e-Prescribing and Patient Safety: Results From a Mixed Method Study

Objective: To describe the perspectives of ambulatory care clinicians on the effect of electronic prescribing (e-prescribing) systems on patient safety outcomes. Study Design: Mixed method study of clinicians and staff in 64 practices using 1 of 6 e-prescribing technologies in 6 US states. Methods: We used clinician surveys (Web-based and paper) and focus groups to obtain the perspectives of clinicians on e-prescribing and patient safety. Results: Providers highly valued having medications prescribed by other providers on the medication list and the ability to access patient medication lists remotely. Providers thought that there will always be prescription or medication errors and that the implementation of e-prescribing software changes rather than eliminates prescription or medication errors. New errors related to the dosing or scheduling of a medication, accidentally prescribing the wrong drug, or duplicate prescriptions. Conclusions: Lessons from the ambulatory care trenches must be considered as technology moves forward so that the hypothesized patient safety gains will be realized

Usability flaws of medication-related alerting functions: A systematic qualitative review

AbstractIntroductionMedication-related alerting functions may include usability flaws that limit their optimal use. A first step on the way to preventing usability flaws is to understand the characteristics of these usability flaws. This systematic qualitative review aims to analyze the type of usability flaws found in medication-related alerting functions.MethodPapers were searched via PubMed, Scopus and Ergonomics Abstracts databases, along with references lists. Paper selection, data extraction and data analysis was performed by two to three Human Factors experts. Meaningful semantic units representing instances of usability flaws were the main data extracted. They were analyzed through qualitative methods: categorization following general usability heuristics and through an inductive process for the flaws specific to medication-related alerting functions.Main resultsFrom the 6380 papers initially identified, 26 met all eligibility criteria. The analysis of the papers identified a total of 168 instances of usability flaws that could be classified into 13 categories of usability flaws representing either violations of general usability principles (i.e. they could be found in any system, e.g. guidance and workload issues) or infractions specific to medication-related alerting functions. The latter refer to issues of low signal-to-noise ratio, incomplete content of alerts, transparency, presentation mode and timing, missing alert features, tasks and control distribution.Main conclusionThe list of 168 instances of usability flaws of medication-related alerting functions provides a source of knowledge for checking the usability of medication-related alerting functions during their design and evaluation process and ultimately constructs evidence-based usability design principles for these functions

Master of Science

thesisElectronic Health Record (EHR) adoption rates have been low in the United States. A key reason for this low adoption rate is poor EHR usability. Currently no standards exist for design, testing and monitoring the usability of EHRs. Therefore, we conducted a usability evaluation of a vendor's product in the Emergency Department at the University of Utah. In the first objective of this study, we evaluated a newly implemented computerized provider order entry application. Four usability experts used the Zhang et al 14 heuristics and 23 predefined tasks to perform the evaluation. The experts found 48 usability problems categorized into 51 heuristic violations. There were 4 cosmetic, 120 minor, 64 major, and 4 catastrophic problems identified. The interrater reliability was 0.81 using Fleis' Kappa, showing a high level of consistency in ratings across evaluators. For the second objective, we used an electronic version of Questionnaire of User Interaction Satisfaction (QUIS 7.0) to evaluate physician satisfaction with the CPOE application in the ED. The physician response rate was 50% (25/50). The total survey mean was 4.87, lower than the -a priori‖ definition for acceptable satisfaction score of 5.0 (of a possible 9). The lowest scale scores were for overall user reaction and learning iv and the highest were for screen, terminology and system capabilities. Further analyses were completed to determine any differences for satisfaction scores between physician trainees and attending. A multifactor ANOVA was performed to examine the combined effect of the different experience levels and sections of the QUIS. The results were significant at -1.43 (p < 0.05) for screen and terminology and system capabilities. In this setting, the ED CPOE application had a high level of usability issues and low mean satisfaction scores among physician end-users. The responsibility for improved usability lies with both vendors developing the product and facilities implementing the product and both should be educated on usability principles. The combination of a user-based and expert-based inspection method yielded congruent findings and was an accurate and efficient means of evaluation

The organisational and communication implications of electronic ordering systems for hospital pathology services

Computerised Provider Order Entry (CPOE) systems provide clinicians with the ability to electronically enter hospital orders for laboratory tests and services. CPOE is able to integrate with hospital information systems and provide point of care decision support to users thereby making a potentially significant contribution to the efficiency and effectiveness of care delivery. The evidence of the impact of CPOE systems on pathology services is not extensive and insufficient attention has been paid to their effect on organisational and communication processes. This thesis aimed to investigate the implications of CPOE systems for pathology laboratories, their work processes and relationships with other hospital departments, using comparative examinations to identify the tasks they are involved in and the particular needs the laboratories expect to be filled by the new system. This longitudinal study of a CPOE system was carried out over three years using multiple cases from a hospital pathology service based at a large Sydney teaching hospital. Multi-methods using quantitative and qualitative data were employed to achieve triangulation of data, theory and methods. The findings provide evidence of a significant 14.3% reduction of laboratory turnaround times from 42 to 36 minutes when laboratory data for two months were compared before and after CPOE implementation. The findings also reveal changes in the pattern and organisation of information communication, highlighting transformations in the way that work is planned, negotiated and synchronised. These findings are drawn together in a comprehensive organisational communication framework that is highly relevant for developing a contingent and situational understanding of the impact of CPOE on pathology services

Retrospective descriptive assessment of clinical decision support medication-related alerts in two Saudi Arabian hospitals

OBJECTIVES: To determine the frequency of clinical decision support system (CDSS) medication-related alerts generated, accepted, or overridden, to assess appropriateness of alert display and overrides, and to characterise the documentation of clinician justification for these overrides in an academic medical centre in Saudi Arabia. MATERIALS AND METHODS: System-generated CDSS reports for the period June 2015 to December 2017 were retrospectively reviewed and analysed. Alerts were classified into different types, and rates of alert overrides calculated as percentages of all generated alerts. A subset of 307 overridden alerts was assessed for appropriateness of display and override by two clinical pharmacists. Physician documentation of reasons for overriding alerts were categorised. RESULTS: A total of 4,446,730 medication-related alerts were generated from both inpatient and outpatient settings, and 4,231,743 (95.2%) were overridden. The most common alert type was 'duplicate drug', accounting for 3,549,736 (79.8%) of alerts. Of 307 alerts assessed for appropriateness, 246 (80%) were judged to be appropriately displayed and 244 (79%) were overridden appropriately. New drug allergy and drug allergy alerts had the highest percentage of being judged as inappropriately overridden. For 1,594,313 alerts (37.7%), 'no overridden reason selected' was chosen from the drop-down menu. CONCLUSIONS: The alert generation and override rate were higher than reported previously in the literature. The small sample size of 307 alerts assessed for appropriateness of alert display and override is a potential limitation. Revision of the CDSS rules for alerts (focusing on specificity and relevance for the local context) is now recommended. Future research should prospectively assess providers' perspectives, and determine patient harm associated with overridden alerts

Electronic Prescribing In Children (EPIC): an evaluation of implementation at a children’s hospital.

Medication errors are common and can cause significant mortality and morbidity. Electronic prescribing (EP), with or without clinical decision support systems (CDSS), is a complex intervention that has been proposed as a solution. US studies indicate that there may be a reduction in medication errors as well as adverse events, but equally new errors may be introduced. There is a paucity of studies assessing the use and impact of EP in the UK hospital setting, especially those involving paediatric patients. The aim of this thesis was to investigate and evaluate the implementation of an EP system at a children's hospital in the UK. The objectives were to assess the effect on prescribing errors, to explore the level of CDSS available and in use within the system, to identify any changes in practice and workflow patterns of healthcare professionals, and to determine the views of patients and users. Mixed qualitative and quantitative methods were used within an evaluation framework (the Cornford framework). The results show an overall reduction in prescribing errors directly as a result of more complete and legible prescriptions after EP. Outpatient errors decreased from 1219/1574 (77.4%) to 33/648 (5.1%), a 72.3% reduction [95% confidence interval (CI) -74.6% to -69.3%]. The number of outpatient visits that were error free increased from 185/883 (21%) to 225/250 (90%), 95% Cl of difference in proportions, 64% to 73.4%. Inpatient errors decreased from 85/1267 (6.7%) to 96/ 2079 (4.6%), 95% CI of difference in proportions, -3.4% to -0.5% There was an increase in discharge prescription errors from 839/1098 (76.4%>) to 1777/2057 (86.4%), 95% CI of difference in proportions, 7.88% to 12.94%. The dosing error rate in all types of prescriptions was lower after EP: 88/3939 (2.2%) vs. 57/4784 (1.2%), 95% CI of difference in proportions, -1.6% to -0.5%, but there was no statistically significant change in severity ratings of dosing errors. New types of errors, such as selection errors, were seen due to EP. Although principles of the medicines use process remained the same, the practical approach to tasks was altered. The system was accepted by users and patients, but there was a desire for further improvements, especially in the level of clinical decision support available to the end user. In conclusion, the EP system was implemented successfully. The benefits in medication safety appear to be the results of effective interaction between system functionality and usability, user acceptance and organisational infrastructure

COMBINING HUMAN FACTORS AND DATA SCIENCE METHODS TO EVALUATE THE USE OF FREE TEXT COMMUNICATION ORDERS IN ELECTRONIC HEALTH RECORDS

Medication errors are a leading cause of death in the United States. Electronic Health Records (EHR) along with Computerized Provider Order Entry (CPOE) are considered promising ways to reduce these errors. However, EHR systems have not eliminated medication errors. Moreover, in some cases they have facilitated errors due to issues such as poor usability and negative effects on clinical workflows. The use of unexpected free text within a CPOE system can serve as a marker that the system does not adequately support clinical workflow. Prior studies have looked at the use of free text within medication orders, but the inclusion of medication related information in communication for non-medication orders (CNMOs), a type of free text order, has not been adequately studied. This mixed-methods study identified the prevalence, nature and reasons for the inclusion of medication related information in CNMOs using a large sample of CNMOs placed at a mid-Atlantic hospital system in 2017, and via interviews with physicians. The study found that more than 42% of CNMOs contain medication related information. Moreover, the use of CNMOs varied significantly across provider types, hospital locations, patient settings and other factors. The study found 10 themes that might cause providers to adopt such workarounds, including missing functionality and poor usability. The viii study also identified several general challenges in communicating medication information in the EHR, and potential solutions to mitigate these challenges. This dissertation also demonstrates how natural language processing could be used to identify medication related CNMOs

EVOLUTION OF INFORMATION TECHONOLOGY IN HEALTHCARE

The healthcare sector is growing rapidly and taking up a significant portion of the GDP in developed countries. The healthcare industry faces significant challenges such as ballooning costs, shortage of qualified personnel, rapidly aging population, and increase of chronic and epidemic diseases. Information technology (IT) has been suggested as a mitigator for some of these challenges. Particularly, IT can enable automation, management, and integration of clinical and business operations for greater efficiency and effectiveness. Studying the evolution of IT in healthcare is essential to be able to understand the past trends, address the current situation, move to the nest stage, and make use of IT to advance the future. However, although there is considerable literature on IT evolution, we observe a lack of studies specific to the evolution of healthcare IT. With the unique challenges of this sector, we attempt to address this gap in this paper. This study will start with a literature review on IT evolution and then develop a model for the evolution of healthcare IT based on the Nolan stage model and its subsequent refinements. The model will be developed with an initial focus on healthcare IT in Singapore. The reason for choosing Singapore is because of its advanced IT and medical infrastructure, yet the spending on healthcare is relatively low compared to other developed countries. In future, our model will be extended to other developed countries in the Asia-Pacific region e.g., Australia and New Zealand, as well as the UK and US