Safety and efficiency considerations for the introduction of electronic ordering in a blood bank.
Abstract: * The introduction of computerized provider order entry (CPOE) systems is associated with major changes in work processes. Implementation strategies need to consider how the technology will affect and be affected by the organization in which it is being installed. The aim of this study was to examine the potential effect of the introduction of a CPOE system on key work processes in a hospital blood bank by using qualitative data from focus groups, interviews, and participant observation and quantitative data of telephone communication. We found that work practices in the blood bank are made up of a mosaic of collaborative processes underpinned by communication channels to facilitate safe and efficient work practices. The introduction of CPOE systems requires consideration of these channels and of the ways that CPOE may disrupt existing communication processes. There needs to be high levels of staff preparedness to minimize patient risk and optimize performance.
Article Type: Report
Subject: Blood banks (Safety and security measures)
Computerized instruments (Usage)
Pathology (Practice)
Communication in medicine (Management)
Patients (Care and treatment)
Patients (Safety and security measures)
Authors: Georgiou, Andrew
Greenfield, Tony
Callen, Joanne
Westbrook, Johanna I.
Pub Date: 06/01/2009
Publication: Name: Archives of Pathology & Laboratory Medicine Publisher: College of American Pathologists Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of American Pathologists ISSN: 1543-2165
Issue: Date: June, 2009 Source Volume: 133 Source Issue: 6
Topic: Event Code: 260 General services; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8093000 Blood Banks & Collection Centers; 3559358 Flexible Automation for Injection Molding; 3573031 Process Control Computer Systems NAICS Code: 621991 Blood and Organ Banks; 33322 Plastics and Rubber Industry Machinery Manufacturing; 334111 Electronic Computer Manufacturing SIC Code: 8099 Health and allied services, not elsewhere classified
Accession Number: 230152022
Full Text: Pathology services have been described as the "hidden science that saves lives." (1) They make an essential contribution to the effective prevention, detection, and management of disease but are still widely perceived as a backroom function, (2) with many people unaware of their vital, ongoing importance.1 There are many signs that this situation is changing, particularly with the emphasis on the role of pathology in patient pathways beginning with the selection of the most appropriate test or investigation onto the interpretation and provision of clinical advice across many clinical specialties. (2) Information and communication technology has a critical part to play in this development. This technology is a central feature of pathology laboratories, particularly in complex hospital settings reliant on the efficient management of information for patient care. (3)

The implementation of computerized provider order entry (CPOE) systems provides a possible foundation for enhancing the role of pathology services in the patient care process. (4) These systems enable doctors, and other authorized clinicians to issue orders electronically, leading to efficient order communication and decision support at the point of ordering. However, CPOE introduction can also be associated with important and disruptive changes to laboratory and clinical professionals' work practices and processes. (5) The planning and implementation of these systems requires consideration of how the technology will both affect and be affected by the organization in which it is being installed. (6) This is of particular importance for pathology departments, which consist of a diverse range of services, each with its own unique tasks and requirements. (2)

Pathology services have received limited attention in the research literature on CPOE, (7) with even less consideration of specific pathology departments and their particular organizational and technical features. The blood bank was chosen for study because of the critical role it has in the safety and quality of patient care. Our aim was to describe key work processes of laboratory professionals within a hospital blood bank and examine the potential effect of the introduction of CPOE systems by using qualitative data from focus groups, interviews, and participant observation and quantitative data of telephone communication.

METHODS

Design and Research Setting

The study was carried out in the blood bank of a 600-bed teaching hospital in Sydney, Australia, which provides a networked blood banking service throughout a large metropolitan area and is involved in the investigation of antibodies and transfusion-related issues. The blood bank has 13 full-time equivalent staff, including 5 scientists and 8 technical officers/assistants. There are also 6 hematologists available on site. It is part of a pathology service made up of more than 300 staff members covering 6 hospitals within an area health service. In November 2005, the Cerner Millennium Pathnet (Kansas City, Missouri) was installed, and in January 2006, PowerChart (version 2004.01; Cerner) was introduced across the hospital. This new integrated system replaced the existing laboratory information system, allowing doctors and other authorized clinicians to electronically place orders for a range of items including pathology and radiology tests. However, during the period of this study, the electronic ordering of blood and blood products from the blood bank had yet to be introduced and was not expected in the foreseeable future.

The study adopted a formative approach to the research setting and was conducted for a period of 14 months, from May 2005 to June 2006. This allowed the research team to examine work process issues and questions as they arose and to assess their likely implications. (8) Qualitative data were generated by using focus groups, interviews, and participant observation. The research was iterative and interactive, incorporating feedback and validation channels and input from senior pathology management staff.9 Quantitative data relating to the number and type of telephone calls received during a period of 1 week (May 5-11, 2005), before the system changeover, were also collected.

Participants and Data Collection

Focus groups.--The study included 2 focus groups made up of 3 and 4 participants. These included 2 hospital scientists and 5 technical officers who were asked a set of semistructured questions about their expectations of the new electronic ordering system. Participants were also asked to outline how the laboratory works and to identify perceived advantages and disadvantages of the new system and how it would affect work processes. The 2 focus groups met on the hospital premises, and the meetings were facilitated by the lead author (A.G.) and were taped and transcribed. This resulted in 29 pages in A4 format.

Interviews.--The focus groups were followed up with a series of face-to-face interviews with 8 laboratory staff members conducted by the lead researcher (A.G.). The 8 interviewees included 2 senior laboratory managers, 2 hospital scientists, and 4 technical officers. Interviews were repeated with participants for clarification of issues raised and to investigate the relevance and validity of emerging themes. Given the size of the blood bank and the difficulties involved in accessing many staff members, the study adopted convenience sampling techniques based on participant availability. (10)

Observations.--Three hours of direct observation of work processes including 4 sessions lasting 30 to 60 minutes were undertaken as a means of comprehending and confirming participants' descriptions of their work processes and any issues they thought relevant. Regular notes were taken of all observations and interviews and compiled in a researcher's log with memos noting reflections on the investigation process. The researcher's log provided an audit trail of the study, documenting decisions and recording issues for follow-up.

All participants were provided with a letter outlining the study, its voluntary nature, and the confidentiality of all findings and participants. The research was approved by the Area Health Service Research Ethics Committee.

Telephone Communication Logs

Blood bank staff kept their own departmental log of telephone calls received during a 1-week period from May 5-11, 2005. The log recorded the time a call was received, the originating ward or location, and the reason for the call. The log did not record "hang-ups" (instances where calls were not answered by blood bank staff). Reasons for calls were categorized by blood bank staff as follows:

1. Wards telephone to order blood/platelets or fresh frozen plasma (FFP).

2. Wards telephone to enquire about the availability of blood product or validity of crossmatch.

3. Wards telephone and ask for a fresh blood product to be dispensed through the hospital Lamson pneumatic air tube (Lamson Engineering, Regents Park NSW, Australia).

4. Wards telephone and ask for a derivative plasma product (eg, albumin) to be dispensed.

5. Wards telephone to confirm receipt of product.

6. Other enquiries.

7. Other phone calls (eg, personal).

The total number of phone calls logged for the 1 week (n = 199) was compared against the total number of calls reported by the hospital communication data logs for the equivalent month (n = 1841; average, 59 per day). Using these figures, we estimated that the phone log sample represented 48% of all calls received.

Data Analysis

NVivo 2.0 software (QSR International Pty Ltd, Doncaster, Australia) was used to assist in the analysis of qualitative data. A grounded theory approach was applied to identify emergent themes using participants' own words. Themes were then reported and discussed with a senior hospital scientist who not only provided a valuable feedback mechanism to enhance the validity of the findings but also participated in the discovery and assessment of the emerging themes.9 Microsoft Excel (Microsoft Corporation, Redmond, Washington) was used to analyze the telephone log data.

RESULTS

Analysis of the qualitative data provided 5 key and recurring considerations relevant to the introduction of CPOE in a blood bank: (1) the role of the blood bank; (2) work processes involved in the blood bank; (3) blood bank interaction with clinical staff; (4) information management in the blood bank; and (5) the impact of electronic ordering.

The Role of the Blood Bank

Participants explained the role of the blood bank as providing compatible blood components for patients, along with a range of tests including blood grouping, antibody screening and identification, and pretransfusion testing. The blood bank dispenses products provided by the Red Cross Blood Transfusion Service collected from blood donors. It uses laboratory testing procedures to ensure that the correct product is safely provided to clinicians and dispensed to the patient. The difference between the blood bank and other pathology departments was described in the following way by the Blood Bank Focus Group on September 1, 2005: "We in the Blood Bank are putting out a result, as every other pathology lab does, but we're also dispensing a product.... [This means] we are interacting at a different level with the clinical areas."

Work Processes Involved in the Blood Bank

The department performs thousands of tests for blood groups and antibody screens in a month. Participants explained that although the blood group test is a fairly simple and straightforward test its accuracy is of critical importance. The overwhelming majority (around 98%) of antibody screens performed by the blood bank will not detect any antibodies. This allows the blood bank to dispense standard products to most people. But for the small percentage of people who do have an antibody, further (often time-consuming and demanding) testing is required to identify the antibody and to provide a red cell product that is not going to be destroyed by the patient's immune system. As a focus group participant explained, "If you look at it simplistically, all we have to do is to do a blood group and an antibody screen and provide product. That's over simplifying it to the max, but in order for us to do that [safely] we've got very, very complicated work processes involved ... to try and account for all possible scenarios where things may go wrong." [Blood Bank Focus Group, September 1, 2005]

Blood Bank Interaction With Clinical Staff

The blood bank process begins with a prescription from a doctor for a blood product, which is communicated to the blood bank either by a transfusion request form, telephone call, or facsimile. Any additional work required is then performed by the blood bank and the product is made available. The blood bank will usually await further communication from the ward asking for the product to be sent. This process relies on telephone communication: "All our work mostly depends on phone calls." [Blood Bank Focus Group, September 1, 2005]

"Traditionally, in smaller labs, ward staff will come down to pick up the blood that's being issued. Here we rely on a Lamson pneumatic tube system to distribute blood around the hospital. Rather than dealing with one issue on one occasion we have to receive a phone call requesting the issue. We then have to go and prepare the blood product for issue in the Lamson system. We send the product and then we expect a phone call back from the ward to say that they've received the product, in case it has gone elsewhere. If we don't get that phone call we've got to contact them and chase them up. It can be very time consuming as well." [Blood Bank Focus Group, September 1, 2005]

The Figure provides an illustration of the type of phone calls received and logged by blood bank staff during a 1-week period between May 5 and May 11, 2005. The total number of calls logged was 199. Most calls involved requests to send blood products (n = 42), order blood products (n = 41), or enquiries about availability (n = 37) and other matters (n = 36).

Participants in the study confirmed that the blood bank communication process is heavily reliant on the timely exchange and confirmation of information between clinical staff in the wards and the blood bank. Senior blood bank staff explained that this process was so important to the blood bank process that electronic ordering of blood and blood products was not expected to proceed until there was confidence that the new CPOE system was able to safely replicate (indeed improve on) existing levels of communication. In the course of this study, the blood bank had also decided to accept only written requests (which could be faxed) for the issue of blood and blood products, as a means of ensuring a reliable audit trail in the dispensing process.

Information Management in the Blood Bank

The blood bank has a responsibility to account for all the blood products that are provided to it by the Red Cross. Participants described this task as particularly important, not only to guard the integrity of the blood product and protect against potential contamination of the patient but also to maintain strict inventory management and control of products. This task is a good example of the context within which the blood bank operates. It was described by one participant in this way:

"... historically, personnel in the blood bank labs have always been very meticulous and very careful and pedantic, I suppose, about rules and regulations, etc. But as we've got larger and larger, it has just been impossible to keep that level of detail in the checking. We've had to accept that people make mistakes and we try to [engineer out] mistakes by utilizing technology and equipment." [Blood Bank Focus Group, September 1, 2005]

Impact of Electronic Ordering

Participants outlined areas where they expected that electronic ordering would affect the blood bank. The most likely change expected to occur was a reduction in the number of telephone calls from clinicians ordering or enquiring about blood products. Participants also thought that electronic ordering could improve monitoring processes by providing a better overview of the blood bank workload, particularly what orders were pending, completed, etc. These changes, in turn, were expected to improve laboratory efficiency.

The other area of impact was in the area of accuracy and accountability, which many thought had obvious ramifications for the quality of service delivered. As one participant explained:

"The accuracy thing is important, because sometimes we've had situations where our blood product will be received, or even transfused up in the ward, and the person who called for the products.... They'll say, 'I said I wanted [a particular product] ...' and the person who took the phone calls will say, 'no, she said [she] wanted this' and you've only got one word against the other, whereas if it's ordered electronically, then we and everyone can see, well this person ordered that. If the wrong products are issued, then at least they know it's our fault because we issued the wrong product. It is in black and white what was ordered."

[Blood Bank Focus Group, September 1, 2005]

COMMENT

The results from this study show that work practices in the blood bank are made up of a complex mosaic of processes involving multidisciplinary collaboration between hematologists, laboratory scientists, technical officers, doctors, and nurses who all form a part of an interrelated system of patient care. This finding reinforces that of other researchers in this field who have described the multilayered and collaborative character of the ordering process (11) and have strongly recommended that new information systems be designed to facilitate these collaborative relationships and be supported by negotiation between different hospital departments. (12) Three areas are highlighted where CPOE's role can affect (either positively or negatively) the blood bank's contribution to the safety and effectiveness of patient care. These are (1) information storage and retrieval; (2) robust communication channels; and (3) safety and quality of patient care.

Information Storage and Retrieval

The communication relationship between clinical staff on the wards and blood bank staff, as revealed in the formal pattern of message exchange between the two, is designed to enhance patient safety. It starts with the preparation of the product and then proceeds to the timely dispatch and receipt of the blood product. In addition to these tasks, the blood bank has vital patient record and material management functions. (13) This includes maintaining (1) antibody files that document reactions that patients have experienced in the course of previous testing and (2) long-term records of patients with hematologic disorders and who can have special requirements. One of the features of CPOE systems is their ability to link to databases containing specific clinical information and error-prevention software. This has obvious advantages for the blood bank and its information-intense role. However, the ability to provide information does not necessarily guarantee that it will be effectively accessed. Badly designed interfaces (eg, fragmented information screens that do not provide an overview) can lead to misinterpretation and have adverse effects on patient care. (14)

Robust Communication Channels

The collaborative effort between staff in the blood bank and the wards relies very heavily on an information infrastructure that allows hospital personnel to discuss and decide upon the best application of care. (15) At present, the telephone plays a major role in this exchange, as shown in the telephone call sample recorded in the Figure. This form of communication can be described as a synchronous channel because the exchange occurs at the same time. The changeover from a synchronous exchange to an asynchronous one (where a message is posted on the system) represents an important change in the ordering process. The advantage of this procedure is that blood bank staff and clinicians are likely to spend less time on the phone "chasing up" orders. But for this exchange to work, it requires a confirmation that the message has been received and that there is a corresponding level of trust in the information. As in the example of the pneumatic tube system, the failure to acknowledge receipt of a product may introduce an added task, that of chasing after the ward for confirmation that the product has been received.

Safety and Quality of Patient Care

The findings also highlight the key safety and quality considerations that underpin the blood bank ordering process. The blood bank, in collaboration with clinical staff, has a responsibility to ensure that patient details and specimens are correctly labeled, to avoid the possibility of patient identification error. This has implications for the integrity of the product and the efficiency with which the product is dispatched. This, in turn, has major consequences for patient care, particularly if the dispatch of blood products is not carried out promptly and efficiently. It is critical, therefore, that the implementation of new computer applications into blood bank settings is carried out in line with the existing skills and work of both laboratory and clinical professionals. (5) Without this attention to work processes and relationships, there is the possibility that "workarounds" will be introduced, forcing staff to undertake ways of achieving things that the system does not readily allow to happen.

Limitations of This Study

The generalization of these findings to other settings is limited by the size of the sample and the circumstances that may be peculiar to the study site. Nevertheless, we believe it is important to undertake such case studies to identify a number of key laboratory processes that other blood banks and pathology laboratories are also likely to confront.

CONCLUSION

The maintenance and enhancement of effective communication channels between the blood bank staff and ward-based clinical staff, along with rigorous monitoring procedures, are essential for the safe and effective implementation of electronic ordering systems. New electronic ordering systems need to (1) facilitate timely communication between the blood bank and ward staff; (2) cater to the information management tasks involved in the blood bank; and (3) optimize the safety and quality components of the blood bank process. These factors are important to the design and functioning of these systems. They can also contribute to ensuring high levels of staff support and preparedness in the face of changes that may be disruptive and difficult.

This study is part of an Australian Research Council Linkage Grant-funded project to evaluate the impact of information and communication technologies on organizational processes and outcomes. It was carried out in partnership with the New South Wales Health Department. We would also like to acknowledge the cooperation of blood bank staff in this study.

References

(1.) The Royal College of Pathologists. Pathology: the hidden science that saves lives. http://www.rcpath.org/index.asp?PageID = 603. Accessed January 27, 2006.

(2.) Report of the review of NHS pathology services in England. Review of NHS Pathology Services in England. http://www.dh.gov.uk. Accessed August 10, 2006.

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(4.) Mekhjian HS, Kumar RR, Kuehn L, et al. Immediate benefits realized following implementation of physician order entry at an academic medical center. J Am Med Inform Assoc. 2002;9(5):529-539.

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(7.) Georgiou A, Williamson M, Westbrook J, Ray S. The impact of computerised physician order entry systems on pathology services: a systematic review. Int J Med Inform. 2007;76(7):514-529.

(8.) Scriven M. Evaluation Thesaurus. 4th ed. Newbury Park, CA: SAGE Publications; 1991.

(9.) Guba E, Lincoln Y. Fourth Generation Evaluation. Newbury Park, CA: SAGE Publications; 1989.

(10.) Bowling A. Research Methods in Health. Buckingham, United Kingdom: Open University Press; 1997.

(11.) Gorman PN, Lavelle MB, Ash JS. Order creation and communication in healthcare. Methods Inf Med. 2003;42(4):376-384.

(12.) Davidson EJ, Chismar W. Examining the organizational implications of IT use in hospital-based health care: a case study of computerized order entry. In: Proceedings from the 32nd Hawaii International Conference on System Sciences; January 5-8, 1999. Maui, Hawaii.

(13.) Hardwick DF, Morrison JI. Directing the Clinical Laboratory. New York, NY: Field & Wood; 1990.

(14.) Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203.

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Andrew Georgiou, MSc; Tony Greenfield, MHA; Joanne Callen, PhD; Johanna I. Westbrook, PhD
Number and type of calls received by the
blood bank between May 5-11, 2005 (n = 199).
FFP indicates fresh frozen plasma.

Send Blood/Platelets/FFP               20%(42)
Send Batch Product                     10%(20)
Confirm Lamson Receipt                  6%(12)
Product Order Blood/Platelets/FFP      21%(41)
Enquiry Only Availability              19%(37)
Enquiry Other                          18%(36)
Personal Calls                          6%(42)

Note: Table made from pie chart.
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