Download computerised prescriber order entry

National electronic Library for Medicines
Medicines Management Overview
March 2012
ELECTRONIC PRESCRIBING (COMPUTERISED PRESCRIBER ORDER
ENTRY)
Annotated bibliography of publications in 2011
Contents
Summary
1
Synopsis
2
Effect on outcomes
4
Summary
Papers on electronic prescribing (computerised
prescriber order entry) published in 2011 are
summarised below under a range of headings: effect
on outcomes; effect on medication errors and patient
safety; other evaluations; system design; alert
presentation; drug interaction processing; other
usability aspects; implementation; general and
miscellaneous.
Effect on medication
errors and patient safety
4
Other evaluations
17
System design
20
Alert presentation
21
Drug interaction
processing
25
Other usability aspects
28
Implementation
33
General/Miscellaneous
34
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Medicines Information
Service, Guy’s Hospital,
London SE1 9RT
Tel: 020 7188 5026
[email protected]
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1
Synopsis
Papers on electronic prescribing (computerised prescriber order entry)
published in 2011 are summarised below under a range of headings. Key
findings are as follows:
Effect on outcomes: An observational before and after study in the ICU of
hospital in Saudi Arabia found no difference in key indicators (mortality,
length of stay, use of mechanical ventilation) following the introduction of
e-prescribing in the unit.
Effect on medication errors and patient safety: Numerous studies were
published in 2011 in a range of healthcare settings. The general
conclusion seems to be that the introduction of e-prescribing is likely to
reduce some types of prescribing (and probably dispensing) errors,
particularly those associated with handwriting, legibility, transcription and
use of abbreviations. Evidence regarding more significant types of error is
equivocal, and some studies have found increased rates of certain types of
error associated with e-prescribing systems, particularly in the period
immediately following implementation. This is perhaps not surprising, as
non-procedural errors will depend not just on the use of an e-prescribing
system per se, but on the specific system used, the clinical decision
support provided (if any) and the arrangements for prioritising and
presenting alerts.
Other evaluations: Studies report the degree of satisfaction of doctors,
patients and pharmacists with e-prescribing systems. Training and
implementation issues appear to have an important bearing. A study in
Australia, comparing a number of commercial e-prescribing packages
against pre-defined criteria, found important differences between
systems.
System design: One paper considered the different features required in an
e-prescribing system for paediatric use from those required for adult
patients. In another study, integrating disease-specific order subsets into
a single general admission order set significantly improved the overall
adoption of order sets by clinicians.
Alert presentation: A common factor of studies of clinicians’ reaction to
alerts provided by e-prescribing systems is that a high proportion are
overridden. System design which avoids “alert fatigue” is thus important.
Drug interaction processing: Considerable differences exist in the way eprescribing systems present potential drug interactions, and in the
knowledge bases they use to identify them. Users appear to require a
system which will grade drug interaction alerts by their (potential)
severity, and make it more difficult to override the most serious alerts.
Other usability aspects: Usability problems appear to be frequent in eprescribing systems (although they do not always affect users’ declared
satisfaction). User-centred design is important. Poor usability is likely to
2
result in users developing “workarounds”, which will have an impact on
the integrity of data and potentially on patient safety.
Implementation: The papers listed describe implementation of eprescribing systems in various settings. It is preferable to involve users in
the design and implementation, and to provide adequate training for all
users.
General: Several papers considering the future of e-prescribing are listed.
It is noted that adoption has not been as rapid as expected in many
countries, and that e-prescribing is not yet a mature technology. If the
potential benefits of e-prescribing in terms of safety and efficiency are to
be realised, it is important that systems should be able to communicate
across the continuum of care. In practice, this happens to only a limited
extent so far.
3
E-prescribing – effects on outcomes
Impact of computerized physician order entry (CPOE) system
on the outcome of critically ill adult patients: a before-after
study
HM Al-Dorzi, HM Tamim, AJ Cherfan, MA Hassan, S Taher, YM Arabi
BMC Medical Informatics and Decision Making 19 Nov 2011;11:71
Background: Computerised physician order entry (CPOE) systems are
recommended to improve patient safety and outcomes. However, their
effectiveness has been questioned. Our objective was to evaluate the
impact of CPOE implementation on the outcome of critically ill patients.
Methods: This was an observational before-after study carried out in a 21bed medical and surgical intensive care unit (ICU) of a 900-bed tertiary
care centre (King Abdulaziz Medical City-Riyadh, Saudi Arabia). It
included all patients admitted to the ICU in the 24 months pre- and 12
months post-CPOE (Misys) implementation. Data were extracted from a
prospectively collected ICU database and included: demographics, Acute
Physiology and Chronic Health Evaluation (APACHE) II score, admission
diagnosis and comorbid conditions. Outcomes compared in different preand post-CPOE periods included: ICU and hospital mortality, duration of
mechanical ventilation and length of stay in ICU and hospital. These
outcomes were also compared in selected high risk subgroups of patients
(age 12-17 years, traumatic brain injury, admission diagnosis of sepsis
and admission APACHE II higher than 23). Multivariate analysis was used
to adjust for imbalances in baseline characteristics and selected clinically
relevant variables.
Results: There were 1638 and 898 patients admitted to the ICU in the
specified pre- and post-CPOE periods, respectively (age 52+/-22 vs 52+/21 years, p = 0.74; APACHE II 24+/-9 vs 24+/-10, p = 0.83). During
these periods, there were no differences in ICU (adjusted odds ratio (aOR)
0.98; 95% CI, 0.7 to 1.3) and in hospital mortality (aOR 1.00; 95% CI,
0.8 to 1.3). CPOE implementation was associated with similar duration of
mechanical ventilation and of stay in the ICU and hospital. There was no
increased mortality or stay in the high risk subgroups after CPOE
implementation.
Conclusions: The implementation of CPOE in an adult medical surgical ICU
resulted in no improvement in patient outcomes in the immediate phase
and up to 12 months after implementation.
http://www.biomedcentral.com/content/pdf/1472-6947-11-71.pdf
Effect on medication errors and patient safety
Impact and determinants of commercial computerized
prescriber order entry on the medication administration
process
I Abbass, S Mhatre, SS Sansgiry, J Tipton, C Frost
Hospital Pharmacy May 2011;46(5):341-348
Purpose: The purpose of this study was to evaluate the impact of
commercial computerised prescriber order entry (CPOE) on efficiency
outcomes in an 864-bed community hospital.
Methods: A retrospective study was developed to measure medication
errors and medication order turnaround time in St. Luke's Episcopal
Hospital located in the Texas Medical Center (USA). The study data were
collected by stratified random sampling through a review of medication
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orders submitted to the pharmacy using a paper-based order system and
the CPOE system. Descriptive frequencies, chi-squared test, Wilcoxon
matched-pairs sign rank test, and logistic regression and multiple
regression analyses were conducted to examine the relationship among
variables.
Results: Of the 1110 total orders reviewed (563 paper-based and 547
CPOE), a total of 135 medication errors were found, with 10.5% in paperbased versus 1.6% in CPOE. The most prevalent errors in paper-based
orders were inappropriate abbreviations (24.4%), incorrect doses
(15.6%), occurrences of allergy (13.3%) and wrong administration
frequency (9.6%). In CPOE orders, the errors were occurrences of allergy
(10.4%), incorrect doses (2.2%) and drug interaction (0.7%). CPOE
resulted in a 50% reduction of medication order turnaround time (median
= 24 minutes CPOE vs 48 minutes paper orders). A potential medication
error, unidentified prescribers within medication orders, urgency of
medication order, and implementation of CPOE were the significant (P less
than 0.05) determinants of medication order turnaround time.
Conclusions: The implementation of a commercial CPOE system reduced
medication errors and improved medication order turnaround times.
http://thomasland.metapress.com/content/3145223846r88632/?p=18b55db0a1e
94e7fb9835dc3c40ba0bb&pi=8
Electronic prescribing within an electronic health record
reduces ambulatory prescribing errors
EL Abramson, Y Barron, K Quaresimo, R Kaushal
Joint Commission Journal on Quality and Patient Safety Oct 2011;37(10):470478
Background: Health policy forces are promoting the adoption of
interoperable electronic health records (EHRs) with electronic prescribing
(e-prescribing). Despite the promise of EHRs with e-prescribing to
improve medication safety in ambulatory care settings - where most
prescribing occurs and where errors are common - few studies have
demonstrated its effectiveness. A study was conducted to assess the
effect of an e-prescribing system with clinical decision support, including
checks for drug allergies and drug-drug interactions, that was integrated
within an EHR on rates of ambulatory prescribing errors.
Methods: In a prospective study using a nonrandomised, pre-post design
with concurrent controls, 6 providers who used a commercial e-prescribing
system were compared with 15 providers who remained paper-based from
Sep 2005 to Jul 2008. Prescribing errors were identified by a standardised
prescription and chart review.
Results: Some 2432 paper prescriptions at baseline and 2079 prescriptions
at one year were analysed. Error rates for e-prescribing adopters
decreased 1.5-fold - from 26.0 errors per 100 prescriptions at baseline
(95% CI, 17.4 to 38.9) to 16.0 errors per 100 prescriptions at one year
(95% CI, 12.7 to 20.2; p = 0.09). Error rates remained unchanged for
nonadopters (37.3 per 100 prescriptions at baseline, 95% CI, 27.6-50.2,
versus 38.4 per 100 prescriptions at one year, 95% CI, 27.4 to 53.9; p =
0.54). Error rates for e-prescribing adopters were significantly lower than
for nonadopters at one year (p less than 0.001). Illegibility errors were
high at baseline and eliminated by e-prescribing.
Conclusions: The preliminary findings from this small group of providers
suggest that e-prescribing systems may decrease ambulatory prescribing
errors, which are occurring at high rates among community-based
providers.
5
http://www.ingentaconnect.com/content/jcaho/jcjqs/2011/00000037/00000010/
art00007
Transitioning between electronic health records: effects on
ambulatory prescribing safety
EL Abramson, S Malhotra, K Fischer, A Edwards, ER Pfoh, et al.
Journal of General Internal Medicine Aug 2011;26(8):868-874
Background: Healthcare providers in the USA who previously used older
electronic health records (EHRs) with electronic prescribing (e-prescribing)
are transitioning to newer systems to be eligible for federal meaningful use
incentives. Little is known about the safety effects of transitioning
between systems.
Objective: To assess the effect of transitioning between EHR systems on
rates and types of prescribing errors, as well as provider perceptions about
the effect on prescribing safety.
Design, Participants: Prospective, case study of 17 physicians at an
academic-affiliated ambulatory clinic from Feb 2008 to Aug 2009. All
physicians transitioned from an older EHR with minimal clinical decision
support (CDS) for e-prescribing to a newer EHR with more robust CDS.
Main Measurements: Prescribing errors were identified by standardised
prescription and chart review. A novel survey instrument was
administered to evaluate providers' perceptions about prescribing safety.
Results: We analysed 1298 prescriptions at baseline, 1331 prescriptions
at 12 weeks post-implementation, and 1303 prescriptions at 1 year postimplementation. Overall prescribing error rates were highest at baseline
(35.7 per 100 prescriptions; 95% CI, 23.2 to 54.8) and lowest 1 year
post-implementation (12.2 per 100 prescriptions; 95% CI, 8.6 to 17.4) (p
less than 0.001). Improvement in prescribing safety was mainly a result
of reducing inappropriate abbreviation errors. However, rates for nonabbreviation prescribing errors were significantly higher at 12 weeks postimplementation than at baseline (17.7 per 100 prescriptions; 95% CI, 9.5
to 33.0, vs 8.5 per 100 prescriptions; 95% CI, 4.6 to 15.9) (p less than
0.001) and no different at baseline from 1 year (10.2 per 100
prescriptions; 95% CI, 6.2 to 18.6) (p = 0.337). Survey results
complemented quantitative findings.
Conclusions: Results from this case study suggest that transitioning
between systems, even to those with more robust CDS, may pose
important safety threats. Recognising the challenges associated with
transitions and refining CDS within systems may help maximise safety
benefits.
http://www.springerlink.com/content/t5471w73527j4250/
Can new technologies reduce the rate of medication errors in
adult intensive care?
(Les nouvelles technologies permettent-elles de réduire les erreurs
médicamenteuses en soins intensifs adultes?)
E Benoit, J Beney
Journal de Pharmacie de Belgique Sep 2011;(3):82-91
Technology to control the monitoring and administration of critical drugs to
unstable patients is widespread in the intensive care environment. Since
the early 2000s computerised physician order entry (CPOE), bar code
assisted medication administration (BCMA), 'smart' infusion pumps (SIP),
electronic medication administration records (eMAR) and automated
dispensing systems (ADS) have been recommended to reduce medication
errors. Some 10 years later, the extent to which they have been
6
adopted is increasing but is still modest. The objective of this study is to
determine the impact of these technologies on the rate of medication
errors (ME) in adult intensive care. CPOE permits a marked and
significant reduction in ME, especially the least critical ones. Only by
adding a clinical decision support system (CDSS), can CPOE achieve a
reduction in serious errors. Used alone, it could even increase them. The
available studies do not have sufficient power to demonstrate the benefits
of SIP or BCMA on ME. However, practices such as overriding of alerts
have been demonstrated with these devices. Power or methodology
problems and conflicting results do not allow the ability of ADS to reduce
the incidence of ME in intensive care to be established. Studies
investigating such technologies are not very recent, are of limited number
and show defects in their methodology, which does not allow us to
determine whether they can reduce the incidence of MEs in the adult
intensive care. Currently, the benefits appear to be limited which may be
explained by the complexity of their integration into the care process.
Special attention should be given to the communication between
caregivers, the human-computer interface and the training of caregivers.
http://www.apb.be/Content/default.asp?pageid=727
Can an electronic prescribing system detect doctors who are
more likely to make a serious prescribing error?
JJ Coleman, K Hemming, PG Nightingale, IR Clark, M Dixon-Woods, RE Ferner, RJ
Lilford
Journal of the Royal Society of Medicine May 2011;104(5):208-218
Objectives: We aimed to assess whether routine data produced by an
electronic prescribing system might be useful in identifying doctors at
higher risk of making a serious prescribing error.
Design: Retrospective analysis of prescribing by junior doctors over 12
months using an electronic prescribing information and communication
system. The system issues a graded series of prescribing alerts (low-level
intermediate, and high-level), and warnings and prompts to respond to
abnormal test results. These may be overridden or heeded, except for
high-level prescribing alerts, which are indicative of a potentially serious
error and impose a 'hard stop'.
Setting: A large teaching hospital in the UK.
Participants: All junior doctors in the study setting.
Main outcome measures: Rates of prescribing alerts and laboratory
warnings and doctors' responses.
Results: Altogether 848,678 completed prescriptions issued by 381
doctors (median 1538 prescriptions per doctor, interquartile range (IQR)
328-3275) were analysed. We identified 895,029 low-level alerts (median
1033 per 1000 prescriptions per doctor, IQR 903-1205) with a median of
34% (IQR 31-39%) heeded; 172,434 intermediate alerts (median 196 per
1000 prescriptions per doctor, IQR 159-266), with a median of 23% (IQR
16-30%) heeded; and 11,940 high-level 'hard stop' alerts. Doctors vary
greatly in the extent to which they trigger and respond to alerts of
different types. The rate of high-level alerts showed weak correlation with
the rate of intermediate prescribing alerts (correlation coefficient, r =
0.40; P less than 0.001); very weak correlation with low-level alerts (r =
0.12, P = 0.019); and showed weak (and sometimes negative) correlation
with propensity to heed test-related warnings or alarms. The degree of
correlation between generation of intermediate and high-level alerts is
insufficient to identify doctors at high risk of making serious errors.
Conclusions: Routine data from an electronic prescribing system should
not be used to identify doctors who are at risk of making serious errors.
7
Careful evaluation of the kinds of quality assurance questions for which
routine data are suitable will be increasingly valuable.
http://jrsm.rsmjournals.com/content/104/5/208.abstract
Using an enhanced oral chemotherapy computerized
provider order entry system to reduce prescribing errors and
improve safety
CM Collins, KA Elsaid
International Journal for Quality in Health Care Feb 2011;23(1):36-43
Objective: To reduce the probability of failure in the oral chemotherapy
order, review and administration process and to reduce oral
chemotherapy-related prescribing errors intercepted by clinical
pharmacists prior to reaching the patient.
Design: A before-and-after cohort study.
Setting: A 719-bed multidisciplinary tertiary care institution in the
USA with a paediatric division and an outpatient cancer centre.
Participants: A multidisciplinary team characterised key elements of the
oral chemotherapy process using healthcare failure modes and effects
analysis (HFMEA).
Interventions: Oral chemotherapy computerised provider order entry
(CPOE) was developed and implemented.
Main Outcome Measures: Pharmacist-intercepted oral chemotherapy
prescribing errors over a 24-month period (before) and over a 6-month
period (after) were analysed according to the error type (errors in clinical
decision making, errors in transcription or errors related to prescribing
policy). The incidence of prescribing errors prior to and following CPOE
implementation was compared by calculating the odds ratio (OR) and the
95% confidence interval (CI).
Results: HFMEA hazard analysis revealed 7 potential failure modes, with
the highest hazard scores in the prescribing and administration
components of the process. CPOE implementation significantly (P =
0.023) reduced prescribing error risk by 69% (OR = 0.31; 95% CI, 0.110.86) and eliminated certain types of errors that can lead to significant
patient harm.
Conclusions: Prescribing oral chemotherapy is a failure mode with
significant risk of inducing patient harm. CPOE is effective in reducing
prescribing errors of oral chemotherapy and should be considered part of a
fail-safe process to improve safety.
http://intqhc.oxfordjournals.org/content/23/1/36.abstract
Impact of electronic prescribing support on the reduction of
transcription errors at the administration stage
(Impacto de la prescripción electrónica asistida en la reducción de los errores de
transcripción a la hoja de administración)
SE Garcia-Ramos, G Baldominos Utrilla
Farmacia Hospitalaria Mar-Apr 2011;35(2):64-69
Objective: To assess the impact of administration errors when transcribing
treatments to nurses' administration forms, and to estimate the impact of
electronically assisted prescribing (EAP) in minimising these errors.
Method: A prospective, observational study in hospitalised patients in
Spain. Changes in treatment in the 24 hours before examination were
analysed for a representative sample. Transcription errors were
detected by checking for discrepancies between the doctors' prescriptions
and the nurses' treatment administration forms. Error incidence was
calculated overall, and by ward, type of error, administration route and
8
potential seriousness. The possible reduction in new errors per day if EAP
were introduced in all wards was estimated.
Results: Of the 416 prescriptions recorded, the overall percentage of
transcription errors was 12.4%, 9.8% in medical units and 15.2% in
surgical units. Most of the errors were made when a new medicine was
added (29.4%) and the frequency of administration was changed (27.4%).
With regard to their seriousness, 98% did not harm the patients, and
57.7% were listed as 'Category C'. Given that one change of treatment is
made per patient per day, introduction of EAP would be predicted to
prevent 64 new errors daily in the hospital.
Conclusions: There are so many transcription errors that they should be
taken into account when designing strategies to improve care quality. EAP
is an efficient tool to eliminate errors associated with the transcription of
prescriptions.
http://www.sciencedirect.com/science/article/pii/S1130634310002217
Safety issues related to the electronic medical record (EMR):
synthesis of the literature from the last decade, 2000-2009
L Harrington, D Kennerly, C Johnson
Journal of Healthcare Management Jan-Feb 2011;56(1):31-43
Healthcare is a complex industry burdened by numerous and complicated
clinical and administrative transactions that require many behavioural
changes by patients, clinicians and provider organisations. While
healthcare information technology (HIT) is intended to relieve some of the
burden by reducing errors, several aspects of systems such as the
electronic medical record (EMR) may actually increase the incidence of
certain types of errors or produce new safety risks that result in harm.
Healthcare leaders must appreciate the complexity surrounding EMRs and
understand the safety issues in order to mandate sound EMR design,
development, implementation and use. This article seeks to inform
executives, clinicians and technology professionals what has been learned
through published research on the safety of HIT systems during the last
decade, focusing on computerised physician order entry (CPOE), clinical
decision support systems (CDSS) and bar-coded medication administration
(BCMA).
http://www.ache.org/pubs/jhm561.cfm
Online detection of potential duplicate medications and
changes of physician behavior for outpatients visiting
multiple hospitals using national health insurance smart
cards in Taiwan
M-H Hsu, Y-T Yeh, C-Y Chen, C-H Liu, C-T Liu
International Journal of Medical Informatics Mar 2011;80(3):181-189
Objectives: Doctor shopping (or hospital shopping), which means changing
doctors (or hospitals) without professional referral for the same or similar
illness conditions, is common in Hong Kong, Taiwan and Japan. Due to
the lack of infrastructure for sharing health information and medication
history among hospitals, doctor-shopping patients are more likely to
receive duplicate medications and suffer adverse drug reactions. The
Bureau of National Health Insurance (BNHI) adopted smart cards (or NHIIC cards) as health cards in Taiwan. With their NHI-IC cards, patients can
freely access different medical institutions. Because an NHI-IC card
carries information about a patient's prescribed medications received from
different hospitals nationwide, we used this system to address the problem
of duplicate medications for outpatients visiting multiple hospitals.
9
Methods: A computerised physician order entry (CPOE) system was
enhanced with the capability of accessing NHI-IC cards and providing
alerts to physicians when the system detects potential duplicate
medications at the time of prescribing. Physician responses to the alerts
were also collected to analyse changes in physicians' behavior. Chisquared tests and two-sided z-tests with Bonferroni adjustments for
multiple comparisons were used to assess statistical significance of
differences in actions taken by physicians over the 3 months.
Results: The enhanced CPOE system for outpatient services was
implemented and installed at the paediatric and urology departments of
Taipei Medical University Wan-Fang Hospital in Mar 2007. The 'Change
Log' that recorded physician behaviour was activated during a 3-month
study period from Apr to Jun 2007. In 67.93% of patient visits, the
physicians read patient NHI-IC cards, and in 16.76% of the reads, the
NHI-IC card contained at least one prescribed medication that was taken
by the patient. Among the prescriptions issued by physicians, on average,
there were 2.36% prescriptions containing at least one medication that
might duplicate the prior prescriptions stored in NHI-IC cards. The rate of
potential duplicate medication alerts for the paediatric department was
higher than that for the urology department (2.78% vs 1.67%). However,
the rate of revisions to prescriptions was higher in the urology department
than the paediatric department. Overall, the rate of physicians reviewing
and revising their prescriptions was 29.25%; the rate of physicians
reviewing without revising their prescriptions was 43.62%; the rate of
physicians turning off the alert screens right after the screens popped up
(override) was 27.13%. Thus, physicians accepted alerts to review their
prescriptions with patients in most situations (72.87%). Moreover, over
the study period, the rate of total revisions made to prescriptions
increased and the 'override' rate decreased.
Conclusions: Our approach enhances the capability of CPOE systems using
NHI-IC cards as a nationwide infrastructure to provide more complete
patient health information and medication history sharing among hospitals
in Taiwan. Thus, our system can provide a better prescribing tool to help
physicians detect potential duplicate medications for frequent doctorshopping patients and hence enhance patient safety across hospital
boundaries. However, the effectiveness of detecting duplicate medications
with our approach is very much dependent on the completeness of NHI-IC
cards, which in turn primarily depends on physicians using the cards when
prescribing.
http://www.ijmijournal.com/article/S1386-5056(10)00215-7/abstract
Effect of e-prescribing systems on patient safety
J Kannry
Mount Sinai Journal of Medicine Nov-Dec 2011;78(6):827-833
E-prescribing systems enable electronic transmissions of prescriptions to
pharmacies from the provider's office. The promise of e-prescribing in
regard to patient safety is reduction in the time gap between point of care
and point of service, reduction in medication errors, and improved quality
of care. This article will give a brief overview of e-prescribing systems,
what is known about these systems and their impact on patient safety,
and what challenges remain. For purposes of this article, the term 'patient
safety' will be used interchangeably with medication errors and adverse
drug events. Although there is some evidence that e-prescribing alone
and e-prescribing with medication decision support can reduce medication
errors, there is also evidence that e-prescribing can be a source of
medication errors. The need for more study is particularly relevant and
timely, as the US Centers for Medicare and Medicaid Services is strongly
10
incentivising providers to use e-prescribing with medication decision
support. Despite concerns about efficiency and dissatisfaction, the
majority of providers believe e-prescribing provides for improved patient
safety. Limited evidence suggests that e-prescribing with medication
decision support can improve patient safety.
http://onlinelibrary.wiley.com/doi/10.1002/msj.20298/abstract
The comparative effectiveness of two electronic prescribing
systems
R Kaushal, Y Barron, EL Abramson
American Journal of Managed Care Dec 2011;17(12-Spec.No.):SP88-SP94
Objectives: The increasingly widespread adoption of electronic health
records (EHRs) is substantially changing the American healthcare delivery
system. Differences in the actual effectiveness of EHRs and their
component applications, including electronic prescribing (e-prescribing), is
not well understood. We compared the effects of two types of eprescribing systems on medication safety as an example of how
comparative effectiveness research (CER) can be applied to the study of
healthcare delivery.
Study Design and Methods: We previously conducted two nonrandomised, prospective studies with pre-post controls comparing
prescribing errors among: (1) providers who adopted a standalone eprescribing system with robust technical and clinical decision support
(CDS) and (2) providers who adopted an EHR with integrated eprescribing with less robust available CDS and technical support. Both
studies evaluated small groups of ambulatory care providers in the same
New York (USA) community using identical methodology including
prescription and chart reviews. We undertook this comparative
effectiveness study to directly compare prescribing error rates among the
2 groups of e-prescribing adopters.
Results: The stand-alone system reduced error rates from 42.5 to 6.6
errors per 100 prescriptions (P less than 0.001). The integrated system
reduced error rates from 26.0 to 16.0 per 100 prescriptions (P = 0.07).
After adjusting for baseline differences, stand-alone users had a 4-fold
lower rate of errors at 1 year (P less than 0.001).
Conclusions: Despite improved work flow integration, the integrated eprescribing application performed less well, most likely due to differences
in available CDS and technical resources. Results from this small study
highlight the importance of CER that directly compares components of
healthcare delivery.
http://www.ajmc.com/publications/issue/2011/2011-12-vol17-SP
The effect of computerized physician order entry and
decision support system on medication errors in the neonatal
ward: experiences from an Iranian teaching hospital
A Kazemi, J Ellenius, F Pourasghar, S Tofighi, A Salehi, A Amanati, UGH Fors
Journal of Medical Systems Feb 2011;35(1):25-37
Medication dosing errors are frequent in neonatal wards. In an Iranian
neonatal ward, a 7.5-months study was designed in three periods to
compare the effect of computerised physician order entry (CPOE) without
and with decision support functionalities in reducing non-intercepted
medication dosing errors in antibiotics and anticonvulsants. Before
intervention (Period 1), error rate was 53%, which did not significantly
change after the implementation of CPOE without decision support (Period
2). However, errors were significantly reduced to 34% after that the
decision support was added to the CPOE (Period 3; P less than 0.001).
11
Dose errors were more often intercepted than frequency errors. Overdose was the most frequent type of medication errors and curtailedinterval was the least. Transcription errors did not reduce after the
implementation of CPOE. Physicians ignored alerts when they could not
understand why they appeared. A suggestion is to add explanations about
these reasons to increase physicians' compliance with the system's
recommendations.
http://www.springerlink.com/content/93221001852844hq/fulltext.pdf
Electronic prescription errors in an ambulatory pharmacy
R Molitor, S Friedman
Journal of Managed Care Pharmacy Nov-Dec 2011;17(9):714-715
Letter reporting an audit of all 300 e-prescriptions received at Evergreen
Professional Center Pharmacy in Kirkland, Washington, USA, an outpatient
hospital pharmacy, over the period from 24 May to 24 June 2011. This
represented nearly 9% of all prescriptions received. These e-prescriptions
were audited for legal and technical requirements as defined by
Washington State law at the time of receipt. 16 categories were identified
as potential sources of error, and errors or omissions were found in 11 of
those categories. Errors included: sent to wrong pharmacy, some patient
or provider information omitted, invalid quantities prescribed and errors in
directions.
The authors conclude that 'e-prescribing has the potential to decrease
medical errors by eliminating poor handwriting, and could improve
continuity of care through prescription documentation in electronic charts.
However, with this technology still in its infancy, input errors should be
anticipated and will need to be addressed by pharmacy staffs now, and
into the near future before e-prescribing evolves into a process which is
superior to current practice.'
http://www.amcp.org/JMCP/2011/November-_December/13686/1033.html
Addition of electronic prescription transmission to
computerized prescriber order entry: effect on dispensing
errors in community pharmacies
TT Moniz, AC Seger, CA Keohane, D Lew Seger, DW Bates, JM Rothschild
American Journal of Health-System Pharmacy 15 Jan 2011;68(2):158-163
Purpose: The addition of electronic prescription transmission to
computeriaed prescriber order entry (CPOE) and its effect on dispensing
errors in community pharmacies were evaluated.
Methods: A controlled, before-and-after trial to measure the effect of
electronic prescribing on dispensing errors in two control clinics and one eprescribing clinic already using CPOE was conducted between Jan and Nov
2006. Prescriptions documented within the CPOE system were reconciled
with dispensed prescription information from participating pharmacy
chains via a national pharmacy information exchange network. Dispensing
errors were defined as discrepancies between the prescriber's written
orders and the dispensed prescription information. Prescriptions filled at
nonparticipating pharmacies were not analysed.
Results: A total of 11,447 prescriptions were written in the control clinics
and 29,575 were written in the e-prescribing clinic. During the
intervention period, 2179 (22%) of 9905 intervention clinic prescriptions
were electronically transmitted, including 621 (28%) available for analysis.
There was no significant difference in the dispensing-error rates between
the baseline and intervention periods for the control clinics. Similarly, the
dispensing-error rates did not differ significantly for the e-prescribing clinic
between the baseline and intervention periods for prescriptions that were
12
not electronically transmitted. The e-prescribing clinic's dispensing-error
rate for electronically transmitted prescriptions during the intervention was
significantly lower than its baseline dispensing-error rate (p = 0.03).
Conclusions: Electronic transmission of prescription data from physicians'
offices to a pharmacy nearly halved the risk of dispensing errors compared
with generating the prescription with outpatient CPOE and printing it and
giving it to the patient.
http://www.ajhp.org/content/68/2/158.abstract
Errors associated with outpatient computerized prescribing
systems
KC Nanji, JM Rothschild, C Salzberg, CA Keohane, K Zigmont, J Devita, TK
Gandhi, AK Dalal, DW Bates, EG Poon
Journal of the American Medical Informatics Association Nov 2011;18(6):767-773
Objective: To report the frequency, types, and causes of errors associated
with outpatient computer-generated prescriptions, and to develop a
framework to classify these errors to determine which strategies have
greatest potential for preventing them.
Materials and Methods: This is a retrospective cohort study of 3850
computer-generated prescriptions received by a commercial outpatient
pharmacy chain across three US states over 4 weeks in 2008. A clinician
panel reviewed the prescriptions using a previously described method to
identify and classify medication errors. Primary outcomes were the
incidence of medication errors; potential adverse drug events, defined as
errors with potential for harm; and rate of prescribing errors by error type
and by prescribing system.
Results: Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of
which 163 (35.0%) were considered potential adverse drug events. Error
rates varied by computerised prescribing system, from 5.1% to 37.5%.
The most common error was omitted information (60.7% of all errors).
Discussion: About one in 10 computer-generated prescriptions included at
least one error, of which a third had potential for harm. This is consistent
with the literature on manual handwritten prescription error rates. The
number, type and severity of errors varied by computerised prescribing
system, suggesting that some systems may be better at preventing errors
than others.
Conclusions: Implementing a computerised prescribing system without
comprehensive functionality and processes in place to ensure meaningful
system use does not decrease medication errors. The authors offer
targeted recommendations on improving computerised prescribing
systems to prevent errors.
http://jamia.bmj.com/content/18/6/767.abstract
Implementation of an e-prescribing service: users'
satisfaction and recommendations
M Shams
Canadian Pharmacists Journal Jul 2011;144(4):186-191
The aim of the present study was to measure the attitudes and
satisfaction of various stakeholders about an electronic prescribing service
(EPS), in order to generate best practice recommendations for further
improvement. Relevant stakeholders included physicians from different
specialties, pharmacy staff (pharmacists and assistant pharmacists),
nurses and outpatients. Participants (n = 283) were randomly selected
from several clinical settings in Muscat, Oman. They were asked to fill out
a questionnaire to measure their satisfaction with the EPS, as well as their
13
attitude toward it, both before and after its integration with a
computerised hospital information and management system (Al-Shifa).
The overall level of satisfaction with the integrated EPS was high.
Physicians, pharmacy staff and nurses highly agreed that the EPS reduced
prescribing errors and they did not want to go back to the paper-based
prescription system. Pharmacy staff and nurses viewed the EPS more
positively and were more satisfied with it than were physicians (p less
than 0.05). It was also found that 74% of patients who responded to the
survey were either satisfied or very satisfied with the EPS and preferred it
over paper-based prescriptions. In conclusion, the majority of
stakeholders were generally satisfied with the current status of the EPS,
but they also perceived a few key weaknesses. A total of 12
recommendations were offered to improve the EPS in clinical settings in
the Sultanate of Oman.
http://www.cpjournal.ca/doi/pdf/10.3821/1913-701X-144.4.186
Electronic prescribing reduces prescribing error in public
hospitals
R Shawahna, N-U Rahman, M Ahmad, M Debray, M Yliperttula, X Decleves
Journal of Clinical Nursing Nov 2011;20(21-22):3233-3245
Aims and objectives: To examine the incidence of prescribing errors in a
main public hospital in Pakistan and to assess the impact of introducing
electronic prescribing system on the reduction of their incidence.
Background: Medication errors are persistent in today's healthcare
system. The impact of electronic prescribing on reducing errors has not
been tested in the developing world.
Design: Prospective review of medication and discharge medication charts
before and after the introduction of an electronic inpatient record and
prescribing system.
Methods: Inpatient records (n = 3300) and 1100 discharge medication
sheets were reviewed for prescribing errors before and after the
installation of an electronic prescribing system on 11 wards.
Results: Medications (13,328 and 14,064) were prescribed for inpatients,
among which 3008 and 1147 prescribing errors were identified, giving an
overall error rate of 22.6% and 8.2% during the periods with paper-based
and electronic prescribing, respectively. Medications (2480 and 2790)
were prescribed for discharge patients, among which 418 and 123 errors
were detected, giving an overall error rate of 16.9% and 4.4% during
paper-based and electronic prescribing, respectively.
Conclusions: Electronic prescribing had a significant effect on the reduction
of prescribing errors.
Relevance to clinical practice: Prescribing errors are commonplace in
public hospitals in Pakistan. The study evaluated the impact of introducing
electronic inpatient records and electronic prescribing on the level of
prescribing errors in a public hospital in Pakistan.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2011.03714.x/abstract
Electronic prescribing increases uptake of clinical
pharmacologists' recommendations in the hospital setting
AB Taegtmeyer, I Curkovic, K Rufibach, N Corti, E Battegay, GA Kullak-Ublick
British Journal of Clinical Pharmacology Dec 2011;72(6):958-964
Aims: To determine whether electronic prescribing facilitates the uptake of
clinical pharmacologists' recommendations for improving drug safety in
medical inpatients.
Methods: Electronic case records and prescription charts (either electronic
or paper) of 502 patients hospitalised on medical wards in a large Swiss
14
teaching hospital between Jan 2009 and Jan 2010 were studied by four
junior and four senior clinical pharmacologists. Drug-related problems
were identified and interventions proposed. The implementation and time
delays of these proposed interventions were compared between the
patients for whom paper drug charts were used and the patients for whom
electronic drug charts were used.
Results: 158 drug-related problems in 109 hospital admissions were
identified and 145 recommendations were made, of which 51% were
implemented. Admissions with an electronic prescription chart (n= 90)
were found to have 2.74 times higher odds for implementation of the
change than those with a paper prescription chart (n= 53) (95% CI, 1.2
to 6.3; P = 0.018, adjusted for any dependency introduced by patient,
ward or clinical team; follow-up for two cases missing). The time delay
between recommendations being made and their implementation (if any)
was minimal (median 1 day) and did not differ between the two groups.
Conclusions: Electronic prescribing in this hospital setting was associated
with increased implementation of clinical pharmacologists'
recommendations for improving drug safety when compared with
handwritten prescribing on paper.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2011.04032.x/abstract
Effects of therapeutic drug monitoring criteria in a
computerized prescriber-order-entry system on the
appropriateness of vancomycin level orders
KA Traugott, PR Maxwell, K Green, C Frei, JS Lewis
American Journal of Health-System Pharmacy 15 Feb 2011;68(4):347-352
Purpose: The effects of therapeutic drug monitoring (TDM) criteria in a
computerized prescriber-order-entry (CPOE) system on the
appropriateness of orders for vancomycin levels were evaluated.
Methods: Vancomycin TDM criteria were developed and implemented in a
CPOE system. These criteria were displayed via a pop-up alert message
when vancomycin levels were ordered and included directions for
appropriate timing and justification for routine monitoring. Data for two
groups of adult inpatients who had vancomycin levels ordered before and
after criteria implementation were compared. Medical records were
retrospectively reviewed for these patients to collect information regarding
patient demographics, vancomycin dosage and indication, concurrent
antibiotics and nephrotoxic agents during vancomycin therapy, length of
stay, duration of vancomycin therapy, and number of vancomycin levels
drawn. The primary outcome was the percentage change in appropriate
vancomycin levels ordered after criteria implementation.
Results: A total of 200 patients were analysed, 100 in each group. The
percentage of appropriate orders for vancomycin levels significantly
increased after criteria implementation (from 58% to 68%, p = 0.02).
The greatest effect on appropriateness occurred with the first level ordered
(52% vs 70% in the pre-implementation and post-implementation groups,
respectively; p = 0.01). The majority of inappropriate levels were due to
improper timing of sample collections, accounting for 55% of the
inappropriate levels evaluated.
Conclusions: A significant increase in the number of appropriately ordered
and drawn serum vancomycin levels occurred after implementation of TDM
criteria in the hospital's CPOE system. The majority of orders that were
deemed inappropriate were due to improper timing of laboratory
collection.
http://www.ajhp.org/content/68/4/347.abstract
15
Identifying, understanding and combating medication errors
introduced by the computerisation of the medication circuit
Connaître, comprendre et lutter contre les erreurs médicamenteuses induites par
l’informatisation du circuit du médicament
V Vialle, T Tiphine, Y Poirier, E Raingeard, D Feldman, J-C Freville
Annales Pharmaceutiques Francaises May 2011;69(3):165-176
Introduction: The aim of the study is to identify medication errors related
to computerised physician order entry (CPOE) in a hospital in France.
Methods: The study covered a period of 1 year (2008 to 2009), during
which medication supply to 378 beds was computerised. Medication errors
were identified from notifications sent to the software supplier,
feedback from health professionals and analysis of pharmacists'
interventions made as a result of prescription errors due to
computerisation. They were classified according to the French medication
error dictionary of the French Society of Clinical Pharmacy.
Results: 35 categories of medication errors were found. Most of them
appeared during prescribing. Dosage and concentration errors, dose
errors, omission errors and drug errors were the most frequent.
Discussion and Conclusions: Three main causes were found: human
factors, closely related to the software settings and the quality of user
training; communication problems, related to the ergonomics; conception
problems, related to the intuitiveness and complexity of the software.
These results confirm the existence of medication errors introduced by
computerised physician order entry systems. They highlight the need for
initial and ongoing training of users, relevant and scalable setup and the
use of mature and accredited software in order to minimise them.
http://www.sciencedirect.com/science/article/pii/S0003450911000277
A clinical information system reduces medication errors in
paediatric intensive care
C Warrick, H Naik, S Avis, P Fletcher, B Dean Franklin, D Inwald
Intensive Care Medicine Apr 2011;37(4):691-694
Purpose: To determine the effect of electronic prescribing (EP) with a
clinical information system (Intellivue Clinical Information Portfolio, Philips,
UK) on prescribing errors and omitted doses in a paediatric intensive care
unit (PICU).
Methods: Prospective audit of prescribing errors and omitted doses for 96hour periods in three epochs: (1) before implementation of EP, (2) 1 week
and (3) 6 months later.
Results: There was a non-significant reduction in prescribing errors: 8.8%
(95% CI, 4.4-13.2) pre-implementation of EP versus 8.1% (4.4-11.8) 1
week after implementation and 4.6% (2.0-7.2) 6 months later. The
prevalence of omitted doses decreased significantly 6 months following
implementation, changing from 8.1% (5.8-10.4) pre-implementation to
10.6% (6.5-14.7) 1 week after implementation and 1.4% (0-2.8%) 6
months after implementation (P less than 0.05).
Conclusions: EP within a clinical information system increases medication
safety in a PICU.
http://www.springerlink.com/content/r807p8l225318470/
Factors contributing to an increase in duplicate medication
order errors after CPOE implementation
TB Wetterneck, JM Walker, MA Blosky, RS Cartmill, P Hoonakker, MA Johnson, E
Norfolk, P Carayon
Journal of the American Medical Informatics Association Nov 2011;18(6):774-782
16
Objective: To evaluate the incidence of duplicate medication orders before
and after computerised provider order entry (CPOE) with clinical decision
support (CDS) implementation and identify contributing factors.
Design: CPOE with duplicate medication order alerts was implemented in a
400-bed Northeastern USA community tertiary care teaching hospital. In
a pre-implementation post-implementation design, trained nurses used
chart review, computer-generated reports of medication orders, provider
alerts and staff reports to identify medication errors in two intensive care
units (ICUs).
Measurement: Medication error data were adjudicated by a physician and
a human factors engineer for error stage and type. A qualitative analysis
of duplicate medication ordering errors was performed to identify
contributing factors.
Results: Data were collected for 4147 patient-days pre-implementation
and 4013 patient-days post-implementation. Duplicate medication
ordering errors increased after CPOE implementation (pre: 48 errors,
2.6% total; post: 167 errors, 8.1% total; p less than 0.0001). Most postimplementation duplicate orders were either for the identical order or the
same medication. Contributing factors included: (1) provider ordering
practices and computer availability, for example, two orders placed within
minutes by different providers on rounds; (2) communication and handoffs, for example, duplicate orders around shift change; (3) CDS and
medication database design, for example confusing alert content, high
false-positive alert rate and CDS algorithms missing true duplicates; (4)
CPOE data display, for example, difficulty reviewing existing orders; and
(5) local CDS design, for example, medications in order sets defaulted as
ordered.
Conclusions: Duplicate medication order errors increased with CPOE and
CDS implementation. Many work system factors, including the CPOE, CDS
and medication database design, contributed to their occurrence.
http://jamia.bmj.com/content/18/6/774.abstract
Other evaluations
Physicians' perception of CPOE implementation
B Allenet, P Bedouch, S Bourget, M Baudrant, L Foroni, J Calop. J-L Bosson
International Journal of Clinical Pharmacy Aug 2011;33(4):656-664
Objective: To identify perceptions held by physicians of the benefits of
computerised physician order entry (CPOE) and factors influencing its
successful implementation in the context of the increased presence of a
clinical pharmacist on the ward.
Setting A 2000-bed university hospital in France.
Method: A cross-section opinion survey was conducted of all permanent
physicians of the hospital to determine their perception of the benefits, or
otherwise, of CPOE. A questionnaire, built upon the analysis of 10
preliminary semi-structured interviews with physicians, was sent to
physicians by electronic and paper mail. It comprised three sections with
a 4-level Likert scale: general perception of CPOE benefits (items 1.1-1.8);
opinion about the introduction of the CPOE system in the hospital (item
2); opinion on the presence of a pharmacist on ward (item 3). A fourth
section recorded the respondent's profile.
Main outcome measures: Level of agreement on the items describing the
general perception of CPOE benefits; opinion on the introduction of a CPOE
system in the hospital; and opinion on the pharmacist's presence on ward.
A Principal Component Analysis (PCA) was conducted on sections one and
17
two. Analysis of this PCA representation in terms of the respondents’
profile was performed.
Results: 101 physicians (18%) participated in the survey. Most (83%)
physicians favoured the implementation of CPOE (item 2). Among the
advantages of CPOE, the greatest agreement concerned items related to
safety and regulatory issues (from 80 to 76% agreement). Other items
related to management issues were perceived as less tangible benefits
(from 50 to 67% agreement). The increased presence of a pharmacist on
the ward was supported by 94% of physicians. The PCA representation
using profile items produced a 2-factor solution, accounting for 68% of the
variance, with former experience of collaboration with a pharmacist (P =
0.002) and senior physician status (P = 0.013) positively influencing the
perception of CPOE.
Conclusions: Endorsement by senior physicians and the presence of a
clinical pharmacist on the ward promote a positive attitude towards CPOE
and facilitate its implementation.
http://www.springerlink.com/content/k8t5307632n5387r/
Patients satisfied with e-prescribing in Sweden: a survey of a
nationwide implementation
T Hammar, S Nystrom, G Petersson, B Astrand, T Rydberg
Journal of Pharmaceutical Health Services Research Jun 2011;2(2):97-105
Objective: To evaluate Swedish patients' attitudes towards e-prescribing,
including the transfer of e-prescriptions, electronic storing of prescriptions
and mail-order prescriptions.
Methods: This study was a nationwide survey of attitudes among Swedish
patients and was conducted as a postal questionnaire. The questionnaire
was developed for the purpose of this study and aimed to evaluate
respondents' views concerning e-prescribing, electronic storing of eprescriptions and mail-order prescriptions from aspects including safety,
personal benefits and effectiveness. A study population of 1500
individuals meeting the inclusion criteria was randomly selected from a
database of individuals in Sweden storing prescriptions electronically (n =
5,840,599). The response rate was 52% (739/1429).
Key findings: The vast majority of the respondents had a positive attitude
towards e-prescriptions (85%, 628/739) and electronic storing of
prescriptions (86%, 633/739), and regarded e-prescriptions to be safe
(79%, 584/739), creating benefits for them (78%, 576/739) and
promoting faster dispensing (69%, 512/739). Significant differences in
attitudes towards e-prescriptions and electronic storing of prescriptions
were detected between age groups. Patients storing all their prescriptions
electronically had a more positive attitude towards both e-prescriptions
and electronic storing of prescriptions compared to patients who stated
they had paper prescriptions. The most common suggestion (n = 27) for
improvement was to extend the information given about the services.
Conclusions: Our nationwide survey showed that a vast majority of
Swedish patients had positive attitudes towards e-prescriptions and
electronic storing of prescriptions. However, a need for extended
information regarding e-prescribing was identified.
http://onlinelibrary.wiley.com/doi/10.1111/j.1759-8893.2011.00040.x/abstract
Doctors' orders - if they're electronic, do they improve
patient satisfaction? A complements/substitutes perspective
CC Queenan, CM Angst, S Devaraj
Journal of Operations Management Nov 2011;29(7-8):639-649
18
Doctors' orders entered with Computerized Physician Order Entry (CPOE)
systems are designed to enhance patient care by standardising routines
that are intended to improve quality of healthcare. As with other health
information technology (IT) performance studies, literature shows
conflicting results regarding the CPOE-performance relationship. By
adopting a more nuanced perspective and employing not just adoption but
extent of use of CPOE, we first examine whether or not CPOE use
improves patient satisfaction. Next, given that CPOEs are implemented in
the backdrop of other hospital IT infrastructure, we examine how IT
infrastructure impacts the relationship between CPOE use and satisfaction,
testing both a complementary and substitution perspective. Finally, we
examine the differential impact of CPOE use between academic and nonacademic hospitals. Using data from 806 hospitals throughout the USA,
we find a positive relationship between extent of CPOE use and patient
satisfaction. Contrary to extant research, our results suggest this
relationship is stronger in non-academic hospitals. We also find evidence
that a hospital's IT infrastructure substitutes for CPOE use in its effect on
patient satisfaction.
http://www.sciencedirect.com/science/article/pii/S0272696311000556
Pharmacists' views on integrated electronic prescribing
systems: associations between usefulness, pharmacological
safety, and barriers to technology use
B Rahimi, T Timpka
European Journal of Clinical Pharmacology Feb 2011;67(2):179-184
Purpose: Integrated electronic prescribing systems (IEPSs) are expected
to improve efficiency and safety in the management of pharmaceuticals
throughout the healthcare sector. In Sweden (population 9 million), more
than 25 million e-prescriptions each year are processed in the National
IEPS. We set out to examine the introduction of an IEPS into pharmacists'
practice with regard to impact on work efficiency and pharmacological
safety.
Methods: A questionnaire was distributed to all pharmacists (n = 74) in a
Swedish municipality (population 145,000), where an IEPS had recently
been introduced. The response rate was 70%.
Results: The IEPS was in general perceived to have expedited the
processing of prescriptions and reduced the risk for prescription errors as
well as the handing over of erroneous medications to patients. We found
that there was a positive correlation between usefulness of the IEPS
system for work efficacy and pharmacological safety, respectively (r =
0 .524, p less than 0.001) and a negative correlation between the
usefulness of the IEPS for work efficacy and perception of barriers to
technology use (r = -0.010, p less than 0.05). We also found that there
was a negative correlation between IEPS usefulness for pharmacological
safety and that barriers to IEPS technology use were experienced (r =
0.031, p less than 0.05).
Conclusions: The results indicate that reduction of system unavailability
due to technical issues will increase the perceived usefulness of IEPSs for
pharmacists with regard to both work efficacy and pharmacological safety.
We conclude that the introduction of an IEPS was well received by
pharmacists; however, barriers to full acceptance remained, in particular,
system unavailability due to technical problems.
http://www.springerlink.com/content/bt43730j4p4h3468/
Setting a standard for electronic prescribing systems
J Reeve, M Sweidan
19
Australian Prescriber Feb 2011;34(1):2-4
In Australia, electronic prescribing (e-prescribing) systems in general
practice were first developed in the early 1990s by a few innovative GPs
who wrote software for their own use. The uptake of e-prescribing
systems was accelerated in 1999 because of Commonwealth government
incentive payments of Aus$ 10,000 to practices that acquired an e-mail
address and used e-prescribing software to write the majority of their
prescriptions. Currently more than 90% of general practitioners use one
of the 20 or so commercial systems that are available to write
prescriptions, order pathology and other tests, record medical progress
notes or communicate with other healthcare providers.
The National Prescribing Service (NPS) has evaluated 7 commonly used
systems against a predefined set of criteria (J Reeve, M Sweidan,
unpublished, 2011). It found that features to support safety and quality
were highly variable between systems and there were some significant
gaps. Clinical decision support features were ranked the most important
for safety and quality, but in 5 of the systems fewer than 50% of these
features were fully implemented (e.g. there were no alerts for harmful
doses or new safety warnings). One of the main reasons for this is the
lack of clinical information resources in a format which is suitable for
decision support. When systems included decision support, it was often
unclear where the information was derived from and whether it was up to
date. Another important safety issue identified was that most systems did
not clearly differentiate between similar-named medicines during
prescribing, increasing the risk of selecting the wrong drug from a list of
products.
The findings of this evaluation highlight the need for guidance or standards
to ensure that essential functionality and safety features are included in all
e-prescribing systems. (19 refs.)
http://www.australianprescriber.com/upload/pdf/articles/1154.pdf
System Design
Using a computerized provider order entry system to meet the
unique prescribing needs of children: description of an advanced
dosing model
JM Ferranti, MM Horvath, J Jansen, P Schellenberger, T Brown, CM DeRienzo, A
Ahmad
BMC Medical Informatics and Decision Making 21 Feb 2011;11:14
Background: It is well known that the information requirements necessary
to safely treat children with therapeutic medications cannot be met with
the same approaches used in adults. Over a 1-year period, Duke
University Hospital (N Carolina, USA) engaged in the challenging task of
enhancing an established computerised provider order entry (CPOE)
system to address the unique medication dosing needs of pediatric
patients.
Methods: An advanced dosing model (ADM) was designed to interact with
our existing CPOE application to provide decision support enabling
complex paediatric dose calculations based on chronological age,
gestational age, weight, care area in the hospital, indication, and level of
renal impairment. Given that weight is a critical component of medication
dosing that may change over time, alerting logic was added to guard
against erroneous entry or outdated weight information.
Results: Paediatric CPOE was deployed in a staggered fashion across 6
care areas over a 14-month period. Safeguards to prevent miskeyed
20
values became important in allowing providers the flexibility to override
the ADM logic if desired. Methods to guard against over- and underdosing were added. The modular nature of our model allows us to easily
add new dosing scenarios for specialised populations as the paediatric
population and formulary change over time.
Conclusions: The medical needs of paediatric patients vary greatly from
those of adults, and the information systems that support those needs
require tailored approaches to design and implementation. When a single
CPOE system is used for both adults and paediatrics, safeguards such as
redirection and suppression must be used to protect children from
inappropriate adult medication dosing content. Unlike other pediatric
dosing systems, our model provides active dosing assistance and dosing
process management, not just static dosing advice.
http://www.biomedcentral.com/content/pdf/1472-6947-11-14.pdf
Improving the utilization of admission order sets in a
computerized physician order entry system by integrating
modular disease specific order subsets into a general
medicine admission order set
RL Munasinghe, C Arsene, TK Abraham, M Zidan, M Siddique
Journal of the American Medical Informatics Association May 2011;18(3):322326
Case description: We evaluated the effects of integrating order subsets for
the most common medical diagnoses into a general medical admission
order set of our electronic medical records (EMR) in order to improve order
set integration by clinicians.
Methods of Implementation: We identified the most common primary and
secondary diagnoses for patients admitted to our medical service and
developed order subsets comprising only the orders necessary for the
management of these individual diagnoses. Using the capabilities of our
computerised physician order entry (CPOE), we nested these order
subsets into the general order set and evaluated the resulting change in
order set utilisation by our clinicians.
Example and Observations: The total number of order sets used by
clinicians in all departments increased 5-fold during the 16-month period
following the implementation of the integrated order sets in Jul 2008. A
before and after time series was used to analyse the trend in increased
order set usage and showed an effect of the intervention (p = 0.023).
Discussion: Integration of disease-specific order subsets into a single
general admission order set significantly improved the overall adoption of
order sets by clinicians. This provides health care systems with the
opportunity to improve patient safety and implement evidence based care
in clinical practice.
http://jamia.bmj.com/content/18/3/322.abstract
Alert Presentation
Alternatives to potentially inappropriate medications for use
in e-prescribing software: triggers and treatment algorithms
AL Hume, BJ Quilliam, R Goldman, C Eaton, KL Lapane
BMJ Quality and Safety Oct 2011;20(10):875-884
Objective: To describe the development of evidence-based electronic
prescribing (e-prescribing) triggers and treatment algorithms for
potentially inappropriate medications (PIMs) for older adults.
21
Design: Literature review, expert panel and focus group.
Setting: Primary care with access to e-prescribing systems.
Participants: Primary care physicians using e-prescribing systems
receiving medication history.
Interventions: Standardised treatment algorithms for clinicians attempting
to prescribe PIMs for older patients.
Main outcome measure: Development of 15 treatment algorithms
suggesting alternative therapies.
Results: Evidence-based treatment algorithms (implemented in RCopia
software, DrFirst, Inc., Rockville, Maryland, USA) were well received by
primary care physicians. Providing alternatives to PIMs would make it
easier for physicians to change decisions at the point of prescribing.
Conclusions: Prospectively identifying older persons receiving PIMs or with
adherence issues and providing feasible interventions may prevent
adverse drug events.
http://qualitysafety.bmj.com/content/20/10/875.abstract
Characteristics of clinical decision support alert overrides in
an electronic prescribing system at a tertiary care paediatric
hospital
YH Jani, N Barber, ICK Wong
International Journal of Pharmacy Practice Oct 2011;19(5):363–366
Electronic prescribing (EP) systems are advocated as a solution to
minimise medication errors. Benefits in patient safety are often as a result
of some clinical decision support (CDS) within the system.
The aim of the study was to look at the characteristics of the CDS alerts
generated within a commercially available EP system in use at a tertiary
care paediatric hospital in the UK.
It was a retrospective review that looked at characterisation of CDS alerts
recorded in the EP system over 1 year.
A total of 16,182 conflict alerts were recorded when ordering 26 836
items, of which 3507 (13 alerts per 100 prescription orders (95% CI, 12.8
to 13.6)) were visible to the user. 89% (3119/3507) of all visible alerts
were overridden by the user at point of prescribing. Drug-allergy conflict
alerts were the most accepted, and exact drug duplication alerts the
least.
To conclude, a high incidence of alerts were overridden, which is
undesirable but consistent with that reported in the literature. The
underlying algorithms for alert generation in many EP systems are not
specific and need to be reviewed.
http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7174.2011.00132.x/abstract
Provider and pharmacist responses to warfarin drug-drug
interaction alerts: a study of healthcare downstream of CPOE
alerts
AM Miller, MS Boro, NE Korman, JB Davoren
Journal of the American Medical Informatics Association Dec
2011;18(Suppl.):i45-i50
Objective: To categorise the appropriateness of provider and pharmacist
responses to warfarin critical drug-drug interaction (cDDI) alerts, assess
responses and actions to the cDDI, and determine the occurrence of
warfarin adverse drug events (ADE) after alerts.
Design: An 18-month, retrospective study of acute care admissions at a
single US Veterans Affairs medical centre using computerised provider
order entry (CPOE).
22
Measurements: Patients included had at least one warfarin cDDI alert.
Chart reviews included baseline laboratory values and demographics,
provider actions, patient outcomes, and associated factors, including other
interacting medications and number of simultaneously processed alerts.
Results: 137 admissions were included (133 unique patients).
Amiodarone, vitamin E in a multivitamin, sulfamethoxazole and
levothyroxine accounted for 75% of warfarin cDDI. Provider responses
were clinically appropriate in 19.7% of admissions and pharmacist
responses were appropriate in 9.5% of admissions. There were 50 ADE
(36.6% of admissions) with warfarin; 80% were rated as having no or
mild clinical effect. An increased number of non-critical alerts at the time
of the reference cDDI alert was the only variable associated with an
inappropriate provider response (p = 0.01).
Limitations: This study was limited by being a retrospective review and the
possibility of confounding variables, such as other interacting medications.
Conclusions: The large number of CPOE alerts may lead to inappropriate
responses by providers and pharmacists. The high rate of ADE suggests a
need for improved medication management systems for patients on
warfarin. This study highlights the possibility of alert fatigue contributing
to the high prevalence of inappropriate alert over-ride text responses.
http://jamia.bmj.com/content/18/Suppl_1/i45.full.pdf+html
How to improve the delivery of medication alerts within
computerized physician order entry systems: an
international Delphi study
D Riedmann, M Jung, WO Hackl, E Ammenwerth
Journal of the American Medical Informatics Association Nov 2011;18(6):760-766
Objectives: To determine what information can be helpful in prioritising
and presenting medication alerts according to the context of the clinical
situation. To assess the usefulness of different ways of delivering
medication alerts to the user.
Design: An international Delphi study with two quantitative rounds. 69
researchers with expertise in computerised physician order entry (CPOE)
systems were asked to estimate the usefulness of 20 possible context
factors, and to assess the potential impact of 6 innovative ways of
delivering alert information on adverse drug event (ADE) rates.
Results: Participants identified the following top 5 context information
items (in descending order of usefulness): (1) severity of the effect of the
ADE the alert refers to; (2) clinical status of the patient; (3) probability of
occurrence of the ADE the alert refers to; (4) risk factors of the patient;
and (5) strength of evidence on which the alert is built. The ways of
delivering alert information with the highest estimated ADE reduction
potential are active alerting, proactive prescription simulation and a
patient medication module that gives patient-oriented alert information.
Limitations: Most participants had a research-oriented focus; therefore the
results may not reflect the opinions of CPOE users or CPOE implementers.
Conclusions: The study results may provide CPOE system developers and
healthcare institutions with information on how to design more effective
alert mechanisms.
http://jamia.bmj.com/content/18/6/760.abstract
Impact of implementing alerts about medication black-box
warnings in electronic health records
DT Yu, DL Seger, KE Lasser, AS Karson, JM Fiskio, AC Seger, DW Bates
Pharmacoepidemiology and Drug Safety Feb 2011;20(2):192-202
23
Background: The US Food and Drug Administration issues black-box
warnings (BBWs) regarding medications with serious risks, yet physician
adherence to the warnings is low.
Methods: We evaluated the impact of delivering BBW-based alerts about
drug-drug, drug-disease and drug-laboratory interactions for prescription
medications in outpatients in an electronic health record with clinical
decision support. We compared the frequency of non-adherence to all
BBWs about drug-drug, drug-disease and drug-laboratory interactions for
30 drugs/drug classes, and by individual drugs/drug groups with BBWs
between the pre- and post-intervention periods. We used multivariate
analysis to identify independent risk factors for non-adherence to BBWs.
Results: There was a slightly higher frequency of non-adherence to BBWs
after the intervention (4.8% vs 5.1%; p = 0.045). In multivariate
analyses, after adjustment for patient and provider characteristics and site
of care, medications prescribed during the pre-intervention period were
less likely to violate BBWs compared to those prescribed during the postintervention period (OR 0.67; 95% CI, 0.47-0.96). However, black-box
warning violations did decrease after the intervention for BBWs about
drug-drug interactions (6.1% vs 1.8%, p less than 0.0001) and drugpregnancy interactions (5.1% vs 3.6%, p = 0.01).
Conclusions: Ambulatory care computerised order entry with prescribing
alerts about BBWs did not improve clinicians' overall adherence to BBWs,
though it did improve adherence for specific clinically important
subcategories.
http://onlinelibrary.wiley.com/doi/10.1002/pds.2088/abstract
Potential safety gaps in order entry and automated drug
alerts: a nationwide survey of VA physician self-reported
practices with computerized order entry
JR Spina, PA Glassman, B Simon, A Lanto, M Lee, F Cunningham, CB Good
Medical Care Oct 2011;49(10):904-910
Objective: Understanding provider perceptions of and experiences with
order entry and order checks (drug alerts) in an electronic prescribing
system may help improve medication safety technology.
Design: Cross-sectional, national survey of US Veterans Administration
physicians practising in various specialties.
Measurement: A 35-question instrument was divided into 4 content
domains. Response options included dichotomous, numerical, multiple
choices and Likert-like scales. Statistical methods included logistic
regression.
Results: The adjusted response rate was 1543 of 3588 (43%). Almost all
providers (90%) felt that the VA electronic prescribing system, including
its order checks, improved prescribing safety to some degree. Most
respondents (72%) reported that they always or almost always document
outside medications in a clinic note, although only 44% always or almost
always entered outside medications in the non-VA medication data field.
Most physicians (88%) who encountered serious allergic or adverse drug
reactions reported either notifying a pharmacist or entering the
information in the allergies/adverse reactions field. Generalists and
physicians with higher numbers of prescriptions were more likely to enter
relevant data into the electronic medical record (or notify a pharmacist, in
the case of adverse reactions). In addition, 48% of providers described
critical drug-drug interaction alerts as very useful; medical specialists
found these less useful, whereas surgical specialists found these more
useful when compared with generalists.
Limitations: The survey was conducted within a single healthcare system.
24
Conclusions: Computerised provider order entry and related order checks
are perceived to improve prescribing safety; however, provider entry of
some relevant information into the appropriate electronic fields may not be
optimal.
http://journals.lww.com/lwwmedicalcare/Abstract/2011/10000/Potential_Safety_Gaps_in_Order_Entry_and_A
utomated.5.aspx
Drug Interaction Processing
Critical drug-drug interactions for use in electronic health
records systems with computerized physician order entry:
review of leading approaches
DC Classen, S Phansalkar, DW Bates
Journal of Patient Safety Jun 2011;7(2):61-65
Medications represent the most common intervention in health care;
despite their benefits, they also lead to an estimated 1.5 million adverse
drug events and tens of thousands of hospital admissions each year.
Although some are not preventable given what is known today, many
types are, and one key cause which is preventable is drug-drug
interactions (DDIs). Most electronic health record systems include
programs that can check and prevent these types of interactions as a
routine part of medication ordering. Studies suggest that these systems
as implemented often do not effectively screen for these DDIs. A major
reason for this deficiency is the lack of any national standard in the
USA for the critical DDIs that should be routinely operationalised in these
complex systems. The authors review the leading critical DDI lists from
multiple sources including several leading health systems, a leading
commercial content provider, the Leapfrog CPOE Testing Standard, and
the new Office of the National Coordinator (ONC) DDI List.
Implementation of strong DDI checking is one of the important steps in
terms of realising the benefits of electronic prescribing with respect to
safety. Hopefully, the ONC list will make it easier for organisations to
ensure they are including the most important interactions, and the
Leapfrog List may help these organisations develop an operational DDI list
that can be practically implemented. In addition, this review has identified
7 common DDIs that can be the starting point for all organisations in this
area of medication safety.
http://journals.lww.com/journalpatientsafety/Abstract/2011/06000/Critical_Drug
_Drug_Interactions_for_Use_in.1.aspx
Evaluation of medication safety in the discharge medication
of 509 surgical inpatients using electronic prescription
support software and an extended operational interaction
classification
T Frolich, O Zorina, AO Fontana, GA Kullak-Ublick, A Vollenweider, S Russmann
European Journal of Clinical Pharmacology Dec 2011;67(12):1273-1282
Purpose: Our aim was to study drug interactions and dose adjustments in
patients with renal impairment in the discharge medication of surgical
inpatients and to evaluate the strengths and limitations of clinical decision
support software (CDSS) for this task.
Methods: This was a cross-sectional study involving 509 surgical patients
of a primary care hospital. We developed a customised interface for the
CDSS MediQ, which we used for automated retrospective identification of
25
drug interactions in the patients' discharge medication. The clinical
relevance of the interactions was evaluated based on the Zurich
Interaction System (ZHIAS) that incorporates the operational classification
of drug interactions (ORCA). Prescriptions were further analysed for
recommended dose adjustments in patients with a glomerular filtration
rate below 60 mL/min.
Results: For the total of 2729 prescriptions written for the 509 patients
enrolled in the study, MediQ generated 2558 interaction alerts and 1849
comments. Among these were 10 'high danger' and 551 'average danger'
alerts that we reclassified according to ORCA criteria. This reclassification
resulted in 10 contraindicated combinations, 77 provisionally
contraindicated combinations and 310 with a conditional and 164 with a
minimal risk of adverse outcomes. The ZHIAS classification also provides
categorical information on expected adverse outcomes and management
recommendations, which are presented in detail. We identified 56
prescriptions without a recommended dose adjustment for impaired renal
function.
Conclusions: CDSS identified a large number of drug interactions in
surgical discharge medication, but according to ZHIAS criteria only a minor
fraction of these appeared to involve a substantial risk to the patient.
CDSS should therefore aim at reducing over-alerting and improve
usability in order to become more efficacious in terms of the prevention of
adverse drug events in clinical practice.
http://www.springerlink.com/content/un408r6675038073/
Electronic drug interaction alerts in ambulatory care: the
value and acceptance of high-value alerts in US medical
practices as assessed by an expert clinical panel
SN Weingart, AC Seger, N Feola, et al.
Drug Safety Jul 2011;34(7):587-593
Computerised physician order entry systems are known to improve patient
safety in acute-care hospitals. However, as clinicians frequently override
drug interaction and allergy alerts, their value in ambulatory care remains
uncertain. This study examined whether ambulatory care clinicians were
more likely to accept drug-drug interaction alerts that an expert panel
judged to be of high clinical value and concluded that expert judgement
should be taken into account when developing electronic decision support.
(14 refs.)
http://www.ingentaconnect.com/content/adis/dsf/2011/00000034/00000007/art
00005
Drug interaction alerts in software - what do general
practitioners and pharmacists want?
KH Yu, M Sweidan, M Williamson, A Fraser
Medical Journal of Australia 5-19 Dec 2011;195(11/12):676-680
Objective: To explore Australian general practitioners' and pharmacists'
preferences in relation to content, format and usability of drug interaction
alerts in prescribing and dispensing software.
Design, Participants and Setting: Surveys that sought opinions on drug
interaction decision support were mailed to a random sample of GPs and
community pharmacists (1000 of each) in Jun 2010.
Main Outcome Measures: Usefulness of various components of drug
interaction information; preferred format of drug interaction alerts; levels
of agreement on the value of various usability features; aspects of drug
interaction decision support users would most like to change.
26
Results: Surveys were returned by 219 GPs and 170 pharmacists. Of the
191 GPs and 138 pharmacists included in the analysis, the vast majority
considered severity, clinical effects and management advice to be mostly
or sometimes useful in drug interaction alerts. The most popular drug
interaction alert format - favoured by 131 GPs (69%) and 115 pharmacists
(83%) - was one with headings and one or two succinct bullet points
under each. The vast majority of respondents also wanted to be able to
differentiate drug interaction alerts by severity, and a majority agreed that
it should be made more difficult to override alerts for severe interactions
and that it should be mandatory to provide a reason for doing so.
Conclusions: GPs and pharmacists want drug interaction alert information
to be relevant, useful, concise, and easy to read and comprehend.
Software vendors and knowledge providers could improve drug
interaction decision support by making changes to the content and format
of drug interaction alerts according to these recommendations.
http://www.mja.com.au/public/issues/195_11_121211/yu10206_fm.html
Development and preliminary evidence for the validity of an
instrument assessing implementation of human-factors
principles in medication-related decision-support systems I-MeDeSA
M Zachariah, S Phansalkar, HM Seidling, PM Neri, KM Cresswell, J Duke, M
Bloomrosen, LA Volk, DW Bates
Journal of the American Medical Informatics Association Dec
2011;18(Suppl.):i62-i72
Background: Medication-related decision support can reduce the frequency
of preventable adverse drug events. However, the design of current
medication alerts often results in alert fatigue and high over-ride rates,
thus reducing any potential benefits.
Methods: The authors previously reviewed human-factors principles for
relevance to medication-related decision support alerts. In this study,
instrument items were developed for assessing the appropriate
implementation of these human-factors principles in drug-drug interaction
(DDI) alerts. User feedback regarding nine electronic medical records was
considered during the development process. Content validity, construct
validity through correlation analysis and inter-rater reliability were
assessed.
Results: The final version of the instrument included 26 items associated
with 9 human-factors principles. Content validation on three systems
resulted in the addition of one principle (Corrective Actions) to the
instrument and the elimination of 8 items. Additionally, the wording of 8
items was altered. Correlation analysis suggests a direct relationship
between system age and performance of DDI alerts (p = 0.0016). Interrater reliability indicated substantial agreement between raters (kappa =
0.764).
Conclusions: The authors developed and gathered preliminary evidence for
the validity of an instrument that measures the appropriate use of humanfactors principles in the design and display of DDI alerts. Designers of DDI
alerts may use the instrument to improve usability and increase user
acceptance of medication alerts, and organisations selecting an electronic
medical record may find the instrument helpful in meeting their clinicians'
usability needs.
http://jamia.bmj.com/content/18/Suppl_1/i62.abstract
27
Development and validation of a survey instrument for
assessing prescribers' perception of computerized drug-drug
interaction alerts
K Zheng, K Fear, BW Chaffee, CR Zimmerman, et al.
Journal of the American Medical Informatics Association Dec
2011;18(Suppl.):i51-i61
Objective: To develop a theoretically informed and empirically validated
survey instrument for assessing prescribers' perception of computerised
drug–drug interaction (DDI) alerts.
Materials and Methods: The survey is grounded in the unified theory of
acceptance and use of technology and an adapted accident causation
model. Development of the instrument was also informed by a review of
the extant literature on prescribers' attitude toward computerized
medication safety alerts and common prescriber-provided reasons for
overriding. To refine and validate the survey, we conducted a two-stage
empirical validation study consisting of a pretest with a panel of domain
experts followed by a field test among all eligible prescribers at our
institution.
Results: The resulting survey instrument contains 28 questionnaire items
assessing six theoretical dimensions: performance expectancy, effort
expectancy, social influence, facilitating conditions, perceived fatigue and
perceived use behaviour. Satisfactory results were obtained from the field
validation; however, a few potential issues were also identified. We
analysed these issues accordingly and the results led to the final survey
instrument as well as usage recommendations.
Discussion: High override rates of computerised medication safety alerts
have been a prevalent problem. They are usually caused by, or
manifested in, issues of poor end user acceptance. However, standardized
research tools for assessing and understanding end users' perception are
currently lacking, which inhibits knowledge accumulation and consequently
forgoes improvement opportunities. The survey instrument presented in
this paper may help fill this methodological gap.
Conclusions: We developed and empirically validated a survey instrument
that may be useful for future research on DDI alerts and other types of
computerized medication safety alerts more generally.
http://jamia.bmj.com/content/18/Suppl_1/i51.abstract
Other Usability Aspects
Does user-centred design affect the efficiency, usability and
safety of CPOE order sets?
J Chan, KG Shojania, AC Easty, EE Etchells
Journal of the American Medical Informatics Association May 2011;18(3):276281
Background: Application of user-centred design principles to computerised
provider order entry (CPOE) systems may improve task efficiency,
usability or safety, but there is limited evaluative research of its impact on
CPOE systems.
Objective: We evaluated the task efficiency, usability, and safety of three
order set formats: our hospital's planned CPOE order sets (CPOE Test),
computer order sets based on user-centred design principles (User
Centred Design) and existing pre-printed paper order sets (Paper).
Participants: 27 staff physicians, residents and medical students.
Setting: Sunnybrook Health Sciences Centre, an academic hospital in
Toronto, Canada.
28
Methods: Participants completed four simulated order set tasks with three
order set formats (two CPOE Test tasks, one User Centred Design, and
one Paper). Order of presentation of order set formats and tasks was
randomised. Users received individual training for the CPOE Test format
only.
Main Measures: Completion time (efficiency), requests for assistance
(usability) and errors in the submitted orders (safety).
Results: 27 study participants completed 108 order sets. Mean task times
were: User Centred Design format 273 sec, paper format 293 sec (p =
0.73 compared to UCD format), and CPOE Test format 637 sec (p less
than 0.0001 compared to UCD format). Users requested assistance in
31% of the CPOE Test format tasks, whereas no assistance was needed
for the other formats (p less than 0.01). There were no significant
differences in number of errors between formats.
Conclusions: The User Centred Design format was more efficient and
usable than the CPOE Test format even though training was provided for
the latter. We conclude that application of user-centred design principles
can enhance task efficiency and usability, increasing the likelihood of
successful implementation
http://jamia.bmj.com/content/18/3/276.abstract
Usability evaluation of order sets in a computerised provider
order entry system
J Chan, KG Shojania, AC Easty, EE Etchells
BMJ Quality and Safety Nov 2011;20(11):932-940
Background: Computerised provider order entry (CPOE) is an important
patient safety intervention that has encountered significant barriers to
implementation. The usability of a CPOE system plays a significant role in
its acceptance. The authors conducted a heuristic evaluation of a CPOE
order set system to uncover existing usability issues prior to
implementation.
Methods: A heuristic evaluation methodology was used to evaluate the
usability of a CPOE test order set system. There are 10 heuristic
principles, such as error prevention, to help users identify and recover
from errors. Evaluators included a staff physician with extensive clinical
experience, and three engineers with expertise in heuristic evaluation
methodology. The results of the heuristic evaluation were used to create a
user centred design prototype.
Results: 92 unique heuristic violations were found for the CPOE test order
set system, including 35 identified by the clinician and at least one
engineer, and 57 of the 92 violations (62%) found only by the clinician.
All evaluators identified at least one violation of each of the 10 usability
heuristics in their analysis of the CPOE system. A user centred design
prototype was created to demonstrate changes that could improve
usability.
Interpretation: The CPOE test order set system had many usability
heuristic violations. Many violations were found by a clinician with
knowledge of the heuristic evaluation process. Implementation of the
CPOE system was deferred and a new user centred design prototype was
developed for future study. The authors recommend conducting heuristic
evaluations early in the process of designing, selecting and implementing
CPOE systems.
http://qualitysafety.bmj.com/content/20/11/932.abstract
Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies
29
JM Grossman, DA Cross, ER Boukus, GR Cohen
Journal of the American Medical Informatics Association 2011;
doi:10.1136/amiajnl-2011-000515 (published early online 18 Nov 2011)
Objective: A core feature of e-prescribing is the electronic exchange of
prescription data between physician practices and pharmacies, which can
potentially improve the efficiency of the prescribing process and reduce
medication errors. Barriers to implementing this feature exist, but they
are not well understood. This study's objectives were to explore recent
experiences of physician practices and pharmacies in the USA with
electronic transmission of new prescriptions and renewals, and identify
facilitators of and barriers to effective electronic transmission and
pharmacy e-prescription processing.
Design: Qualitative analysis of 114 telephone interviews conducted with
representatives from 97 organisations between Feb and Sep 2010,
including 24 physician practices, 48 community pharmacies and three
mail-order pharmacies actively transmitting or receiving e-prescriptions
via Surescripts.
Results: Practices and pharmacies generally were satisfied with electronic
transmission of new prescriptions but reported that the electronic renewal
process was used inconsistently, resulting in inefficient workarounds for
both parties. Practice communications with mail-order pharmacies were
less likely to be electronic than with community pharmacies because of
underlying transmission network and computer system limitations. While
e-prescribing reduced manual prescription entry, pharmacy staff
frequently had to complete or edit certain fields, particularly drug name
and patient instructions.
Conclusions: Electronic transmission of new prescriptions has matured.
Changes in technical standards and system design and more targeted
physician and pharmacy training may be needed to address barriers to erenewals, mail-order pharmacy connectivity, and pharmacy processing of
e-prescriptions.
http://jamia.bmj.com/content/early/2011/11/17/amiajnl-2011-000515.full
Determination of the effectiveness of two methods for
usability evaluation using a CPOE medication ordering
system
R Khajouei, A Hasman, MWM Jaspers
International Journal of Medical Informatics May 2011;80(5):341-350
Objectives: To assess the effectiveness of two usability evaluation
methods, cognitive walkthrough (CW) and think aloud (TA), for identifying
usability problems and to compare the performance of CW and TA in
identifying different types of usability problems.
Methods: A CW was performed by two usability evaluators and 10
physicians were recruited to perform a TA usability testing of a CPOE
system (Medicator). The severity of identified usability problems was
determined and the usability problems were categorised based on the User
Action Framework (UAF). The potential of usability problems to cause
medication errors was also determined. The thoroughness, validity and
effectiveness of the two methods were compared.
Results: 57 unique usability problems of different severity, spread over the
four phases of interaction as defined by the UAF, were identified. The
effectiveness of the TA method for identifying usability problems was 0.08
higher than that of the CW (0.70 vs 0.62). The thoroughness (the extent
to which a method can identify existing usability problems) of the TA was
higher for the 'Planning' and 'Assessment' phases and lower for the
'Translation' phase (as defined by UAF). The thoroughness of TA for
30
identifying problems that may potentially result in medication errors was
higher than that of CW (0.81 vs 0.68). The number of usability problems
identified by each of the methods was significantly less than the total
number of real usability problems detected in Medicator (p less than
0.001). The observed differences between the number of real usability
problems identified by CW and TA (38 vs 41), the difference between the
average severity of the detected problems by CW and TA (2.37 vs 2.41),
and the difference for identifying problems potentially resulting in
medication errors (15 vs 18) were not statistically significant (p greater
than 0.4).
Conclusions: This study shows that although TA showed a slightly better
effectiveness, there is no significant difference between the performance
of the CW and the TA methods in terms of number of usability problems
identified and the mean severity of these problems. Since no single
evaluation method will uncover all of the usability problems a combination
of methods is advised as the most appropriate approach, especially if
usability problems can lead to potentially fatal outcomes.
http://www.sciencedirect.com/science/article/pii/S1386505611000505
Clinicians' satisfaction with CPOE ease of use and effect on
clinicians' workflow, efficiency and medication safety
R Khajouei, PC Wierenga, A Hasman, MWM Jaspers
International Journal of Medical Informatics May 2011;80(5):297-309
Objectives: To study the satisfaction of end-users of a computerised
physician order entry (CPOE) system concerning ease of use and the effect
on users' workflow, efficiency and medication safety and to seek users'
opinions regarding required improvements of the system. Usability
evaluation had shown that this system, which was in use for almost a
decade, contained a number of severe usability problems. So another
objective of the study was to determine whether there was a direct
relation between user satisfaction and the results of a usability evaluation
of the system.
Methods: Two survey questionnaires were distributed to CPOE system
users (physicians and nurses) working in inpatient departments of a
university hospital in the Netherlands. Questionnaires included items that
were rated using a 5-point Likert scale. Multiple choice questions with
space for free text additions also were used to collect qualitative data
concerning the use of the CPOE system and the users' opinion concerning
system requirements for improvement. Data were analysed using
descriptive statistics and by the use of Mann–Whitney U and Kruskal Wallis
tests.
Results: 217 physicians and 587 nurses were eligible to participate in this
study (response rate 49% and 56% respectively). Physicians were
satisfied with the CPOE ease of use (median 3.8, interquartile range (IQR)
3.3-4), and the effect on workflow (median 3.7, IQR 3.3-4), medication
safety (median 3.75, IQR 3-4) and efficiency (median 4, IQR 3-4). Nurses
also had a positive attitude towards CPOE ease of use (median 3.6, IQR 34) and its effect on workflow (median 3, IQR 3-3.6), medication safety
(median 3, IQR 2.5-3.5) and efficiency (median 3.5, IQR 3-4). Users
mainly indicated that the system needs: supplementary functionalities
(e.g. alerts for allergies), improvement of current functionalities,
integration with other hospital information systems and improvement of
information presentation (e.g. a clear medication overview). Users did not
use some current functionalities because of lack of awareness of the
functionalities or having difficulty in using them.
31
Conclusions: Users of this CPOE system, which has been used for almost a
decade, were satisfied with the system's ease of use and its effect on
efficiency, workflow and medication safety although the system showed
many usability problems and lacked some functionalities. In this case
study, therefore, there seems no direct relation between the results of the
usability evaluation performed earlier and user satisfaction as determined
in the current study.
http://www.sciencedirect.com/science/article/pii/S1386505611000554
Evaluating the medication process in the context of CPOE
use: the significance of working around the system
Z Niazkhani, H Pirnejad, H van der Sijs, J Aarts
International Journal of Medical Informatics Jul 2011;80(7):490-506
Objective: To evaluate the problems experienced after implementing a
computerised physician order entry (CPOE) system, their possible root
causes, and the responses of providers in order to incorporate the system
into daily workflow.
Methods: A qualitative study in the medication-use process after
implementation of a CPOE system in an academic hospital in the
Netherlands. Data included 21 interviews with clinical end-users, paperbased and system-generated documents used daily in the process, and
educational materials used to train users.
Findings: The problems in the medication-use process included cognitive
overload on physicians and nurses, unmet information needs,
miscommunication of orders and ideas, problematic coordination of
interrelated tasks between co-working professionals, a potentially faulty
administration phase, and suboptimal monitoring of the medication plans.
These problems were mainly rooted in the lack of mobile computer
devices, the uneasy integration of coexisting electronic and paper-based
systems, suboptimal usability of the system, and certain organisational
factors with regard to procuring drugs affecting the technology use.
Various types of workarounds were used to address the difficulties,
including phone calls, taking multiple paper notes, issuing paper-based
and verbal orders, double-checking, using other patients' procured drugs
or another department's drug supply, and modifying and annotating the
printed orders.
Conclusions: This study shows how providers are actively involved in
working around the interruptions in workflow by bypassing the technology
or adapting the work processes. Although certain workarounds help to
maintain smooth workflow and/or to ensure patient safety, others may
burden providers by necessitating extra time and effort and/or
endangering patient safety. It is important that workarounds having a
negative nature are recognised and discussed in order to find solutions to
mitigate their effects.
http://www.sciencedirect.com/science/article/pii/S138650561100075X
Implementation
ASHP guidelines on pharmacy planning for implementation
of computerized provider-order-entry systems in hospitals
and health systems
32
ASHP Section of Pharmacy Informatics and Technology
American Journal of Health-System Pharmacy 15 Mar 2011;68(6):e9-e31
The purpose of these guidelines is to provide guidance to pharmacists in
hospitals and health systems on planning for, implementing and enhancing
safe, computerised provider-order-entry (CPOE) systems. To date, most
CPOE guidelines have concentrated on the functionality required in a CPOE
system, despite the fact that most CPOE system implementations occur
using commercial systems whose functionality is largely pre-determined.
These guidelines are intended to help pharmacy directors, managers,
informaticists and project managers successfully engage in this type of
CPOE system implementation.
http://www.ajhp.org/content/68/6.toc
Meaningful use of electronic prescribing in 5 exemplar
primary care practices
JC Crosson, RS Etz, S Wu, SG Straus, D Eisenman, DS Bell
Annals of Family Medicine Sep-Oct 2011;9(5):392-397
Purpose: Successful use of electronic prescribing (e-prescribing) is a key
requirement for demonstrating meaningful use of electronic health records
to qualify for Federal incentives in the USA. Currently, many physicians
who implement e-prescribing fail to make substantial use of these
systems, and little is known about factors contributing to successful eprescribing use. The objective of this study was to identify successful
implementation and use techniques.
Methods: We conducted a multimethod qualitative case study of 5
ambulatory primary care practices identified as exemplars of effective eprescribing. The practices were identified by a group of e-prescribing
experts. Field researchers conducted in-depth interviews and observed
prescription-related workflow in these practices.
Results: In these exemplar practices, successful use of e-prescribing
required practice transformation. Practice members reported extensive
efforts to redesign work processes to take advantage of e-prescribing
capabilities and to create specific e-prescribing protocols to distribute
prescription-related work among practice team members. These practices
had substantial resources to support e-prescribing use, including local
physician champions, ongoing training for practice members and
continuous on-site technical support. Practices faced considerable
challenges during use of e-prescribing, however, deriving from problems
coordinating new work processes with pharmacies and ineffective health
information exchange that required workarounds to ensure the
completeness of patient medical records.
Conclusions: More widespread implementation and effective use of eprescribing in ambulatory care settings will require practice transformation
efforts that focus on work process redesign while being attentive to effects
on patient and pharmacy involvement in prescribing. Improved health
information exchange is required to realise fully the expected quality,
safety and efficiency gains of e-prescribing.
http://www.annfammed.org/content/9/5/392.abstract
Electrifying prescriptions
A Heed, L Campbell
Hospital Pharmacy Europe Mar-Apr 2011;(055):14,16
In 2009, Newcastle-upon-Tyne Hospitals NHS Foundation Trust went live
with Cerner Millenium, a system which delivers electronic prescribing (EP)
and administration on 27 wards with roll-out over 4 months. Some
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experiences are described. The design was based on Connecting for
Health and DM+D guidelines. The most successful order sets developed
were for post-operative analgesia which were developed with a team of
anaesthetists, emphasising the need for end-users to be involved in the
design of the system.
http://www.hospitalpharmacyeurope.com/default.asp
General/Miscellaneous
The future of electronic prescribing
J Aarts
Studies in Health Technology and Informatics 2011;166:13-17
Implementing electronic prescribing in health care has been a slow
process. Health authorities are now requiring mandatory electronic
prescribing because of patient safety concerns. Electronic prescribing is
not yet a mature technology, and may therefore pose a risk, especially
if organisational conditions are not taken into account. This paper offers
some thoughts on the future of electronic prescribing in practice. It is
especially important to extend electronic prescribing to the continuum of
care in order avoid medication safety falling between the cracks of
fragmented health care organisations.
http://www.booksonline.iospress.nl/Content/View.aspx?piid=19700
An assessment of Health Care Information and Management
Systems Society and Leapfrog data on computerized provider
order entry
ML Diana, A Swanson Kazley, N Menachemi
Health Services Research Oct 2011;46(5):1575-1591
Objective: To assess the internal consistency and agreement between the
(US) Health Care Information and Management Systems Society (HIMSS)
and the Leapfrog computerized provider order entry (CPOE) data.
Data Sources: Secondary hospital data collected by HIMSS Analytics, the
Leapfrog Group and the American Hospital Association from 2005 to 2007.
Study Design: Dichotomous measures of full CPOE status were created for
the HIMSS and Leapfrog datasets in each year. We assessed internal
consistency by calculating the percentage of full adopters in a given year
that report full CPOE status in subsequent years. We assessed the level of
agreement between the two datasets by calculating the kappa statistic and
McNemar's test. We examined responsiveness by assessing the change in
full CPOE status rates, over time, reported by HIMSS and Leapfrog data,
respectively.
Principal Findings. Findings indicate minimal agreement between the two
datasets regarding positive hospital CPOE status, but adequate agreement
within a given dataset from year to year. Relative to each other, the
HIMSS data tend to overestimate increases in full CPOE status over time,
while the Leapfrog data may underestimate year over year increases in
national CPOE status.
Conclusions: Both Leapfrog and HIMSS data have strengths and
weaknesses. Those interested in studying outcomes associated with CPOE
use or adoption should be aware of the strengths and limitations of the
Leapfrog and HIMSS datasets. Future development of a standard
definition of CPOE status in hospitals will allow for a more comprehensive
validation of these data.
http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01259.x/abstract
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Ohio physicians' intent to adopt electronic prescribing
SL Pinto, NS Weber
Journal of Pharmacy Technology Jul-Aug 2011;27(4):168-174
Background: Currently in health care, communication between prescribers
and pharmacists routinely entails paper and a telephone. Many
professional associations have strongly advocated the adoption of
electronic prescribing (e-prescribing) in physicians' clinical practices to
decrease medication errors and adverse drug events. However, very few
physicians have adopted this technology in the USA.
Objective: To determine the relationship between Ohio (USA) physicians'
demographics and their intention to adopt e-prescribing; assess the
relationships between attitudes, subjective norms and perceived
behavioural control as applied to physicians' intention to adopt eprescribing; and identify factors that can predict physicians’ intention
toward the adoption of e-prescribing.
Methods: In this exploratory cross-sectional study, we used a selfadministered survey. The survey was developed based on the constructs
of the Theory of Planned Behavior. It was mailed to 1500 physicians
currently practising in Ohio. Demographic information about the
respondents was collected. Pearson correlation was used to assess the
relationship between demographics and intention to adopt e-prescribing.
Multiple regression analysis was used to identify the factors predicting
intention.
Results: The overall survey response rate was 15.33% (N = 230). A
significant weak negative correlation was found between physicians' ages
(r = -0.180; p = 0.007) and their intention to adopt electronic
prescribing. A statistically significant negative correlation was also found
between practice type (r = –0.196; p = 0.003) and the intention to adopt
electronic prescribing. Attitude was the strongest predictor of intention to
adopt e-prescribing (beta = 0.539; p = 0.000).
Conclusions: Physicians with more positive attitudes, positive subjective
norms, and positive perceived behavioural control have a stronger
intention to adopt e-prescribing.
http://www.jpharmtechnol.com/abstracts/volume27/July-Aug/vol27-num4pg168.php
Electronic information and clinical decision support for
prescribing: state of play in Australian general practice
J Robertson, AJ Moxey, DA Newby, MB Gillies, M Williamson, S-A Pearson
Family Practice Feb 2011;28(1):93-101
Background: Investments in e-health worldwide have been mirrored in
Australia, with more than 90% of general practices computerised. Recent
e-health incentives promote the use of up to date electronic information
sources relevant to general practice with flexibility in mode of access.
Objective: To determine Australian GPs' access to and use of electronic
information sources and computerised clinical decision support systems
(CDSSs) for prescribing.
Methods: Semi-structured interviews were conducted with 18 experienced
GPs and 9 GP trainees in New South Wales, Australia in 2008. A thematic
analysis of interview transcripts was undertaken.
Results: Information needs varied with clinical experience, and people
resources (specialists, GP peers and supervisors for trainees) were often
preferred over written formats. Experienced GPs used a small number of
electronic resources and accessed them infrequently. Familiarity from
training and early clinical practice and easy access were dominant
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influences on resource use. Practice time constraints meant relevant
information needed to be readily accessible during consultations, requiring
integration or direct access from prescribing software. Quality of
electronic resource content was assumed and cost a barrier for some GPs.
Conclusions: The current Australian practice incentives do not prescribe
which information resources GPs should use. Without integration into
practice computing systems, uptake and routine use seem unlikely. CDSS
developments must recognise the time pressures of practice, preference
for integration and cost concerns. Minimum standards are required to
ensure that high-quality information resources are integrated and
regularly updated. Without standards, the anticipated benefits of
computerisation on patient safety and health outcomes will be uncertain.
http://fampra.oxfordjournals.org/content/28/1/93.full.pdf+html
Results of the Arizona Medicaid health information
technology pharmacy focus groups
TL Warholak, A Murcko, M McKee, T Urbine
Research in Social and Administrative Pharmacy Dec 2011;7(4):438-443
Background: In 2007, a US Federal Medicaid Transformation Grant was
awarded to design, develop and deploy a statewide Health Information
Exchange and Electronic Health Record in Arizona, United States.
Objective: To explore the health information technology needs, knowledge
and expectations of Arizona's health care professionals, moderated focus
groups were conducted. This article describes the results of the
pharmacist focus groups.
Methods: Focus group activities included a brief presentation, completion
of a paper-based survey and group discussion. The methods included
solicitation by invitation, participant selection, meeting content, collaterals,
focus group execution, recording, analysis and discerning comparability
among groups.
Results: Pharmacy focus group discussions centred on electronic
prescribing, including the anticipated advantages: reducing handwriting
interpretation errors, improving formulary compliance, improving
communication with prescribers, increasing efficiency, and ensuring data
accuracy. Disadvantages included: medication errors, inadequate training
and knowledge of software applications, and inflated patient expectations.
Conclusions: Pharmacists ranked e-prescribing as the highest priority
feature of an electronic health system.
http://www.sciencedirect.com/science/article/pii/S1551741110001026
Value of e-prescribing questioned
PC Webster
Canadian Medical Association Journal 4 Oct 2011;183(14):1575-1577
News feature outlining progress with electronic transfer of prescriptions in
Canada. Canada Health Infoway, the federally-funded not-for-profit
organisation responsible for developing electronic health records, is now
urging more rapid progress toward e-prescribing. However, while several
provinces have built centralised drug information systems that
theoretically allow e-prescribing, there are few doctors in Canada who are
electronically transmitting prescriptions to pharmacies. Meanwhile, some
Canadian researchers are sceptical that e-prescribing will achieve the
hoped-for benefits in terms of faster filling of prescriptions and fewer
medication errors.
http://www.cmaj.ca/content/183/14/1575.full.pdf+html
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