JONA Volume 44, Number 2, pp 117-120 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
The Impact of Health Information Technology on Staffing Jennifer C. Goldsack, MChem, MA (Oxon.), MS Edmondo J. Robinson, MD, MS, MBA Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital. Health information technology (HIT), especially the electronic medical record (EMR), has the potential to improve the efficiency and effectiveness of healthcare providers.1,2 However, the healthcare industry has proven to be the last bastion of paper record keeping and processes. Clinicians’ concerns about the impact of electronic systems on the efficiency of their work present a significant barrier to adoption.3-5 Unfortunately, evidence relating to the impact of HIT on the work of staff on general hospital units is relatively sparse, has focused on more established electronic systems such as computerized provider order entry (CPOE), and remains heavily influenced by results from seminal early studies.6-9 In response, investigators have turned to other industries to better understand how efficiency may be impacted by the adoption of EMR systems.10,11 After significant investments in information technology (IT) during the 1990s, industries including telecommunications, banking, and retail gained substantial operating efficiencies.12 Based on
Author Affiliations: Research Associate (Ms Goldsack), Associate Chief Medical Officer (Dr Robinson), The Value Institute, Christiana Care Health System, Newark, Delaware. The authors declare no conflicts of interest. Correspondence: Ms Goldsack, The Value Institute, Christiana Care Health System, 4755 Ogletown Stanton Rd, Newark, DE 19718 ([email protected]). DOI: 10.1097/NNA.0000000000000035
JONA Vol. 44, No. 2 February 2014
the assumption that healthcare could experience similar productivity gains, potential efficiency savings at 90% adoption of EMR have been estimated as equivalent to annual savings of $13.7 billion on inpatient nursing time alone.13 However, it is important to note that the industries where the introduction of IT has yielded the most significant productivity gains have experienced widespread elimination or displacement of large portions of their workforce. Bar-codes at self-checkouts, automated teller machines, and access to online reservations, shopping, and banking were designed to improve the service to the customer and reduce costs for the provider but simultaneously revolutionized the distribution and use of the workforce in their respective industries. Because organizational factors have a significant impact on implementation and use of HIT,14 and organizations characterized by collaboration, teamwork, and supportive leadership are more likely to report successful technology implementation and use,15 it is critical that hospital administrators pay careful attention to staffing decisions as HIT is introduced to clinical settings in the coming years. We propose a framework of factors to consider when making staffing decisions after the introduction of new HIT (Figure 1). First, staffing considerations in the setting of HIT implementation should maximize quality and safety to the extent that it is measureable. ‘‘Meaningful use’’ was included in The Health Information Technology for Economic and Clinical Health Act, part of The American Recovery and Reinvestment Act of 2009,16 to incentivize healthcare providers to not only adopt EMR systems but also use them in ways that would improve the quality and safety of patient care.17 Quality of care can be hard to define and measure and often varies with the interests of different stakeholders in the healthcare system.18 In its most general terms, it is the degree to which health services increase the
117
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. A conceptual framework of factors to consider when making staffing decisions after the introduction of new HIT.
likelihood of desired health outcomes and are consistent with current professional knowledge.19 Although it is possible to measure quality of care, it is difficult to do so.20 However, HIT has been shown to positively affect quality of care through improvements in guideline-based care and surveillance and monitoring of disease.1 The impact of HIT on safety is more tangible yet may not be any easier to understand. Metrics such as medication errors and adverse drug events can be measured and benchmarked but are not always easily accessible to managers. Given these challenges, metrics focused on evaluating quality and safety in the changing HIT environment should be relevant, readily measureable, and important to the institution. The importance of HIT implementation on improvements in quality and safety may require a staffing approach that has less emphasis on staffing reduction and more emphasis on obtaining or retraining staff that focus on realizing the expected gains from the implementation. The 2nd consideration is organizational priorities. Improvements in quality and safety are typically high on the list for most organizations. In addition, priorities such as improved efficiency, patient- and familycentered care, education, research, and others will have varying degrees of prioritization based on the needs of the organization. When making staffing decisions in the setting of HIT implementation, a clear understanding of organization priorities will need to be obtained. Commonly, improved efficiency is a high organization priority in the setting of new HIT. For inpatient care, the impact of HIT on efficiency may be determined by measuring provider time efficiency, utilization of care (length of stay, unneces-
118
sary laboratory tests, medication overutilization, cost per case, etc), and overall staffing needs. In a systematic review of studies investigating the impact of HIT on efficiency of care, 8 of the 11 included studies showed decreased rates of health services utilization, but the effect of HIT on provider time was mixed.1 Early investigation into the impact of using EMRs compared with paper records indicated that electronic recording took longer than paper recording.21 A systematic review of CPOE-oriented studies provided compelling evidence that physicians experience a significant increase in documentation time (238.4%) after the impact of such systems.22 Electronic medical records have also been shown to have an unfavorable impact on the nursing time spent documenting when the patient is the sampling unit and the variable examined is time spent documenting per patient.23-25 However, when the impact is assessed for the total working shift, the impact of EMRs on nursing time is favorable,26-30 suggesting that there may be operational efficiencies due to HIT that are not yet understood. Overall, evidence to date indicates that a goal of improved provider efficiency for physicians and nurses is unlikely to be realized after the introduction of HIT into inpatient settings. To be fair, measurements of the impact of HIT on workflow and time efficiency to dateVparticularly for physiciansVhave focused on assessing the user perspective for a single activity, such as documentation.22 Given the evidence that HIT can yield time efficiencies such as accessing a patient chart8 or maintaining patients’ flow sheets,9 there is an increasingly compelling argument to assess the impact of HIT at a unit or even system
JONA Vol. 44, No. 2 February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
level.31 A broader view of the impact of HIT may significantly affect staffing decisions. To take this more comprehensive approach, a better understanding of the impact of HIT on the activities of all staff involved in inpatient careVdirectly and indirectlyVis essential. The 3rd factor to consider is optimizing the function of the multidisciplinary team. There is little doubt that HIT is complicating the roles of the multidisciplinary teams working in inpatient units. Physicians are spending increasing amounts of time on documentation tasks that do not require their level of training. This increased documentation has been associated with physician dissatisfaction with EMR systems.21 Qualitative studies have begun to probe some of the complex socio-techno issues that are anticipated as HIT is integrated into the clinical setting,15,32-35 but changes in work practice as a result of HIT introduction have emerged as a strong concern for both physicians and nurses.36 There is evidence that clinicians’ apprehension about the impact that HIT may have on the efficiency of their work remains a significant barrier to adoption of these technologies in inpatient settings.3-5,37 As the era of the paperless hospital looms in the United States, the redistribution of time benefits across tasks and between different staff members must be better understood to staff units appropriately to pursue the dual aims of improved efficiency and increased effectiveness of healthcare providers. Accomplishing these goals will require that all members of the multidisciplin-
ary team work to the top of their license. Innovative approaches such as telemedicine and social medicine that use HIT to network providers around the care of a particular patient should be incorporated into the inpatient setting. To do this, staff may need to be retrained or repurposed to focus less on individual task management and more on optimal multidisciplinary team function. As hospitals spend millions of dollars to comply with meaningful use, they will likely look to their managers to deliver on the promise of improved efficiency in the form of cost savings. Managers have already begun implementing novel solutions, including the introduction of new roles that blend patient care technician roles with unit clerk responsibilities at the authors’ institution, but their impact has not yet been formally evaluated. If the healthcare industry aspires to achieve the same efficiency gains, with simultaneous improvement in quality and safety, as seen in other sectors, then significant changes in staffing are inevitable. The information currently available to managers to address these staffing needs across all roles in the inpatient setting is inadequate. In the absence of definitive data to optimize the relationship between staff and HIT, managers should consider a framework of factors including a focus on quality and safety, organizational priorities, and optimizing multidisciplinary team function. This framework will likely allow managers to evaluate the impact of HIT and inform ongoing decisions about eliminating, retraining or refocusing staff roles.
References 1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-752. 2. Blumenthal D, Glaser JP. Information technology comes to medicine. N Engl J Med. 2007;356:2527-2534. 3. Keohane C, Bane A, Featherstone E, et al. Quantifying nursing workflow in medication administration. J Nurs Adm. 2008; 38:19-26. 4. Fisher S, Creusat J, McNamara D. Improving Physician Adoption of CPOE Systems. Alpharetta, GA: McKesson Provider Technologies; 2008. 5. Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff. 2004;23:184-190. 6. Westbrook JI, Li L, Georgiou A, et al. Impact of an electronic medication management system on hospital doctors’ and nurses’ work: a controlled pre-post, time and motion study. [published online ahead of print September 9, 2013]. J Am Med Inform Assoc. 7. Overhage J, Perkins S, Tierney W, et al. Controlled trial of direct physician order entry: effects on physicians’ time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc. 2001;8:361-371. 8. Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. In: Proceedings of Symposium
JONA Vol. 44, No. 2 February 2014
9.
10.
11.
12.
13.
14.
15.
16.
Computed Applied Medical Care. Bethesda, MD: American Medical Informatics Association; 1994:996. Tierney W, Miller M, Overhage J, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;269:379-383. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. 2005;24(5):1103-1117. Bigelow J, Fonkych K, Fung C, Wang J. Analysis of Healthcare Interventions That Change Patient Trajectories. Santa Monica, CA: RAND; 2005. Bower A. The Diffusion and Value of Healthcare Information Technology. Santa Monica, CA: RAND; 2005. Pub. no. MG-272-HLTH. Girosi F, Meili RC, Scoville R. Extrapolating Evidence of Health Information Technology Savings and Costs, Pub. no. MG-410. Santa Monica, CA: RAND; 2005. Sec. 4.2.6. Pub. no. MG-410. Randell R, Dowding D. Organisational influences on nurses’ use of clinical decision support systems. Int J Med Inform. 2010;79:e412-e421. Ash JS, Sittig DF, Seshadri V, et al. Adding insight: a qualitative cross-site study of physician order entry. Int J Med Inform. 2005;74:623-628. HITECH Act. http://www.hhs.gov/ocr/privacy/hipaa/understanding/ coveredentities/hitechact.pdf. Accessed September 12, 2013.
119
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
17. Blumenthal D, Tavenner M. The ‘‘meaningful use’’ regulation for electronic health records. N Engl J Med. 2010;363:501-504. 18. Blumenthal D. Quality of careVwhat is it? N Engl J Med. 1996;335(12):891-894. 19. Lohr KN, Schroeder SA. A strategy for quality assurance in Medicare. N Engl J Med. 1990;322:1161-1171. 20. Brooke RH, McGlynn EA, Shekelle PG. Defining and measuring quality of careVa perspective from US researchers. Int J Qual Health Care. 2000;12:281-295. 21. Perry JJ, Sutherland J, Symington C, Dorland K, Mansour M, Stiell IG. Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study. [publisher online ahead of print August 23, 2013]. Emerg Med J. 22. Poissant L, Pereira J, Tamblyn R, Kamasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005; 12(5):505-516. 23. Kovner C, Schuchman L, Mallard C. The application of pen based computer technology to home health care. Comput Nurs. 1997;15:237-244. 24. Ammenwerth E, Eichstadter R, Haux R, Pohl U, Rebel S, Ziegler S. A randomized evaluation of a computer-based nursing documentation system. Methods Inf Med. 2001;40:61-68. 25. Bosman RJ, Rood E, Oudemans-Van Straaten HM, Van Der Spoel JI, Wester JP, Zandstra DF. Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Med. 2003;29:83-90. 26. Menke JA, Broner CW, Campbell DY, McKissick MY, Edwards-Beckett JA. Computerized clinical documentation system in the pediatric intensive care unit. BMC Med Inform Decis Making. 2001;1:3. 27. Pierpont GL, Thilgen D. Effect of computerized charting on nursing activity in intensive care. Crit Care Med. 1995;23: 1067-1073.
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28. Marasovic C, Kenney C, Elliott D, Sindhusake D. A comparison of nursing activities associated with manual and automated documentation in an Australian intensive care unit. Comput Nurs. 1997;15:205-211. 29. Minda S, Brundage DJ. Time differences in handwritten and computer documentation of nursing assessment. Comput Nurs. 1994;12:277-279. 30. Wong DH, Gallegos Y, Weinger MB, Clack S, Slagle J, Anderson CT. Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system. Crit Care Med. 2003;31:2488-2494. 31. Pinsonneault A, Rivard S. Information technology and the nature of managerial work: from the productivity paradox to the Icarus Paradox? MIS Q. 1998;22:287-311. 32. Koppel R, Metlay J, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. 2005;293(10):1197-1203. 33. Beuscart-Zephir M, Pelayo S, Anceaux F, et al. Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. Int J Med Inform. 2005;74: 629-641. 34. Callen JL, Braithwaite J, Westbrook JI. Contextual implementation model: a framework for assisting clinical information system implementations. J Am Med Inform Assoc. 2008;15: 255-262. 35. Pirnejad H, Niazkhani Z, van der Sijs H, et al. Evaluation of the impact of a CPOE system on nurse-physician communication. Methods Inf Med. 2009;48:350-360. 36. Georgiou A, Ampt A, Creswick N, et al. Computerized provider order entryVwhat are health professionals concerned about? A qualitative study in an Australian hospital. Int J Med Inform. 2009;78:60-70. 37. Callen JL, Westbrook JI, Braithwaite J. The effect of physicians’ long-term use of CPOE on their test management work practices. J Am Med Inform Assoc. 2006;13:643-652.
JONA Vol. 44, No. 2 February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
The Impact of Health Information Technology on Staffing Jennifer C. Goldsack, MChem, MA (Oxon.), MS Edmondo J. Robinson, MD, MS, MBA Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital. Health information technology (HIT), especially the electronic medical record (EMR), has the potential to improve the efficiency and effectiveness of healthcare providers.1,2 However, the healthcare industry has proven to be the last bastion of paper record keeping and processes. Clinicians’ concerns about the impact of electronic systems on the efficiency of their work present a significant barrier to adoption.3-5 Unfortunately, evidence relating to the impact of HIT on the work of staff on general hospital units is relatively sparse, has focused on more established electronic systems such as computerized provider order entry (CPOE), and remains heavily influenced by results from seminal early studies.6-9 In response, investigators have turned to other industries to better understand how efficiency may be impacted by the adoption of EMR systems.10,11 After significant investments in information technology (IT) during the 1990s, industries including telecommunications, banking, and retail gained substantial operating efficiencies.12 Based on
Author Affiliations: Research Associate (Ms Goldsack), Associate Chief Medical Officer (Dr Robinson), The Value Institute, Christiana Care Health System, Newark, Delaware. The authors declare no conflicts of interest. Correspondence: Ms Goldsack, The Value Institute, Christiana Care Health System, 4755 Ogletown Stanton Rd, Newark, DE 19718 ([email protected]). DOI: 10.1097/NNA.0000000000000035
JONA Vol. 44, No. 2 February 2014
the assumption that healthcare could experience similar productivity gains, potential efficiency savings at 90% adoption of EMR have been estimated as equivalent to annual savings of $13.7 billion on inpatient nursing time alone.13 However, it is important to note that the industries where the introduction of IT has yielded the most significant productivity gains have experienced widespread elimination or displacement of large portions of their workforce. Bar-codes at self-checkouts, automated teller machines, and access to online reservations, shopping, and banking were designed to improve the service to the customer and reduce costs for the provider but simultaneously revolutionized the distribution and use of the workforce in their respective industries. Because organizational factors have a significant impact on implementation and use of HIT,14 and organizations characterized by collaboration, teamwork, and supportive leadership are more likely to report successful technology implementation and use,15 it is critical that hospital administrators pay careful attention to staffing decisions as HIT is introduced to clinical settings in the coming years. We propose a framework of factors to consider when making staffing decisions after the introduction of new HIT (Figure 1). First, staffing considerations in the setting of HIT implementation should maximize quality and safety to the extent that it is measureable. ‘‘Meaningful use’’ was included in The Health Information Technology for Economic and Clinical Health Act, part of The American Recovery and Reinvestment Act of 2009,16 to incentivize healthcare providers to not only adopt EMR systems but also use them in ways that would improve the quality and safety of patient care.17 Quality of care can be hard to define and measure and often varies with the interests of different stakeholders in the healthcare system.18 In its most general terms, it is the degree to which health services increase the
117
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. A conceptual framework of factors to consider when making staffing decisions after the introduction of new HIT.
likelihood of desired health outcomes and are consistent with current professional knowledge.19 Although it is possible to measure quality of care, it is difficult to do so.20 However, HIT has been shown to positively affect quality of care through improvements in guideline-based care and surveillance and monitoring of disease.1 The impact of HIT on safety is more tangible yet may not be any easier to understand. Metrics such as medication errors and adverse drug events can be measured and benchmarked but are not always easily accessible to managers. Given these challenges, metrics focused on evaluating quality and safety in the changing HIT environment should be relevant, readily measureable, and important to the institution. The importance of HIT implementation on improvements in quality and safety may require a staffing approach that has less emphasis on staffing reduction and more emphasis on obtaining or retraining staff that focus on realizing the expected gains from the implementation. The 2nd consideration is organizational priorities. Improvements in quality and safety are typically high on the list for most organizations. In addition, priorities such as improved efficiency, patient- and familycentered care, education, research, and others will have varying degrees of prioritization based on the needs of the organization. When making staffing decisions in the setting of HIT implementation, a clear understanding of organization priorities will need to be obtained. Commonly, improved efficiency is a high organization priority in the setting of new HIT. For inpatient care, the impact of HIT on efficiency may be determined by measuring provider time efficiency, utilization of care (length of stay, unneces-
118
sary laboratory tests, medication overutilization, cost per case, etc), and overall staffing needs. In a systematic review of studies investigating the impact of HIT on efficiency of care, 8 of the 11 included studies showed decreased rates of health services utilization, but the effect of HIT on provider time was mixed.1 Early investigation into the impact of using EMRs compared with paper records indicated that electronic recording took longer than paper recording.21 A systematic review of CPOE-oriented studies provided compelling evidence that physicians experience a significant increase in documentation time (238.4%) after the impact of such systems.22 Electronic medical records have also been shown to have an unfavorable impact on the nursing time spent documenting when the patient is the sampling unit and the variable examined is time spent documenting per patient.23-25 However, when the impact is assessed for the total working shift, the impact of EMRs on nursing time is favorable,26-30 suggesting that there may be operational efficiencies due to HIT that are not yet understood. Overall, evidence to date indicates that a goal of improved provider efficiency for physicians and nurses is unlikely to be realized after the introduction of HIT into inpatient settings. To be fair, measurements of the impact of HIT on workflow and time efficiency to dateVparticularly for physiciansVhave focused on assessing the user perspective for a single activity, such as documentation.22 Given the evidence that HIT can yield time efficiencies such as accessing a patient chart8 or maintaining patients’ flow sheets,9 there is an increasingly compelling argument to assess the impact of HIT at a unit or even system
JONA Vol. 44, No. 2 February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
level.31 A broader view of the impact of HIT may significantly affect staffing decisions. To take this more comprehensive approach, a better understanding of the impact of HIT on the activities of all staff involved in inpatient careVdirectly and indirectlyVis essential. The 3rd factor to consider is optimizing the function of the multidisciplinary team. There is little doubt that HIT is complicating the roles of the multidisciplinary teams working in inpatient units. Physicians are spending increasing amounts of time on documentation tasks that do not require their level of training. This increased documentation has been associated with physician dissatisfaction with EMR systems.21 Qualitative studies have begun to probe some of the complex socio-techno issues that are anticipated as HIT is integrated into the clinical setting,15,32-35 but changes in work practice as a result of HIT introduction have emerged as a strong concern for both physicians and nurses.36 There is evidence that clinicians’ apprehension about the impact that HIT may have on the efficiency of their work remains a significant barrier to adoption of these technologies in inpatient settings.3-5,37 As the era of the paperless hospital looms in the United States, the redistribution of time benefits across tasks and between different staff members must be better understood to staff units appropriately to pursue the dual aims of improved efficiency and increased effectiveness of healthcare providers. Accomplishing these goals will require that all members of the multidisciplin-
ary team work to the top of their license. Innovative approaches such as telemedicine and social medicine that use HIT to network providers around the care of a particular patient should be incorporated into the inpatient setting. To do this, staff may need to be retrained or repurposed to focus less on individual task management and more on optimal multidisciplinary team function. As hospitals spend millions of dollars to comply with meaningful use, they will likely look to their managers to deliver on the promise of improved efficiency in the form of cost savings. Managers have already begun implementing novel solutions, including the introduction of new roles that blend patient care technician roles with unit clerk responsibilities at the authors’ institution, but their impact has not yet been formally evaluated. If the healthcare industry aspires to achieve the same efficiency gains, with simultaneous improvement in quality and safety, as seen in other sectors, then significant changes in staffing are inevitable. The information currently available to managers to address these staffing needs across all roles in the inpatient setting is inadequate. In the absence of definitive data to optimize the relationship between staff and HIT, managers should consider a framework of factors including a focus on quality and safety, organizational priorities, and optimizing multidisciplinary team function. This framework will likely allow managers to evaluate the impact of HIT and inform ongoing decisions about eliminating, retraining or refocusing staff roles.
References 1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-752. 2. Blumenthal D, Glaser JP. Information technology comes to medicine. N Engl J Med. 2007;356:2527-2534. 3. Keohane C, Bane A, Featherstone E, et al. Quantifying nursing workflow in medication administration. J Nurs Adm. 2008; 38:19-26. 4. Fisher S, Creusat J, McNamara D. Improving Physician Adoption of CPOE Systems. Alpharetta, GA: McKesson Provider Technologies; 2008. 5. Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff. 2004;23:184-190. 6. Westbrook JI, Li L, Georgiou A, et al. Impact of an electronic medication management system on hospital doctors’ and nurses’ work: a controlled pre-post, time and motion study. [published online ahead of print September 9, 2013]. J Am Med Inform Assoc. 7. Overhage J, Perkins S, Tierney W, et al. Controlled trial of direct physician order entry: effects on physicians’ time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc. 2001;8:361-371. 8. Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. In: Proceedings of Symposium
JONA Vol. 44, No. 2 February 2014
9.
10.
11.
12.
13.
14.
15.
16.
Computed Applied Medical Care. Bethesda, MD: American Medical Informatics Association; 1994:996. Tierney W, Miller M, Overhage J, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;269:379-383. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. 2005;24(5):1103-1117. Bigelow J, Fonkych K, Fung C, Wang J. Analysis of Healthcare Interventions That Change Patient Trajectories. Santa Monica, CA: RAND; 2005. Bower A. The Diffusion and Value of Healthcare Information Technology. Santa Monica, CA: RAND; 2005. Pub. no. MG-272-HLTH. Girosi F, Meili RC, Scoville R. Extrapolating Evidence of Health Information Technology Savings and Costs, Pub. no. MG-410. Santa Monica, CA: RAND; 2005. Sec. 4.2.6. Pub. no. MG-410. Randell R, Dowding D. Organisational influences on nurses’ use of clinical decision support systems. Int J Med Inform. 2010;79:e412-e421. Ash JS, Sittig DF, Seshadri V, et al. Adding insight: a qualitative cross-site study of physician order entry. Int J Med Inform. 2005;74:623-628. HITECH Act. http://www.hhs.gov/ocr/privacy/hipaa/understanding/ coveredentities/hitechact.pdf. Accessed September 12, 2013.
119
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
17. Blumenthal D, Tavenner M. The ‘‘meaningful use’’ regulation for electronic health records. N Engl J Med. 2010;363:501-504. 18. Blumenthal D. Quality of careVwhat is it? N Engl J Med. 1996;335(12):891-894. 19. Lohr KN, Schroeder SA. A strategy for quality assurance in Medicare. N Engl J Med. 1990;322:1161-1171. 20. Brooke RH, McGlynn EA, Shekelle PG. Defining and measuring quality of careVa perspective from US researchers. Int J Qual Health Care. 2000;12:281-295. 21. Perry JJ, Sutherland J, Symington C, Dorland K, Mansour M, Stiell IG. Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study. [publisher online ahead of print August 23, 2013]. Emerg Med J. 22. Poissant L, Pereira J, Tamblyn R, Kamasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005; 12(5):505-516. 23. Kovner C, Schuchman L, Mallard C. The application of pen based computer technology to home health care. Comput Nurs. 1997;15:237-244. 24. Ammenwerth E, Eichstadter R, Haux R, Pohl U, Rebel S, Ziegler S. A randomized evaluation of a computer-based nursing documentation system. Methods Inf Med. 2001;40:61-68. 25. Bosman RJ, Rood E, Oudemans-Van Straaten HM, Van Der Spoel JI, Wester JP, Zandstra DF. Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Med. 2003;29:83-90. 26. Menke JA, Broner CW, Campbell DY, McKissick MY, Edwards-Beckett JA. Computerized clinical documentation system in the pediatric intensive care unit. BMC Med Inform Decis Making. 2001;1:3. 27. Pierpont GL, Thilgen D. Effect of computerized charting on nursing activity in intensive care. Crit Care Med. 1995;23: 1067-1073.
120
28. Marasovic C, Kenney C, Elliott D, Sindhusake D. A comparison of nursing activities associated with manual and automated documentation in an Australian intensive care unit. Comput Nurs. 1997;15:205-211. 29. Minda S, Brundage DJ. Time differences in handwritten and computer documentation of nursing assessment. Comput Nurs. 1994;12:277-279. 30. Wong DH, Gallegos Y, Weinger MB, Clack S, Slagle J, Anderson CT. Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system. Crit Care Med. 2003;31:2488-2494. 31. Pinsonneault A, Rivard S. Information technology and the nature of managerial work: from the productivity paradox to the Icarus Paradox? MIS Q. 1998;22:287-311. 32. Koppel R, Metlay J, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. 2005;293(10):1197-1203. 33. Beuscart-Zephir M, Pelayo S, Anceaux F, et al. Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. Int J Med Inform. 2005;74: 629-641. 34. Callen JL, Braithwaite J, Westbrook JI. Contextual implementation model: a framework for assisting clinical information system implementations. J Am Med Inform Assoc. 2008;15: 255-262. 35. Pirnejad H, Niazkhani Z, van der Sijs H, et al. Evaluation of the impact of a CPOE system on nurse-physician communication. Methods Inf Med. 2009;48:350-360. 36. Georgiou A, Ampt A, Creswick N, et al. Computerized provider order entryVwhat are health professionals concerned about? A qualitative study in an Australian hospital. Int J Med Inform. 2009;78:60-70. 37. Callen JL, Westbrook JI, Braithwaite J. The effect of physicians’ long-term use of CPOE on their test management work practices. J Am Med Inform Assoc. 2006;13:643-652.
JONA Vol. 44, No. 2 February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
