Cognitive analysis of physicians' medication ordering activity.

Computerized Physician Order Entry (CPOE) addresses critical functions in healthcare systems. As the name clearly indicates, these systems focus on order entry. With regard to medication orders, such systems generally force physicians to enter exhaustively documented orders. But a cognitive analysis of the physician's medication ordering task shows that order entry is the last (and least) important step of the entire cognitive therapeutic decision making task. We performed a comparative analysis of these complex cognitive tasks in two working environments, computer-based and paper-based. The results showed that information gathering, selection and interpretation are critical cognitive functions to support the therapeutic decision making. Thus the most important requirement from the physician's perspective would be an efficient display of relevant information provided first in the form of a summarized view of the patient's current treatment, followed by in a more detailed focused display of those items pertinent to the current situation. The CPOE system examined obviously failed to provide the physicians this critical summarized view. Following these results, consistent with users' complaints, the Company decided to engage in a significant re-engineering process of their application.

Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process.

The objective of this study was to analyze the impact of medication ordering and administration functions of CPOE on doctor-nurse communications and cooperation. We performed an extensive analysis of the work situations in several departments of three different hospitals. One of the hospitals is still using paper-based orders, the second one is currently implementing a patient care information system (PCIS), but the analysis was carried out with paper-based orders. The third hospital has a PCIS installed with available medication ordering functions. We used standard methods from cognitive psychology to analyze physicians, and nurses' activity, communications and cooperation. This approach was combined with a usability analysis of both work systems, paper and computer-based. The paper-based situation is characterized by a synchronous cooperation with a distributed decision-making where physicians and nurses rely mostly on verbal communications to coordinate their actions; paper order sheets are weakly structured and poorly support the documentation task. In the computer situation, physicians and nurses work in an asynchronous mode, and leave to the system the coordination of their actions. Orders are exhaustively documented but some data may be misinterpreted. Some of these problems are due to usability flaws of the Human Computer Interface. We conclude with recommendations for usability improvement of CPOE systems, combined with recommendations for the organization of doctor-nurse communication when implementing such systems.

A usability study of CPOE's medication administration functions: impact on physician-nurse cooperation.

Implementation of CPOE systems in Healthcare Institutions has proven efficient in reducing medication errors but it also induces hidden side-effects on Doctor-Nurse cooperation. We propose a usability engineering approach to this problem. An extensive activity analysis of the medication ordering and administration process was performed in several departments of 3 different hospitals. Two of these hospitals are still using paper-based orders, while the 3rd one is in the roll-out phase of medication functions of its CPOE system. We performed a usability assessment of this CPOE system. The usability assessment uncovered usability problems for the entry of medication administration time scheduling by the physician and revealed that the information can be ambiguous for the nurse. The comparison of cooperation models in both situation shows that users tend to adopt a distributed decision making paradigm in the paper-based situation, while the CPOE system supports a centralized decision making process. This analysis can support recommendation for the re-engineering of the Human-Computer Interface.

The HEGP component-based clinical information system.

OBJECTIVES: The opening of the Georges Pompidou University Hospital (HEGP) in southwest Paris from the merging of three aging facilities was the opportunity to conceive and deploy a brand new clinical information system (CIS) based on a component-based approach. This paper describes the process of selection of the business components, the main functions currently in use, and the technical infrastructure that proved necessary. METHODS: The HEGP CIS features generic and healthcare-related components. The generic components include a reference manager, a security manager, a document manager, a Corba bus, and various mediation and supervision tools. The healthcare-related components include the patient, healthcare record, act management, and resource scheduler components. RESULTS: Major functions of CIS were operational at the opening of the hospital in July 2000. Two years later, the unique patient record and the provider order entry system were used in 96% of the concerned healthcare units. Sixty-five percent of the biological orders and 55% of the imaging orders were directly entered by the physicians. Access to investigation results including on-line availability of images is used by physicians in 100% of the units. DISCUSSION AND CONCLUSION: A component-based approach was found to be high-performing and cost-effective for the design and deployment of HEGP CIS.