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

Can Utilizing a Computerized Provider Order Entry (CPOE) System Prevent Hospital Medical Errors and Adverse Drug Events?

Computerized provider order entry (CPOE) systems allow physicians to prescribe patient services electronically. In hospitals, CPOE essentially eliminates the need for handwritten paper orders and achieves cost savings through increased efficiency. The purpose of this research study was to examine the benefits of and barriers to CPOE adoption in hospitals to determine the effects on medical errors and adverse drug events (ADEs) and examine cost and savings associated with the implementation of this newly mandated technology. This study followed a methodology using the basic principles of a systematic review and referenced 50 sources. CPOE systems in hospitals were found to be capable of reducing medical errors and ADEs, especially when CPOE systems are bundled with clinical decision support systems designed to alert physicians and other healthcare providers of pending lab or medical errors. However, CPOE systems face major barriers associated with adoption in a hospital system, mainly high implementation costs and physicians’ resistance to change

체계적 문헌고찰과 메타분석을 통한 전산처방자동화시스템과 관련된 처방오류 평가 연구

학위논문 (석사) -- 서울대학교 대학원 : 약학대학 약학과, 2020. 8. 김은경.Computerized Physician Order Entry (CPOE) systems and Clinical Decision Support Systems (CDSS) have been proven to contribute to improve patients safety and quality of care; however, the adoption of computerization introduced a new type of error, called system-related or technology-induced errors. A comprehensive evaluation regarding the prevalence of CPOE-related errors (CRE) is lacking. The aim of this study was to describe the prevalence of CRE evaluated by pharmacists and to evaluate the association between the introduction of CPOE and prescribing errors. A systematic review and meta-analysis were conducted of studies retrieved from the MEDLINE, Embase, Cochrane, and Scopus up to March 2020. All studies reporting the rate of prescribing errors related to CPOE were included. The prevalence of CRE among overall prescribing errors occurred in the hospitals was estimated using pooled prevalence estimate with a 95% confidence interval (CI) and relative risk (RR) was calculated for the subgroup analysis. A total of 14 studies were identified and included in the systematic review and meta-analysis. In the meta-analysis of 13 data of estimate, the overall pooled prevalence of CRE across studies were 32.36% (95% CI 22.87 – 42.62). Among the 6 types of error identified throughout the studies: omission, wrong drug, wrong dose, wrong route/form, wrong time, and monitoring error, the main type of error related to CPOE were wrong dose (47.28%, 95% CI 38.38-56.26), followed by wrong drug (14.45%, 95% CI 7.96-22.40). The subgroup analysis revealed that the risk of error was not significantly reduced with CPOE (RR 0.842, 95% CI 0.559 – 1.268), except omission which was significantly reduced after the implementation of CPOE (RR 0.484, 95% CI 0.282 – 0.831). Our study findings support that system-related errors were a major reason for CPOE not delivering a significant reduction in the overall rate of clinical errors. A considerable risk for prescribing errors still exists, which healthcare professionals should be aware that CPOE could also lead to a new type of medication errors. In order to reduce the prescribing error related to CPOE, the system should be continually examined and users should receive periodic and multidisciplinary training on the use of CPOE and CDSS.처방자동화시스템(Computerized Physician Order Entry, CPOE)과 임상의사결정지원시스템(Clinical Decision Support System)의 활성화로 전체적인 처방오류의 비율은 감소하였지만, CPOE와 같은 새로운 시스템으로 인하여 새로운 오류가 출현되었다. 본 연구는 원내 CPOE와 관련된 약물 처방오류 중 약사가 평가한 처방오류의 발생률과 CPOE 도입 전후 오류유형의 변화를 파악하고자 선행연구들을 대상으로 체계적 문헌고찰과 메타분석을 수행하였다. PubMed, EMBASE, Cochrane Register of Controlled Trials, Scopus에서 2020년 3월까지 검색되는 문헌 중 CPOE 도입 후 발생한 처방오류에 해당하는 문헌을 추출하였고 선정 및 제외기준에 따라 총 14개의 최종 문헌을 선정하였다. 처방오류의 합동 발생률 수치와 CPOE 도입 전과 후 유형 별 처방오류 발생의 상대 위험도 및 95% 신뢰 구간은 랜덤 효과 모델을 적용하여 제시하였다. CPOE 도입 후 전체 처방오류 중 CPOE로 인한 처방오류의 발생률 추정치 범위는 12.78%에서 58.54% 사이였고 랜덤 효과 모델에서 계산된 합동 발생률은 32.36%였다 (95% 신뢰 구간 22.87-42.62). National Coordinating Council for Medication Error Reporting and Prevention 분류체계에 기반하여 문헌에서 추출 가능한 처방오류의 유형을 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 투여 시간 오류, 약물 모니터링과 같이 총 6개 유형으로 분류하였을 때, 용량오류가 47.28% (95% 신뢰 구간 38.38-56.26)로 가장 높았고 그 다음은 약물 오류가 14.45% (95% 신뢰 구간 7.96-22.40)으로 높았다. CPOE 도입 전과 후의 처방오류 유형별 발생을 비교하기 위하여 하위그룹 메타 분석을 하였을 때, CPOE 도입 후 전체적인 처방오류의 발생률은 CPOE 도입 전에 비해 통계적으로 유의하게 증가하지 않았으나 (Relative risk, RR 0.842, 95% 신뢰 구간 0.559-1.168), 6개 처방오류 유형 중 메타분석이 가능한 5개 오류 유형 중 (처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링) 처방 누락오류만 CPOE 도입 후 유의하게 줄어들었다 (RR 0.484, 95% 신뢰 구간 0.282-0.831). 체계적 문헌고찰 및 메타분석을 통해 새로운 기술인 CPOE 도입 후 CPOE와 관련된 처방오류가 전체 처방오류 중 1/3의 빈도로 발생하는 것으로 파악되었다. 처방오류의 유형 중 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링의 오류의 발생 비율은 CPOE 도입 전과 후에 유의한 변화를 보이지 않았으나, 처방 누락의 비율은 CPOE 도입 후에 낮아진 것으로 나타났다. 약물처방의 전자화와 처방 지원 시스템과 같은 새로운 기술의 도입으로 단순 실수로 인한 처방오류는 방지되었으나 다양한 처방오류가 지속해서 발생함으로 환자의 안전을 위한 시스템 사용자의 지속적인 교육과 시스템의 기술적 개선으로 처방오류의 예방, 감지, 및 모니터링의 노력이 필요하다.1. Introduction 1 2. Methods 3 3. Results 8 4. Discussion 25 5. Conclusion 31 References 32 Appendix 40 요약 (국문초록) 48Maste

Improving Computerized Provider Order Entry Usage in a Community Hospital

The healthcare industry is now faced with the balance between instituting computerized technology and providing safe, high quality, efficient, and lower cost patient care. An important aspect of computer technology is the direct entry of orders electronically by providers into the electronic health record, termed computerized provider order entry (CPOE). This translational research project begins by defining CPOE and discussing CPOE’s effect on patient safety and quality of care by reducing preventable medical errors and adverse drug events and CPOE’s effect on healthcare costs. Regulatory requirements pertaining to CPOE are discussed; providers are expected to be proficient in CPOE in order to meet these requirements. A literature review of barriers to CPOE usage, interventions to implement and improve usage of CPOE, and trends in CPOE usage is conducted and discussed. The purpose of this quality improvement project was to improve CPOE medication order usage among providers within a community hospital by utilizing the provider order entry user satisfaction and usage survey (POEUSUS) to identify barriers to the utilization of CPOE and by employing the technology acceptance model (TAM) and the provision of a CPOE facilitator on the patient care units for twelve hours per week for eight weeks. At the conclusion of the eight-week intervention, the CPOE utilization rates were determined and followed over an eight week interval and were compared to pre-intervention rates. Additionally, providers’ rated their satisfaction of the CPOE facilitator by completing a facilitator survey after each assistance session. The results of this project demonstrated an increase in CPOE medication order usage, from 45.4% CPOE medication order usage during the eight-week pre-intervention period to 55.6% CPOE medication order usage during the eight-week post-intervention period. A statistically significant improvement in provider CPOE satisfaction occurred after the intervention, and providers expressed high degrees of satisfaction with the real-time assistance of the CPOE facilitator. Aspects of CPOE admired by providers and recommendations of providers to changes in CPOE were determined. Finally, age was inversely related and previous computer experiment was positively related to CPOE medication order usage pre-intervention, meaning that younger providers and providers with more computer experience used CPOE more often

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems

Importance: The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. Objective: To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. Design, Setting, and Participants: This quality improvement study used usability tests requiring internal medicine physicians, residents, and physician assistants to enter prescriptions electronically, including indication, for 8 clinical scenarios. The tool order assignments were randomized and prescribers were asked to use the prototype for 4 of the scenarios and their usual system for the other 4. Time on task, number of clicks, and order details were captured. User satisfaction was measured using posttask ratings and a validated system usability scale. The study participants practiced in 2 health systems\u27 outpatient practices. Usability tests were conducted between April and October of 2017. Main Outcomes and Measures: Usability (efficiency, error rate, and satisfaction) of indications-based computerized provider order entry prototype vs the electronic prescribing interface of 2 electronic health record vendors. Results: Thirty-two participants (17 attending physicians, 13 residents, and 2 physician assistants) used the prototype to complete 256 usability test scenarios. The mean (SD) time on task was 1.78 (1.17) minutes. For the 20 participants who used vendor 1\u27s system, it took a mean (SD) of 3.37 (1.90) minutes to complete a prescription, and for the 12 participants using vendor 2\u27s system, it took a mean (SD) of 2.93 (1.52) minutes. Across all scenarios, when comparing number of clicks, for those participants using the prototype and vendor 1, there was a statistically significant difference from the mean (SD) number of clicks needed (18.39 [12.62] vs 46.50 [27.29]; difference, 28.11; 95% CI, 21.47-34.75; P \u3c .001). For those using the prototype and vendor 2, there was also a statistically significant difference in number of clicks (20.10 [11.52] vs 38.25 [19.77]; difference, 18.14; 95% CI, 11.59-24.70; P \u3c .001). A blinded review of the order details revealed medication errors (eg, drug-allergy interactions) in 38 of 128 prescribing sessions using a vendor system vs 7 of 128 with the prototype. Conclusions and Relevance: Reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction

A Systematic Review Of The Types And Causes Of Prescribing Errors Generated From Using Computerized Provider Order Entry Systems in Primary and Secondary Care

Objective To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. Materials and Methods We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. Results A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users’ work processes, and clinical decision support systems. Displaying an incomplete list of a patient’s medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users’ misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. Discussion and Conclusions Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users’ workflow expectations

Refining Computerized Physician Order Entry Initiatives in an Adult Intensive Care Unit

Computerized physician order entry (CPOE) is used in healthcare organizations to improve workflow processes and transcription, as well as to prevent prescribing errors. Previous research has indicated challenges associated with CPOE for end-users that predispose patients to unsafe practices. Unsafe CPOE practices can be detrimental within the intensive care unit (ICU) setting due to the complexity of nursing care. Consequently, end-user satisfaction and understanding of CPOE and electronic health record (EHR) functionality are vital to avoid error omissions. CPOE initiatives should be refined post system implementation to improve clinical workflow, medication processes, and end-user satisfaction. The purpose of this quality improvement project was to refine CPOE system initiatives and develop an e-learning educational module to facilitate end-user understanding of and satisfaction with CPOE. The Iowa model of evidence-based practice, Lean methodology, and Provider Order Entry User Satisfaction and Usage Survey (POESUS) were used to guide the study. An e-learning module was implemented to increase staff understanding of the newly implemented CPOE system, and a plan was provided for ongoing data collection and investigation of end-user satisfaction and medication inadequacies with the CPOE system. A mixed-method design was recommended to key stakeholders to identify the impact of the e-learning course and refined CPOE initiatives on both end-user satisfaction and patient outcomes in the medical-surgical ICU. Findings from the study informed the impact of e-learning educational modules with CPOE system implementation. Those in organizations implementing advanced technology such as CPOE and EHR systems in critical care settings will find this paper of interest

A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting

Renny Varghese Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting (Under the direction of Russell Toal, Associate Professor) Electronic medical records (EMRs) have become recognized as an important tool for improving patient safety and quality of care. Decision support tools such as alerting functions for patient medication allergies are a key part of reducing the frequency of serious medication problems. Kaiser Permanente Georgia (KPGA) implemented its EMR system in the primary care departments at Kaiser\u27s twelve facilities in the greater metro Atlanta area over a six month period beginning in June 2005 and ending December 2005. The aim of this study is to analyze the impact of the EMR implementation on the number of drug allergy overrides within this large HMO outpatient setting. Research was conducted by comparing the rate of drug allergy overrides during pre and post EMR implementation. The timeline will be six months pre and post implementation. Observing the impact of the incidence rate of drug allergy alerts after the implementation provided insight into the effectiveness of EMRs in reducing contraindicated drug allergies. Results show that the incidence rate of drug allergy overrides per 1,000 filled prescriptions rose by a statistically significant 5.9% (ñ \u3e 0.0002; 95% CI [-1.531, -0.767]) following the implementation. Although results were unexpected, several factors are discussed as to the reason for the increase. Further research is recommended to explore trends in provider behavior, KPGA specific facilities and departments, and in other KP regions and non-KP healthcare settings. INDEX WORDS: electronic medical records, drug allergy overrides, patient safety, medication errors, decision support tools, outpatient setting, primary care, computerized provider order entr