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Carrying out [[CPOE|computer provider order entry (CPOE)]] orders has complicated communications between physicians and nurses. [http://www.chcf.org/~/media/Files/PDF/C/PDF%20CPOEfactsheet.pdf] As a computer now relays orders between nurses and the physicians, there is loss of communication between them that can affect the patient care processes that used to take place when orders were written on paper.

== Introduction ==

CPOE systems appear to be based on a linear sequence for processing orders.  As an order is entered, orders are transcribed and then distributed to nurses who will carry out those orders into functions such as medication administration, and treatment.(2) However, most of the time this process is not linear.  Decisions about patient care are made in the context of dynamic negotiations. Communication between the patient’s care providers are at times unpredictable, and may not follow a pre-fixed sequence of steps that are built into computer programs.(3) Entry of an order into a computer field gives an “illusion of communication”(4) if the entering provider believes that the order is going to the right place, and that someone will see it and act on it. 

Articulation work is work that arises as an integral part of cooperation to ensure smooth coordination of care.  It is mostly invisible and is not often recognized by others as being an important part of patient care.(5) Face to face communication is still the predominant method for exchange of information between health care providers.(6) Communication tasks are necessary but not replaceable as we do not yet have the technology capable of transforming human conversations into human-computer interactions.(7)   

Computer orders can be entered anywhere in the hospital, or even remote from the hospital. Yet in some cases, providers have no way of telling if the order was accepted or carried out.(8)  If nurses do not know an order is being written, the order may be missed.  It can also cause confusion if the nurse does not know why the order was written.(9)  

== Studies ==

There are very few studies that have looked at the physician-nurse dyad and how CPOE has impacted communication between them.(10)  However, there are two studies that sought solutions to communication problems inherent in CPOE.  In France, nurses and physicians were given computers on carts that could be taken with them during patient rounds. This enhanced communication between the physicians and nurses at the point of care and justified the costs of additional hardware.(11) In another study, nurses at the Mayo Clinic Arizona, a 200-bed acute care facility, were proactive in finding solutions to communications problems before implementing CPOE.  A team of nursing and IT staff determined that the nurses’ main concern would be the loss of visual cues when new orders were being written.  They found solutions by choosing a web-based application for order notification that displayed and differentiated both routine and stat orders on monitors laced throughout the unit.  They also adapted a nursing assignment sheet to a web-based application that could be viewed and updated in real time.  This enabled a physician to identify his patient’s nurse and view a direct phone number where she could be reached.(12)  Both studies showed that further use of technology—mobile computers so that nurses could participate in medical rounds and new applications that made nurses’ work more visible for themselves and others—helped with physician-nurse communication.

End-user satisfaction of CPOE has also differed between nurses and ordering providers (13).

== References ==

# First Consulting Group. (2000). Computer physician order entry. Fact sheet prepared for the California HealthCare Foundation. Retrievable at: [http://www.chcf.org/~/media/Files/PDF/C/PDF%20CPOEfactsheet.pdf]
# Gorman, P. N., Lavelle, M. B., & Ash, J. S.  (2003). Order creation and communication in healthcare. Methods of Information in Medicine, 42, 376-84.  Retrievable at: [http://www.ohsu.edu/academic/dmice/research/cpoe/publications/gormanpn_ordercreation_mim_2003.pdf]
# Berg, M. (1999). Patient care information systems and health care work:  a sociotechnical approach. International Journal of Medical Informatics, 55, 78-101. Retrievable at: [http://www.sciencedirect.com.liboff.ohsu.edu/science/article/pii/S1386505699000118]
# Dykstra, R. (2002). Computerized physician order entry and communication:  reciprocal impacts.  AMIA Annual Symposium Proceedings, 2002, 230-234.  Retrievable at: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244295/?page=1]
# Goorman, E., & Berg, M. (2000). Modelling nursing activities: electronic patient records and their discontents. Nursing Inquiry, 7, 3-9.  Retrievable at:  [http://onlinelibrary.wiley.com/doi/10.1046/j.1440-1800.2000.00053.x/full]
# Safran, C., Sands, D.Z., & Rind D.M. (1999). Online medical records:  a decade of experience. Methods of Information in Medicine, 38, 308-12.  Retrievable at: [http://www.schattauer.de/en/magazine/subject-areas/journals-a-z/methods/contents/archive/issue/715/manuscript/67.html]
# Coiera, E. (2000). When conversation is better than computation.  Journal of the American Medical Informatics Association, 7 (3), 277-286.  Retrievable at: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC61430/]
# 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 Informatics Association, 11, 104-112, [DOI: 10.1197/jamia.M1471.]
# Dykstra, R. (2002). Computerized physician order entry and communication:  reciprocal impacts.  AMIA Annual Symposium Proceedings, 2002, 230-234.  Retrievable at: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244295/?page=1]
# Pirnejad, H., Niazkhani, Z., van der Sijs, H., Berg, M., & Bal, R. (2008). Impact of a computerized physician order entry system on nurse-physician collaboration in the medication process.  International Journal of Medical informatics, 77, 735-744. Retrievable at:  [http://www.ncbi.nlm.nih.gov/pubmed/18514020]
# Beuscart-Zephir, M. C., Pelayo, S., Anceaux, F., Meaux, J.-J.,Degroisse, M., & Degoulet, P. (2005) Impact of CPOE on doctor-nurse cooperation for the medication 	ordering and administration process. International Journal of Medical Informatics, 74, 629-641.  Retrievable at: [http://www.sciencedirect.com.liboff.ohsu.edu/science/article/pii/S1386505605000158]
# Wright, M. J., Frey, K., Scherer,J., & Hilton, D. (2006 ). Maintaining excellence in physician nurse communication with CPOE:  a nursing informatics team approach. Journal of Healthcare Information Management, 20(2), 65-70. Retrievable at:  [http://www.himss.org/content/files/jhim/20-2/JHIM_Spring2006_ALL.pdf#page=65]
# Hoonakker, P. L., Carayon, P., Brown, R. L., Cartmill, R. S., Wetterneck, T. B., & Walker, J. M. (2013). Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units. Journal of the American Medical Informatics Association, 20(2), 252-259. Retrievable at:  [http://www.ncbi.nlm.nih.gov/pubmed/23100129]


Submitted by Julianne Bava

[[Category:BMI512-FALL-11]]