Modeling variation of clinical team processes with multiple sequence alignment.

Our objective was to model process variation of Emergency Medical Service teams responding to simulated pediatric emergencies and determine if sequence alignment distinguishes performance quality. We performed a retrospective process analysis by watching and coding activities in videos from standardized simulations of 42 Emergency Medical Service teams. Teams were classified into high- or low-performing groups based on the Clinical Teamwork Scale™. Activities were coded according to resuscitation tasks, performer, and times. We used ClustalG to align task sequences within and between groups, and measured similarity. Teams within and between performance levels had an average sequence similarity of 52 ± 7% and 50 ± 7%. Teams performed clinically appropriate tasks that varied in prioritization, for example, performing compressions or connecting the EKG monitor early. There was no statistical difference in gross similarity between groups but specific differences in prioritization may have had clinically meaningful implications. Alignment could improve by accounting for task duration and concurrency.

Perceptions of physician order entry: results of a cross-site qualitative study.

OBJECTIVE: To identify perspectives of success factors for implementing computerized physician order entry (POE) in the inpatient setting. DESIGN: Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. RESULTS: A taxonomy of ten high level themes was developed, including 1) separating POE from other processes, 2) terms, concepts, and connotations, 3) context, 4) tradeoffs, 5) conflicts and contradictions, 6) collaboration and trust, 7) leaders and bridgers, 8) the organization of information, 9) the ongoing nature of implementation, and 10) temporal concerns. CONCLUSION: The identified success factors indicate that POE implementation is an iterative and difficult process, but informants perceive it is worth the effort.

Order creation and communication in healthcare.

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.

What's so special about medications: a pharmacist's observations from the POE study.

Observations from a multi-site observational study of physician order entry (POE) confirm that implementing POE is problematic, and suggest that implementing medication order entry is particularly difficult. A pharmacist participating in the study group sought to answer the question: What makes medications different? Analysis of themes specific to medication POE in this study's large data set was undertaken using a grounded theory approach. Emerging themes in the data are explored and include: (1) order complexity and the consequences of error; (2) impacts on professional roles; (3) prescribing needs in different settings; and (4) technology impact on medication administration. Awareness of potential roadblocks and lessons learned from previous implementation attempts should help organizations considering medication POE to optimize their own strategies.

Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data.

This paper explores the attributes of quality in recorded clinical encounter data, examines issues in measuring these attributes, and describes a method for measuring two attributes, completeness and correctness. The method is defined in the context of computer-based records and is demonstrated in a pilot study. Videotaped physician-patient encounters and an empiric process of determining a gold standard for content are used. The methodology was found to be feasible. Problems encountered during the pilot study can be remedied.

Multiple perspectives on physician order entry.

OBJECTIVE: Describe the complex interplay of perspectives of physicians, administrators, and information technology staff regarding computerized physician order entry (POE) in hospitals. METHODS: Linstone's Multiple Perspectives Model provided a framework for organizing the results of a qualitative study done at four sites. Data from observation, focus groups, and formal and informal interviews were analyzed by four researchers using a grounded approach. RESULTS: It is not a simple matter of physicians hating POE and others loving it. The issues involved are both complex and emotional. All groups see both positive and negative aspects of POE. CONCLUSION: The Multiple Perspectives Model was useful for organizing a description to aid in understanding all points of view. It is imperative that those implementing POE understand all views and plan implementation strategies accordingly.

A taxonomy of generic clinical questions: classification study.

OBJECTIVE: To develop a taxonomy of doctors' questions about patient care that could be used to help answer such questions. DESIGN: Use of 295 questions asked by Oregon primary care doctors to modify previously developed taxonomy of 1101 clinical questions asked by Iowa family doctors. SETTING: Primary care practices in Iowa and Oregon. PARTICIPANTS: Random samples of 103 Iowa family doctors and 49 Oregon primary care doctors. MAIN OUTCOME MEASURES: Consensus among seven investigators on a meaningful taxonomy of generic questions; interrater reliability among 11 individuals who used the taxonomy to classify a random sample of 100 questions: 50 from Iowa and 50 from Oregon. RESULTS: The revised taxonomy, which comprised 64 generic question types, was used to classify 1396 clinical questions. The three commonest generic types were "What is the drug of choice for condition x?" (150 questions, 11%); "What is the cause of symptom x?" (115 questions, 8%); and "What test is indicated in situation x?" (112 questions, 8%). The mean interrater reliability among 11 coders was moderate (kappa=0.53, agreement 55%). CONCLUSIONS: Clinical questions in primary care can be categorised into a limited number of generic types. A moderate degree of interrater reliability was achieved with the taxonomy developed in this study. The taxonomy may enhance our understanding of doctors' information needs and improve our ability to meet those needs.

Perceptions of house officers who use physician order entry.

OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process.

Physician order entry in U.S. hospitals.

OBJECTIVE: Determine the percent of U.S. hospitals where computerized physician order entry (POE) is available and the extent of its use. METHODS: A survey was sent to a systematic sample of 1,000 U.S. hospitals asking about availability of POE, whether usage is required, percent of physicians using it, and percent of orders entered by computer. RESULTS: About 66% do not have POE available. Of the 32.1% that have it completely or partially available, 4.9% require its usage, over half report usage by under 10% of physicians, and over half report that fewer than 10% of orders are entered this way. Analysis of comments showed that many hospitals have POE available for use by non-physicians only, but that they hope to offer it to physicians after careful planning. CONCLUSION: Most U.S. hospitals have not yet implemented POE. Complete availability throughout the hospital is rare, very few require its use, low percentages of physicians are actual users, and low percentages of orders are entered this way. On a national basis, computerized order entry by physicians is not yet widespread.

Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered.

Primary care physicians have many questions about optimal care while they are seeing patients, but they pursue only about 30% of their questions. The authors designed a study to determine the factors that motivate physicians to pursue answers to some of their questions, while leaving the majority of their questions unanswered. They interviewed 49 non-academic primary care physicians during office hours to record clinical questions as they arose in the course of patient care. The physicians then recorded their perceptions of each question with respect to 12 factors expected to motivate information seeking. Two to five days after the interview, each physician was telephoned to determine which questions had been pursued. In a multiple logistic-regression model only two factors were significant predictors of pursuit of new information: the physician's belief that a definitive answer existed, and the urgency of the patient's problem. Other factors, including the difficulty of finding the answer, potential malpractice liability, potential help or harm to the patient, and self-perceived knowledge of the problem, were not significant in the model. Primary care physicians are significantly more likely to pursue answers to their clinical questions when they believe that definitive answers to those questions exist, and when they perceive the patient's problem to be urgent. Medical information systems must be shown to have direct and immediate benefits to solving the problems of patient care if they are to be more widely used by practitioners.

Can primary care physicians' questions be answered using the medical journal literature?

Medical librarians and informatics professionals believe the medical journal literature can be useful in clinical practice, but evidence suggests that practicing physicians do not share this belief. The authors designed a study to determine whether a random sample of "native" questions asked by primary care practitioners could be answered using the journal literature. Participants included forty-nine active, nonacademic primary care physicians providing ambulatory care in rural and nonrural Oregon, and seven medical librarians. The study was conducted in three stages: (1) office interviews with physicians to record clinical questions; (2) online searches to locate answers to selected questions; and (3) clinician feedback regarding the relevance and usefulness of the information retrieved. Of 295 questions recorded during forty-nine interviews, 60 questions were selected at random for searches. The average total time spent searching for and selecting articles for each question was forty-three minutes. The average cost per question searched was $27.37. Clinician feedback was received for 48 of 56 questions (four physicians could not be located, so their questions were not used in tabulating the results). For 28 questions (56%), clinicians judged the material relevant; for 22 questions (46%) the information provided a "clear answer" to their question. They expected the information would have had an impact on their patient in nineteen (40%) cases, and an impact on themselves or their practice in twenty-four (51%) cases. If the results can be generalized, and if the time and cost of performing searches can be reduced, increased use of the journal literature could significantly improve the extent to which primary care physicians' information needs are met.