University of Wisconsin–Madison

CPOE Implementation in ICU’s

  • Overview: This project built on an interdisciplinary research network, and:

    • examined the value of Computerized Provider Order Entry (CPOE) technology from the perspective of: patient safety, quality of care, and financial outcomes;
    • used human factors analysis methods for improving the design and implementation of CPOE, and;
    • examined the impact of CPOE on end users.

    Aim #1: The project determined the effect of CPOE on safety and quality of care in six ICUs by examining the impact of CPOE on medication errors and Adverse Drug Events (ADEs) and a variety of measures of quality of care, including the relation between length of stay and mortality.

    Aim #2: The project determined the impact of CPOE on physicians, nurses, pharmacists, and respiratory therapists (all end users) in ICUs. Specific measures related to end users’ perceptions of and attitudes about CPOE and the CPOE change process will include:

    • CPOE Characteristics: user-friendliness, usability, expectations and attitudes toward technology;

    • Job Characteristics: job control, workload, challenge, role ambiguity;

    • Quality of Working Life (QWL): job satisfaction, stress, organizational commitment and safety/quality of care; and

    • CPOE Change Process: employee involvement and participation, feedback, training and learning.

    Aim #3: Examined the use of prospective human factors analysis in CPOE implementation. The research team used proactive work flow analysis, risk assessment, and usability evaluations to identify changes in CPOE design and implementation.

    Documents:
    Final Project Report
    Project Summary
    Definition of a Medication Order

    Funding: Agency for Healthcare Research and Quality (AHRQ)

  • Pascale Carayon, PhD
    Procter & Gamble Bascom Professor in Total Quality
    Department of Industrial and Systems Engineering
    Director, Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Kenneth Wood, DO
    Chief Medical Officer
    Geisinger Medical Center, Danville, PA

    James Walker, MD, FACP
    Formerly Chief Health Information Officer
    Geisinger Health System, Danville, PA

    Peter Hoonakker, PhD
    Research Scientist, Associate Director of Research
    Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Ann Schoofs Hundt, PhD
    Research Scientist, Associate Director of Education
    Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Tosha Wetterneck, MD, MS
    Associate Professor of Medicine
    Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Roger Brown, PhD
    Professor, School of Nursing
    Director, Research Design Methodology and Statistics Unit
    University of Wisconsin-Madison

    Randi Cartmill, MS
    Researcher, Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Graduate Student Team Members

    Kerry McGuire, PhD
    Bonnie Paris, PhD
    Kara Schultz, PhD

  • Carayon, P., Wetterneck, T.B., Alyousef, B., Brown, R.L., Cartmill, R.S., McGuire, K., Hoonakker, P.L.T., Slagle, J., Schultz van Roy, K., Walker, J.M., Weinger, M.B., Xie, A., & Wood, K.E. (2015). Impact of electronic health records technology on the work and workflow of physicians in the intensive care units. International Journal of Medical Informatics (IJMI), 84 (8), 578-594. http://dx.doi.org/10.1016/j.ijmedinf.2015.04.002

    Carayon, P., Wetterneck, T.B., Cartmill, R.S., Blosky, M.A., Brown, R.L., Kim, R., Kukreja, S., Johson, M.A., Paris, B., Wood, K.E., & Walker, J. (2013). Characterising the complexity of medication safety using a human factors approach: An observational study in two intensive care units. BMJ Quality & Safety, 23 (1), 56-65. PMCID: PMC3938094

    Douglas, S., Cartmill, R.S., Brown, R., Hoonakker, P., Slagle, J., Van Roy, K., Walker, J.M., Weinger, M.B., Wetterneck, T., & Carayon, P. (2013). The work of adult and pediatric intensive care unit nurses. Nursing Research, 62 (1), 50-58.PMID: 23222843

    Hundt, A.S., Adams, J.A., Schmid, J.A., Musser, L.M., Walker, J., Wetterneck, T.B., Douglas, S.V., Paris, B.L., & Carayon, P. (2013). Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.International Journal of Medical Informatics, 82 (1), 25-38. PMCID: PMC3430828

    Hoonakker, P., Carayon, P., Brown, R.L., Cartmill, R.S., Wetterneck, T.B., & Walker, J. (2013). Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.Journal of the American Medical Informatics Association, 20 (2), 252-259. PMCID: PMC3638190

    Hoonakker, P., Carayon, P., Walker, J., Brown, R.L., & Cartmill, R.S. (2013). The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units. International Journal of Medical Informatics, 82 (5), 107-117. PMCID: PMC3624062

    Waterson, P., Hoonakker, P. L., & Carayon, P. (2013). Special issue on human factors and the implementation of health information technology (HIT): Comparing approaches across nations. International Journal of Medical Informatics,5(82), 277-280. PMID: 23375708

    Cartmill, R.S., Walker, J.M., Blosky, M.A., Brown, R.L., Djurkovic, S., Dunham, D.B., Gardill, D., Haupt, M.T., Parry, D., Wetterneck, T.B., Wood, K.E., & Carayon, P. (2012). Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. International Journal of Medical Informatics, 81 (11), 782-791.PMID: 22947701

    Hoonakker, P., Carayon, P., Gurses, A., Brown, R., Khunlertkit, A., McGuire, K., & Walker, J.M. (2011). Measuring workload of ICU nurses with a questionnaire survey: The NASA Task Load Index (TLX). IIE Transactions on Healthcare Systems Engineering, 1 (2), 131-143. PMCID: PMC3388621

    Carayon, P., Cartmill, R.S., Blosky, M.A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A.S., Norfolk, E., Wetterneck, T.B. & Walker, J. (2011). ICU nurses’acceptance of electronic health records. Journal of the American Medical Informatics Association, 18 (6), 812-819. PMCID: PMC3197984

    Hoonakker, P., Cartmill, R.S., Carayon, P., & Walker, J. (2011). Development and psychometric qualities of the SEIPS survey to evaluate CPOE/EHR implementation in ICUs. International Journal of Healthcare Information Systems and Informatics, 6 (1), 51-69. PMCID: PMC3070305

    Wetterneck, T., Walker, J., Blosky, M.A., Cartmill, R.S., Hoonakker, P., Johnson, M.A., Norfolk, E., & Carayon, P. (2011). Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Journal of the American Medical Informatics Association, 18 (6), 774-782. PMCID: PMC3198002

    Carayon, P., Cartmill, R.S., Blosky, M.A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A.S., Norfolk, E., Wetterneck, T.B. & Walker, J. (2011). EHR acceptance by ICU physicians and nurses. Proceedings of the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Oviedo, Spain.

    Hoonakker, P., Wetterneck, T., Carayon, P., Cartmill, R.S., & Walker, J. (2011). Drug alerts override from a human factors perspective. Proceedings of the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Oviedo, Spain. pp. 367-371.

    Wetterneck, T., Paris, B., Blosky, Walker, J., M.A., Cartmill, R.S., & Carayon, P. (2011). A Method for Evaluating Medication Error Recovery Processes in the ICU. Paper presented at the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Oviedo, Spain.

    Wetterneck T.B. (2011). Error recovery in health care. In P. Carayon (Ed.). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2 ed., pp. 449-461). CRC Press: Boca Raton, FL.

    Hoonakker, P., Carayon, P. & Walker, J. (2010). Measurement of CPOE end-user satisfaction among ICU physicians and nurses. Applied Clinical Informatics, 1 (3), 268-285. PMCID: PMC3059318

    Wetterneck, T.B., Cartmill, R.S., Walker, J.M., Carayon, P. (2010). Duplicate medication orders after CPOE implementation.Journal of Hospital Medicine, 5 (3), 81.

    Carayon, P., Faye, H., Hundt, A.S., Karsh, B-T., Wetterneck, T.B. (2010). Patient safety and proactive risk assessment. In Yuehwen (Ed.), Handbook of Healthcare Delivery Systems, 12, (pp. 1-15). Taylor & Francis: London.

    Hoonakker, P., Cartmill, R.S., Carayon, P., & Walker, J. (2010). Development of the survey to evaluate CPOE/EHR implementation in ICUs. Technical Report, Center for Quality and Productivity Improvement (CQPI), Madison, WI.

    Hoonakker, P., Carayon, P., Wood, K., & Walker, J. (2010). Implementation of healthcare technology and workload of nurses in the intensive care units. Poster presented at the ICOH WOPS Conference, Amsterdam, The Netherlands.

    Schneider, K., Nichols, L., Stevens, C., & Hook, J.M. (2010). AHRQ Publication No. 10-0095-3-EF. (Prepared by John Snow, Inc. under contract No. HHSA 290200900018I, TO 3). Success stories from the AHRQ-funded health IT portfolio.

    Carayon, P. (2009). EHR-related medication errors and events in ICUs. Paper presented at the Human Factors and Ergonomics Society (HFES) 53rd Annual Meeting, San Antonio, TX.

    Djurkovic, S., Cartmill, R.S., Blosky, M.A., Dunham, D., Gardill, D., Haupt, M., Parry, D., Walker, J.M., Wetterneck, T.B., Wood, K.E., & Carayon, P. (2009). CPOE Implementation decreases the time to the administration of the first dose of antibiotic. Paper presented at the 2010 Society for Critical Care Medicine Conference, Miami, FL.

    Hoonakker, P., Carayon, P., Cartmill, R.S., Walker, J., & Korunka, C. (2009). Healthcare Information Technology Implementation and Workload, Burnout and Perceived Quality of Care and Patient Safety among Nurses in the ICU.Paper presented at the APA/NIOSH Conference, San Juan, Puerto Rico.

    Carayon, P. (2008). Macroergonomics issues in the design, implementation and use of electronic health record in intensive care units. Paper presented at the Human Factors and Ergonomics Society (HFES) 52nd Annual Meeting, New York, NY.

    Hoonakker, P., Carayon, P., Douglas, S., Schulz, K., Walker, J., & Wetterneck, T.B. (2008). Communication in the ICU and then relation with quality of care and patient safety from a nurse perspective. Paper presented at the Human Factors and Ergonomics Society (HFES) 54th Conference, San Franscisco, CA.

    Hoonakker, P., Carayon, P., Walker, J., & Wetterneck, T.B. (2008). Coordination in the ICU and the relation with quality of care and patient safety. Paper presented at the Healthcare Systems Ergonomics and Patient Safety (HEPS) 2008 Conference, Strasbourg, France.

    Hoonakker, P., Carayon, P., Douglas, S., Schulz, K., Walker, J.M., & Wetterneck, T.B. (2008). Communication in intensive care units. Paper presented at the ODAM 2008 Conference, Guaruja, Brazil.

    Paris, B., Carayon, P., Wetterneck, T.B., Blosky, M.A., & Walker, J. (2008). Safety of the antibiotic medication use process in the intensive care unit. Proceedings of the Human Factors and Ergonomics Society (HFES) 52nd Annual Meeting,New York, NY.

    Wetterneck, T., Paris, B., Blosky, M.A., Cartmill, R.S., Walker, J., & Carayon, P. (2008). Error recovery in the ICU medication use process. Paper presented at the Healthcare Ergonomics Systems and Patient Safety (HEPS) 2008 Conference, Strasbourg, France.

    Wetterneck, T.B., Paris, B., Walker, J., & Carayon, P. (2008). CPOE functionalities and medication ordering errors in the ICU. Proceedings of the 9th International Symposium on Human Factors in Organizational Design and Management,Sao Paulo, Brazil.

    Van Roy, K.S. (2008). The perceived workload of ICU physicians and physician extenders and its relationship to burnout, patient safety, and quality care. PhD Dissertation, University of Wisconsin – Madison.

    Hoonakker, P. & Carayon, P. (2007). Selection of an instrument to measure end-user satisfaction. Paper presented at the Work with Computing Systems (WWCS) Conference, Stockholm, Sweden.

    Schultz, K., Slagle, J., Brown, R., Douglas, S., Frederick, B., Lakhani, M., Scruggs, J., Slater, B., Weinger, M.B., Wood, K.E., & Carayon, P. (2006). Development of job analysis tool for assessing the work of physicians in the intensive care unit. Paper presented at the Human Factors and Ergonomics Society (HFES) 50th Annual Meeting, Santa Monica, CA.

    Li, Q., Douglas, S., Hundt, A.S., & Carayon, P. (2006). A heuristic evaluation of a computerized provider order entry (CPOE) technology. Proceedings of the IEA 2006 Congress, Elsevier Ltd.: London.

  • Questionnaires

    3 Month Post-Implementation Questionnaire
    12 Month Post-Implementation Questionnaire – Physicians
    12 Month Post-Implementation Questionnaire – Nurses

    Usability Resources

    In this research, a participatory ergonomics model served as the basis for creating a network of usability coordinators. These coordinators work in various capacities at Geisinger Health System in Information Technology and Operations (both local and regional) related to the design and implementation of an electronic health record (EHR). Through hands-on training and practice evaluation sessions, researchers impart knowledge, oversee testing, and guide follow-up on usability issues related to user-centered design of software and the HIT interface. The knowledge and usability skills ultimately become “standard operating procedure” throughout the continuous design, redesign and implementation of the EHR. Likewise the network of usability coordinators serves as a resource for fellow coordinators as they assist and provide feedback to each other in the design, execution, evaluation, and follow up related to usability evaluations they conduct.

    Training resources include:
    Training Session I covers usability principles and methods. As a result of this introductory session, all participants conducted paired heuristic evaluations of one aspect of the EHR, the electronic medication administration record (eMAR). The following morning the attendees reconvened and prioritized the findings of the evaluation.

    Session 1: Usability Evaluations: Heuristic Evaluations

    Usability Evaluation Planning Document
    Heuristic Evaluation Definitions and Worksheet
    Heuristic Evaluation Script

    Training Session II covers scenario-based usability evaluations. The recently-trained usability coordinators instructend-users to perform tasks. The end-users’ facility when performing various tasks, as well as the verbal assessments they shared, were collected and later presented at a wrap-up session when the usability coordinators reconvened the following day. Once again results were prioritized.

    Session 2: Usability Evaluations Through Scenario-Based Evaluations

    Usability Evaluation Planning Document
    Specifications, Script, Data, Collection Tool for eMAR Usability Testing Evaluation

    References: An annotated bibliography of journal articles, books and other references that address important concepts of usability and usability principles and results of actual tests applied to health information technology.

    Usability Concepts and Terms

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