Running head: COMPUTERIZED PHYSICIAN ORDER ENTRY TRAINING

Computerized Physician Order Entry Training Matthew Stryker Post University http://discoverglobe.net/welcome/?page_id=79

COMPUTERIZED PHYSICIAN ORDER ENTRY TRAINING

Introduction This paper will introduce training for a hospital that may implement a Computerized Physician Order Entry System (CPOES). This training will incorporate Gagne, Briggs and Wagers nine events of instruction (Hodell, 2011) and also Magers criterion referenced instruction model (instructionaldesign.org, 2012). These instructional theories make the outcome and objectives clear and direct the students learning. The system will be implemented hospital wide one department at a time. Any employee who will use the CPOE system to place orders, fill orders or access the program for management purposes will receive the training. The population who will receive this training includes physicians, nurses, radiologists, therapist among many others. The paper will then outline the training and the components of the training. This new system will be completely computerized so there will be a large technology aspect to the training. It is important that the participants actually use the program at it will actually be used when fully implemented. The final part of the paper will discuss how technology will be utilized in the training. Theoretical Framework The training which the staff will receive is for a program which they will use every day. It is not a theory that they may decide whether they feel it is important to their specific job. It is not a problem that has multiple ways to form a solution and they can choose which one they feel most comfortable with. The theory that will be proposed in this paper is Criterion Referenced Instruction (CRI) by Robert Mager. In CRI there are specific identified outcomes expected from the instruction. These objectives will be stated from the outset of the learning activity. Then the learners will practice the skills to be learned and finally they will be tested on the mastery of those skills (Instructionaldesign.org, 2012).

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This type of training was selected because the employees must have one hundred percent mastery of the system or patient lives will be in danger. The program will also be used differently between areas of the hospital and categories of employees so their objectives will differ and must be clearly stated. Specific to these objectives are that they must state what the learners must be able to do, the conditions that they will have to do them in and the accuracy with which they must be performed (Cox, 2002). The actual training lesson outline will use part of Gagne, Briggs and Wagers nine events of instruction. This training will be utilizing the gaining attention, direction, recall, delivery of content and, practice and assessment events of instruction (Hodell, 2011). This training is educating employees on a change in process and not necessarily new information. This process will require that most of the time of the instruction will be spent on practice and will simulate the act of actually placing, fulfilling, and charting orders for patients (Bell, Kanar, & Kozlowski, 2008). Proposal of Learning Activity There are hospitals today that are updating many parts of their daily processes and procedures. Some past procedures and processes were carried out with paper ordering and manual processing. Today many physicians write their orders for patients on a sheet of paper. That paper is then processed by the Health Unit Coordinator (HUC) who will decipher what the doctor has ordered and then place the order into a computer. The paper order is then placed in a binder that is placed on a shelf with many other binders. When an order is fulfilled the nurse then charts that it was completed. This takes an extra person who has to interpret what the doctor has written on the paper. Sometimes the handwriting is not legible and possible order errors can

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occur. The major problem with the current system is the amount of time it takes to place the order or find the order if there is a question about it. The proposed training will be for new software that reduces paper and will speed up the ordering process while reducing errors. The training will be for new software that allows the physician to directly place the order into the computer system. The order can be processed quicker and will reduce any errors that might occur by a HUC misreading a physicians hand writing or entering something wrong. The physician will be able to rate the order as STAT, ASAP or Routine. The nurse, therapist, pharmacy or other party who is going to fulfill the order can then see which orders need to be done first second and so on. This training will be required for all staff in the hospital that will be ordering or processing patient orders. The program is going to be used differently by different categories of staff members in the hospital but in each category the employees will use the program in the exact same way. Radiologists, respiratory therapists, and other services will use the program to receive orders and schedule procedures for the patients. Nurses will use the program to see that their patients orders have been fulfilled and processed in the order of urgency as specified by the doctor. With the program being such a large undertaking it will occur in phases. Certain areas and employees will begin using the program before others. The first areas that will begin the training will most likely be the regular MED-SURG floors. These patients are not in great danger if their orders take a little longer to be processed. Starting in an area of the hospital where patients are put at minimal risk is very important (Altuwaijri, Bahanshal, & Almehaid, 2011). It is possible that there may be some bugs or issues with the program at the initial implementation. Establishing the program in a safe environment is key to not putting patients at risk. Once this area is defined the training will begin.

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The training will be started by forming a group of experts from each of the employee categories (nurses, physicians, pharmacists etc.) that will be using the system. These experts have been called different things. They have been referred to as champions (Upperman et al., 2005) or more commonly as super-users (Altuwaijri et al., 2011). For the remainder of this paper they will be referred to as super-users. The super-users will help train the other staff members and be available to help once the program begins to be implemented in the workplace. The trainings will take place in computer labs within the hospital. The entire program is computer based. This will require all users to have a basic mastery of computers and how to access programs and navigate through them. A population analysis will determine whether there will need to be technical training prior to the CPOE training. The hospital currently requires computer charting and other computer skills so there should not be a large need for basic computer training. The employees will need to know how to access the system and then maneuver within the system for their specified use of the program. This will be modeled by the instructor and then practiced by the learners. To help the learners practice the program they will be given specific tasks that they will complete. If they have difficulty completing the tasks then they can ask the instructor or a superuser for help. In order to complete the training and receive credit for finishing, the learners will be required to show mastery by completing cases at the end of the training. Physicians will be required to analyze patient data and symptoms and then prescribe medication, a procedure or other need for the patient without error. Nurses will be required to access patient information, report and chart what orders have been fulfilled and what orders still need to be filled. Pharmacists will be able to access their orders, fill the orders, send the orders, and mark that the orders have been checked and sent. Other areas will have to complete tasks related to their field.

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In order to give employees time to practice there will be tutorials available on the employee website. There will be a beta version available for employees to practice their specific tasks and even others if they wish (Gardner & Jeon, 2009). The online cases should have the ability to provide feedback and assistance if desired. The employee website will also provide a forum for discussion where employees can post questions and comments about the program. This will serve as an informal environment where information can be shared but also as a medium for developers to improve the system based on user feedback. The training will begin with Gagnes first instructional event which is gain the audiences attention (Hodell, 2011). A video or presentation of a situation where a physician places an order with the current system will be shown to the learners. It is a routine order but there are multiple orders on one sheet. That sheet is then given to the HUC where they have difficulty deciphering the physicians hand writing and puts the wrong order into the computer. It may also show the HUC trying to reach the Physician for conformation of the order but is unable to reach them. The patient then receives the wrong dose of medicine or the wrong labs were taken. Then the advantages of the new CPOE system will be introduced. The instructor will then lead directly into stating the objectives. These will be placed on the screen in front of the room and/or placed on a handout. These objectives will follow Magers guidelines for objectives which focus on performance, condition and criteria (Cox, 2002). One sample objective would be; given a computer with access to the CPOE system, the Physician will be able to place patient orders into the CPOE system with 100% accuracy and within 1 minute for each order. Another example for nurses would be; given a computing device with the CPOE system the nurse will be able to use all aspects of the CPOE system including accessing patient

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data and orders, fill or schedule orders placed based on status, charting work that has been done and communicating to other departments and employees if needed. The learning objectives may be different for each department and type of employee. These objectives will help guide the learners and help them understand what they are going to need to be able to do at the end of the training (Cox, 2002). The next two events are recall and delivery (Hodell, 2011). In recall the instructor will establish that this is going to be a change in procedure for physicians and others who may place orders for patients and then the way those orders will be filled and charted. This leads into the delivery part of the instruction where the new process is introduced and modeled for the learners. There will be a screen in front of the room where the trainees can observe the program being used while they work through the system on their own computing devices. The instructor will work through several different scenarios according to the audience and answer questions during the instruction. The trainees will then be given time to practice. They can work through scenarios given to them or derive their own based on the department they may work in. The trauma department may have common orders that differ from cardiac or labor and delivery. This will also be a time for the instructor to go around the room and help resolve any issues that may arise during this time. The final event is assessment (Hodell, 2011). The trainees will be required to complete three to scenarios in a row with 100% accuracy and within a specific time limit. If the trainees can do this they will be considered to have mastered use of the program and are finished with the training. If they are not successful, they will need to practice on the trial version at the employee website and take an assessment again with the educator assigned to their area of the hospital.

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Employee motivation is an aspect that will need to be taken into consideration when conducting training as well. Debow (2008) says some learners will be motivated intrinsically, but the majority will be looking for extrinsic rewards (p. 20). Debow (2008) says that some possible extrinsic rewards are certificates or continuing education credits (CEUs). There may also be some sort of monetary compensation for the time spent in the training. Other non-incentive aspects that will help with motivation will be efficient instruction. Specializing the training for one type of user will eliminate employees losing interest because of irrelevant material. The training should also be available to them at a most convenient time. There can also be an option for the employees to practice online and take the assessment with the educator and if they pass they do not have to attend formal training. Technology The technology required to perform this training will be the same technology which will be required to use the system. There will need to be access to a device with access to the hospitals server and the physician order entry system. This could be available via computer, tablet or other mobile computing device. The choice of technology is decided by each department of the hospital by a team of employees. In order to use mobile devices the hospital will need a secured wireless network and a sound technology infrastructure to support the workload the new program will place on it (Altuwaijri, Bahanshal & Almehaid, 2011). The hospital currently has a laboratory which houses approximately 20 computers. There are other rooms available to work with individuals who will use laptops, tablets or small mobile devices. These areas will be sufficient for training since the implementation of the program will occur in phases instead of the entire hospital at once.

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This technology will support learning because it provides flexibility in the teaching and learning of the system. Individuals will have the ability to sign in at home and explore the beta version of the program. The web page will also allow for a discussion board and interaction between users. The use of different computing devices also makes the training free from the restrictions of a computer lab. This is especially useful if another department wishes to use the lab at the same time. The use of technology fits directly into the objectives because the employees will be asked to use the same technology on their floor during all of their shifts. Having the program available online will allow them to practice on their own time and in essence test out of the formal training. The use of the actual required technology and simulation of scenarios also leads to a more authentic assessment and transfer into actual use in the hospital (Chan Yuen & Gurman, 2010). Assessment and Evaluation As stated earlier, the employees will be assessed on how accurately and quickly they can complete three scenarios for the instructor or super-users who have been trained to administer the assessment. These scenarios are directly related to the everyday tasks in which the employees will be required to perform during their daily work routine. This type of assessment was chosen because it is an authentic assessment. Authentic assessment is assessment that truly assesses what is being learned but also enhances learning. Wiggins (1990) says that authentic assessment is forward-looking while traditional assessments are more directed to prior learning (p. 3). This forward-looking aspect is what enhances the trainees learning. The employees will know what they will be assessed on and how the assessments will be conducted (Wiggins, 1990).

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There are several key components with an Authentic Assessment. The tasks need to be an actual task which will help them in life outside of the classroom, consistent with the curriculum and guide learning (Palm, 2008). They must also be completed in the same manner as they would in the real world. The same conditions, context and products need to be present (Palm 2008). Chen and Gurnam (2010) say that the task must be completed in real world settings (p. 154). Whether you call it the setting, environment, or context it means that the assessment should include as many as the aspects of the real world. The assessment for the employees in the CPOE training will seek to be as real life as possible. The CPOE system will be accessed through technology with access to the hospitals servers. The employees will be required to complete the learning activity and assessment on the same devices that will be available to them in their work environment. If possible the employees will leave the instruction room and move to the employees work setting to complete the assessment. Completing the assessment in the employees everyday work environment may be met with some difficulties. There may not be available space or computing devices in their work area. Nurses and Physicians who will be utilizing the CPOE system inside of patients rooms may find it difficult to find empty rooms in order to take the assessment. If will also be difficult to simulate other factors that an employee will be facing on a regular work day. It is common for family members to be present. The employees will have multiple patients and other needs vying for time and mental focus. The goal will is to make it as authentic as possible. If a more authentic location is not available the assessment will take place in the training room. Once the evaluation area has been determined, the assessment administrator will give the employees the scenario. The administrator will then time the employees as they work through the

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scenario. The employees will have three minutes to complete each scenario. They must also complete the scenario with zero mistakes. Within the three minute time frame the employees are allowed to correct mistakes that they notice. If there are still mistakes after three minutes or if the employees take longer than three minutes to complete the scenario then they have not passed and will require further training.

Conclusion The CPOE systems training is designed to allow the hospitals employees a variety of ways to access the new program and learn the intricacies associated with it. The employees will have access to the program online through the hospitals employee website, in the hospitals various computer labs and eventually through instructor led training throughout the hospital. This will lead to more proficient users of the CPOE system, a more efficient physician ordering process and possibly higher patient satisfaction. The informal and formal training aspects have been set up to meet the different needs of the different employees of the hospital. The support structure, such as formal training and discussion board, will help resolve any user issues and help the IT department detect any program bugs or errors. These will both ensure a more smooth and effective implementation of the program into everyday use in the hospital. The use of criterion referenced instruction and authentic assessment will also help ensure that there is little difficulty in the transition between the current physician order entry system and the new computerized physician order entry system. They focus the trainee on the desired outcome and guide the trainees during the instruction.

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References
Altuwaijri, M. M., Bahanshal, A., & Almehaid, M. (2011). Implementation of computerized physician order entry in National Guard hospitals: Assessment of critical success factors. [Article]. Journal of Family & Community Medicine, 18(3), 143-151. doi: 10.4103/2230-8229.90014 Bell, B. S., Kanar, A. M., & Kozlowski, S. W. J. (2008). Current issues and future directions in simulationbased training in North America. [Article]. International Journal of Human Resource Management, 19(8), 1416-1434. doi: 10.1080/09585190802200173 Chan Yuen, F., & Gurnam Kaur, S. (2010). Authentic assessment and pedagogical strategies in higher education. [Article]. Journal of Social Sciences (15493652), 6(2), 153-161. Cox, S. (2002). Criterion-referenced instruction (Robert F. Mager). Journal of Educational Computing, Design & Telecommunications. Retrieved from: http://coe.ksu.edu/jecdol/Vol_3/articles/Cox.htm DeBow, D. P. (2008). Computerized physician order entry. [Article]. Distance Learning, 5(2), 15-24. Gardner, J., & Jeon, T. (2009). Creating task-centered instruction for web-based instruction: obstacles and solutions. [Article]. Journal of Educational Technology Systems, 38(1), 21-34. Hodell, C. (2011). Isd from the ground up: A no-nonsense approach to instructional design (3rd ed.). United States of America: American Society for Training & Development. Palm, T. (2008). Performance Assessment and Authentic Assessment: A Conceptual Analysis of the Literature. Practical Assessment Research & Evaluation, 13(4). Retrieved from http://pareonline.net/pdf/v13n4.pdf Upperman, J. S., Staley, P., Friend, K., Benes, J., Dailey, J., Neches, W., & Wiener, E. S. (2005). The introduction of computerized physician order entry and change management in a tertiary pediatric hospital. Pediatrics, 116(5), e634-e642. doi: 10.1542/peds.2004-0066

COMPUTERIZED PHYSICIAN ORDER ENTRY TRAINING Wiggins, G. (1990). The case for authentic assessment. Practical Assessment, Research & Evaluation, 2(2). Retrieved from http://www.eric.ed.gov/PDFS/ED328611.pdf

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