An Emerging Health Care

With great attention being placed on medication safety and reduction of healthcare costs, involvement of information technology in health care is increasing (Kuperman & Gibson, 2003). Examples of this so-called patient care information systems are order entry systems, medical records systems, radiology information systems and patient information systems with Computerized Provider Order Entry, or Computer Physician Order Entry, (CPOE) receiving valuable attention (Ash, Berg, & Coiera, 2004).

Thus, this paper will be focused on CPOE as an emerging health care technology. CPOE, as defined by (Campbvell et al. , 2006), is: …the process by which physicians or their surrogates (but not intermediaries) directly enter medical orders into a computer application (p. 547). With this transformation from handwriting orders into encoding them into the computer, CPOE is seen as an important platform for the enhancement of health care delivery (Gibson & Kuperman, 2003).

Gibson and Kuperman (2003) have noted the positive outcomes of CPOE in the following areas: a) preventive care measures; b) compliance with drug monitoring; c) laboratory test ordering; d) radiologic test ordering; e) medication error reduction; f) decrease length of hospital stay; g) time-saving communication with the healthcare team; h) standardization of practice; i) clinical decision support; and, j) storage of data for management, quality, and research monitoring.

Thus, CPOE is seen as the ticket for the avoidance of underuse, misuse, and overuse of health care (Gibson & Kuperman, 2003) with endorsements from the Leapfrog Group as being an important leap for health care quality (Gibson & Kuperman, 2003). Yet, as in any other technology, the complexity, advanced features, and high demands of CPOE can lead to consequences that are unintentional (Campbell et al. , 2006).

Though CPOE also bears positive and beneficial UC’s, the alarming negative consequences which affects the healthcare, especially that of nursing services, will be the focus of this study with the aim of presenting the adverse UC’s of using such an emerging health care technology. CPOE: NOT ALL GOOD Campbell and colleagues (2006) conducted a study that pointed out to 9 different unintended consequences of CPOE to healthcare.

In decreasing frequency, these UC’s are: a) more/new work for clinicians; b) workflow issues; c) never ending system demands; d) paper persistence; e) changes in communication patterns and practices; f) negative emotions; g) new kinds of errors; h) changes in the power structure; and i) overdependence on technology (p. 549). (See table 1). Among these UC’s, others affect the medical professionals or the healthcare organizations only while some encompasses its effect on nursing services.

Since this paper is focused on the UC’s that affect the clinical nursing care, focus is given on the following UC’s of CPOE: a) workflow issues; and, b) changes in communication patterns and practices. Workflow Issues Clinical workflows are complex thereby necessitating dynamism (Campbell et al. 2006). With traditional health care workflows, steps are more adaptable and include a variety of checks and balances, interventions and exceptions (Campbell et al. , 2006). These consist of several concurrent and asynchronous steps that could adjust, cease, or intervene in the processing of medical orders (Campbell et al.

, 2006). CPOE, as evidenced by the study of Campbell et al. , (2006), abolish these multiple interdependent steps resulting in lesser procedure reviews and greater potential hardships. CPOE has clinical ordering processes that follow predictable steps where the doctor encodes and order, the system delivers it to the rightful destination, the order is processed, and the request is acted upon (Campbell et al. , 2006). But then, this rigid adaptation of hospital procedures is different from what occurs in the real setting (Campbell et al. , 2006).

In actual practice, simultaneous actions on wide dimensions like assessing patients, carrying out orders, and responding to emergencies, require flexibility by healthcare providers especially that of nurses (Ash, Berg, & Coiera, 2004). As Campbell et al. (2006) note, nurses are with good experiences are able to blend orders as necessary. Ash, Berg, and Coiera (2004) agrees to this by stating that in everyday health care work, experienced nurses are more often knowledgeable about medications than many other junior physicians who populate the ward.

With the strict implementation of rules by CPOE, this flexibility of nurses especially in areas of emergency care and “stat” actions are disregarded and are not permitted (Campbell et al. , 2006). This is in favor of quality and management control, but has great risks for health care provision (Campbell et al. , 2006). This shows CPOE’s failure to support individual role players and work-shifting in the health care area that may lead to ineffective work activity synchronizations (Capmbell et al. , 2006).

As such, this lack of support for the highly flexible and fluid ways of real life clinical workflow is burdensome for medical and nursing professionals (Ash, Berg, & Coiera, 2004). Changes in Communication Patterns and Practices Health care professionals are connected by sharing professional opinions and needs through noting progress and conducting referrals (Ash, Berg, & Coiera, 2004). CPOE alters this traditional pattern by replacing previously interpersonal conversations regarding provision of care with a computer system that creates problems in the clinical care work (Campbell et al. , 2006).

By communicating only through the computer, physicians are provided with an “illusion of communication” by believing that entry of an order into the system guarantees that proper people will receive it and take appropriate actions (Campbell et al. , 2006). This places the blame on nurses for non-carrying out of orders as they are expected to have performed it (Campbell et al. , 2006). But with a fast-paced work in wards and special areas, nurses are more often on bedside care rather than facing the computer resulting in delayed notification of new orders, or worse non-information at all (Campbell et al.

, 2006). Also, the time that elapsed from the physician seeing the patient and encoding the order may take precious moments that may consist of changes in the status of the patient’s condition (Campbell et al. , 2006). This results in untimely orders received by nurses, who are the implementers of such encoded orders. Communication also involves more than transferring information. More importantly, it is about evaluating the person’s reception and understanding of the situation and the willingness to intervene on that information through feedbacks (Ash, Berg, & Coiera, 2004).

With face-to-face conversations by doctors and nurses, timely feedbacks are given by each resulting to more appropriate interventions (Campbell et al. , 2006). With CPOE, the lessened feedback leads to orders missed, diagnostic tests delayed, and medications not given at all because timely feedbacks have not been exchanged (Ash, Berg, & Coiera, 2004). This disregard for interpersonal communications by CPOE can be troublesome for the clinical work.

With a reduction in face-to-face communications, errors due to miscommunications, delayed actions, and fewer team-wide discussions may result (Campbell et al. , 2006). CONCLUSION With the complexity and imperfections of human operations, even emerging technologies with good intentions are expected to have, in one way or the other, unintended consequences. In the light of CPOE’s, though intentions are directed towards improving safety and quality of health care, some effects result as this new technology is embraced by healthcare practice that has long survived without the use of such.

As it affects aspects of healthcare, nurses, who implement most of the orders entered by doctors through CPOE’s, are also affected. As CPOE disrupts the conventional health care workflow, it also changes the flexible roles of nurses and care providers in terms of clinical work and responsibilities. In the light of CPOE changing interpersonal communication practices, the traditional face-to-face interactions are lessened thereby leading to poor coordination among nurses and physicians and other ancillary care providers.

Thus, with the promise benefits of CPOE, a clear review of the already known and possible unintended consequences to health and nursing care must be made if CPOE is to be imposed in health settings. By doing so, preparations for these effects may be made leading to a more enjoyment of CPOE good effects rather than suffering from its adverse unintended consequences.


Ash, J. S. , Berg, M. , & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors.

Journal of the American Medical Infromatics Association, 11, 104-112. Campbell, E. M. , Sittig, D. F. , Ash, J. S. , Guappone, K. P. , & Dykstra, R. H. (2006). Types of unintended consequences related to Computerized Provider Order Entry. Journal of the American Medical Infromatics Association, 13 (5), 547-556. Coyne, C. J. (2008). Unintended consequences. In: Fortier, J. (Ed. ), Key concepts in free markets: Executive summaries in the History and theory of free market economics, 115-138. Vancouver, BC: The Fraser Institute.

Kuperman, G. J. & Gibson, R. F. (2003). Computer physician order entry: Benefits, costs, and issues. Annals of Internal Medicine, 139, 31-39. Merton K. (1936). The unanticipated consequences of purposive social action. American Sociological Review, 1, 894-904. MSN Encarta (2008). Side effect. Retrieved October 23, 2008, from http://encarta. msn. com/dictionary_/side%2520effects. html Spratto, G. R. & Woods, A. L. (2008). PDR Nurse’s Drug Handbook, vii-xvii. United States: Thomson Delmar Learning.

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