Clinician Perceptions on the Use of Free-Text Communication Orders

Swaminathan Kandaswamy; Zoe Pruitt; Sadaf Kazi; Jenna Marquard; Saba Owens; Daniel J. Hoffman; Raj M. Ratwani; Aaron Z. Hettinger

doi:10.1055/s-0041-1731002

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2021; 12(03): 484-494
DOI: 10.1055/s-0041-1731002

Research Article

Clinician Perceptions on the Use of Free-Text Communication Orders

Authors

Swaminathan Kandaswamy

¹Department of Pediatrics, Emory University, School of Medicine, Atlanta, Georgia, United States
Zoe Pruitt

²MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
Sadaf Kazi

²MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States

³Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
Jenna Marquard

⁴Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, Massachusetts, United States
Saba Owens

²MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
Daniel J. Hoffman

⁵Robert H. Smith School of Business, University of Maryland College Park, Maryland, United States
Raj M. Ratwani

²MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States

³Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
Aaron Z. Hettinger

²MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States

³Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States

Abstract

Objective The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information.

Methods We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes.

Results Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders.

Discussion Clinicians' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR's structured order entry must be redesigned to support clinicians' cognitive and workflow needs that are currently being addressed via the use of free-text orders.

Conclusion Clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.

Keywords

electronic health records and systems - communication - safety - workaround

Full Text

References

References
1 Schmidt IK, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med 2002; 54 (12) 1767-1777
2 Boev C, Xia Y. Nurse-physician collaboration and hospital-acquired infections in critical care. Crit Care Nurse 2015; 35 (02) 66-72
3 Joint Commissionon on Health Care Quality and Safety. Sentinel Event Statistics Data - Root Causes by Event Type. (2004 - 2015). Accessed 2016 at: http://info.jcrinc.com/rs/494-MTZ-066/images/Sentinel39.pdf
4 National patient safety goals effective July 2020 for the hospital program. [Internet] [cited 2020 July 21]. Accessed 2020 at: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_hap_jul2020.pdf
5 Taylor SP, Ledford R, Palmer V, Abel E. We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication. BMJ Qual Saf 2014; 23 (07) 584-588
6 Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003; 139 (01) 31-39
7 Singh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study. Arch Intern Med 2009; 169 (10) 982-989
8 Palchuk MB, Fang EA, Cygielnik JM. et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. J Am Med Inform Assoc 2010; 17 (04) 472-476
9 Zhou L, Mahoney LM, Shakurova A. et al. How many medication orders are entered through free-text in EHRs?--a study on hypoglycemic agents. AMIA Annu Symp Proc 2012; 2012: 1079-1088
10 Kandaswamy S, Hettinger AZ, Hoffman DJ, Ratwani RM, Marquard J. Communication through the electronic health record: frequency and implications of free text orders. JAMIA Open 2020; 3 (02) 154-159
11 Hajihashemi Z, Pancoast P. Reducing free-text communication orders placed by providers using association rule mining. AMIA Annu Symp Proc 2012; 2012: 1254-1259
12 Smith CNC, Quan SD, Morra D. et al. Understanding interprofessional communication: a content analysis of email communications between doctors and nurses. Appl Clin Inform 2012; 3 (01) 38-51
13 Cheng DR, South M. Electronic task management system: a pediatric institution's experience. Appl Clin Inform 2020; 11 (05) 839-845
14 Dingley C, Daugherty K, Derieg MK, Persing R. Improving patient safety through provider communication strategy enhancements. Advances in Patient Safety 2008
15 Pitts SI, Barasch N, Maslen AT. et al. Understanding CancelRx: results of end-to-end functional testing, proactive risk assessment, and pilot implementation. Appl Clin Inform 2019; 10 (02) 336-347
16 Tschannen D, Kalisch BJ. The impact of nurse/physician collaboration on patient length of stay. J Nurs Manag 2009; 17 (07) 796-803
17 Renz SM, Carrington JM. Nurse-physician communication in long-term care: literature review. J Gerontol Nurs 2016; 42 (09) 1-8
18 Nguyen C, McElroy LM, Abecassis MM, Holl JL, Ladner DP. The use of technology for urgent clinician to clinician communications: a systematic review of the literature. Int J Med Inform 2015; 84 (02) 101-110
19 von Gaudecker JR. Interprovider communication using a scheduled provider alert-response communication system in 3 inpatient neurology units. J Neurosci Nurs 2017; 49 (05) 272-273
20 Walsh C, Siegler EL, Cheston E. et al; Informatics Intervention Research Collaboration (I2RC). Provider-to-provider electronic communication in the era of meaningful use: a review of the evidence. J Hosp Med 2013; 8 (10) 589-597
21 Hospital & Health Systems | Cerner. [Internet]. [cited 2020 July 29]. Accessed 2020 at: https://www.cerner.com/solutions/health-systems
22 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006; 13 (05) 547-556
23 McDonald CJ, Callaghan FM, Weissman A, Goodwin RM, Mundkur M, Kuhn T. Use of internist's free time by ambulatory care electronic medical record systems. JAMA Intern Med 2014; 174 (11) 1860-1863
24 Baron JM, Dighe AS. Computerized provider order entry in the clinical laboratory. J Pathol Inform 2011; 2 (01) 35
25 Sittig DF, Ash JS, Guappone KP, Campbell EM, Dykstra RH. Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument. Int J Med Inform 2008; 77 (07) 440-447
26 Johnson CM, Khan A, Stark S, Samee M. A nurse shadowing program for physicians: bridging the gap in understanding nursing roles. J Nurs Adm 2020; 50 (06) 310-313
27 Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic health record usability issues and potential contribution to patient harm. JAMA 2018; 319 (12) 1276-1278
28 Zahabi M, Kaber DB, Swangnetr M. Usability and safety in electronic medical records interface design: a review of recent literature and guideline formulation. Hum Factors 2015; 57 (05) 805-834
29 Ratwani RM, Reider J, Singh H. A decade of health information technology usability challenges and the path forward. JAMA 2019; 321 (08) 743-744
30 Hettinger AZ, Fairbanks RJ, Hegde S. et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. J Healthc Risk Manag 2013; 33 (02) 11-20
31 Walsh KE, Secor JL, Matsumura JS. et al. Promoting secure provider-to-provider communication with electronic health record messaging: an educational outreach study. J Healthc Qual 2018; 40 (05) 283-291
32 Brown N, Eghdam A, Koch S. Usability evaluation of visual representation formats for emergency department records. Appl Clin Inform 2019; 10 (03) 454-470
33 Orenstein EW, Boudreaux J, Rollins M. et al. Formative usability testing reduces severe blood product ordering errors. Appl Clin Inform 2019; 10 (05) 981-990

Supplementary Material

Supplementary Material (PDF) (opens in new window)