The American healthcare system has changed substantially in the recent past, but it is yet to acquire the level of effectiveness that policymakers and the general public desire. America is running one of the most expensive healthcare systems in the world, but the massive spending is not reflected in the quality of care (Bernstei, 2014). The convergence of information technology and medicine was tipped to reduce medical errors, reduce the cost of healthcare, and improve the quality of care. Computerized Physician Order Entry (CPOE) and Clinical Decision Support (CDS) are examples of application of information technology in the clinical setting. The adoption of information systems in healthcare has both benefits and unintended consequences. Further, some healthcare centers, especially those in developing countries, may have challenges integrating such systems in their processes.
CPOE is part of hospital information systems. It is a subsystem in which the physician enters instructions for patient treatment in a clinical setting. It is a computerized alternative to paper and verbal prescriptions. Through the systems, physicians can specify medication, laboratory, referral, radiology information, and other patient data. The entered orders are shared with other medical departments such as the pharmacy over a computer network. CPOE works hand –in- hand with clinical decision support (CDS) systems. CDS helps clinicians and primary care providers to analyze patient data and come up with a diagnosis. Clinicians have to review big volumes of data to make accurate decisions; reviewing the data manually can consume a lot of time. CDSs reduce the times needed to make data-driven clinical decisions. There is evidence that computerized hospital systems such as CPOE and CDS improve the accuracy of clinical decisions, enhance communication and coordination between different clinical departments, improve the quality of care, enhance clinical workflow, and reduce the cost of healthcare.
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One of the primary goals of healthcare systems is to improve patient safety and the quality of care. Medical errors are costly to both patients and healthcare centers; they can cause the patients permanent disability and lengthen hospital stays. Also, clinical errors expose physicians and healthcare centers to legal claims. While it is impossible to have zero medical errors, they can be reduced since most medical errors are preventable (Bates et al., 1999). CPOE enables physicians to enter standardized and legible orders, thus reducing medical errors. In paper-based clinical systems, most medical errors occur during the ordering process ( Khammarnia et al., 2017 ). When medical staff such as nurses and laboratory operators receive inaccurate instructions from physicians, they will give the patients inefficient services. In some CPOE systems, physicians do not type out the orders but use standardized formats that everyone in the clinical setting can understand. This reduces errors resulting from misinterpretation of medical orders. Armada et al. (2014) investigated the impact of CPOE on the reduction of prescription errors in ICU wards. They found out that the adoption of CPOE reduced prescription errors from 44.8 % to 0.8%.
Clinical workflow has a significant impact on patient health outcomes. Clinical workflow describes the process of delivery of clinical services, from how specific tasks are performed to the order in which they happen. Clinical systems are often complex; they consist of both specialized and non-specialized staff. Some tasks are done individually but most require collaboration between multiple departments. An efficient clinical workflow system requires structuring of tasks, coordination of work, information processing and flow, and constant monitoring (Niazkhani, Berg, Pirnejad, & Aarts, 2009). CPOE and other health information systems improve clinical workflow by making it more efficient and collaborative. CPOE enables physicians to enter orders remotely; more than one clinician can use particular patient information simultaneously. Further, clinical information systems such as CPOE give clinicians access to more data and analysis tools. The use of technology reduces the amount of time spent on intermediary tasks such as looking for data and transcribing. This increases the amount of time the physician spends with the patients, thus increasing the quality of care (Niazkhani et al., 2009). The removal of intermediary tasks between different departments also reduces the drug turnaround time (Niazkhani et al., 2009).
The integration of information technology in healthcare has also had negative impacts, especially on the clinical workflow. The use of CPOE may increase the amount of time needed to perform tasks such as capturing structured data. The usability of CPOE systems limits physicians. If the system is not user-friendly, it means users will spend more time entering and retrieving data than they will spend with the patients. Further, users may be forced to use ineffective and time-consuming alternatives to overcome system inflexibilities that result from hardware and software errors. CPOE reduces interpersonal communication in the clinical setting. Most orders are communicated over the computerized systems. Reduced interpersonal communication means fewer opportunities for team-wide negotiations. Migration from paper-based systems to CPOE might lead to redelegation of tasks. This leaves some staff out the tasking loop, changes communication and collaboration mechanisms, and creates uncertainties over who should perform specific tasks (Pontefract et al., 2018). Niazkhani et al. (2009) assert that redelegation of tasks can assign some medical staff roles that do not fit their job descriptions. For instance, some CPOE force physicians to perform clerical duties (Niazkhani et al., 2009). These shortcomings can be addressed by increasing the user-friendliness of the health information systems, training clinicians on how to use the systems, and redeveloping systems to reduce inflexibilities.
Though computerized medical systems offer health organizations numerous benefits, some health centers, especially those in developing countries, may not be able to migrate from paper-based systems due to several barriers. These barriers include lack of financial incentives, inadequate training, lack of long-term financial commitment, and diffusion of technology (Doolan & Bates, 2002). The cost of implementing computerized hospital systems is in the range of millions of dollars. Health centers are unlikely to adopt computerized systems if the short-term and long-term gains cannot justify such a hefty investment. In some instances, adoption of technology can lead to little to no cost saving for physicians and healthcare centers. For example, in some pay-for-service systems, reducing hospital length-of-stay reduces hospitals' finances (Doolan & Bates, 2002). Reducing hospital length-of-stay is one of the positive benefits of CPOE. Diffusion of technology describes the attributes of a new technology that determine its rate of adoption. These attributes include usability, comparative advantage, complexity, and trialability. Hospitals are more likely to adopt CPOE if they can see its benefits, and the physicians are willing and able to use it.
Gregory and Tembo (2017) conducted a study to establish the factors limiting the integration of technology in healthcare in developing countries. These factors include inadequate training and high implementation costs. The cost of implementing computerized healthcare systems in developing countries is as high as in the developing countries, but there is a mismatch in the earnings. Healthcare organizations in developing countries earn lower revenue, implying that investing in computerized healthcare systems might not be justifiable (Gregory and Tembo, 2017). Developing countries experience training gaps regarding the use of health information systems. The training gaps result in adoption bottlenecks and a negative attitude towards healthcare information systems among medical staff (Gregory and Tembo, 2017). Also, there is inadequate information on the benefits of healthcare information systems among physicians and policymakers in developing countries.
In summary, hospital information systems such as CPOE and CDSS offer numerous benefits to patients, physicians, and healthcare centers. The main benefits are the reduction of medical errors and making clinical workflows more efficient. The negative impacts of the information systems include reduced interpersonal communication, task redelegation, and increasing the time it takes to perform certain tasks. Some healthcare centers, especially those in developing countries, may take longer to realize the benefits of clinical information systems due to barriers to adoption of the technology. The main obstacles are inadequate training and high implementation costs.
References
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Pontefract, S. K., Coleman, J. J., Vallance, H. K., Hirsch, C. A., Shah, S., Marriott, J. F., & Redwood, S. (2018). The impact of computerized physician order entry and clinical decision support on pharmacist-physician communication in the hospital setting: A qualitative study. PloS one , 13 (11), e0207450.
