Berg, M.

Patients and Their Problems: Situated Alliances of Patient-Centred Care and Pathway Development (In Book)

2012-01-01T00:00:00Z

Understanding handling of drug safety alerts: a simulation study (Article)

2010-05-01T00:00:00Z

Purpose: To study correctness of drug safety alert handling and error type in a computerized physician order entry (CPOE) system in a simulated work environment. Methods: Disguised observation study of 18 physicians (12 from internal medicine and 6 from surgery) entering 35 orders of predefined patient cases with 13 different drug safety alerts in a CPOE. Structured interviews about how the generated drug safety alerts were handled in the simulation test and resemblance of the test to the normal work environment. Handling and reasons for this were scored for correctness and error type. Results: Thirty percent of alerts were handled incorrectly, because the action itself and/or the reason for the handling were incorrect. Sixty-three percent of the errors were categorized as rule based and residents in surgery used incorrect justifications twice as often as residents in internal medicine. They often referred to monitoring of incorrect substances or parameters. One alert presented as a second alert in one screen was unconsciously overridden several times. One quarter of residents showed signs of alert fatigue. Conclusion: Although alerts were mainly handled correctly, underlying rules and reasoning were often incorrect, thereby threatening patient safety. This study gave an insight into the factors playing a role in incorrect drug safety alert handling that should be studied in more detail. The results suggest that better training, improved concise alert texts, and increased specificity might help. Furthermore, the safety of the predefined override reason 'will monitor' and double alert presentation in one screen is questioned.

Functionality test for drug safety alerting in computerized physician order entry systems (Article)

2010-04-01T00:00:00Z

Purpose: To evaluate the functionality of drug safety alerting in hospital computerized physician order entry (CPOE) systems by a newly developed comprehensive test. Methods: Comparative evaluation of drug safety alerting quality in 6 different CPOEs used in Dutch hospitals, by means of 29 test items for sensitivity and 19 for specificity in offices of CPOE system vendors. Sensitivity and specificity were calculated for the complete test, and for the categories "within-order checks", "patient-specific checks", and "checks related to laboratory data and new patient conditions". Qualitative interviews with 16 hospital pharmacists evaluating missing functionality and corresponding pharmacy checks. Results: Sensitivity ranged from 0.38 to 0.79 and specificity from 0.11 to 0.84. The systems achieved the same ranking for sensitivity as for specificity. Within-order checks and patient-specific checks were present in all systems; alert generation or suppression due to laboratory data and new patient conditions was largely absent. Hospital pharmacists unanimously rated checks on contra-indications (absent in 2 CPOEs) and dose regimens less than once a day (absent in 4 CPOEs) as important. Pharmacists' opinions were more divergent for other test items. A variety of pharmacy checks were used, and clinical rules developed, to address missing functionality. Conclusions: Our test revealed widely varying functionality and appeared to be highly discriminative. Basic clinical decision support was partly absent in two CPOEs. Hospital pharmacists did not rate all test items as important and tried to accommodate the lacking functionality by performing additional checks and developing clinical rules.

Evaluation of the impact of a CPOE system on nurse-physician communication--a mixed method study. (Article)

2009-12-01T00:00:00Z

OBJECTIVES: To assess the impact of a CPOE system on medication-related communication of nurses and physicians. METHODS: In six internal medicine wards of an academic medical center, two questionnaires were used to evaluate nurses' attitudes toward the impact of a paper-based medication system and then a CPOE system on their communication in medication-related-activities (medication work). The questionnaires were analyzed using t-tests, followed by Bonferroni correction. Nine nurses and six physicians in the same wards were interviewed after the implementation to determine how their communication and their work have been impacted by the system. RESULTS: The total response rates were 54% and 52% for pre- and post-implementation questionnaires. It was shown that after implementation, the legibility and completeness of prescriptions were significantly improved (P <.001) and the administration system had a more intelligible layout (P <.001), with a more reliable overview (P <.001). The analysis of the interviews supported and confirmed the findings of the surveys. Moreover, they showed communication problems that caused difficulties in integrating medication work of nurses into physicians'. To compensate for these, nurses and physicians devised informal interactions and practices (workarounds), which often represented risks for medication errors. CONCLUSION: The introduction of CPOE system with paper-based medication administration system improved prescription legibility and completeness but introduced many workflow impediments and as a result error-inducing conditions. In order to prevent such an effect, CPOE systems have to support the level of communication which is necessary to integrate the work of nurses and physicians.

Time-dependent drug-drug interaction alerts in care provider order entry: software may inhibit medication error reductions (Article)

2009-11-01T00:00:00Z

Time-dependent drug-drug interactions (TDDIs) are drug combinations that result in a decreased drug effect due to coadministration of a second drug. Such interactions can be prevented by separately administering the drugs. This study attempted to reduce drug administration errors due to overridden TDDIs in a care provider order entry (CPOE) system. In four periods divided over two studies, logged TDDIs were investigated by reviewing the time intervals prescribed in the CPOE and recorded on the patient chart. The first study showed significant drug administration error reduction from 56.4 to 36.2% (p<0.05), whereas the second study was not successful (46.7 and 45.2%; p>0.05). Despite interventions, drug administration errors still occurred in more than one third of cases and prescribing errors in 79-87%. Probably the low alert specificity, the unclear alert information content, and the inability of the software to support safe and efficient TDDI alert handling all diminished correct prescribing, and consequently, insufficiently reduced drug administration errors.

Unintended consequences of reducing QT-alert overload in a computerized physician order entry system (Article)

2009-09-01T00:00:00Z

Purpose: After complaints of too many low-specificity drug-drug interaction (DDI) alerts on QT prolongation, the rules for QT alerting in the Dutch national drug database were restricted in 2007 to obviously QT-prolonging drugs. The aim of this virtual study was to investigate whether this adjustment would improve the identification of patients at risk of developing Torsades de Pointes (TdP) due to QT-prolonging drug combinations in a computerized physician order entry system (CPOE) and whether these new rules should be implemented. Methods: During a half-year study period, inpatients with overridden DDI alerts regarding QT prolongation and with an electrocardiogram recorded before and within 1 month of the alert override were included if they did not have a ventricular pacemaker and did not use the low-risk combination cotrimoxazole and tacrolimus. QT-interval prolongation and the risk of developing TdP were calculated for all patients and related to the number of patients for whom a QT-alert would be generated in the new situation with the restricted database. Results: Forty-nine patients (13%) met the inclusion criteria. In this study population, knowledge base-adjustment would reduce the number of alerts by 53%. However, the positive predictive value of QT alerts would not change (31% before and 30% after) and only 47% of the patients at risk of developing TdP would be identified in CPOEs using the adjusted knowledge base. Conclusion: The new rules for QT alerting would result in a poorer identification of patients at risk of developing TdP than the old rules. This is caused by the many non-drug-related risk factors for QT prolongation not being incorporated in CPOE alert generation. The partial contribution of all risk factors should be studied and used to create clinical rules for QT alerting with an acceptable positive predictive value.

The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review (Article)

2009-07-01T00:00:00Z

Previous studies have shown the importance of workflow issues in the implementation of CPOE systems and patient safety practices. To understand the impact of CPOE on clinical workflow, we developed a conceptual framework and conducted a literature search for CPOE evaluations between 1990 and June 2007. Fifty-one publications were identified that disclosed mixed effects of CPOE systems. Among the frequently reported workflow advantages were the legible orders, remote accessibility of the systems, and the shorter order turnaround times. Among the frequently reported disadvantages were the time-consuming and problematic user-system interactions, and the enforcement of a predefined relationship between clinical tasks and between providers. Regarding the diversity of findings in the literature, we conclude that more multi-method research is needed to explore CPOE's multidimensional and collective impact on especially collaborative workflow.

Drug safety alert generation and overriding in a large Dutch university medical centre (Article)

2009-07-01T00:00:00Z

PURPOSE: To evaluate numbers and types of drug safety alerts generated and overridden in a large Dutch university medical centre. METHODS: A disguised observation study lasting 25 days on two internal medicine wards evaluating alert generation and handling of alerts. A retrospective analysis was also performed of all drug safety alerts overridden in the hospital using pharmacy log files over 24 months. RESULTS: In the disguised observation study 34% of the orders generated a drug safety alert of which 91% were overridden. The majority of alerts generated (56%) concerned drug-drug interactions (DDIs) and these were overridden more often (98%) than overdoses (89%) or duplicate orders (80%). All drug safety alerts concerning admission medicines were overridden.Retrospective analysis of pharmacy log files for all wards revealed one override per five prescriptions. Of all overrides, DDIs accounted for 59%, overdoses 24% and duplicate orders 17%. DDI alerts of medium-level seriousness were overridden more often (55%) than low-level (22%) or high-level DDIs (19%). In 36% of DDI overrides, it would have been possible to monitor effects by measuring serum levels. The top 20 of overridden DDIs accounted for 76% of all DDI overrides. CONCLUSIONS: Drug safety alerts were generated in one third of orders and were frequently overridden. Duplicate order alerts more often resulted in order cancellation (20%) than did alerts for overdose (11%) or DDIs (2%). DDIs were most frequently overridden. Only a small number of DDIs caused these overrides. Studies on improvement of alert handling should focus on these frequently-overridden DDIs.

Building an inter-organizational communication network and challenges for preserving interoperability (Article)

2008-12-01T00:00:00Z

Background: The ideal scenario for information technology to bridge information gaps between primary and secondary healthcare and to improve the quality of healthcare in the medication process is to build an interoperable communication network. This type of undertaking requires diverse information systems to be integrated, and central to this are the preservation of data integrity and the integration of different pieces of patient data. Objectives and methodology: In this study, we focused on sources of challenges to the integration process and to the building of an interoperable communication network. Interviews, document analysis, and observations were conducted to evaluate the integration process in a project that involved medication data communication between primary healthcare providers (i.e., general practitioners and community pharmacists) and secondary healthcare providers (i.e., hospital pharmacists and specialist physicians). Results: The project encountered numerous integration problems, many of which persisted even after extensive technical intervention. An analysis of the problems revealed that they were mostly rooted either in problematic integration of work processes or in the way the system was used. Despite the project's ideal technical condition, the integration could be accomplished only by applying human interfaces. Conclusion: The main challenge to building interoperable communication network does not lie in technical integration. The real problem occurs when the technical linkage is implemented without the work processes being aligned and integrated.

Impact of a computerized physician order entry system on nurse-physician collaboration in the medication process (Article)

2008-11-01T00:00:00Z

Background: Due to their efficiency and safety potential, computerized physician order entry (CPOE) systems are gaining considerable attention in in-patient settings. However, recent studies have shown that these systems may undermine the efficiency and safety of the medication process by impeding nurse-physician collaboration. Objective: To evaluate the effects of a CPOE system on the mechanisms whereby nurses and physicians maintain their collaboration in the medication process. Setting and methodology: Six internal medicine wards at the Erasmus Medical Centre were included in this study. A questionnaire was used to record nurses' attitudes towards the effectiveness of the former paper-based system. A similar questionnaire was used to evaluate nurses' attitudes with respect to a CPOE system that replaced the paper-based system. The data were complemented and triangulated through interviews with physicians and nurses. Results: Response rates for the analyzed questions in the pre- and post-implementation questionnaires were 54.3% (76/140) and 52.14% (73/140). The CPOE system had a mixed impact on medication work: while it improved the main non-supportive features of the paper-based system, it lacked its main supportive features. The interviews revealed more detailed supportive and non-supportive features of the two systems. A comparison of supportive features of the paper-based system with non-supportive features of the CPOE system showed that synchronisation and feedback mechanisms in nurse-physician collaborations have been impaired after the CPOE system was introduced. Conclusion: This study contributes to an understanding of the affected mechanisms in nurse-physician collaboration using a CPOE system. It provides recommendations for repairing the impaired mechanisms and for redesigning the CPOE system and thus for better supporting these structures.

Intra-organizational communication in healthcare - Considerations for standardization and ICT application (Article)

2008-09-05T00:00:00Z

Objectives: Intra-organizational communication is mostly interpersonal. Synchronous interruptive communication is recognized as a primary source of inefficiency and error in healthcare, and there is much potential for information and communication technology (ICT) to improve such communication. As recently suggested, however, due to communication failures ICT can also compound medical errors. In this paper we analyze factors that restrict the role of ICT in improving interpersonal healthcare communication and suggest solutions. Methods: We critically analyzed the literature from a selection of diverse scientific disciplines. These were related to interpersonal communication, to the role and place of standardization and computerization in its improvement, and to reducing medical errors. Results: Four possible scenarios were defined on how ICT can serve healthcare communication. Two differing conceptual frameworks about communication in health-care were discussed. Considering "information space" as a part of "communication space" allows the recognition and control of the source of the semantic gaps in conventional standardization and an enhancement of the role of ICT in improving intra-organizational communication. Moreover, cognitive, social, and organizational dimensions of complexity in interpersonal communication can be managed. Three approaches to control the variability in those dimensions and to promote the role of ICT in intra-organizational communication were discussed. Conclusion: A multi-dimensional approach is required to promote the role of ICT in intro-organizational communication in healthcare. Parallel to conventional standardization, at least three dimensions need to be addressed: controlling the effect of the social context, developing standard information processing skills, and most importantly, controlling variations in care practices' performance.

Intensified preventive care to reduce cardiovascular risk in healthcare centres located in deprived neighbourhoods: A randomized controlled trial (Article)

2008-08-01T00:00:00Z

Background: We examined the effectiveness of a structured collaboration in general practice between a practice nurse, a peer health educator, the general practitioner (GP) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases. DESIGN: A randomized controlled trial in three healthcare centres (18 GPs) in deprived neighbourhoods of two major Dutch cities. Methods: Two hundred seventy-five high-risk patients (30-70 years) from various ethnic groups were randomized to intervention (n=137) or usual care group (n=138). We determined group differences in outcomes [10-year absolute risk (Framingham risk equation), blood pressure, lipids and body mass index] at 12-month follow-up. Results: The 10-year absolute risk was reduced by 1.76% (standard error: 0.81) in intervention and by 2.27% (standard error: 0.69) in usual care group; the difference in mean change was 0.88% [95% confidence interval: -1.16 to 2.93]. In both groups significant reductions were observed in the following individual risk factors: total cholesterol, total cholesterol/high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol, with no relevance between group differences. Conclusion: The cardiovascular risk profile of intervention and control patients improved after 1-year follow-up. However, no extra effect of the structured preventive care on the risk for cardiovascular diseases was achieved.

Turning Off Frequently Overridden Drug Alerts: Limited Opportunities for Doing It Safely (Article)

2008-07-01T00:00:00Z

Objectives: This study sought to identify opportunities to safely turn off frequently overridden drug-drug interaction alerts (DDIs) in computerized physician order entry (CPOE). Design: Quantitative retrospective analysis of drug safety alerts overridden during 1 month and qualitative interviews with 24 respondents (18 physicians and 6 pharmacists) about turning off frequently overridden DDI alerts, based on the Dutch drug database, in a hospital setting. Screen shots and complete texts of frequently overridden DDIs were presented to physicians of internal medicine, cardiology, and surgery and to hospital pharmacists who were asked whether these could be turned off hospital-wide without impairing patient safety, and the reasons for their recommendations. Results: Data on the frequency of alerts overridden in 1 month identified 3,089 overrides, of which 1,963 were DDIs. The category DDIs showed 86 different alerts, of which 24 frequently overridden alerts, accounting for 72% of all DDI overrides, were selected for further evaluation. The 24 respondents together made 576 assessments. Upon investigation, differences in the reasons for turning off alerts were found across medical specialties and among respondents within a specialty. Frequently mentioned reasons for turning off were "alert well known," "alert not serious," or "alert not needing (additional) action," or that the effects of the combination were monitored or intended. For none of the alerts did all respondents agree that it could be safely turned off hospital-wide. The highest agreement was 13 of 24 respondents (54%). A positive correlation was found between the number of alerts overridden and the number of clinicians recommending to turn them off. Conclusion: Although the Dutch drug database is already a selected reduction from all DDIs mentioned in literature, the majority of respondents wanted to turn off DDI alerts to reduce alert overload. Turning off DDI alerts hospital-wide appeared to be problematic because of differences among physicians regarding drug-related knowledge and of differences across the hospital in routine drug monitoring practices. Furthermore, several reasons for suppression of alerts could be questioned from a safety perspective. Further research should investigate when each of the following might help: changes in alert texts; new differential alert triggers based on clinician knowledge or specialty; and nonintrusive alert presentation so long as serum levels and patient parameters are measured and stay within limits.

Building quality report cards for geriatric care in The Netherlands: using concept mapping to identify the appropriate "building blocks" from the consumer's perspective (Article)

2008-02-01T00:00:00Z

Abstract PURPOSE: This article reports on a study to identify "building blocks" for quality report cards for geriatric care. Its aim is to present (a) the results of the study and (b) the innovative step-by-step approach that was developed to arrive at these results. DESIGN AND METHODS: We used Concept Mapping/Structured Conceptualization to define the building blocks. Applied to this study, we carried out Concept Mapping using several data collection methods: (a) a Web search, (b) semistructured interviews, (c) document analysis, (d) questionnaires, and (e) focus groups. RESULTS: The findings showed that, although home care and institutional care for elderly adults share many quality themes, experts need to develop separate quality report cards for the two types of geriatric care. Home care consumers attach more value to the availability, continuity, and reliability of care, whereas consumers of institutional care value privacy, respect, and autonomy most. This study also showed, unlike many other quality report card studies, that consumers want information on structure, process and outcome indicators, and rating outcome indicators such as effectiveness and safety of care both for home care and for institutional care. Concept Mapping proved to be a valuable method for developing quality report cards in health care. IMPLICATIONS: Building blocks were delivered for two quality report cards for geriatric care and will be used when quality report cards are built in The Netherlands. For the U.S. context, this study shows that current national report cards for geriatric care should be supplemented with quality-of-life data.

OZIS and the politics of safety: Using ICT to create a regionally accessible patient medication record (Article)

2007-06-01T00:00:00Z

In studies on success and failure of ICT applications in health care, the 'context' is often used to explain the failure of a system and seldom to explain the success of a system. Science and Technology Studies (STS) have showed that for understanding success and failure of phenomena, one has to take a symmetrical approach and thus use the same concept for analyzing success and failure. In this article we analyze the success of OZIS, a communication protocol that makes it possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. Though OZIS serves a common goal - reducing medication errors - the stakeholders that are involved also have other, competing, interests. By focussing on the context and more specifically the interests of the stakeholders, we will show how the success of OZIS can be explained. By doing this, we will also show that this context is highly dynamic and that continuously changing incentives and constraints within the context lead to both facilitating and threatening the success of OZIS.

Extending the understanding of computerized physician order entry: Implications for professional collaboration, workflow and quality of care (Article)

2007-06-01T00:00:00Z

Objective: To describe the perceived effect of computerized physician order entry (CPOE) on professional collaboration, workflow and quality of care. Design: Semi-structured interviews with experts involved in the design, implementation and evaluation of computerized physician order systems in the United States. Measurements: The interview transcripts were analyzed using six key concepts that identify context, professional collaboration, workflow and quality of care. Results: The interviews reveal the complexity of CPOE. Although providers enter the orders, others collaborate in the decision-making process. There is a profound impact on workflow beyond that of the provider. While quality of care is the main impetus for implementation, it remains terribly difficult to measure the impact on quality. Conclusions: A proper understanding of CPOE as a collaborative effort and the transformation of the health care activities into integrated care programs requires an understanding of how orders are created and processed, how CPOE as part of an integrated system can support the workflow, and how risks affecting patient care can be identified and reduced, especially during hand-offs in the workflow.

Completeness of medical records in emergency trauma care and an IT-based strategy for improvement (Article)

2007-06-01T00:00:00Z

The medical trauma record, produced in the Accident & Emergency Departments (AEDs) receives much attention from both health-care professionals and parties interested in quality of care. While it is an important data source for health-care professionals in their everyday work, and for quality assessment by third parties, the (paper) medical record is usually negatively evaluated because of incompleteness. In this article, we show that completeness is relative to the purpose for which the record is used. We distinguish two contexts in which the trauma record is used: the primary-care process at the AED, and assessment and monitoring of trauma care. Incompleteness of the medical record is valued differently in these contexts. Especially with regard to the information demands of quality assessment, and more specifically the national trauma registry, the work processes in the AED have not evolved sufficiently as yet. Information technology has great power to improve completeness and to facilitate quality assessment, but it cannot solve the problem of incompleteness in itself. One solution we propose is to restructure the recording process by introducing a clerk. This clerk could also be a nurse or physician who is temporarily released from direct patient care.

Inter-organisational communication networks in healthcare: centralised versus decentralised approaches (Article)

2007-01-01T00:00:00Z

Background: To afford efficient and high quality care, healthcare providers increasingly need to exchange patient data. The existence of a communication network amongst care providers will help them to exchange patient data more efficiently. Information and communication technology (ICT) has much potential to facilitate the development of such a communication network. Moreover, in order to offer integrated care interoperability of healthcare organizations based upon the exchanged data is of crucial importance. However, complications around such a development are beyond technical impediments. Objectives: To determine the challenges and complexities involved in building an Inter-organisational Communication network (IOCN) in healthcare and the appropriations in the strategies. Case study: Interviews, literature review, and document analysis were conducted to analyse the developments that have taken place toward building a countrywide electronic patient record and its challenges in The Netherlands. Due to the interrelated nature of technical and non-technical problems, a socio-technical approach was used to analyse the data and define the challenges. Results: Organisational and cultural changes are necessary before technical solutions can be applied. There are organisational, financial, political, and ethicolegal challenges that have to be addressed appropriately. Two different approaches, one ‘‘centralised’’ and the other ‘‘decentralised’’ have been used by Dutch healthcare providers to adopt the necessary changes and cope with these challenges. Conclusion: The best solutions in building an IOCN have to be drawn from both the centralised and the decentralised approaches. Local communication initiatives have to be supervised and supported centrally and incentives at the organisations’ interest level have to be created to encourage the stakeholder organisations to adopt the necessary changes.

Understanding implementation: the case of a computerized physician order entry system in a large Dutch university medical center. (Article)

2004-05-01T00:00:00Z

Most studies of the impact of information systems in organizations tend to see the implementation process as a "rollout" of technology, as a technical matter removed from organizational dynamics. There is substantial agreement that the success of implementing information systems is determined by organizational factors. However, it is less clear what these factors are. The authors propose to characterize the introduction of an information system as a process of mutual shaping. As a result, both the technology and the practice supported by the technology are transformed, and specific technical and social outcomes gradually emerge. The authors suggest that insights from social studies of science and technology can help to understand an implementation process. Focusing on three theoretical aspects, the authors argue first that the implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Second, following Orlikowski's concept of "emergent change," they suggest that implementing a system is, by its very nature, unpredictable. Third, they argue that success and failure are not dichotomous and static categories, but socially negotiated judgments. Using these insights, the authors have analyzed the implementation of a computerized physician order entry (CPOE) system in a large Dutch university medical center. During the course of this study, the full implementation of CPOE was halted, but the aborted implementation exposed issues on which the authors did not initially focus.

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands (Article)

2003-01-01T00:00:00Z

OBJECTIVES: To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations. DESIGN: Analysis of the primary care sections of clinical practice guidelines. SETTING: Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands. MAIN OUTCOME MEASURES: Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence. RESULTS: Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews. CONCLUSION: The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.