Effects of Computerized Provider Order Entry and Nursing Documentation on Workflow

Abstract

Objectives: The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). Methods:The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions.Results: There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and ⁄ or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. Conclusions:The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider-computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected. ACADEMIC EMERGENCY MEDICINE 2008; 15:908-915 ª 2008 by the Society for Academic Emergency MedicineKeywords: electronic medical records, computerized provider order entry, emergency medicine, medical services, patient care processes E lectronic documentation and computerized provider order entry (CPOE) may in themselves take longer than their paper counterparts, 1,2 but provide an infrastructure that supports improved patient safety, improved information flows, and smoothed patient care processes. [3][4][5][6][7][8][9] Although there are recognized barriers to implementation of CPOE in the emergency department (ED), 10 there are significant potential benefits to doing so. [11][12][13] Published studies of CPOE implementations in the ED have demonstrated improved compliance with guidelines 14 and improved time to administering time-sensitive care. 15 A study of CPOE implementation in the ED by Piasecki et al. 16 found cost savings in terms of nonphysician staff time, but not in physician time. It is also known that implementation of CPOE can lead to unexpected results including effects on workflow and communication.17 A reciprocal impact of CPOE on communication has been previously reported. 18The Barnes-Jewish Hospital ED (affiliated with Washington University in St. Louis, MO) added CPOE and fully electronic nursing documentation to its impleme...

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