364 Building Capacity for Health Informatics in the Future

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This article is published online with Open Access by IOS Press and distributed under the terms
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doi:10.3233/978-1-61499-742-9-364

The Impact of Computerized Provider

Order Entry on Nursing Practice
Rosabella VITOa,1, Elizabeth M. BORYCKI a,
Andre W. KUSHNIRUKa and Tracey SCHNEIDERa
a
School of Health Information Science, University of Victoria, Canada

Abstract. Health information systems, such as Computerized Provider Order

Entry (CPOE), are suggested to be used as an intervention for addressing errors
that arise in the medication process. Nurses are involved in all stages of the
medication process; however, little is known about the impact of using CPOE on
nursing practice. A grounded theory approach was employed to answer the
question of “How do nurses perceive the impact of CPOE on the medication
process and collaborative practice?” Ten participants were interviewed. Of the ten
individuals who participated in the study, eight were observed for two hours
during their work shift. The data were analyzed using a constant comparative
method. The participants described using CPOE that was integrated with an
electronic medication administration record (eMAR). Use of CPOE had relational,
contextual, cognitive, and workflow implications. The findings of this research can
be used to inform workflow modeling, CPOE design, and change management.

Keywords. computerized provider order entry, electronic medication

administration, patient safety, medication administration

1. Introduction

In Canada, medication related errors are considered to be the most common type of
adverse event [1]. The use of computerized provider order entry (CPOE) is suggested
as a strategy to address medication errors [2, 3]. However, little is known about the
impact of CPOE use on nurses’ work and collaborative practice [4-6]. Therefore, the
work aims to answer the following research question: “How do nurses perceive the
impact of CPOE on the medication process and collaborative practice?” The findings
arising from this research outline the perspectives of nurses who use CPOE that has
been integrated with an electronic medication administration system (eMAR).

2. Review of the Literature

Nurses are involved in all stages in the medication process. This process involves five
dynamic stages: prescribing, transcribing, dispensing and compounding, administering,
and surveillance of the effects of the medication [7]. The medication process involves
collaboration among multiple healthcare providers and the patient [8]. Communication
exchange between health professionals is an essential aspect of this process [9]. The

1
Rosabella Vito: [email protected]
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complexity of the medication process and the involvement of multiple providers make
the medication process prone to errors. For health professionals and organizations, it is
important to mitigate these errors due to the obvious financial and patient mortality
repercussions associated with error prone medication processes [10]. Medication errors
may occur at any stage of the medication process, where an error can potentially harm
or can lead to patient harm [5, 11]. It is estimated that three out of four errors were
caused by system failures during the medication process [12]. Automating the steps in
the various stages of the medication process has been found to be pivotal to the
minimization of failures in the medication process and to promote a truly closed looped
system [12, 13]. CPOE is generally defined as an electronic system that allows for
provider order entry. There are a variety of CPOE designs. CPOE may be integrated
with an electronic medical record (EMR) and may include clinical decision supports
[11, 14]. There are reported benefits of using CPOE to reduce medication errors.
However, the limitations associated with this research, including the presence of
modest sample sizes, and a tendency to focus on prescribing and the perspectives of
physicians alone [4 – 6, 15]. There is a need to study the perspectives of nurses as well
as other members of the multi-disciplinary team where CPOE use and nurses’ work is
concerned. Therefore, there is a need to study the impact of CPOE’s from a nursing
perspective.

3. Methods

The researchers employed a grounded theory approach towards exploring the question
of “How do nurses perceive the impact of CPOE on the medication process and on
collaborative practice?” Grounded theory is an emerging methodology in health
informatics that can be used to gather data and develop ontologies [16], from which
one can guide design and implementation of a closed loop system for the medication
process.

3.1 Participants and Recruitment

Registered nurses (RN) with a minimum of one-year of experience on a medical unit,

and who had been working with CPOE for at least a year were invited to participate in
the study. Hospital unit managers distributed the invitation letter via email to potential
participants. Interested RNs contacted the researcher directly if they wished to
participate in the study. If a RN expressed interest in participating in the study the
researcher explained the study purpose, procedures, and the time commitment for
taking part in the study. Also, the researcher obtained verbal consent, and set up an
interview and observation date. Participants were given a gift card in appreciation of
volunteering their time. The gift card value is approximately worth $20 CAD, which is
less than the hourly rate of the participants.

3.2 Settings

The study took place on several medical units in three tertiary hospitals. A single
CPOE system has been used in these tertiary hospitals for a period of eight years at the
time of the study (2006 - 2014). The CPOE system is embedded in an existing EMR
designed by an outsourced vendor. The CPOE system is customized to the organization
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with standardized orders. Also, the medication orders entered into CPOE are
automatically transcribed to the electronic medication record (eMAR). Changes in
medication orders lead to changes in the eMAR. RNs use both the CPOE and the
eMAR.

3.3 Procedure

Interviews and observations were used to collect the study data from the participants.
Participating RNs were interviewed for approximately 60 to 90 minutes. Participants
were asked to describe the medication process using CPOE, and their perceived impact
of using CPOE in their practice. Generally, they were asked about the nursing roles in
the medication process, the interaction with other disciplines, and how they use the
CPOE within their roles. Also, further clarifying questions were asked based on their
descriptions, such as “How do you know that a medication order was changed? How
was this communicated?” Following an interview, any participants who agreed, were
observed for two hours during a work shift. Field notes were made by the researcher
during the observations.

3.4 Analysis

There were ten participants who were interviewed, and only eight participants out of
the ten agreed to be observed. A constant comparative method was adopted for this
study, where the coding process is iterative and continuous [16]. The interview
transcripts and the field notes from the observations were reviewed line-by-line and
were assigned codes. Following completion of the coding of the data, the codes with
similar attributes were grouped into categories and further grouped into themes. Any
categories and themes that appeared across 50% or more of the participants were
retained and were reported on.

4. Results

The results discussed in this section focused on the themes and categories that appeared
in both the interviews and the observations.
Table 1. Themes and Categories that appeared in Both the Interviews and Observations
Themes Categories
Review Information Medications, Orders
Paper Use Organize Work
Logistics Wireless Carts, Medication Supply
Medication Administration Record (eMAR), Documentation

4.1 Review Information

Reviewing information is the process of reading through the different components of a

patient’s EMR to identify pertinent information that will guide care, as is the case in
the medication process. Reviewing information may also include a verbal report from
the previous nurse who highlights certain information from the previous shift to the
oncoming nurse. In the interview, all of the participants (100%, n = 10) mentioned
using the EMR to review information during their work shift. This is consistent with
 R. Vito et al. / The Impact of Computerized Provider Order Entry on Nursing Practice 367

what was observed. The participants used the eMAR (100%, n = 8) and the orders tab
(75%, n = 6) to review the medications and orders that needed to be given and executed.

4.2 Paper Use

From reviewing the information, participants (100%, n = 8) were observed to write

down and highlight in their printed patient list any orders that were pertinent for their
shift. This is consistent with the participants’ (70%, n = 7) explanation in the interviews,
as described in this statement:

“… I have to highlight or make small notes on the side to help me remember,

because the [EMR] sometimes get populated with so many
orders…”(Participant 6)

Participants use paper to help them organize their work by writing “small notes” of
orders and medication times. The “small notes” are highlighted, and they are intended
to be short. The intent is to help the nurse to remember that an action is required.

4.3 Logistics

Logistics involves the management of the medication supplies and computer devices.
In the interview, RNs described managing the medication supply by checking that the
medications are delivered from the pharmacy (60%, n = 6), and they prepare the
medications for each of their patients (70%, n = 7). Also, RNs may use the wireless
computer cart, but its use may be limited to the room space, the wireless reliability, and
access to a computer (e.g. isolation rooms). This is reflected in the following
participant statement:

“..umm the room space sometimes does not allow for it [wireless computer cart].
And so umm I bring the computer to the doors of the room, and then I’ll just
walk to the patient to the computer…”(Participant 0)

This description is consistent with what was observed. From the RNs who were
observed (62.5%, n = 5), they had the wireless carts parked in the hallway a few steps
into their assigned patient rooms, while others moved the wireless carts with them up to
the door of their assigned patient room.

4.4 Medication Administration

All the RNs (100%, n=10) stated that the eMAR contains the list of patient medications
with the appropriate administration schedules indicated by time and by a designated
color. The eMAR helps with organizing RNs’ work, and the color scheme provides
cues, for example, a yellow cell cues the RN for scheduled medications. This is
consistent in the observation where the RNs (60%, n = 6) refer to the eMAR colors to
cue them on what to give, and to organize their work as the RNs take note of the
medication schedule. Also, in the interview the RNs said that they documented
administered medications in the eMAR (60%, n=6). This behavior was consistently
seen in all the RNs who were observed (100%, n = 8). In the observation, RNs
documented the medications post administration and there were a few who documented
368 R. Vito et al. / The Impact of Computerized Provider Order Entry on Nursing Practice

pre-administration. The documentation prior to administration is further described in

the participant statement below:
“Yea, I usually mark it as done first umm before I go in the room, because I find,
my personal thing is I am more likely to forget to mark it off ...” (Participant 5)

Documentation prior to administering a medication is a workaround. To ensure the

nurse still administers the medication, the medication is poured into the medicine cup
(which acts a reminder).

5. Discussion

From a RN perspective, the use of a CPOE that has been integrated with an eMAR has
relational, contextual, cognitive, and workflow implications, that at some instances lead
to workarounds. In developing a closed loop medication system, information relational
dynamics, such as nurse-to-nurse collaboration, and considering what other information
contributes to nurse decision making during medication administration is necessary.
Also, nurses require a means to organize this information for multiple patients and over
their shift. Such organization reduces cognitive load and supports workflow as nurses
travel long distances during a shift. Future CPOE design and CPOE implementations
should consider including mobile devices, alerts, and workflow modeling that takes
into account nurse information needs. A limitation of this study is that it focused on the
medical RN perspective. Further research of other disciplines in other settings is
required. Also, explore on how CPOE and eMAR support synchronization of their
work throughout the medication process, and the workarounds they employ.

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