sergej Roman, Stefan Welte; Pharmacy Department: Maren Bechberger, Kristin Egenberger, Katrin Hörth, Stefanie Walk-Fritz.


Supplementary Material



Publication History

Received: 29 June 2022

Accepted: 27 September 2022

Article published online:
05 April 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Niazkhani Z, Pirnejad H, Berg M, Aarts J. The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review. J Am Med Inform Assoc 2009; 16 (04) 539-549
    CrossrefPubMedGoogle Scholar
  • 2 Zheng K, Guo MH, Hanauer DA. Using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research. J Am Med Inform Assoc 2011; 18 (05) 704-710
    CrossrefPubMedGoogle Scholar
  • 3 Overhage JM, Perkins S, Tierney WM, McDonald CJ. Controlled trial of direct physician order entry: effects on physicians' time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc 2001; 8 (04) 361-371
    CrossrefPubMedGoogle Scholar
  • 4 Pizziferri L, Kittler AF, Volk LA. et al. Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study. J Biomed Inform 2005; 38 (03) 176-188
    CrossrefPubMedGoogle Scholar
  • 5 Devine EB, Hollingworth W, Hansen RN. et al. Electronic prescribing at the point of care: a time-motion study in the primary care setting. Health Serv Res 2010; 45 (01) 152-171
    CrossrefPubMedGoogle Scholar
  • 6 Devin J, Costello J, McCallion N. et al. Impact of an electronic health record on task time distribution in a neonatal intensive care unit. Int J Med Inform 2021; 145: 104307
    CrossrefPubMedGoogle Scholar
  • 7 Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care 1994;996;
    PubMedGoogle Scholar
  • 8 Shu K, Boyle D, Spurr C. et al. Comparison of time spent writing orders on paper with computerized physician order entry. Stud Health Technol Inform 2001; 84 (Pt 2): 1207-1211
    PubMedGoogle Scholar
  • 9 Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA 1993; 269 (03) 379-383
    CrossrefPubMedGoogle Scholar
  • 10 Hanauer DA, Zheng K, Commiskey EL, Duck MG, Choi SW, Blayney DW. Computerized prescriber order entry implementation in a physician assistant-managed hematology and oncology inpatient service: effects on workflow and task switching. J Oncol Pract 2013; 9 (04) e103-e114
    CrossrefPubMedGoogle Scholar
  • 11 Westbrook JI, Li L, Georgiou A, Paoloni R, Cullen J. Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study. J Am Med Inform Assoc 2013; 20 (06) 1150-1158
    CrossrefPubMedGoogle Scholar
  • 12 Hoonakker PL, Carayon P, Brown RL, Cartmill RS, Wetterneck TB, Walker JM. Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units. J Am Med Inform Assoc 2013; 20 (02) 252-259
    CrossrefPubMedGoogle Scholar
  • 13 Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff (Millwood) 2004; 23 (04) 184-190
    CrossrefPubMedGoogle Scholar
  • 14 Walk SU, Bertsche T, Kaltschmidt J. et al. Rule-based standardised switching of drugs at the interface between primary and tertiary care. Eur J Clin Pharmacol 2008; 64 (03) 319-327
    CrossrefPubMedGoogle Scholar
  • 15 Jungreithmayr V, Meid AD, Haefeli WE, Seidling HM. Implementation Team. The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study. BMC Med Inform Decis Mak 2021; 21 (01) 279
    CrossrefPubMedGoogle Scholar
  • 16 Aktionsbündnis Patientensicherheit e.V.. Gute Verordnungspraxis in der Arzneimitteltherapie. [Web Page]. 2020; Accessed January 24, 2022 at: https://www.aps-ev.de/handlungsempfehlungen/ 2022
    PubMedGoogle Scholar
  • 17 GKV-Spitzenverband, Kassenärztliche Bundesvereinigung, Deutsche Krankenhausgesellschaft e. V. Rahmenvertrag über ein Entlassmanagement beim Übergang in die Versorgung nach Krankenhausbehandlung nach § 39 Abs. 1a SGB V (Rahmenvertrag Entlassmanagement). [legal text]. 2022; Accessed June 09, 2022 at: https://www.kbv.de/media/sp/Rahmenvertrag_Entlassmanagement.pdf
    PubMed
  • 18 Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc 2017; 24 (02) 413-422
    CrossrefPubMedGoogle Scholar
  • 19 Hollnagel E. The ETTO Principle: Efficiency-Thoroughness Trade-off: Why Things that Go Right Sometimes Go Wrong. 1st ed.. London: CRC Press; 2017
    CrossrefGoogle Scholar
  • 20 Baysari MT, van Dort BA, Prgomet M. et al. The efficiency-thoroughness trade-off after implementation of electronic medication management: a qualitative study in paediatric oncology. Int J Qual Health Care 2020; 32 (08) 511-516
    CrossrefPubMedGoogle Scholar
  • 21 Aufegger L, Serou N, Chen S, Franklin BD. Evaluating users' experiences of electronic prescribing systems in relation to patient safety: a mixed methods study. BMC Med Inform Decis Mak 2020; 20 (01) 62
    CrossrefPubMedGoogle Scholar
  • 22 Melnick ER, Harry E, Sinsky CA. et al. Perceived electronic health record usability as a predictor of task load and burnout among US physicians: mediation analysis. J Med Internet Res 2020; 22 (12) e23382
    CrossrefPubMedGoogle Scholar
  • 23 Kauppinen H, Ahonen R, Mäntyselkä P, Timonen J. Medication safety and the usability of electronic prescribing as perceived by physicians—a semistructured interview among primary health care physicians in Finland. J Eval Clin Pract 2017; 23 (06) 1187-1194
    CrossrefPubMedGoogle Scholar
  • 24 Griffon N, Schuers M, Joulakian M, Bubenheim M, Leroy JP, Darmoni SJ. Physician satisfaction with transition from CPOE to paper-based prescription. Int J Med Inform 2017; 103: 42-48
    CrossrefPubMedGoogle Scholar
  • 25 Brown CL, Mulcaster HL, Triffitt KL. et al. A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. J Am Med Inform Assoc 2017; 24 (02) 432-440
    CrossrefPubMedGoogle Scholar
  • 26 Coleman JJ, Hodson J, Thomas SK, Brooks HL, Ferner RE. Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system. J Am Med Inform Assoc 2015; 22 (01) 206-212
    CrossrefPubMedGoogle Scholar
  • 27 Asaro PV, Boxerman SB. Effects of computerized provider order entry and nursing documentation on workflow. Acad Emerg Med 2008; 15 (10) 908-915
    CrossrefPubMedGoogle Scholar
  • 28 Ampt A, Westbrook J, Creswick N, Mallock N. A comparison of self-reported and observational work sampling techniques for measuring time in nursing tasks. J Health Serv Res Policy 2007; 12 (01) 18-24
    CrossrefPubMedGoogle Scholar
  • 29 Yen K, Shane EL, Pawar SS, Schwendel ND, Zimmanck RJ, Gorelick MH. Time motion study in a pediatric emergency department before and after computer physician order entry. Ann Emerg Med 2009; 53 (04) 462-468.e1
    CrossrefPubMedGoogle Scholar