Computerized Provider Order Entry Adoption: Implications
for Clinical Workflow
Emily M. Campbell, R.N, M.S.
, Kenneth P. Guappone, M.D., Ph.D.
, Dean F. Sittig, Ph.D.
Richard H. Dykstra, M.D., M.S.
, and Joan S. Ash, M.B.A., Ph.D.
Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA;
Portland Medical Center, Portland, USA;
UT-Memorial Hermann Center for Healthcare Quality and Safety, University of Texas School of Health
Information Sciences, Houston, TX, USA.
OBJECTIVE: To identify and describe unintended ad-
verse consequences related to clinical workflow when
implementing or using computerized provider order
entry (CPOE) systems.
METHODS: We analyzed qualitative data from field
observations and formal interviews gathered over a
three-year period at five hospitals in three organiza-
tions. Five multidisciplinary researchers worked togeth-
er to identify themes related to the impacts of CPOE
systems on clinical workflow.
RESULTS: CPOE systems can affect clinical work by 1)
introducing or exposing human/computer interaction
problems, 2) altering the pace, sequencing, and dyna-
mics of clinical activities, 3) providing only partial
support for the work activities of all types of clinical
personnel, 4) reducing clinical situation awareness, and
5) poorly reflecting organizational policy and procedure.
CONCLUSIONS: As CPOE systems evolve, those in-
volved must take care to mitigate the many unintended
adverse effects these systems have on clinical workflow.
Workflow issues resulting from CPOE can be mitigated
by iteratively altering both clinical workflow and the
CPOE system until a satisfactory fit is achieved.
KEY WORDS: attitude to computers; hospital information systems;
user–computer interface; physician order entry.
J Gen Intern Med 24(1):21–6
© Society of General Internal Medicine 2008
Health care providers use computerized provider order entry
(CPOE) systems to place orders for medications, laboratory
tests and other ancillary services.
CPOE has been shown to
decrease medication ordering errors and redundant test order-
ing, promote practice standardization, and reduce overall
Despite these benefits, CPOE systems have
yet to be widely adopted for several reasons, including the high
cost of implementation, clinician resistance to technology, worry
regarding practice disruption and loss of productivity, fear of
technology failure, and the inability of some CPOE implementa-
tions to integrate with existing healthcare systems.
more, there is evidence that unintended adverse consequences
can surround the implementation and ongoing maintenance of
Recent, conflicting reports about the role of
CPOE in the reduction of medication errors and associated costs
have cast some doubt on the actual scale of improvements to be
gained as CPOE systems have generated new kinds of medical
errors, negatively affected patient outcomes, and resulted in
higher overall medical costs for those institutions implementing
Thus, there remains a need for ongoing analysis of
CPOE to understand the causes of these issues and help find
A growing body of research explores the impact of integrat-
ing clinical information systems, including CPOE, within
Regardless of the study focus, one theme
consistently emerges: embedding CPOE in healthcare funda-
mentally changes the way clinicians coordinate their work
activities and collaborate to deliver care.
Indeed, in our
prior work we identified nine broad categories of unintended
adverse consequences related to CPOE, negative impact on
workflow emerged as the most frequently occurring theme.
The purpose of this current study was to explore these workflow
issues in greater detail.
We broadly define workflow as the activities, tools, and
processes needed to produce or modify work, products, or
More specifically, clinical workflow encompasses all
of the 1) activities, 2) technologies, 3) environments, 4) people,
and 5) organizations engaged in providing and promoting
A sociotechnical evaluation framework
five components of clinical work as a single work system; that
is, the components cannot be effectively analyzed in isolation.
To understand the effects of embedding CPOE into existing
care delivery systems, we must focus on how the systems as a
whole responds to the change. When using this approach, one
should not separate the information technology system from
its implementation. Even exquisitely designed and coded
software can be implemented poorly. Conversely, poorly engi-
neered software can promote process improvements if it is well
implemented. Thus any evaluation of a CPOE system must
study the system as configured, implemented and used
Received July 28, 2008
Revised October 9, 2008
Accepted October 16, 2008
Published online November 20, 2008