Health (HITECH) Act, financially incen- ... answered two questions: 1) What is the dif- ference in nurses' .... How would you describe the transition to the new EHr with cPoE? ... How has your role with other departments/disciplines changed?
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Nurses’ Views Transitioning from a Best-of-Breed Clinical Information System to a One-Vendor Electronic Health Record with Computerized Provider Order Entry By Willa Fields, RN, DNSc, FHIMSS; Ana-Maria Gallo, RN, PhD, CNS, RNC; Maryann Cone, RN, MS, NEA-BC; Janet Hanley, RN, MBA, NEA-BC; Julie McCoy, RN, BSN, MAS, CPHQ; Sandra McCullough, RN, BA, BSN; Alice Chow, MAS; and Angie Mendoza, RN, BSN, CPHIMS ABSTRACT Objective: To investigate nurses’ views on the transition from a best-of-breed clinical information system with disparate clinical computer systems to an integrated, comprehensive electronic health record with computerized provider order entry. Methodology: A quantitative/qualitative research design was used. An online survey for system use, quality, and satisfaction was conducted two months pre- and one year post-implementation. Survey data were analyzed for statistical differences. Semi-structured interviews were conducted one and twelve months post-implementation. Interview data were analyzed with a constant comparative content analysis methodology to establish emergent themes. Results: Survey response rates were 50 percent (n=546) and 45 percent (n=501) for the pre- and post-surveys. Electronic health record use increased significantly in the post-survey. Nurses rated quality and satisfaction with the system lower in the post-survey. Thirty-two nurses participated in the initial interviews, and 33 in the one-year post-implementation interviews. Thematically, emotions, communication/ relationships, training and education, system design and process change, and safety emerged from the one-month post-implementation interviews, while transitioning, information integration, patient care coordination, and system design emerged from the one-year post-implementation interviews. Initial interview comments were more negative (1,562 negative vs. 372 positive comments), whereas one-year interview comments were less negative (571 negative vs. 551 positive comments). Conclusion: Transitioning to a new electronic health record is difficult and disruptive for nurses. Electronic health record development needs to focus on usability and user satisfaction.
KEYWORDS Electronic health record, computerized provider order entry, nurses.
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records (EHR) and computerized provider order entry (CPOE) are being implemented in hospitals at an increasing rate in the United States, although adoption has been slower than expected.1,2 In 2004, President George W. Bush set a goal for most Americans to have access to an EHR by 2014. President Barack Obama reaffirmed this goal, and, with the passage of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, financially incentivized providers and healthcare organizations to implement certified EHRs and use them in a meaningful way. Historically, hospitals have implemented a best-of-breed approach to clinical information systems that included disparate systems with varying levels of integration. A best of breed approach serves a professional group (nurses, physicians, pharmacists) or department (intensive care unit, emergency department, laboratory) with a niche system designed to support unique clinical, information, and administrative needs. When clinicians needed data from multiple systems, interfaces were built to export/import data, or devised complex desktop integration strategies. These strategies required expertise, time, and money lectronic health
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Transitioning to a new electronic health record is difficult and disruptive for nurses. Electronic health record development needs to focus on usability and user satisfaction. to build, test, implement, and support. Increasingly complex clinical information systems created workflow challenges for those needing to access multiple systems to provide patient care and maintenance challenges for the information technology staff. A single vendor EHR decreases the need for complex interfaces and provides more easily accessible data for all hospital disciplines and departments. Hospitals that have best of breed clinical information systems are transitioning to comprehensive EHRs with CPOE to qualify for HITECH funds. Although more recent studies have demonstrated positive outcomes for EHRs, nurses, physicians, and other clinicians are not satisfied with the functionality, quality, or usability of the systems.3 Research on the effects of EHR implementations will assist others in designing better systems and preparing staff for the change. This research study answered two questions: 1) What is the difference in nurses’ views on the use, quality, and satisfaction between a best of breed clinical information system and a single vendor EHR with CPOE?; and 2) What is the effect of transitioning from a best of breed clinical information system to a single vendor EHR with CPOE on nurses and nurses’ work?
Background and Significance Three progressive systematic reviews of the literature on health information technology have been published since 2006. Chaudry et al.4 reviewed studies between 1995 and 2004, and concluded that organizations with EHRs increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors, although there was no conclusive
evidence on improving patient outcomes. Goldzweig et al.5 reviewed studies between 2004 and 2007, and concluded that although there was a proliferation of patient-focused applications, there was little formal evaluation of these implementations. Buntin et al. 3 reviewed studies between 2007 and 2010 and concluded that 92 percent of the studies reached positive conclusions, although dissatisfaction remained a problem and barrier to achieving the potential of health information technology. Research on the effects of EHRs and CPOE on nurses have demonstrated changed communication patterns6, fear of missing order7,8, less face time and collaboration with physicians7,9, issues with workflow integration6 and disruption10 and less time spent clarifying orders.11 Some studies have demonstrated it takes longer to document in EHRs12,13 while other investigations demonstrated electronic documentation takes less time.12,14 Abbass, Helton, Mhatre, and Sansgiry15 found no conclusive evidence that technologies improved the efficiency of patient care delivery. Information processing and the ability to scan information quickly were found to be important to nurses as they provide care in a fast paced environment.16 Understudied areas include transitioning from older, best of breed EHRs to comprehensive, one vendor EHRs with CPOE, and the impact this change has on nurses and nurses’ work.
Methods A mixed method pre-post survey and interview research design was used to evaluate nurses’ views on transitioning from a best of breed clinical information system to a one vendor electronic health record with CPOE.
Survey Methodology Nurses’ views on the use, quality, and satisfaction of the best of breed clinical information system and the single vendor EHR with CPOE were determined with an online survey conducted two months preimplementation and again at one year post implementation of the single vendor EHR. The survey included demographic questions (gender, age, years as a nurse, nursing degrees, position, shift, and previous experience with electronic health records and CPOE) and 34 Likert-type questions (1=never/almost never to 5=always/almost always) that were designed from a literature review of the use, quality, and user satisfaction with electronic health records.17 After Institutional Review Board approval, an email with a link to the online survey was sent to the approximately 1,100 nurses. Flyers were posted on the nursing units with information on how to participate in the survey, and unit computers had stickers with the web address for the survey. Staff were also informed about the survey in staff and other meetings. The Chief Nursing Officer sent unit managers weekly progress reports with their unit’s response rate. The same recruitment process was utilized for the one year post-implementation surveys. Demographic data were analyzed with descriptive statistics. Differences in the extent of use, quality, and user satisfaction were tested with a Mann Whitney U test. Significance levels were set at p=
