An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

Decision Support Systems

Decision support systems (DSS) have evolved over the past four decades from theoretical concepts into real world computerized applications. DSS architecture contains three key components: knowledge base, computerized model, and user interface. DSS simulate cognitive decision-making functions of humans based on artificial intelligence methodologies (including expert systems, data mining, machine learning, connectionism, logistical reasoning, etc.) in order to perform decision support functions. The applications of DSS cover many domains, ranging from aviation monitoring, transportation safety, clinical diagnosis, weather forecast, business management to internet search strategy. By combining knowledge bases with inference rules, DSS are able to provide suggestions to end users to improve decisions and outcomes. This book is written as a textbook so that it can be used in formal courses examining decision support systems. It may be used by both undergraduate and graduate students from diverse computer-related fields. It will also be of value to established professionals as a text for self-study or for reference

Electronic Falls Reporting System Implementation: Evaluating Data Collection Methods and Studying User Acceptance

In this research, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a long-term residential care facility (LTRCF) using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: 1) System-level benefits and costs, 2) System usability, via scenario-based use cases, 3) A holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and 4) User technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder. The electronic falls reporting system was successfully implemented, with 100% electronic submission rate at 3-months post-implementation period. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to Health IT (Information Technology) implementations in other LTRCFs

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

An investigation of labour ward care to inform the design of a computerised decision support system for the management of childbirth

Merged with duplicate record 10026.1/622 on 03.04.2017 by CS (TIS)Patient monitoring is a complex task, particularly during childbirth, where assessment of the baby's condition is inferred from the continuous electronic recording of the baby's heart rate pattern and maternal uterine contractions (CTG). Computerised decision support has long been advocated, as difficulties in the interpretation of the CTG have led to failure to intervene and unnecessary intervention. The problem is large, for obstetric litigation now accounts for 80% of the UK National Health Service litigation bill. The Plymouth Perinatal Research Group has developed a computerised decision support system for patient monitoring during childbirth and the UK Medical Research Council has agreed to fund a multicentre randomised trial. The work of this thesis was an investigation of the labour ward care system to inform the human-centred design of the decision support system for patient monitoring in childbirth, prior to the clinical trial. It was recognised that many decision support systems have failed to gain clinical acceptance, as conventional design models were inadequate. Lack of attention to the organisational context of the care system and the process of the direct patient care led to the design of inflexible 'expert' systems, which constrained working practices. A pilot ethnographic study of an existing decision support system, used for the analysis of umbilical cord blood samples, was undertaken to clarify the research approach required for the main study. It was found that barriers to effective use within the wider work system included inadequate implementation and lack of organisational support. A case study approach produced a more comprehensive account of the context and process of the use of the computer system. The main study combined qualitative with quantitative techniques to investigate the system of care in childbirth, both outside and within the delivery room, to provide a unique, holistic perspective. The organisational context of the labour ward was investigated by direct observation of clinicians over the course of their work for 220 hours. Observations were documented and transcribed to computer text files. Patterns of actions and events were coded using ATLAS(ti) data analysis software. The codes were counted and tabulated to model the main features of this labour ward care system, which was expressed in the form of a rich picture diagram. These findings were confirmed by a limited study of five other UK labour wards. The core qualitative categories, derived from the observation data, found a complex and problematic relationship between communication, decision making and accountability. Decisions were often made outside the delivery room and were subject to misinterpretation and bias. The organisational hierarchy made it difficult for junior staff to question clinical management decisions. A system of tacit practice, external demands upon clinicians and transient allocation of junior midwives to labour ward militated against teamwork. This increased the vulnerability of the care of mothers to error. The process of direct patient care, within the individual delivery room, of 20 mothers in labour was captured in a novel audio-video observation study. The 111 hours of first stage labour and 12 hours of second stage labour were recorded and digitised to computer files. Recurrent actions and patterns of behaviour were coded both quantitatively and qualitatively using ATLAS(ti) data analysis software. Midwives left the room on average every 15 minutes to be absent for 27% of the first stage of labour. Record keeping occurred on average every 10 minutes and accounted for 19% of midwives' time. Midwives had little time to talk with mothers and only sat down at the bedside for 15% of the time. Psychosocial support was not given priority. Parents were generally excluded from communication between clinicians yet 108 clinicians took part in the care of the 20 women. Pressures from medicolegal directives and task-orientated imperatives overshadowed meaningful interaction with parents and caused spurious care priorities. This work has revealed the need for a critical reassessment of the type of support that is required for monitoring situations in all areas of medicine. A range of functions, such as shared information displays and models, have been suggested to augment roles and relationships between clinicians and parents to support patient-centred care. The present work has revealed that a combination of computer-based technology and changes to working practice can support the parents, their individual carers and their various roles. In this way the system of care can be more aligned to the objective of a safe and emotionally satisfying birth experience for parents and staff. A further programme of research is required to follow-up the existing studies, develop these new forms of interaction between technology and clinicians, and evaluate their effectiveness. The research methods employed in the present work will provide a more comprehensive evaluation of the decision support system in the forthcoming multicentre trial. The methods of investigation have also been shown to be of relevance to patient safety research, service delivery and training.Plymouth Perinatal Research Group Postgraduate Medical Schoo