Abstract
In order to improve the quality of healthcare, computerized physician order entries (CPOEs) have been invented to replace the traditional handwritten ones. The benefits of CPOEs are many and diverse; but, their implementation and use is yet to be absolute. In this case, adopting the new technology is not due to the ease in which it is implemented; but rather its relative advantage in relation to expected outcomes. Elements such as communication channels, feasible time frame and supportive social structures are important for the implementation of an innovation. Change is very imperative because it is mainly associated with advancement and improved standards of living. The use of CPOE is one such change aimed at improving and advancing the health care delivery system. As a new policy, the Shepherd Center will be targeted as an ideal location for the implementation of this new technology and its benefits will be evaluated. A pre-post evaluation method will be used and Pearson’s Chi-square test will determine the difference before, during and after the implementation of CPOE. The diffusion theory of innovation will be used to discuss adoption of the technology at the center.
The computerized physician order entry (CPOE) is the use of computers in health care settings to assist in the entry of medication orders from a mobile device or a computer. In addition, the order is documented and captured in a digital, structured, and computable format that is used to improve safety and organization (Centers for Medicare & Medicaid Services, 2010). This system is very effective at the ordering stage when most medication errors and adverse drug effects occur (Reidmann et al., 2011). In comparison to the traditional handwritten orders, the use of CPOE eliminates the issues of illegible handwriting, transcription errors, delayed response time, inaccuracy and failure of completion, and generally improves delivery of health care. Previous studies have indicated that significant reductions in prescribing errors, dosing errors and adverse drug effects (Nuckols et al., 2014; Shamliyan, Duval, Du, & Kane, 2008). The use of CPOE helps to automate dosing and subsequently avoid the errors that occur due to manual calculations (Roberts et al., 2013). This system has not yet been integrated in Shepherd Center, a nursing home in Atlanta, Georgia; therefore, the aim of this paper is to investigate the effectiveness of the policy of computerized orders in comparison to that of handwritten orders among physicians in improving patient quality of care and safety.
Justification
Medication errors are a major source of death and injury in most hospital settings. Shamliyan et al. (2008) cites that at least 500,000 patients in the world will die due to adverse drug effects on annual basis. This results in high health care costs that total up to $ 5.6 million each year. Ordering and transcription from physicians results in 50-61% of all the medication errors. The Institute of Medicine declares that medication errors are a menace to patient safety; thus, an electronic approach is deemed an auspicious solution (Shamliyan et al., 2008). Whereas most hospitals have realized the benefits of this new technology, it is important to note the benefits realized are different depending on implementation design. The Shepherd Center has not yet embraced this new technology, but due to the benefits realized by other nursing homes, there is need to adopt this new technology, and the diffusion of innovation theory will be used to illustrate this (Lee, Hsieh & Hsu, 2011).
Hypothesis
There is no significant difference between computerized physician order entry policy and the traditional handwritten order policy.
Theoretical Framework
Rogers (1995, p. 5) defines diffusion as the “process by which an innovation is communicated through certain channels over time among the members of a social system.” The rate at which potential adopters choose to accept or reject an innovation is greatly determined by the beliefs they have about the innovation and availability of resources (Mustonen-Ollila & Lyytinen, 2003). This theory entails emulation of pattern of policy from one individual or institution to another. This theory takes more effect when emulation is influenced policy choices of other individuals or institutions within a particular network. Influence occurs through normative pressure, learning, competition, imitation, and coercion (Berry & Berry, 2014). Based on this school of thought, learning and competition is the most influential factor that is prompting adoption of the CPOE policy at the Shepherd Center. Innovations that are deemed to have a higher level of relative advantage have greater trialability, compatibility and observability, and reduced complexity are adopted more readily compared with other innovations (Achugbue, 2014). In an attempt to emerge as an institution with the most efficient healthcare system, adoption of the CPOE, whose use has been proven effective in other hospitals, is paramount at the Shepherd Center.
Implementation Policy Plan
Identify the problem: This policy arises out of the need to improve patient care quality and safety.
Stakeholder involvement and responsibilities: I will be the person in charge of ensuring that the implementation of this new policy succeeds. Other people who will be involved in the implementation of this policy will involve the staff, management, beneficiaries and donors/sponsors. Each person will be given his or her responsibility based on his/her qualifications and expertise.
Evidence that the policy has a high probability of success: The diffusion of innovation theory will be applied to decide whether this policy will be implemented or not. However, based on the discussion earlier on about the benefits of the computerized orders, the diffusion of innovation theory will support the adoption of this new policy.
Draft Policy: A document will be drafted and all the stakeholders will be involved. It will entail a comprehensive layout of the policy, and all the areas that will be involved, available resources, and the activities of all those involved. The draft policy will be reviewed to enable preparation of the final policy that will be approved by the internal committee, and an external committee consisting of experts in the implementation of policies.
Approval of final policy: The final policy will be prepared based on the review of the draft policy; it will incorporate all recommendation and changes suggested in the draft policy.
Implementation: This will be a three-phased activity in that data will be collected prior to training or any form of sensitization to obtain the baseline characteristics that will form a basis for comparison during analysis. Subsequently, data will be obtained half-way the implementation process, and at the end. A pre-post study design will be used (Harris, et al., 2006). Training will take place in all the departments of the hospital, right from the front office, nurse, physician, pharmacist and laboratory technician/phlebotomist. I will liaise with the administration to allow training without interfering the duties. In addition, I will ask the administration to organize a time when staff members are accessible. Training will be done in shifts; in the morning and afternoon to ensure everyone is taught. The training will be conducted for one month by an Information Technology expert. According to Kuo, Wei, Hu & Yang (2013, p. 56-57) and Sanson-Fisher (2004), supportive social structures should be put in place to allow the implementation of a new technology, and the administration will aid in provision of these.
Training topics will be on medication use and safety, CPOE and its importance in documentation, as well as its integration in the facility. Short-term outcomes will be determined after the first two months of training, and modifications done to ensure the system fully supports integration of the CPOE. Later on, at the end of the entire six months, another evaluation will be conducted to determine the long term outcomes. The interview guide in appendix 1 will be used to obtain qualitative data. Quantitative data to validate information from the subjects and to aid in triangulation will be obtained by measuring the effects, for example, the percentage of reduction in medication errors and adverse drug effects.
Evaluation, Review and Revision of Policy: Both quantitative and qualitative information will be obtained on the effectiveness. The SPSS software will be used to perform analytical functions. Binomial test will be used to evaluate effectiveness of CPOE among the physicians while Pearson’s chi-square test will check for differences in outcomes before, during and after the intervention. A confidence interval of 0.05 will be used. Qualitative data will be transcribed, cleaned and arranged in themes. The results of the evaluation will determine how the policy will be revised in the event the desired outcome will not have been achieved.
References
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Berry, F., & Berry, W. (2014). Innovations and diffusion: Models in policy research. In P. Sabatier & C. Weible (Eds.), Theories of the policy process (3rd ed.) (pp. 307-314). Philadelphia: Westview Press.
Centers for Medicare & Medicaid Services. (2010). Medicare & Medicaid EHR Incentive Program. Web.
Harris, A., McGregor, J., Perencevich, E., Furuno, J., Zhu, J., Peterson, D., & Finkelstein, J. (2006). The use and interpretation of quasi-experimental studies in medical informatics. Journal of the American Medical Informatics Association, 13(1), 16-23.
Kuo, Wei, Hu & Yang, H. (2013). Applying innovation theory in observing emerging technology acceptance. International Journal of Systems Applications, Engineering & Development, 7(1), 56-65.
Lee, Y.-H., Hsieh, Y.-C., & Hsu, C.-N. (2011). Adding Innovation Diffusion Theory to the Technology Acceptance Model: Supporting Employees’ Intentions to use E-Learning Systems. Educational Technology & Society, 14 (4), 124–137.
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Nuckols, T., Smith-Spangler, C., Morton, S., Asch, S., Patel, V., Anderson, L., … Shekelle, P. (2014). The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews, 3(56), 1- 12.
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Utley, R. (2011). Theory and Research for Academic Nurse Educators: Application to Practice. Sudbury: Jones and Bartlett Publishers.
Interview guide
- What are the benefits of the CPOE policy towards enhancing health care quality and patient safety?
- What is your role in the implementing the CPOE policy?
- What skills do you possess that will enable you to effectively and efficiently use the computerized physician order entries?
- Explain available social structures that will support the implementation of this new technology.
- What are the perceived barriers to implementation of CPOE at this center?