Order Creation and Communication in Healthcare

Summary

Objectives: The aim of this paper is to examine the adequacy of the concept of Physician Order Entry (POE) as a model for clinical systems, and to suggest an alternative understanding of the order creation and communication process.

Methods: The study is based on an interpretative analysis of POE as a model for clinical systems and the results of our recent fieldwork.

Results: Observations from our recent fieldwork suggest that orders, like patient care in general, emerge from interactions among patients, physicians, nurses, family members, and others, employing a variety of technologies and information resources in the process. Orders as we have observed them originate, are negotiated, and are carried out in a dynamically evolving group with fluctuating membership and shifting role responsibilities. Furthermore, orders by themselves represent only a partial picture of what is done for the patient.

Conclusion: We argue that information systems are more likely to be helpful if they accommodate and facilitate POE as a multidisciplinary collaboration effort and fit better into the larger system of patient care.

Keywords

Computerized physician order entry (CPOE) - human computer interaction - social informatics - distributed cognition

• References

• 1 Harvey AM, Johns RJ, McKusick VA, Owens AH, Ross RS. The Principles and Practice of Medicine. 22 ed. Norwalk, CT: Appleton and Lange; 1988
• 2 Delcambre L, Maier D, Bowers S, Deng L, Weaver M, Gorman P. et al. Bundles in Captivity: An Application of Superimposed Information. In: The 17th International Conference on Data Engineering. April 2-6, 2001. Heidelberg.:
• 3 Gorman P, Ash J, Lavelle M, Lyman J, Delcambre L, Maier D. Bundles in the wild: Managing information to solve problems and maintain situation awareness. Library Trends 2000; 49 (Suppl. 02) 266-89.
• 4 Gorman P, Lavelle M, Delcambre L, Maier D. Following Experts at Work in their Own Information Spaces: Using Observational Methods to Develop Tools for the Digital Library. Journal of the American Society of Information Science and Technology. 2001 (in press).
• 5 Ash JS, Gorman PN, Lavelle M, Lyman J. Multiple perspectives on physician order entry. American Medical Informatics Association Fall Symposium. 2000: 27-31.
• 6 Ash JS, Gorman PN, Hersh WR, Poulsen SB, Lavelle M. Perceptions of house officers who use physician order entry. Proceedings – the Annual Symposium on Computer Applications in Medical Care. 1999: 471-5.
• 7 Ash JS, Gorman PN, Hersh WR. Physician order entry in U.S. hospitals. Proceedings – the Annual Symposium on Computer Applications in Medical Care. 1998: 235-9.
• 8 Alderson P. The importance of theories in health care. BMJ 1998; 217: 1007-10.
• 9 Landauer TK. The Trouble with Computers: Usability, Usefulness, and Productivity. Cambridge: MIT Press; 1995
• 10 Goorman E, Berg M. Modeling nursing activities: electronic patient records and their discontents. Nursing Inquiry 2000; 7 (Suppl. 01) 3-9.
• 11 Woods DD, Patterson ES. How Unexpected Events Produce an Escalation of Cognitive and Coordinative Demands. In: Hancock P, Desmond P. editors. Stress Workload and Fatigue. Hillsdale, NJ: Lawrence Erlbaum; 2000
• 12 Carlin G. Brain Droppings. Hyperion. 1998
• 13 Annas GJ. Reframing the debate on health care reform by replacing our metaphors. New England Journal of Medicine 1995; 332 (Suppl. 11) 744-7.
• 14 Malone RE. Policy as product. Morality and metaphor in health policy discourse. Hastings Center Report 1999; 29 (Suppl. 03) 16-22.
• 15 DiBello L. Solving the Problem of Employee Resistance to Technology by Reframing the Problem as One of Experts and Their Tools. In: Salas E, Klein G. editors. Linking Expertise and Naturalistic Decision Making. Mahwah, New Jersey: Erlbaum; 2001. pp. 71-94.
• 16 Bishop APB, Lynch C, Borgman CL, Marshall CC, Star SL, Bowker GC. Digital Library Use: Social Practice in Design and Evaluation. In: Proceedings of the Fifth ACM conference on ACM 2000 digital libraries. 2000. San Antonio, TX USA: ACM; pp. 276-7.
• 17 Hutchins E, Klausen T. Distributed cognition in an airline cockpit. In: Engestrom Y, Middleton T. editors. Cognition and communication at work. New York: Cambridge University Press; 1998. pp. 15-34.
• 18 Hutchins E. How a cockpit remembers its speed. Cognitive Science 1995; 19: 265-88.
• 19 Hutchins E. Cognition in the Wild. Cambridge: MIT Press; 1995
• 20 Goodwin JS, Goodwin JM. The tomato effect. Rejection of highly efficacious therapies. JAMA 1984; 251 (Suppl. 18) 2387-90.
• 21 Bonet S, Agusti A, Arnau JM, Vidal X, Diogene E, Galve E. et al. Beta-adrenergic blocking agents in heart failure: benefits of vasodilating and non-vasodilating agents according to patients’ characteristics: a meta-analysis of clinical trials. Archives of Internal Medicine 2000; 160 (Suppl. 05) 621-7.
• 22 Miller RA, Masarie Jr FE. The demise of the “Greek Oracle” model for medical diagnostic systems. Methods of Information in Medicine 1990; 29 (Suppl. 01) 1-2.
• 23 Gorman PN. Information seeking in primary care: Conceptual models and empirical studies. In: Wilson T, Allen D. editors. Exploring the contexts of information seeking behaviour. Proceedings of the 2nd International Conference on Information Needs, Seeking and Use in different Context, Sheffield, 1998. London/Los Angeles: Taylor Graham; 1999. pp. 226-40.
• 24 Nardi BA, O’Day VL. Information Ecologies: Using Technology With Heart. Cambridge: MIT Press; 1999
• 25 Woods DD. Panel 2: Broad-based Systems Approaches. Testimony of David Woods, Past President, Human Factors and Ergonomics Society. In: National Summit on Medical Errors and Patient Safety Research:; September 11, 2000;. Washington DC: Quality Interagency Coordination Task Force.;
• 26 AHA Guide to Computerized Physician Order-Entry Systems. White Paper. Chicago, Illinois: American Hospital Association; November; 2000
• 27 Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N. et al. The impact of computerized physician order entry on medication error prevention. Journal of the American Medical Informatics Association 1999; 6 (Suppl. 04) 313-21.
• 28 Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme Jr JF. et al. A computer-assisted management program for antibiotics and other antiinfective agents. New England Journal of Medicine 1998; 338 (Suppl. 04) 232-8.
• 29 Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. Journal of the American Medical Informatics Association 1997; 4 (Suppl. 05) 364-75.
• 30 Carpenter JD, Gorman PN. What’s So Special About Medications: A Pharmacist’s Observations from the POE Study. Proc AMIA Symp. 2001
• 31 Bullough VL, Bullough B. The Care of the sick: the emergence of modern nursing. New York: Prodist; 1978
• 32 Porter R. The greatest benefit to mankind: a medical history of humanity. New York: W. W. Norton; 1999
• 33 Reverby S. Ordered to care: the dilemma of American nursing, 1850-1945. New York: Cambridge University Press; 1987
• 34 McNutt RA, Abrams R, Arons DC. Patient safety efforts should focus on medical errors. JAMA 2002; 287 (Suppl. 15) 1997-2001.
• 35 Hazlehurst B. Computation and Cognition in the Cockpit: Handling interruptions in the task of running a checklist. International Journal of Aviation Psychology. 2002 (in press).
• 36 Smith PJ, McCoy CE, Orasanu J. Distributed Cooperative Problem-Solving in the Air Traffic Management System. In: Salas E, Klein G. editors. Linking Expertise and Naturalistic Decision Making. Mahwah, New Jersey: Erlbaum; 2001. pp. 367-82.
• 37 Xiao Y, Mackenzie CF, Patey R. The LOTAS Group. Team Coordination and Breakdowns in a Real-Life Stressful Environment. In: Proceedings of the Human Factors Society 42nd Annual Meeting; October 5-9, 1998;. Chicago, Illinois: Human Factors and Ergonomic Society.;
• 38 Helmreich RL, Merritt AC. Safety and error management: The role of Crew Resource Management. In: Hayward BJ, Lowe AR. editors. Aviation Resource Management. Aldershot, UK: Ashgate.; 2000. pp. 107-19.
• 39 Forsythe DE, Buchanan BG. Broadening our approach to evaluating medical information systems. Proceedings – the Annual Symposium on Computer Applications in Medical Care. 1991: 8-12.
• 40 Xiao Y, Mackenzie CF. The LOTAS Group. Do Surgeons, Nurses, and Anesthesiologists Perceive the Same Care Differently (abstract). Journal of Clinical Monitoring and Computing 1998; 14 7-8 524-5.