Pediatric Informatics: Computer Applications in Child Health (Health ...

8 Complexity in Healthcare Information Technology Systems 103
Many institutions have not installed a companion electronic medication
administration record (eMAR) concurrently with CPOE implementation. Amazingly,
in 2008, not all vendors even offer both components for an ordering-to- administration
integrated inpatient medication management. The resulting temporal and cognitive
disconnect between the paper MAR and the computerized CPOE orders is an errorprone
system that is frustrating and labor intensive for clinical caregivers. Neither
complex technological solutions nor cumbersome medication reconciliation procedures
using extensive human work-arounds (including hiring additional nursing/
pharmacy staff) have entirely mitigated the risk of communication glitches and
medication delivery failures. 60 Currently, the safest procedure is to maintain effective
direct methods for nurse, physician, and pharmacist communication.
In a paper-based world, the bedside nurses receive a visual cue when a physician
writes an order in the bedside chart. CPOE eliminates this cue because physicians
can enter orders from remote locations unobserved by the nurse. On a general
Pediatric ward, this scenario can cause a delay in therapy and possible harm to the
patient. In an ICU, this problem is magnified by patient acuity and the large number
of time-sensitive orders.
Before any CPOE system is implemented, all care providers must understand
that CPOE is not a replacement for effective interpersonal communication between
care team members. Physicians must continue to notify bedside nurses of changes
in management. Strong verbal communication is one of the critical factors that differentiated
the successful CPOE implementation in the scenario outlined above.
8.3.4.2 Workflow Issues: Patient Movement and Multiple Transfers
The dynamic, “real-time” nature of the critical care transport process between units,
to radiology or operating rooms, or by ambulance between institutions, places
unstable patients at high risk for serious error. Monitoring patient movement and
documenting transfers while responding to new orders in near real-time is vital for
in inpatient critical care venues and any HIT system must respond to this need.
Tracking of inpatients in “real-time” is one of the most challenging aspects of a
pediatric critical care CPOE implementation. Orders and medication delivery must
follow patients through a number of off-unit venues, including hallways and other
unusual areas, especially during surge capacity situations.
Based on hospital policies and patient needs, transfers may require that orders
be temporarily suspended or modified. Some transfers require discontinuation of
all existing orders. Other situations require that all existing orders be continued,
despite a physical move. Effectively managing the dynamic needs of critically ill
patients moving from the Emergency Room to an ICU, to OR, and back, via the
Radiology facility, followed by a second trip to the OR can be extremely challenging
for computer and human systems designers and implementers of CPOE/medication
reconciliation utilities. Obviously, policies must be developed to manage transfer
situations within every CPOE implementation and providers must be educated