Attitudes and perceptions of pediatric residents on transitioning to CPOE.

BACKGROUND: Many resident physicians have experienced transitioning from traditional paper documentation and ordering to an electronic process during their training. OBJECTIVE: We sought to investigate the attitudes and perceptions of residents related to implementation of computer provider order entry (CPOE) and clinical decision support (CDS). METHODS: Pediatric residents completed web-based surveys prior to CPOE implementation and at 6 months and 12 months after implementation. The survey assessed resident attitudes and perceptions related to CPOE and the use of CDS tools. Additionally, at 6 and 12 months, residents were asked how electronic medical record (EMR) resources might impact future career decisions. RESULTS: Prior to CPOE implementation, 70% of residents were looking forward to CPOE, but 28% did not want to transition from paper ordering. At 12 months post-implementation, 80% of residents favored CPOE over paper ordering and only 3.33% wished to revert to paper ordering. Residents reported an increase in time needed to enter admission orders 6-months after CPOE implementation. By 12 months post-implementation, there was no significant difference in perceived time to complete admission orders when compared to pre-CPOE responses. Most residents (91.67%) identified that overall EMR resources were an important factor when considering future employment opportunities. The most important factors included the degree of EMR implementation, technology resources and the amount of support staff. The least important factors included patient portal access and which EMR product is used. CONCLUSIONS: Overall, residents demonstrated a preference for CPOE compared to traditional paper order entry. Many residents remained unaware of CDS tools embedded within CPOE at the 12 month follow-up, but a majority of residents did find them helpful and felt more knowledgeable about current guidelines. EMR resources, including degree of EMR implementation, technology resources and support staff are likely to be important factors as residents take future employment opportunities into consideration.

Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support.

OBJECTIVE: Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system. METHODS: Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans) to be used independently or as part of larger electronic order sets. Analysis of incidents reported during CPOE implementation and medication variances reports was used to determine the effectiveness of the ASP adaptation. RESULTS: 769 unique PowerPlans were used 15,889 times in the first 30 days after CPOE implementation. Of these, 43 were PowerPlans included in the ASP design and were used a total of 1149 times (7.2% of all orders). During CPOE implementation, 437 incidents were documented, 1.1% of which were associated with ASP content or workflow. Additionally, analysis of medication variance following CPOE implementation showed that ASP errors accounted for 2.9% of total medication variances. DISCUSSION: ASP content and workflow accounted for proportionally fewer incidents than expected as compared to equally complex and frequently used CPOE content. CONCLUSION: Well-defined ASP recommendations and modular design strengthened successful CPOE implementation, as well as the adoption of specialized pediatric ASP expertise with other facilities.

DDT contamination of benthic macroinvertebrates and sediments from tributaries of Wheeler Reservoir, Alabama.

Residues of DDT (1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane) were measured quarterly during 1983-84 in bottom sediments and benthic macroinvertebrates from heavily contaminated sections of Huntsville Spring Branch (HSB) and Indian Creek (IC), backwater streams on Wheeler Reservoir (Alabama). Bottom muds from both channel and overbank locations contained mean concentrations of DDTR (DDT and its metabolites) ranging from 12 to 2,730 ppm (dry weight). Sediment DDTR were highest in HSB at stations closest to the original DDT source. Stations in IC, downstream from HSB, had progressively lower DDTR as distance from the DDT source increased. Macroinvertebrate DDTR measured from several stations suggested bioaccumulation of residues mainly through food webs; however, at the most contaminated locations, substrate and mode of life appeared to override trophic level effects in determining DDTR in the benthos. There is apparently an upper limit to the amount of DDTR these organisms usually accumulate. For example, detritivore DDTR from channel sediments at two stations just downstream from the DDT source averaged 125.1 and 157.9 ppm, respectively, although sediment DDTR at these two sites averaged 2,730 ppm and 96 ppm, respectively. Benthic macroinvertebrates in the highly contaminated sediments of HSB and IC apparently acquire DDTR from water, sediments, and food.