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

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

Coincidence of length spectra does not imply isospectrality

Penrose--Lifshits mushrooms are planar domains coming in nonisometric pairs with the same geodesic length spectrum. Recently S. Zelditch raised the question whether such billiards also have the same eigenvalue spectrum for the Dirichlet Laplacian (conjecturing ``no''). Here we show that generically (in the class of smooth domains) the two members of a mushroom pair have different spectra.Comment: 8 pages, 5 figure

Time dependence of Bragg forward scattering and self-seeding of hard x-ray free-electron lasers

Free-electron lasers (FELs) can now generate temporally short, high power x-ray pulses of unprecedented brightness, even though their longitudinal coherence is relatively poor. The longitudinal coherence can be potentially improved by employing narrow bandwidth x-ray crystal optics, in which case one must also understand how the crystal affects the field profile in time and space. We frame the dynamical theory of x-ray diffraction as a set of coupled waves in order to derive analytic expressions for the spatiotemporal response of Bragg scattering from temporally short incident pulses. We compute the profiles of both the reflected and forward scattered x-ray pulses, showing that the time delay of the wave $\tau$ is linked to its transverse spatial shift $\Delta x$ through the simple relationship $\Delta x = c\tau \cot\theta$, where $\theta$ is the grazing angle of incidence to the diffracting planes. Finally, we apply our findings to obtain an analytic description of Bragg forward scattering relevant to monochromatically seed hard x-ray FELs.Comment: 11 pages, 6 figure

Medical information prior to invasive medical procedures in otorhinolaryngology–head and neck surgery in France

SummaryBased on a review of the medical literature (PubMed database, keywords: medical information, informed consent), the authors analyse the main medicolegal aspects concerning the patient information that must be provided in France prior to any invasive diagnostic or therapeutic medical procedures in otorhinolaryngology head and neck surgery, as well as the patient's perception and recall of the information provided, the quality of the information provided and problems encountered in providing this information. In the light of this review, several solutions are recommended to improve this essential phase prior to obtaining the patient's informed consent

Black holes, cosmological singularities and change of signature

There exists a widespread belief that signature type change could be used to avoid spacetime singularities. We show that signature change cannot be utilised to this end unless the Einstein equation is abandoned at the suface of signature type change. We also discuss how to solve the initial value problem and show to which extent smooth and discontinuous signature changing solutions are equivalent.Comment: 14pages, Latex, no figur

Two-Dimensional Hydrodynamic Simulations of Convection in Radiation-Dominated Accretion Disks

The standard equilibrium for radiation-dominated accretion disks has long been known to be viscously, thermally, and convectively unstable, but the nonlinear development of these instabilities---hence the actual state of such disks---has not yet been identified. By performing local two-dimensional hydrodynamic simulations of disks, we demonstrate that convective motions can release heat sufficiently rapidly as to substantially alter the vertical structure of the disk. If the dissipation rate within a vertical column is proportional to its mass, the disk settles into a new configuration thinner by a factor of two than the standard radiation-supported equilibrium. If, on the other hand, the vertically-integrated dissipation rate is proportional to the vertically-integrated total pressure, the disk is subject to the well-known thermal instability. Convection, however, biases the development of this instability toward collapse. The end result of such a collapse is a gas pressure-dominated equilibrium at the original column density.Comment: 10 pages, 7 figures, accepted for publication in ApJ. Please send comments to [email protected]

Steep sharp-crested gravity waves on deep water

A new type of steady steep two-dimensional irrotational symmetric periodic gravity waves on inviscid incompressible fluid of infinite depth is revealed. We demonstrate that these waves have sharper crests in comparison with the Stokes waves of the same wavelength and steepness. The speed of a fluid particle at the crest of new waves is greater than their phase speed.Comment: 4 pages, 2 figures, submitted to Phys. Rev. Let

Initial Data for General Relativity with Toroidal Conformal Symmetry

A new class of time-symmetric solutions to the initial value constraints of vacuum General Relativity is introduced. These data are globally regular, asymptotically flat (with possibly several asymptotic ends) and in general have no isometries, but a $U(1)\times U(1)$ group of conformal isometries. After decomposing the Lichnerowicz conformal factor in a double Fourier series on the group orbits, the solutions are given in terms of a countable family of uncoupled ODEs on the orbit space.Comment: REVTEX, 9 pages, ESI Preprint 12

Laplacian Growth, Elliptic Growth, and Singularities of the Schwarz Potential

The Schwarz function has played an elegant role in understanding and in generating new examples of exact solutions to the Laplacian growth (or "Hele- Shaw") problem in the plane. The guiding principle in this connection is the fact that "non-physical" singularities in the "oil domain" of the Schwarz function are stationary, and the "physical" singularities obey simple dynamics. We give an elementary proof that the same holds in any number of dimensions for the Schwarz potential, introduced by D. Khavinson and H. S. Shapiro [17] (1989). A generalization is also given for the so-called "elliptic growth" problem by defining a generalized Schwarz potential. New exact solutions are constructed, and we solve inverse problems of describing the driving singularities of a given flow. We demonstrate, by example, how \mathbb{C}^n - techniques can be used to locate the singularity set of the Schwarz potential. One of our methods is to prolong available local extension theorems by constructing "globalizing families". We make three conjectures in potential theory relating to our investigation