Chemotherapy Order Entry by a Clinical Support Pharmacy Technician in an Outpatient Medical Day Unit.

PubMed

Neville, Heather; Broadfield, Larry; Harding, Claudia; Heukshorst, Shelley; Sweetapple, Jennifer; Rolle, Megan

2016-01-01

Pharmacy technicians are expanding their scope of practice, often in partnership with pharmacists. In oncology, such a shift in responsibilities may lead to workflow efficiencies, but may also cause concerns about patient risk and medication errors. The primary objective was to compare the time spent on order entry and order-entry checking before and after training of a clinical support pharmacy technician (CSPT) to perform chemotherapy order entry. The secondary objectives were to document workflow interruptions and to assess medication errors. This before-and-after observational study investigated chemotherapy order entry for ambulatory oncology patients. Order entry was performed by pharmacists before the process change (phase 1) and by 1 CSPT after the change (phase 2); order-entry checking was performed by a pharmacist during both phases. The tasks were timed by an independent observer using a personal digital assistant. A convenience sample of 125 orders was targeted for each phase. Data were exported to Microsoft Excel software, and timing differences for each task were tested with an unpaired t test. Totals of 143 and 128 individual orders were timed for order entry during phase 1 (pharmacist) and phase 2 (CSPT), respectively. The mean total time to perform order entry was greater during phase 1 (1:37 min versus 1:20 min; p = 0.044). Totals of 144 and 122 individual orders were timed for order-entry checking (by a pharmacist) in phases 1 and 2, respectively, and there was no difference in mean total time for order-entry checking (1:21 min versus 1:20 min; p = 0.69). There were 33 interruptions not related to order entry (totalling 39:38 min) during phase 1 and 25 interruptions (totalling 30:08 min) during phase 2. Three errors were observed during order entry in phase 1 and one error during order-entry checking in phase 2; the errors were rated as having no effect on patient care. Chemotherapy order entry by a trained CSPT appeared to be just as safe and efficient as order entry by a pharmacist. Changes in pharmacy technicians' scope of practice could increase the amount of time available for pharmacists to provide direct patient care in the oncology setting.

Decision Support Alerts for Medication Ordering in a Computerized Provider Order Entry (CPOE) System

PubMed Central

Beccaro, M. A. Del; Villanueva, R.; Knudson, K. M.; Harvey, E. M.; Langle, J. M.; Paul, W.

2010-01-01

Objective We sought to determine the frequency and type of decision support alerts by location and ordering provider role during Computerized Provider Order Entry (CPOE) medication ordering. Using these data we adjusted the decision support tools to reduce the number of alerts. Design Retrospective analyses were performed of dose range checks (DRC), drug-drug interaction and drug-allergy alerts from our electronic medical record. During seven sampling periods (each two weeks long) between April 2006 and October 2008 all alerts in these categories were analyzed. Another audit was performed of all DRC alerts by ordering provider role from November 2008 through January 2009. Medication ordering error counts were obtained from a voluntary error reporting system. Measurement/Results Between April 2006 and October 2008 the percent of medication orders that triggered a dose range alert decreased from 23.9% to 7.4%. The relative risk (RR) for getting an alert was higher at the start of the interventions versus later (RR= 2.40, 95% CI 2.28-2.52; p< 0.0001). The percentage of medication orders that triggered alerts for drug-drug interactions also decreased from 13.5% to 4.8%. The RR for getting a drug interaction alert at the start was 1.63, 95% CI 1.60-1.66; p< 0.0001. Alerts decreased in all clinical areas without an increase in reported medication errors. Conclusion We reduced the quantity of decision support alerts in CPOE using a systematic approach without an increase in reported medication errors PMID:23616845

Implementation of a pharmacy automation system (robotics) to ensure medication safety at Norwalk hospital.

PubMed

Bepko, Robert J; Moore, John R; Coleman, John R

2009-01-01

This article reports an intervention to improve the quality and safety of hospital patient care by introducing the use of pharmacy robotics into the medication distribution process. Medication safety is vitally important. The integration of pharmacy robotics with computerized practitioner order entry and bedside medication bar coding produces a significant reduction in medication errors. The creation of a safe medication-from initial ordering to bedside administration-provides enormous benefits to patients, to health care providers, and to the organization as well.

Impact of Computerized Provider Order Entry on Pharmacist Productivity

PubMed Central

Hatfield, Mark D.; Cox, Rodney; Mhatre, Shivani K.; Flowers, W. Perry

2014-01-01

Abstract Purpose: To examine the impact of computerized provider order entry (CPOE) implementation on average time spent on medication order entry and the number of order actions processed. Methods: An observational time and motion study was conducted from March 1 to March 17, 2011. Two similar community hospital pharmacies were compared: one without CPOE implementation and the other with CPOE implementation. Pharmacists in the central pharmacy department of both hospitals were observed in blocks of 1 hour, with 24 hours of observation in each facility. Time spent by pharmacists on distributive, administrative, clinical, and miscellaneous activities associated with order entry were recorded using time and motion instrument documentation. Information on medication order actions and order entry/verifications was obtained using the pharmacy network system. Results: The mean ± SD time spent by pharmacists per hour in the CPOE pharmacy was significantly less than the non-CPOE pharmacy for distributive activities (43.37 ± 7.75 vs 48.07 ± 8.61) and significantly greater than the non-CPOE pharmacy for administrative (8.58 ± 5.59 vs 5.72 ± 6.99) and clinical (7.38 ± 4.27 vs 4.22 ± 3.26) activities. The CPOE pharmacy was associated with a significantly higher number of order actions per hour (191.00 ± 82.52 vs 111.63 ± 25.66) and significantly less time spent (in minutes per hour) on order entry and order verification combined (28.30 ± 9.25 vs 36.56 ± 9.14) than the non-CPOE pharmacy. Conclusion: The implementation of CPOE facilitated pharmacists to allocate more time to clinical and administrative functions and increased the number of order actions processed per hour, thus enhancing workflow efficiency and productivity of the pharmacy department. PMID:24958959

Introducing Physician Order Entry at a Major Academic Medical Center: I. Impact on Organizational Culture and Behavior.

ERIC Educational Resources Information Center

Massaro, Thomas A.

1993-01-01

Implementation of the University of Virginia Medical Center's computerized system for mandatory recordkeeping of physician orders is discussed, focusing on administrative issues: delays, costs, disruption of work routine and behavior, and the need to bring in a senior management team. Recommendations are made for institutions with similar…

Effect of closed-loop order processing on the time to initial antimicrobial therapy.

PubMed

Panosh, Nicole; Rew, Richardd; Sharpe, Michelle

2012-08-15

The results of a study comparing the average time to initiation of i.v. antimicrobial therapy with closed-versus open-loop order entry and processing are reported. A retrospective cohort study was performed to compare order-to-administration times for initial doses of i.v. antimicrobials before and after a closed-loop order-processing system including computerized prescriber order entry (CPOE) was implemented at a large medical center. A total of 741 i.v. antimicrobial administrations to adult patients during designated five-month preimplementation and postimplementation study periods were assessed. Drug-use reports generated by the pharmacy database were used to identify order-entry times, and medication administration records were reviewed to determine times of i.v. antimicrobial administration. The mean ± S.D. order-to-administration times before and after the implementation of the CPOE system and closed-loop order processing were 3.18 ± 2.60 and 2.00 ± 1.89 hours, respectively, a reduction of 1.18 hours (p < 0.0001). Closed-loop order processing was associated with significant reductions in the average time to initiation of i.v. therapy in all patient care areas evaluated (cardiology, general medicine, and oncology). The study results suggest that CPOE-based closed-loop order processing can play an important role in achieving compliance with current practice guidelines calling for increased efforts to ensure the prompt initiation of i.v. antimicrobials for severe infections (e.g., sepsis, meningitis). Implementation of a closed-loop order-processing system resulted in a significant decrease in order-to-administration times for i.v. antimicrobial therapy.

Individualization through standardization: electronic orders for subcutaneous insulin in the hospital.

PubMed

Kennihan, Mary; Zohra, Tatheer; Devi, Radha; Srinivasan, Chitra; Diaz, Josefina; Howard, Bradley S; Braithwaite, Susan S

2012-01-01

The objective was to design electronic order sets that would promote safe, effective, and individualized order entry for subcutaneous insulin in the hospital, based on a review of best practices. Saint Francis Hospital in Evanston, Illinois, a community teaching hospital, was selected as the pilot site for 6 hospitals in the Health Care System to introduce an electronic medical record. Articles dealing with management of hospital hyperglycemia, medical order entry systems, and patient safety were reviewed selectively. In the published literature on institutional glycemic management programs and insulin order sets, features were identified that improve safety and effectiveness of subcutaneous insulin therapy. Subcutaneous electronic insulin order sets were created, designated in short: "patients eating", "patients not eating", and "patients receiving overnight enteral feedings." Together with an option for free text entry, menus of administration instructions were designed within each order set that were applicable to specific insulin orders and expressed in standardized language, such as "hold if tube feeds stop" or "do not withhold." Two design features are advocated for electronic order sets for subcutaneous insulin that will both standardize care and protect individualization. First, within the order sets, the glycemic management plan should be matched to the carbohydrate exposure of the patients, with juxtaposition of appropriate orders for both glucose monitoring and insulin. Second, in order to convey precautions of insulin use to pharmacy and nursing staff, the prescriber must be able to attach administration instructions to specific insulin orders.

Computerized N-acetylcysteine physician order entry by template protocol for acetaminophen toxicity.

PubMed

Thompson, Trevonne M; Lu, Jenny J; Blackwood, Louisa; Leikin, Jerrold B

2011-01-01

Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in treating acetaminophen poisoning. An 18-month retrospective review of computerized inpatient pharmacy records for NAC use was performed. All patients who received NAC for the treatment of acetaminophen poisoning were included. Each record was analyzed to determine the form of NAC given and whether an administration error occurred. In the 82 cases of acetaminophen poisoning in which NAC was given, no medication administration errors were identified. Oral NAC was given in 31 (38%) cases; intravenous NAC was given in 51 (62%) cases. In this retrospective analysis of N-acetylcysteine administration using computerized physician order entry and order sets, no medication administration errors occurred. CPOE is an effective tool in safely executing complicated protocols in an inpatient setting.

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

PubMed

Georgiou, Andrew; Prgomet, Mirela; Paoloni, Richard; Creswick, Nerida; Hordern, Antonia; Walter, Scott; Westbrook, Johanna

2013-06-01

We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems.

PubMed

Aziz, Muhammad Tahir; Ur-Rehman, Tofeeq; Qureshi, Sadia; Bukhari, Nadeem Irfan

Medication errors in chemotherapy are frequent and lead to patient morbidity and mortality, as well as increased rates of re-admission and length of stay, and considerable extra costs. Objective: This study investigated the proposition that computerised chemotherapy ordering reduces the incidence and severity of chemotherapy protocol errors. A computerised physician order entry of chemotherapy order (C-CO) with clinical decision support system was developed in-house, including standardised chemotherapy protocol definitions, automation of pharmacy distribution, clinical checks, labeling and invoicing. A prospective study was then conducted in a C-CO versus paper based chemotherapy order (P-CO) in a 30-bed chemotherapy bay of a tertiary hospital. Both C-CO and P-CO orders, including pharmacoeconomic analysis and the severity of medication errors, were checked and validated by a clinical pharmacist. A group analysis and field trial were also conducted to assess clarity, feasibility and decision making. The C-CO was very usable in terms of its clarity and feasibility. The incidence of medication errors was significantly lower in the C-CO compared with the P-CO (10/3765 [0.26%] versus 134/5514 [2.4%]). There was also a reduction in dispensing time of chemotherapy protocols in the C-CO. The chemotherapy computerisation with clinical decision support system resulted in a significant decrease in the occurrence and severity of medication errors, improvements in chemotherapy dispensing and administration times, and reduction of chemotherapy cost.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

An inventory of publications on electronic medical records revisited.

PubMed

Moorman, P W; Schuemie, M J; van der Lei, J

2009-01-01

In this short review we provide an update of our earlier inventories of publications indexed in MedLine with the MeSH term 'Medical Records Systems, Computerized'. We retrieved and analyzed all references to English articles published before January 1, 2008, and indexed in PubMed with the MeSH term 'Medical Records Systems, Computerized'. We retrieved a total of 11,924 publications, of which 3937 (33%) appeared in a journal with an impact factor. Since 2002 the number of yearly publications, and the number of journals in which those publications appeared, increased. A cluster analysis revealed three clusters: an organizational issues cluster, a technically oriented cluster and a cluster about order-entry and research. Although our previous inventory in 2003 suggested a constant yearly production of publications on electronic medical records since 1998, the current inventory shows another rise in production since 2002. In addition, many new journals and countries have shown interest during the last five years. In the last 15 years, interest in organizational issues remained fairly constant, order entry and research with systems gained attention, while interest in technical issues relatively decreased.

Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients.

PubMed

Vermeulen, K M; van Doormaal, J E; Zaal, R J; Mol, P G M; Lenderink, A W; Haaijer-Ruskamp, F M; Kosterink, J G W; van den Bemt, P M L A

2014-08-01

Prescribing medication is an important aspect of almost all in-hospital treatment regimes. Besides their obviously beneficial effects, medicines can also cause adverse drug events (ADE), which increase morbidity, mortality and health care costs. Partially, these ADEs arise from medication errors, e.g. at the prescribing stage. ADEs caused by medication errors are preventable ADEs. Until now, medication ordering was primarily a paper-based process and consequently, it was error prone. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) is considered to enhance patient safety. Limited information is available on the balance between the health gains and the costs that need to be invested in order to achieve these positive effects. Aim of this study was to study the balance between the effects and costs of CPOE/CDSS compared to the traditional paper-based medication ordering. The economic evaluation was performed alongside a clinical study (interrupted time series design) on the effectiveness of CPOE/CDSS, including a cost minimization and a cost-effectiveness analysis. Data collection took place between 2005 and 2008. Analyses were performed from a hospital perspective. The study was performed in a general teaching hospital and a University Medical Centre on general internal medicine, gastroenterology and geriatric wards. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) was compared to a traditional paper based system. All costs of both medication ordering systems are based on resources used and time invested. Prices were expressed in Euros (price level 2009). Effectiveness outcomes were medication errors and preventable adverse drug events. During the paper-based prescribing period 592 patients were included, and during the CPOE/CDSS period 603. Total costs of the paper-based system and CPOE/CDSS amounted to €12.37 and €14.91 per patient/day respectively. The Incremental Cost-Effectiveness Ratio (ICER) for medication errors was 3.54 and for preventable adverse drug events 322.70, indicating the extra amount (€) that has to be invested in order to prevent one medication error or one pADE. CPOE with basic CDSS contributes to a decreased risk of preventable harm. Overall, the extra costs of CPOE/CDSS needed to prevent one ME or one pADE seem to be acceptable. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

[Is the ICU staff satisfied with the computerized physician order entry? A cross-sectional survey study].

PubMed

Fumis, Renata Rego Lins; Costa, Eduardo Leite Vieira; Martins, Paulo Sergio; Pizzo, Vladimir; Souza, Ivens Augusto; Schettino, Guilherme de Paula Pinto

2014-01-01

To evaluate the satisfaction of the intensive care unit staff with a computerized physician order entry and to compare the concept of the computerized physician order entry relevance among intensive care unit healthcare workers. We performed a cross-sectional survey to assess the satisfaction of the intensive care unit staff with the computerized physician order entry in a 30-bed medical/surgical adult intensive care unit using a self-administered questionnaire. The questions used for grading satisfaction levels were answered according to a numerical scale that ranged from 1 point (low satisfaction) to 10 points (high satisfaction). The majority of the respondents (n=250) were female (66%) between the ages of 30 and 35 years of age (69%). The overall satisfaction with the computerized physician order entry scored 5.74±2.14 points. The satisfaction was lower among physicians (n=42) than among nurses, nurse technicians, respiratory therapists, clinical pharmacists and diet specialists (4.62±1.79 versus 5.97±2.14, p<0.001); satisfaction decreased with age (p<0.001). Physicians scored lower concerning the potential of the computerized physician order entry for improving patient safety (5.45±2.20 versus 8.09±2.21, p<0.001) and the ease of using the computerized physician order entry (3.83±1.88 versus 6.44±2.31, p<0.001). The characteristics independently associated with satisfaction were the system's user-friendliness, accuracy, capacity to provide clear information, and fast response time. Six months after its implementation, healthcare workers were satisfied, albeit not entirely, with the computerized physician order entry. The overall users' satisfaction with computerized physician order entry was lower among physicians compared to other healthcare professionals. The factors associated with satisfaction included the belief that digitalization decreased the workload and contributed to the intensive care unit quality with a user-friendly and accurate system and that digitalization provided concise information within a reasonable time frame.

Core drug-drug interaction alerts for inclusion in pediatric electronic health records with computerized prescriber order entry.

PubMed

Harper, Marvin B; Longhurst, Christopher A; McGuire, Troy L; Tarrago, Rod; Desai, Bimal R; Patterson, Al

2014-03-01

The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process. A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated. Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process. We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

PubMed

Schreiber, Richard; Sittig, Dean F; Ash, Joan; Wright, Adam

2017-09-01

In this report, we describe 2 instances in which expert use of an electronic health record (EHR) system interfaced to an external clinical laboratory information system led to unintended consequences wherein 2 patients failed to have laboratory tests drawn in a timely manner. In both events, user actions combined with the lack of an acknowledgment message describing the order cancellation from the external clinical system were the root causes. In 1 case, rapid, near-simultaneous order entry was the culprit; in the second, astute order management by a clinician, unaware of the lack of proper 2-way interface messaging from the external clinical system, led to the confusion. Although testing had shown that the laboratory system would cancel duplicate laboratory orders, it was thought that duplicate alerting in the new order entry system would prevent such events. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Computerized Physician Order Entry

PubMed Central

Khanna, Raman; Yen, Tony

2014-01-01

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks. PMID:24381708

Medication-related clinical decision support in computerized provider order entry systems: a review.

PubMed

Kuperman, Gilad J; Bobb, Anne; Payne, Thomas H; Avery, Anthony J; Gandhi, Tejal K; Burns, Gerard; Classen, David C; Bates, David W

2007-01-01

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

A system to improve medication safety in the setting of acute kidney injury: initial provider response.

PubMed

McCoy, Allison B; McCoy, Allison Beck; Peterson, Josh F; Gadd, Cynthia S; Gadd, Cindy; Danciu, Ioana; Waitman, Lemuel R

2008-11-06

Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.

Computerized physician order entry: promise, perils, and experience.

PubMed

Khanna, Raman; Yen, Tony

2014-01-01

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

CPOE in Iran--a viable prospect? Physicians' opinions on using CPOE in an Iranian teaching hospital.

PubMed

Kazemi, Alireza; Ellenius, Johan; Tofighi, Shahram; Salehi, Aref; Eghbalian, Fatemeh; Fors, Uno G

2009-03-01

In recent years, the theory that on-line clinical decision support systems can improve patients' safety among hospitalised individuals has gained greater acceptance. However, the feasibility of implementing such a system in a middle or low-income country has rarely been studied. Understanding the current prescription process and a proper needs assessment of prescribers can act as the key to successful implementation. The aim of this study was to explore physicians' opinions on the current prescription process, and the expected benefits and perceived obstacles to employ Computerised Physician Order Entry in an Iranian teaching hospital. Initially, the interview guideline was developed through focus group discussions with eight experts. Then semi-structured interviews were held with 19 prescribers. After verbatim transcription, inductive thematic analysis was performed on empirical data. Forty hours of on-looker observations were performed in different wards to explore the current prescription process. The current prescription process was identified as a physician-centred, top-down, model, where prescribers were found to mostly rely on their memories as well as being overconfident. Some errors may occur during different paper-based registrations, transcriptions and transfers. Physician opinions on Computerised Physician Order Entry were categorised into expected benefits and perceived obstacles. Confidentiality issues, reduction of medication errors and educational benefits were identified as three themes in the expected benefits category. High cost, social and cultural barriers, data entry time and problems with technical support emerged as four themes in the perceived obstacles category. The current prescription process has a high possibility of medication errors. Although there are different barriers confronting the implementation and continuation of Computerised Physician Order Entry in Iranian hospitals, physicians have a willingness to use them if these systems provide significant benefits. A pilot study in a limited setting and a comprehensive analysis of health outcomes and economic indicators should be performed, to assess the merits of introducing Computerised Physician Order Entry with decision support capabilities in Iran.

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

PubMed

Dekarske, Brian M; Zimmerman, Christopher R; Chang, Robert; Grant, Paul J; Chaffee, Bruce W

2015-12-01

Computerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug-drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug-drug interactions when ordering medications in an electronic medical record. In this prospective, randomized crossover study, providers were randomized into cohorts that required a reason for overriding a medication alert from a customized or non-customized list of override reasons and/or by free-text entry. The primary outcome was to compare override responses that appropriately correlate with the alert type between the customized and non-customized configurations. The appropriateness of a subset of free-text responses that represented an affirmative and active acknowledgement of the alert without further explanation was classified as "indeterminate." Results were analyzed in three different ways by classifying indeterminate answers as either appropriate, inappropriate, or excluded entirely. Secondary outcomes included the appropriateness of override reasons when comparing cohorts and individual providers, reason selection based on order within the override list, and the determination of the frequency of free-text use, nonsensical responses, and multiple selection responses. Twenty-two clinicians were randomized into 2 cohorts and a total of 1829 alerts with a required response were generated during the study period. The customized configuration had a higher rate of appropriateness when compared to the non-customized configuration regardless of how indeterminate responses were classified (p<0.001). When comparing cohorts, appropriateness was significantly higher in the customized configuration regardless of the classification of indeterminate responses (p<0.001) with one exception: when indeterminate responses were considered inappropriate for the cohort of providers that were first exposed to the non-customized list (p=0.103). Free-text use was higher in the customized configuration overall (p<0.001), and there was no difference in nonsensical response between configurations (p=0.39). There is a benefit realized by using a customized list for medication override reasons. Poor application design or configuration can negatively affect provider behavior when responding to important medication alerts. Copyright © 2015. Published by Elsevier Ireland Ltd.

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

PubMed

Terrell, Kevin M; Perkins, Anthony J; Hui, Siu L; Callahan, Christopher M; Dexter, Paul R; Miller, Douglas K

2010-12-01

Emergency physicians prescribe several discharge medications that require dosage adjustment for patients with renal disease. The hypothesis for this research was that decision support in a computerized physician order entry system would reduce the rate of excessive medication dosing for patients with renal impairment. This was a randomized, controlled trial in an academic emergency department (ED), in which computerized physician order entry was used to write all prescriptions for patients being discharged from the ED. The sample included 42 physicians who were randomized to the intervention (21 physicians) or control (21 physicians) group. The intervention was decision support that provided dosing recommendations for targeted medications for patients aged 18 years and older when the patient's estimated creatinine clearance level was below the threshold for dosage adjustment. The primary outcome was the proportion of targeted medications that were excessively dosed. For 2,783 (46%) of the 6,015 patient visits, the decision support had sufficient information to estimate the patient's creatinine clearance level. The average age of these patients was 46 years, 1,768 (64%) were women, and 1,523 (55%) were black. Decision support was provided 73 times to physicians in the intervention group, who excessively dosed 31 (43%) prescriptions. In comparison, control physicians excessively dosed a significantly larger proportion of medications: 34 of 46, 74% (effect size=31%; 95% confidence interval 14% to 49%; P=.001). Emergency physicians often prescribed excessive doses of medications that require dosage adjustment for renal impairment. Computerized physician order entry with decision support significantly reduced excessive dosing of targeted medications. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis

PubMed Central

2014-01-01

Background The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors. Methods Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data. Results Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR) = 0.47, 95% CI 0.31 to 0.71) and medication errors (RR = 0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P < 0.001). Other context and implementation variables were seldom reported. Conclusions In hospital-related settings, implementing CPOE is associated with a greater than 50% decline in pADEs, although the studies used weak designs. Decreases in medication errors are similar and robust to variations in important aspects of intervention design and context. This suggests that CPOE implementation, as subsidized under the HITECH Act, may benefit public health. More detailed reporting of the context and process of implementation could shed light on factors associated with greater effectiveness. PMID:24894078

Systematic Review of Medical Informatics-Supported Medication Decision Making.

PubMed

Melton, Brittany L

2017-01-01

This systematic review sought to assess the applications and implications of current medical informatics-based decision support systems related to medication prescribing and use. Studies published between January 2006 and July 2016 which were indexed in PubMed and written in English were reviewed, and 39 studies were ultimately included. Most of the studies looked at computerized provider order entry or clinical decision support systems. Most studies examined decision support systems as a means of reducing errors or risk, particularly associated with medication prescribing, whereas a few studies evaluated the impact medical informatics-based decision support systems have on workflow or operations efficiency. Most studies identified benefits associated with decision support systems, but some indicate there is room for improvement.

Lessons from a Successful Implementation of a Computerized Provider Order Entry System

PubMed Central

Jacobs, Brian R.; Hallstrom, Craig K.; Hart, Kim Ward; Mahoney, Daniela; Lykowski, Gayle

2007-01-01

OBJECTIVES The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success. PMID:23055847

Comparison of alphabetical versus categorical display format for medication order entry in a simulated touch screen anesthesia information management system: an experiment in clinician-computer interaction in anesthesia.

PubMed

Marian, Anil A; Dexter, Franklin; Tucker, Peter; Todd, Michael M

2012-05-29

Anesthesia information management system (AIMS) records should be designed and configured to facilitate the accurate and prompt recording of multiple drugs administered coincidentally or in rapid succession. We proposed two touch-screen display formats for use with our department's new EPIC touch-screen AIMS. In one format, medication "buttons" were arranged in alphabetical order (i.e. A-C, D-H etc.). In the other, buttons were arranged in categories (Common, Fluids, Cardiovascular, Coagulation etc.). Both formats were modeled on an iPad screen to resemble the AIMS interface. Anesthesia residents, anesthesiologists, and Certified Registered Nurse Anesthetists (n = 60) were then asked to find and touch the correct buttons for a series of medications whose names were displayed to the side of the entry screen. The number of entries made within 2 minutes was recorded. This was done 3 times for each format, with the 1st format chosen randomly. Data were analyzed from the third trials with each format to minimize differences in learning. The categorical format had a mean of 5.6 more drugs entered using the categorical method in two minutes than the alphabetical format (95% confidence interval [CI] 4.5 to 6.8, P < 0.0001). The findings were the same regardless of the order of testing (i.e. alphabetical-categorical vs. categorical - alphabetical) and participants' years of clinical experience. Most anesthesia providers made no (0) errors for most trials (N = 96/120 trials, lower 95% limit 73%, P < 0.0001). There was no difference in error rates between the two formats (P = 0.53). The use of touch-screen user interfaces in healthcare is increasingly common. Arrangement of drugs names in a categorical display format in the medication order-entry touch screen of an AIMS can result in faster data entry compared to an alphabetical arrangement of drugs. Results of this quality improvement project were used in our department's design of our final intraoperative electronic anesthesia record. This testing approach using cognitive and usability engineering methods can be used to objectively design and evaluate many aspects of the clinician-computer interaction in electronic health records.

Comparison of alphabetical versus categorical display format for medication order entry in a simulated touch screen anesthesia information management system: an experiment in clinician-computer interaction in anesthesia

PubMed Central

2012-01-01

Background Anesthesia information management system (AIMS) records should be designed and configured to facilitate the accurate and prompt recording of multiple drugs administered coincidentally or in rapid succession. Methods We proposed two touch-screen display formats for use with our department’s new EPIC touch-screen AIMS. In one format, medication “buttons” were arranged in alphabetical order (i.e. A-C, D-H etc.). In the other, buttons were arranged in categories (Common, Fluids, Cardiovascular, Coagulation etc.). Both formats were modeled on an iPad screen to resemble the AIMS interface. Anesthesia residents, anesthesiologists, and Certified Registered Nurse Anesthetists (n = 60) were then asked to find and touch the correct buttons for a series of medications whose names were displayed to the side of the entry screen. The number of entries made within 2 minutes was recorded. This was done 3 times for each format, with the 1st format chosen randomly. Data were analyzed from the third trials with each format to minimize differences in learning. Results The categorical format had a mean of 5.6 more drugs entered using the categorical method in two minutes than the alphabetical format (95% confidence interval [CI] 4.5 to 6.8, P < 0.0001). The findings were the same regardless of the order of testing (i.e. alphabetical-categorical vs. categorical - alphabetical) and participants’ years of clinical experience. Most anesthesia providers made no (0) errors for most trials (N = 96/120 trials, lower 95% limit 73%, P < 0.0001). There was no difference in error rates between the two formats (P = 0.53). Conclusions The use of touch-screen user interfaces in healthcare is increasingly common. Arrangement of drugs names in a categorical display format in the medication order-entry touch screen of an AIMS can result in faster data entry compared to an alphabetical arrangement of drugs. Results of this quality improvement project were used in our department’s design of our final intraoperative electronic anesthesia record. This testing approach using cognitive and usability engineering methods can be used to objectively design and evaluate many aspects of the clinician-computer interaction in electronic health records. PMID:22643058

CPOE system design aspects and their qualitative effect on usability.

PubMed

Khajouei, Reza; Jaspers, Monique W M

2008-01-01

Although many studies have discussed the benefits of Computerized Provider Order Entry (CPOE) systems, their configuration can have a great impact on clinicians' adoption of these systems. Poorly designed CPOE systems can lead to usability problems, users' dissatisfaction and may disrupt normal flow of clinical activities. This paper reports on a literature review focused on the identification of CPOE medication systems' design aspects that impact CPOE systems' usability and create opportunities for medication errors. Our review is based on a systematic literature search in PubMed, EMBASE and Ovid MEDLINE for relevant publications from 1986-2006. We categorized the design aspects extracted from relevant publications into six different groups: 1) timing of alerts, 2) log in/out procedures, 3) pick lists and drop down menus, 4) clues and guidelines, 5) documentation and data entry options, and 6) screen display and layout. Our review shows that the manner in which a CPOE system is configured can have a high impact on ease of system use, task behavior of clinicians in ordering drugs, and medication errors. Characterization of consequences associated with certain CPOE design aspects provides insight into how CPOE system designs can be improved to enhance physicians' adoption of these systems and their success. Recommendations are provided to enable CPOE system designers to create CPOE systems that are not only more user friendly and efficient but safer.

Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting

PubMed Central

Harshberger, Cara A.; Harper, Abigail J.; Carro, George W.; Spath, Wayne E.; Hui, Wendy C.; Lawton, Jessica M.; Brockstein, Bruce E.

2011-01-01

Purpose: Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites. Methods: This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems. Results: The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system. Conclusion: Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety. PMID:22043187

A New Patient Record System Using the Laser Card

PubMed Central

Brown, J.H.U.; Vallbona, Carlos

1988-01-01

A method of handling medical data in the form of patient records including physical findings such as x-rays has been devised using a laser card coupled to a p.c. for data input and output. A satisfactory software system which encompasses a formalized medical record system dealing with events rather than chronological order of entry has been devised and is now under test in a community health clinic. Future directions of the card research are discussed and expanded upon. ImagesFig. 7

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

PubMed

Pirnejad, Habibollah; Niazkhani, Zahra; van der Sijs, Heleen; Berg, Marc; Bal, Roland

2008-11-01

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. 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. 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. 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.

Will Decision Support in Medications Order Entry Save Money? A Return On Investment Analysis of the Case of the Hong Kong Hospital Authority

PubMed Central

Fung, Kin Wah; Vogel, Lynn Harold

2003-01-01

The computerized medications order entry system currently used in the public hospitals of Hong Kong does not have decision support features. Plans are underway to add decision support to this system to alert physicians on drug-allergy conflicts, drug-lab result conflicts, drug-drug interactions and atypical dosages. A return on investment analysis is done on this enhancement, both as an examination of whether there is a positive return on the investment and as a contribution to the ongoing discussion of the use of return on investment models in health care information technology investments. It is estimated that the addition of decision support will reduce adverse drug events by 4.2 – 8.4%. Based on this estimate, a total net saving of $44,000 – $586,000 is expected over five years. The breakeven period is estimated to be between two to four years. PMID:14728171

Impact of Training Method on the Behavior of Physicians towards the Use of Computerized Provider Order Entry Systems

ERIC Educational Resources Information Center

Martinez, Fernando

2012-01-01

The use of workflow or simulated training has been used in the training of medical students for several decades. As technology emerged, training using simulation has grown as an effective way of enhancing training outcomes and increasing the clinical effectiveness of medical students. As a result of a heightened focus on the integration of…

National trends in safety performance of electronic health record systems in children's hospitals.

PubMed

Chaparro, Juan D; Classen, David C; Danforth, Melissa; Stockwell, David C; Longhurst, Christopher A

2017-03-01

To evaluate the safety of computerized physician order entry (CPOE) and associated clinical decision support (CDS) systems in electronic health record (EHR) systems at pediatric inpatient facilities in the US using the Leapfrog Group's pediatric CPOE evaluation tool. The Leapfrog pediatric CPOE evaluation tool, a previously validated tool to assess the ability of a CPOE system to identify orders that could potentially lead to patient harm, was used to evaluate 41 pediatric hospitals over a 2-year period. Evaluation of the last available test for each institution was performed, assessing performance overall as well as by decision support category (eg, drug-drug, dosing limits). Longitudinal analysis of test performance was also carried out to assess the impact of testing and the overall trend of CPOE performance in pediatric hospitals. Pediatric CPOE systems were able to identify 62% of potential medication errors in the test scenarios, but ranged widely from 23-91% in the institutions tested. The highest scoring categories included drug-allergy interactions, dosing limits (both daily and cumulative), and inappropriate routes of administration. We found that hospitals with longer periods since their CPOE implementation did not have better scores upon initial testing, but after initial testing there was a consistent improvement in testing scores of 4 percentage points per year. Pediatric computerized physician order entry (CPOE) systems on average are able to intercept a majority of potential medication errors, but vary widely among implementations. Prospective and repeated testing using the Leapfrog Group's evaluation tool is associated with improved ability to intercept potential medication errors. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

A usability study of CPOE's medication administration functions: impact on physician-nurse cooperation.

PubMed

Beuscart-Zéphir, Marie Catherine; Pelayo, Sylvia; Degoulet, Patrice; Anceaux, Françoise; Guerlinger, Sandra; Meaux, Jean-Jacques

2004-01-01

Implementation of CPOE systems in Healthcare Institutions has proven efficient in reducing medication errors but it also induces hidden side-effects on Doctor-Nurse cooperation. We propose a usability engineering approach to this problem. An extensive activity analysis of the medication ordering and administration process was performed in several departments of 3 different hospitals. Two of these hospitals are still using paper-based orders, while the 3rd one is in the roll-out phase of medication functions of its CPOE system. We performed a usability assessment of this CPOE system. The usability assessment uncovered usability problems for the entry of medication administration time scheduling by the physician and revealed that the information can be ambiguous for the nurse. The comparison of cooperation models in both situation shows that users tend to adopt a distributed decision making paradigm in the paper-based situation, while the CPOE system supports a centralized decision making process. This analysis can support recommendation for the re-engineering of the Human-Computer Interface.

RPMIS: The Roswell Park Management Information System

PubMed Central

Priore, R.L.; Lane, W.W.; Edgerton, F.T.; Naeher, C.H.; Reese, P.A.

1978-01-01

This paper presents a generalized approach to data entry and editing utilizing formatted video computer terminals. The purpose of the system developed is to facilitate the creation of many small data bases, with a minimum of implementation time, while maintaining extensive editing capability and preserving ease of use by data entry personnel. RPMIS has demonstrated its utility in shortening the time between research activities and clinical application of results. The system allows entry and retrieval of overlapping subsets of the patient's record in an order and format most appropriate to the individual application. It is used for production of synoptic presentations of information from the labs, the ward and the clinic. RPMIS was designed for the clinical trials setting and has been well received and implemented for numerous such studies. Additional uses have included several registries, screening clinics, retrospective studies, and epidemiologic investigations. The system has found fortuitous use in maintaining curriculum vitae, publications lists and continuing medical education credits.

Linking medical records to an expert system

NASA Technical Reports Server (NTRS)

Naeymi-Rad, Frank; Trace, David; Desouzaalmeida, Fabio

1991-01-01

This presentation will be done using the IMR-Entry (Intelligent Medical Record Entry) system. IMR-Entry is a software program developed as a front-end to our diagnostic consultant software MEDAS (Medical Emergency Decision Assistance System). MEDAS (the Medical Emergency Diagnostic Assistance System) is a diagnostic consultant system using a multimembership Bayesian design for its inference engine and relational database technology for its knowledge base maintenance. Research on MEDAS began at the University of Southern California and the Institute of Critical Care in the mid 1970's with support from NASA and NSF. The MEDAS project moved to Chicago in 1982; its current progress is due to collaboration between Illinois Institute of Technology, The Chicago Medical School, Lake Forest College and NASA at KSC. Since the purpose of an expert system is to derive a hypothesis, its communication vocabulary is limited to features used by its knowledge base. The development of a comprehensive problem based medical record entry system which could handshake with an expert system while creating an electronic medical record at the same time was studied. IMR-E is a computer based patient record that serves as a front end to the expert system MEDAS. IMR-E is a graphically oriented comprehensive medical record. The programs major components are demonstrated.

Designing an architectural style for dynamic medical Cross-Organizational Workflow management system: an approach based on agents and web services.

PubMed

Bouzguenda, Lotfi; Turki, Manel

2014-04-01

This paper shows how the combined use of agent and web services technologies can help to design an architectural style for dynamic medical Cross-Organizational Workflow (COW) management system. Medical COW aims at supporting the collaboration between several autonomous and possibly heterogeneous medical processes, distributed over different organizations (Hospitals, Clinic or laboratories). Dynamic medical COW refers to occasional cooperation between these health organizations, free of structural constraints, where the medical partners involved and their number are not pre-defined. More precisely, this paper proposes a new architecture style based on agents and web services technologies to deal with two key coordination issues of dynamic COW: medical partners finding and negotiation between them. It also proposes how the proposed architecture for dynamic medical COW management system can connect to a multi-agent system coupling the Clinical Decision Support System (CDSS) with Computerized Prescriber Order Entry (CPOE). The idea is to assist the health professionals such as doctors, nurses and pharmacists with decision making tasks, as determining diagnosis or patient data analysis without stopping their clinical processes in order to act in a coherent way and to give care to the patient.

Technology utilization to prevent medication errors.

PubMed

Forni, Allison; Chu, Hanh T; Fanikos, John

2010-01-01

Medication errors have been increasingly recognized as a major cause of iatrogenic illness and system-wide improvements have been the focus of prevention efforts. Critically ill patients are particularly vulnerable to injury resulting from medication errors because of the severity of illness, need for high risk medications with a narrow therapeutic index and frequent use of intravenous infusions. Health information technology has been identified as method to reduce medication errors as well as improve the efficiency and quality of care; however, few studies regarding the impact of health information technology have focused on patients in the intensive care unit. Computerized physician order entry and clinical decision support systems can play a crucial role in decreasing errors in the ordering stage of the medication use process through improving the completeness and legibility of orders, alerting physicians to medication allergies and drug interactions and providing a means for standardization of practice. Electronic surveillance, reminders and alerts identify patients susceptible to an adverse event, communicate critical changes in a patient's condition, and facilitate timely and appropriate treatment. Bar code technology, intravenous infusion safety systems, and electronic medication administration records can target prevention of errors in medication dispensing and administration where other technologies would not be able to intercept a preventable adverse event. Systems integration and compliance are vital components in the implementation of health information technology and achievement of a safe medication use process.

The Medical Gopher—A Microcomputer System to Help Find, Organize and Decide About Patient Data

PubMed Central

McDonald, Clement J.; Tierney, William M.

1986-01-01

We have developed a microcomputer-based medical workstation that does some of physicians' “gopher” work of fetching, organizing, reviewing and recording. For two years physicians have used the first version of this system to order all diagnostic tests in a general medicine clinic. They are about to use a newer version to write prescriptions and office visit notes and to find general medical and patient-specific information. Users can enter data into this system by “pointing” with a “mouse” to menu items displayed on a video terminal. In the course of a computer activity, a physician can obtain information about drugs, tests and different diagnoses, as well as about the patient. The microcomputer workstations are linked to each other and to a central hospital information system through a high-speed network link. Our physicians have accepted the initial order-entry system, and early experience suggests they prefer this faster and more sophisticated system. PMID:3811348

Comprehensive analysis of a medication dosing error related to CPOE.

PubMed

Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L

2005-01-01

This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

User satisfaction with computerized order entry system and its effect on workplace level of stress.

PubMed

Ghahramani, Nasrollah; Lendel, Irina; Haque, Rehan; Sawruk, Kathryn

2009-06-01

To evaluate the impact of Computerized Provider Order Entry (CPOE) on workplace stress and overall job performance, as perceived by medical students, housestaff, attending physicians and nurses, after CPOE implementation at Penn State-Milton S. Hershey Medical Center, an academic tertiary care facility, in 2005. Using an online survey, the authors studied attitudes towards CPOE among 862 health care professionals. The main outcome measures were job performance and perceived stress levels. Statistical analyses were conducted using the Statistical Analytical Software (SAS Inc, Carey, NC). A total of413 respondents completed the entire survey (47.9 % response rate). Respondents in the younger age group were more familiar with the system, used it more frequently, and were more satisfied with it. Interns and residents were the most satisfied groups with the system, while attending physicians expressed the least satisfaction. Attending physicians and fellows found the system least user friendly compared with other groups, and also tended to express more stress and frustration with the system. Participants with previous CPOE experience were more familiar with the system, would use the system more frequently and were more likely to perceive the system as user friendly. User satisfaction with CPOE increases by familiarity and frequent use of the system. Improvement in system characteristics and avoidance of confusing terminology and inconsistent display of data is expected to enhance user satisfaction. Training in the use of CPOE should start early, ideally integrated into medical and nursing school curricula and form a continuous, long-term and user-specific process. This is expected to increase familiarity with the system, reducing stress and leading to improved user satisfaction and to subsequent enhanced safety and efficiency.

A Development of Automatic Audit System for Written Informed Consent using Machine Learning.

PubMed

Yamada, Hitomi; Takemura, Tadamasa; Asai, Takahiro; Okamoto, Kazuya; Kuroda, Tomohiro; Kuwata, Shigeki

2015-01-01

In Japan, most of all the university and advanced hospitals have implemented both electronic order entry systems and electronic charting. In addition, all medical records are subjected to inspector audit for quality assurance. The record of informed consent (IC) is very important as this provides evidence of consent from the patient or patient's family and health care provider. Therefore, we developed an automatic audit system for a hospital information system (HIS) that is able to evaluate IC automatically using machine learning.

Linked Orders Improve Safety in Scheduling and Administration of Chemotherapeutic Agents

PubMed Central

Whipple, Nancy; Boulware, Joy; Danca, Kala; Boyarin, Kirill; Ginsberg, Eliot; Poon, Eric; Sweet, Micheal; Schade, Sue; Rogala, Jennifer

2010-01-01

The pharmacologic treatment for cancer must adhere to complex, finely orchestrated treatment plans, including not only chemotherapy medications, but pre/post-hydration, anti-emetics, anti-anxiety, and other medications that are given before, during and after chemotherapy doses. The treatment plans specify the medications and dictate precise dosing, frequency, and timing. This is a challenge to most Computerized Physician Order Entry (CPOE), Pharmacy and Electronic Medication Administration record (eMAR) Systems. Medications are scheduled on specific dates, referred to as chemo days, from the onset of the treatment, and precisely timed on the designated chemo day. For patients enrolled in research protocols, the adherence to the defined schedule takes on additional import, since variation is a violation of the protocol. If the oncologist determines that medications must be administered outside the defined constraints, the patient must be un-enrolled from the protocol and the course of therapy is re-written. Pharmacy and eMAR systems utilized in processing chemotherapy medications must be able to support the intricate relationships between each drug defined in the treatment plans. PMID:21347104

Discrepancies in medication entries between anesthetic and pharmacy records using electronic databases.

PubMed

Vigoda, Michael M; Gencorelli, Frank J; Lubarsky, David A

2007-10-01

Accurate recording of disposition of controlled substances is required by regulatory agencies. Linking anesthesia information management systems (AIMS) with medication dispensing systems may facilitate automated reconciliation of medication discrepancies. In this retrospective investigation at a large academic hospital, we reviewed 11,603 cases (spanning an 8-mo period) comparing records of medications (i.e., narcotics, benzodiazepines, ketamine, and thiopental) recorded as removed from our automated medication dispensing system with medications recorded as administered in our AIMS. In 15% of cases, we found discrepancies between dispensed versus administered medications. Discrepancies occurred in both the AIMS (8% cases) and the medication dispensing system (10% cases). Although there were many different types of user errors, nearly 75% of them resulted from either an error in the amount of drug waste documented in the medication dispensing system (35%); or an error in documenting the medication in the AIMS (40%). A significant percentage of cases contained data entry errors in both the automated dispensing and AIMS. This error rate limits the current practicality of automating the necessary reconciliation. An electronic interface between an AIMS and a medication dispensing system could alert users of medication entry errors prior to finalizing a case, thus reducing the time (and cost) of reconciling discrepancies.

Effects of computerized prescriber order entry on pharmacy order-processing time.

PubMed

Wietholter, Jon; Sitterson, Susan; Allison, Steven

2009-08-01

The effect of computerized prescriber order entry (CPOE) on the efficiency of medication-order-processing time was evaluated. This study was conducted at a 761-bed, tertiary care hospital. A total of 2988 medication orders were collected and analyzed before (n = 1488) and after CPOE implementation (n = 1500). Data analyzed included the time the prescriber ordered the medication, the time the pharmacy received the order, and the time the order was completed by a pharmacist. The mean order-processing time before CPOE implementation was 115 minutes from prescriber composition to pharmacist verification. After CPOE implementation, the mean order-processing time was reduced to 3 minutes (p < 0.0001). The time that an order was received by the pharmacy to the time it was verified by a pharmacist was reduced from 31 minutes before CPOE implementation to 3 minutes after CPOE implementation (p < 0.0001). The implementation of CPOE reduced the order-processing time (from order composition to verification) by 97%. Additionally, pharmacy-specific order-processing time (from order receipt in the pharmacy to pharmacist verification) was reduced by 90%. This reduction in order-processing time improves patient care by shortening the interval between physician prescribing and medication availability and may allow pharmacists to explore opportunities for enhanced clinical activities that will further positively impact patient care. CPOE implementation reduced the mean pharmacy order-processing time from composition to verification by 97%. After CPOE implementation, a new medication order was verified as appropriate by a pharmacist in three minutes, on average.

Assessment of Pharmacy Information System Performance in Three Hospitals in Eastern Province, Saudi Arabia

PubMed Central

El.Mahalli, Azza; El-Khafif, Sahar H.; Yamani, Wid

2016-01-01

The pharmacy information system is one of the central pillars of a hospital information system. This research evaluated a pharmacy information system according to six aspects of the medication process in three hospitals in Eastern Province, Saudi Arabia. System administrators were interviewed to determine availability of functionalities. Then, system users within the hospital were targeted to evaluate their level of usage of these functionalities. The study was cross-sectional. Two structured surveys were designed. The overall response rate of hospital users was 31.7 percent. In all three hospitals studied, the electronic health record is hybrid, implementation has been completed and the system is running, and the systems have computerized provider order entry and clinical decision support. Also, the pharmacy information systems are integrated with the electronic health record, and computerized provider order entry and almost all prescribing and transcription functionalities are available; however, drug dispensing is a mostly manual process. However, the study hospitals do not use barcode-assisted medication administration systems to verify patient identity and electronically check dose administration, and none of them have computerized adverse drug event monitoring that uses the electronic health record. The numbers of users who used different functionalities most or all of the time was generally low. The highest frequency of utilization was for patient administration records (56.8 percent), and the lowest was for linkage of the pharmacy information system to pharmacy stock (9.1 percent). Encouraging users to use different functionalities was highly recommended. PMID:26903780

Assessment of Pharmacy Information System Performance in Three Hospitals in Eastern Province, Saudi Arabia.

PubMed

El Mahalli, Azza; El-Khafif, Sahar H; Yamani, Wid

2016-01-01

The pharmacy information system is one of the central pillars of a hospital information system. This research evaluated a pharmacy information system according to six aspects of the medication process in three hospitals in Eastern Province, Saudi Arabia. System administrators were interviewed to determine availability of functionalities. Then, system users within the hospital were targeted to evaluate their level of usage of these functionalities. The study was cross-sectional. Two structured surveys were designed. The overall response rate of hospital users was 31.7 percent. In all three hospitals studied, the electronic health record is hybrid, implementation has been completed and the system is running, and the systems have computerized provider order entry and clinical decision support. Also, the pharmacy information systems are integrated with the electronic health record, and computerized provider order entry and almost all prescribing and transcription functionalities are available; however, drug dispensing is a mostly manual process. However, the study hospitals do not use barcode-assisted medication administration systems to verify patient identity and electronically check dose administration, and none of them have computerized adverse drug event monitoring that uses the electronic health record. The numbers of users who used different functionalities most or all of the time was generally low. The highest frequency of utilization was for patient administration records (56.8 percent), and the lowest was for linkage of the pharmacy information system to pharmacy stock (9.1 percent). Encouraging users to use different functionalities was highly recommended.

An Integrated Computerized Triage System in the Emergency Department

PubMed Central

Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

2008-01-01

Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >290,000 pediatric and adult patients. PMID:18999190

Computer order entry systems in the emergency department significantly reduce the time to medication delivery for high acuity patients.

PubMed

Syed, Shahbaz; Wang, Dongmei; Goulard, Debbie; Rich, Tom; Innes, Grant; Lang, Eddy

2013-07-05

Computerized physician order entry (CPOE) systems are designed to increase safety and improve quality of care; however, their impact on efficiency in the ED has not yet been validated. This study examined the impact of CPOE on process times for medication delivery, laboratory utilization and diagnostic imaging in the early, late and control phases of a regional ED-CPOE implementation. Three tertiary care hospitals serving a population in excess of 1 million inhabitants that initiated the same CPOE system during the same 3-week time window. Patients were stratified into three groupings: Control, Early CPOE and Late CPOE (n = 200 patients per group/hospital site). Eligible patients consisted of a stratified (40% CTAS 2 and 60% CTAS 3) random sample of all patients seen 30 days preceding CPOE implementation (Control), 30 days immediately after CPOE implementation (Early CPOE) and 5-6 months after CPOE implementation (Late CPOE). Primary outcomes were time to (TT) from physician assignment (MD-sign) up to MD-order completion. An ANOVA and t-test were employed for statistical analysis. In comparison with control, TT 1st MD-Ordered Medication decreased in both the Early and Late CPOE groups (102.6 min control, 62.8 Early and 65.7 late, p < 0.001). TT 1st MD-ordered laboratory results increased in both the Early and Late CPOE groups compared to Control (76.4, 85.3 and 73.8 min, respectively, p < 0.001). TT 1st X-Ray also significantly increased in both the Early and Late CPOE groups (80.4, 84.8 min, respectively, compared to 68.1, p < 0.001). Given that CT and ultrasound imaging inherently takes increased time, these imaging studies were not included, and only X-ray was examined. There was no statistical difference found between TT discharge and consult request. Regional implementation of CPOE afforded important efficiencies in time to medication delivery for high acuity ED patients. Increased times observed for laboratory and radiology results may reflect system issues outside of the emergency department and as a result of potential confounding may not be a reflection of CPOE impact.

Using intranet-based order sets to standardize clinical care and prepare for computerized physician order entry.

PubMed

Heffner, John E; Brower, Kathleen; Ellis, Rosemary; Brown, Shirley

2004-07-01

The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE's benefits and offer opportunities to acculturate physicians toward standardized care. INTRANET CLINICIAN ORDER FORMS (COF): The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources. Work on COF began in March 2000 with transfer of 25 MUSC paper-based order set forms to an intranet site. Physician groups developed additional order sets, which number more than 200. Web traffic increased progressively during a 24-month period, peaking at more than 6,400 hits per month to COF. Decision support tools improved compliance with Centers for Medicare & Medicaid Services core indicators. Clinicians demonstrated a willingness to develop and use order sets and decision support tools posted on the COF site. COF provides a low-cost method for preparing caregivers and institutions to adopt CPOE and standardization of care. The educational resources, relevant links to external resources, and communication alerts will all link to CPOE, thereby providing a head start in CPOE implementation.

Information technology and medication safety: what is the benefit?

PubMed Central

Kaushal, R; Bates, D

2002-01-01



 Medication errors occur frequently and have significant clinical and financial consequences. Several types of information technologies can be used to decrease rates of medication errors. Computerized physician order entry with decision support significantly reduces serious inpatient medication error rates in adults. Other available information technologies that may prove effective for inpatients include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In outpatients, computerization of prescribing and patient oriented approaches such as personalized web pages and delivery of web based information may be important. Public and private mandates for information technology interventions are growing, but further development, application, evaluation, and dissemination are required. PMID:12486992

Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study.

PubMed

Zucker, Jason; Mittal, Jaimie; Jen, Shin-Pung; Cheng, Lucy; Cennimo, David

2016-03-01

There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART. This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study. Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention. Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact. © 2016 Pharmacotherapy Publications, Inc.

Creating a medical English-Swedish dictionary using interactive word alignment.

PubMed

Nyström, Mikael; Merkel, Magnus; Ahrenberg, Lars; Zweigenbaum, Pierre; Petersson, Håkan; Ahlfeldt, Hans

2006-10-12

This paper reports on a parallel collection of rubrics from the medical terminology systems ICD-10, ICF, MeSH, NCSP and KSH97-P and its use for semi-automatic creation of an English-Swedish dictionary of medical terminology. The methods presented are relevant for many other West European language pairs than English-Swedish. The medical terminology systems were collected in electronic format in both English and Swedish and the rubrics were extracted in parallel language pairs. Initially, interactive word alignment was used to create training data from a sample. Then the training data were utilised in automatic word alignment in order to generate candidate term pairs. The last step was manual verification of the term pair candidates. A dictionary of 31,000 verified entries has been created in less than three man weeks, thus with considerably less time and effort needed compared to a manual approach, and without compromising quality. As a side effect of our work we found 40 different translation problems in the terminology systems and these results indicate the power of the method for finding inconsistencies in terminology translations. We also report on some factors that may contribute to making the process of dictionary creation with similar tools even more expedient. Finally, the contribution is discussed in relation to other ongoing efforts in constructing medical lexicons for non-English languages. In three man weeks we were able to produce a medical English-Swedish dictionary consisting of 31,000 entries and also found hidden translation errors in the utilized medical terminology systems.

Creating a medical English-Swedish dictionary using interactive word alignment

PubMed Central

Nyström, Mikael; Merkel, Magnus; Ahrenberg, Lars; Zweigenbaum, Pierre; Petersson, Håkan; Åhlfeldt, Hans

2006-01-01

Background This paper reports on a parallel collection of rubrics from the medical terminology systems ICD-10, ICF, MeSH, NCSP and KSH97-P and its use for semi-automatic creation of an English-Swedish dictionary of medical terminology. The methods presented are relevant for many other West European language pairs than English-Swedish. Methods The medical terminology systems were collected in electronic format in both English and Swedish and the rubrics were extracted in parallel language pairs. Initially, interactive word alignment was used to create training data from a sample. Then the training data were utilised in automatic word alignment in order to generate candidate term pairs. The last step was manual verification of the term pair candidates. Results A dictionary of 31,000 verified entries has been created in less than three man weeks, thus with considerably less time and effort needed compared to a manual approach, and without compromising quality. As a side effect of our work we found 40 different translation problems in the terminology systems and these results indicate the power of the method for finding inconsistencies in terminology translations. We also report on some factors that may contribute to making the process of dictionary creation with similar tools even more expedient. Finally, the contribution is discussed in relation to other ongoing efforts in constructing medical lexicons for non-English languages. Conclusion In three man weeks we were able to produce a medical English-Swedish dictionary consisting of 31,000 entries and also found hidden translation errors in the utilized medical terminology systems. PMID:17034649

An Automated Medical Information Management System (OpScan-MIMS) in a Clinical Setting

PubMed Central

Margolis, S.; Baker, T.G.; Ritchey, M.G.; Alterescu, S.; Friedman, C.

1981-01-01

This paper describes an automated medical information management system within a clinic setting. The system includes an optically scanned data entry system (OpScan), a generalized, interactive retrieval and storage software system(Medical Information Management System, MIMS) and the use of time-sharing. The system has the advantages of minimal hardware purchase and maintenance, rapid data entry and retrieval, user-created programs, no need for user knowledge of computer language or technology and is cost effective. The OpScan-MIMS system has been operational for approximately 16 months in a sexually transmitted disease clinic. The system's application to medical audit, quality assurance, clinic management and clinical training are demonstrated.

Health information technology and the medical school curriculum.

PubMed

Triola, Marc M; Friedman, Erica; Cimino, Christopher; Geyer, Enid M; Wiederhorn, Jo; Mainiero, Crystal

2010-12-01

Medical schools must teach core biomedical informatics competencies that address health information technology (HIT), including explaining electronic medical record systems and computerized provider order entry systems and their role in patient safety; describing the research uses and limitations of a clinical data warehouse; understanding the concepts and importance of information system interoperability; explaining the difference between biomedical informatics and HIT; and explaining the ways clinical information systems can fail. Barriers to including these topics in the curricula include lack of teachers; the perception that informatics competencies are not applicable during preclinical courses and there is no place in the clerkships to teach them; and the legal and policy issues that conflict with students' need to develop skills. However, curricular reform efforts are creating opportunities to teach these topics with new emphasis on patient safety, team-based medical practice, and evidence-based care. Overarching HIT competencies empower our students to be lifelong technology learners.

Data delivery workflow in an academic information warehouse.

PubMed

Erdal, Selnur; Rogers, Patrick; Santangelo, Jennifer; Buskirk, Jason; Ostrander, Michael; Liu, Jianhua; Kamal, Jyoti

2008-11-06

The Ohio State University Medical Center (OSUMC) Information Warehouse (IW) collects data from many systems throughout the OSUMC on load cycles ranging from real-time to on-demand. The data then is prepared for delivery to diversity of customers across the clinical, education, and research sectors of the OSUMC. Some of the data collected at the IW include patient management, billing and finance, procedures, medications, lab results, clinical reports, physician order entry, outcomes, demographics, and so on. This data is made available to the users of the IW in variety of formats and methods.

The effect of the electronic medical record on nurses' work.

PubMed

Robles, Jane

2009-01-01

The electronic medical record (EMR) is a workplace reality for most nurses. Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. EMRs can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design. Well-designed and well-implemented computerized provider order entry (CPOE) systems can streamline nurses' work. Generational differences in acceptance of and facility with EMRs can be addressed through open, healthy communication.

Considerations for setting up an order entry system for nuclear medicine tests.

PubMed

Hara, Narihiro; Onoguchi, Masahisa; Nishida, Toshihiko; Honda, Minoru; Houjou, Osamu; Yuhi, Masaru; Takayama, Teruhiko; Ueda, Jun

2007-12-01

Integrating the Healthcare Enterprise-Japan (IHE-J) was established in Japan in 2001 and has been working to standardize health information and make it accessible on the basis of the fundamental Integrating Healthcare Enterprise (IHE) specifications. However, because specialized operations are used in nuclear medicine tests, online sharing of patient information and test order information from the order entry system as shown by the scheduled workflow (SWF) is difficult, making information inconsistent throughout the facility and uniform management of patient information impossible. Therefore, we examined the basic design (subsystem design) for order entry systems, which are considered an important aspect of information management for nuclear medicine tests and needs to be consistent with the system used throughout the rest of the facility. There are many items that are required by the subsystem when setting up an order entry system for nuclear medicine tests. Among these items, those that are the most important in the order entry system are constructed using exclusion settings, because of differences in the conditions for using radiopharmaceuticals and contrast agents and appointment frame settings for differences in the imaging method and test items. To establish uniform management of patient information for nuclear medicine tests throughout the facility, it is necessary to develop an order entry system with exclusion settings and appointment frames as standard features. Thereby, integration of health information with the Radiology Information System (RIS) or Picture Archiving Communication System (PACS) based on Digital Imaging Communications in Medicine (DICOM) standards and real-time health care assistance can be attained, achieving the IHE agenda of improving health care service and efficiently sharing information.

Safe and successful implementation of CPOE for chemotherapy at a children's cancer center.

PubMed

Hoffman, James M; Baker, Donald K; Howard, Scott C; Laver, Joseph H; Shenep, Jerry L

2011-02-01

Computerized prescriber order entry (CPOE) for medications has been implemented in only approximately 1 in 6 United States hospitals, with CPOE for chemotherapy lagging behind that for nonchemotherapy medications. The high risks associated with chemotherapy combined with other aspects of cancer care present unique challenges for the safe and appropriate use of CPOE. This article describes the process for safe and successful implementation of CPOE for chemotherapy at a children's cancer center. A core principle throughout the development and implementation of this system was that it must be as safe (and eventually safer) as existing paper systems and processes. The history of requiring standardized, regimen-specific, preprinted paper order forms served as the foundation for safe implementation of CPOE for chemotherapy. Extensive use of electronic order sets with advanced functionality; formal process redesign and system analysis; automated clinical decision support; and a phased implementation approach were essential strategies for safe implementation of CPOE. With careful planning and adequate resources, CPOE for chemotherapy can be safely implemented.

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

PubMed

Niazkhani, Zahra; Pirnejad, Habibollah; van der Sijs, Heleen; Aarts, Jos

2011-07-01

To evaluate the problems experienced after implementing a computerized physician order entry (CPOE) system, their possible root causes, and the responses of providers in order to incorporate the system into daily workflow. 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, paper-based and system-generated documents used daily in the process, and educational materials used to train users. 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 organizational 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. 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 recognized and discussed in order to find solutions to mitigate their effects. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Optimization of Vertical Double-Diffused Metal-Oxide Semiconductor (VDMOS) Power Transistor Structure for Use in High Frequencies and Medical Devices

PubMed Central

Farhadi, Rozita; Farhadi, Bita

2014-01-01

Power transistors, such as the vertical, double-diffused, metal-oxide semiconductor (VDMOS), are used extensively in the amplifier circuits of medical devices. The aim of this research was to construct a VDMOS power transistor with an optimized structure to enhance the operation of medical devices. First, boron was implanted in silicon by implanting unclamped inductive switching (UIS) and a Faraday shield. The Faraday shield was implanted in order to replace the gate-field parasitic capacitor on the entry part of the device. Also, implanting the UIS was used in order to decrease the effect of parasitic bipolar junction transistor (BJT) of the VDMOS power transistor. The research tool used in this study was Silvaco software. By decreasing the transistor entry resistance in the optimized VDMOS structure, power losses and noise at the entry of the transistor were decreased, and, by increasing the breakdown voltage, the lifetime of the VDMOS transistor lifetime was increased, which resulted in increasing drain flow and decreasing Ron. This consequently resulted in enhancing the operation of high-frequency medical devices that use transistors, such as Radio Frequency (RF) and electrocardiograph machines. PMID:25763152

Optimization of Vertical Double-Diffused Metal-Oxide Semiconductor (VDMOS) Power Transistor Structure for Use in High Frequencies and Medical Devices.

PubMed

Farhadi, Rozita; Farhadi, Bita

2014-01-01

Power transistors, such as the vertical, double-diffused, metal-oxide semiconductor (VDMOS), are used extensively in the amplifier circuits of medical devices. The aim of this research was to construct a VDMOS power transistor with an optimized structure to enhance the operation of medical devices. First, boron was implanted in silicon by implanting unclamped inductive switching (UIS) and a Faraday shield. The Faraday shield was implanted in order to replace the gate-field parasitic capacitor on the entry part of the device. Also, implanting the UIS was used in order to decrease the effect of parasitic bipolar junction transistor (BJT) of the VDMOS power transistor. The research tool used in this study was Silvaco software. By decreasing the transistor entry resistance in the optimized VDMOS structure, power losses and noise at the entry of the transistor were decreased, and, by increasing the breakdown voltage, the lifetime of the VDMOS transistor lifetime was increased, which resulted in increasing drain flow and decreasing Ron. This consequently resulted in enhancing the operation of high-frequency medical devices that use transistors, such as Radio Frequency (RF) and electrocardiograph machines.

SAKURA-viewer: intelligent order history viewer based on two-viewpoint architecture.

PubMed

Toyoda, Shuichi; Niki, Noboru; Nishitani, Hiromu

2007-03-01

We propose a new intelligent order history viewer applied to consolidating and visualizing data. SAKURA-viewer is a highly effective tool, as: 1) it visualizes both the semantic viewpoint and the temporal viewpoint of patient records simultaneously; 2) it promotes awareness of contextual information among the daily data; and 3) it implements patient-centric data entry methods. This viewer contributes to decrease the user's workload in an order entry system. This viewer is now incorporated into an order entry system being run on an experimental basis. We describe the evaluation of this system using results of a user satisfaction survey, analysis of information consolidation within the database, and analysis of the frequency of use of data entry methods.

Evaluation of causes and frequency of medication errors during information technology downtime.

PubMed

Hanuscak, Tara L; Szeinbach, Sheryl L; Seoane-Vazquez, Enrique; Reichert, Brendan J; McCluskey, Charles F

2009-06-15

The causes and frequency of medication errors occurring during information technology downtime were evaluated. Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated. Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors. Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

PubMed

Wakefield, Douglas S; Ward, Marcia M; Loes, Jean L; O'Brien, John

2010-01-01

We report how seven independent critical access hospitals collaborated with a rural referral hospital to standardize workflow policies and procedures while jointly implementing the same health information technologies (HITs) to enhance medication care processes. The study hospitals implemented the same electronic health record, computerized provider order entry, pharmacy information systems, automated dispensing cabinets (ADC), and barcode medication administration systems. We conducted interviews and examined project documents to explore factors underlying the successful implementation of ADC and barcode medication administration across the network hospitals. These included a shared culture of collaboration; strategic sequencing of HIT component implementation; interface among HIT components; strategic placement of ADCs; disciplined use and sharing of workflow analyses linked with HIT applications; planning for workflow efficiencies; acquisition of adequate supply of HIT-related devices; and establishing metrics to monitor HIT use and outcomes.

Legacy system integration using web technology

NASA Astrophysics Data System (ADS)

Kennedy, Richard L.; Seibert, James A.; Hughes, Chris J.

2000-05-01

As healthcare moves towards a completely digital, multimedia environment there is an opportunity to provide for cost- effective, highly distributed physician access to clinical information including radiology-based imaging. In order to address this opportunity a Universal Clinical Desktop (UCD) system was developed. A UCD provides a single point of entry into an integrated view of all types of clinical data available within a network of disparate healthcare information systems. In order to explore the application of a UCD in a hospital environment, a pilot study was established with the University of California Davis Medical Center using technology from Trilix Information Systems. Within this pilot environment the information systems integrated under the UCD include a radiology information system (RIS), a picture archive and communication system (PACS) and a laboratory information system (LIS).

Return on Investment Point of Service Computerized Provider Charge Entry

PubMed Central

Kiepek, Wendy; FitzHenry, Fern; Shultz, Edward K

2003-01-01

Provider charge entry systems offer many benefits to users and organizations. At Vanderbilt University Medical Center, a web-based provider charge entry system promises to deliver benefits in reducing days in accounts receivable, reducing labor required for claims and edit processing, and implementing business rules that deliver both strategic and financial benefits. PMID:14728396

Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment

PubMed Central

Ahmad, Asif; Teater, Phyllis; Bentley, Thomas D.; Kuehn, Lynn; Kumar, Rajee R.; Thomas, Andrew; Mekhjian, Hagop S.

2002-01-01

The benefits of computerized physician order entry have been widely recognized, although few institutions have successfully installed these systems. Obstacles to successful implementation are organizational as well as technical. In the spring of 2000, following a 4-year period of planning and customization, a 9-month pilot project, and a 14-month hiatus for year 2000, the Ohio State University Health System extensively implemented physician order entry across inpatient units. Implementation for specialty and community services is targeted for completion in 2002. On implemented units, all orders are processed through the system, with 80 percent being entered by physicians and the rest by nursing or other licensed care providers. The system is deployable across diverse clinical environments, focused on physicians as the primary users, and accepted by clinicians. These are the three criteria by which the authors measured the success of their implementation. They believe that the availability of specialty-specific order sets, the engagement of physician leadership, and a large-scale system implementation were key strategic factors that enabled physician-users to accept a physician order entry system despite significant changes in workflow. PMID:11751800

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

PubMed Central

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, , Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals. PMID:29445698

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran.

PubMed

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

Automated identification of drug and food allergies entered using non-standard terminology.

PubMed

Epstein, Richard H; St Jacques, Paul; Stockin, Michael; Rothman, Brian; Ehrenfeld, Jesse M; Denny, Joshua C

2013-01-01

An accurate computable representation of food and drug allergy is essential for safe healthcare. Our goal was to develop a high-performance, easily maintained algorithm to identify medication and food allergies and sensitivities from unstructured allergy entries in electronic health record (EHR) systems. An algorithm was developed in Transact-SQL to identify ingredients to which patients had allergies in a perioperative information management system. The algorithm used RxNorm and natural language processing techniques developed on a training set of 24 599 entries from 9445 records. Accuracy, specificity, precision, recall, and F-measure were determined for the training dataset and repeated for the testing dataset (24 857 entries from 9430 records). Accuracy, precision, recall, and F-measure for medication allergy matches were all above 98% in the training dataset and above 97% in the testing dataset for all allergy entries. Corresponding values for food allergy matches were above 97% and above 93%, respectively. Specificities of the algorithm were 90.3% and 85.0% for drug matches and 100% and 88.9% for food matches in the training and testing datasets, respectively. The algorithm had high performance for identification of medication and food allergies. Maintenance is practical, as updates are managed through upload of new RxNorm versions and additions to companion database tables. However, direct entry of codified allergy information by providers (through autocompleters or drop lists) is still preferred to post-hoc encoding of the data. Data tables used in the algorithm are available for download. A high performing, easily maintained algorithm can successfully identify medication and food allergies from free text entries in EHR systems.

Computerized physician order entry from a chief information officer perspective.

PubMed

Cotter, Carole M

2004-12-01

Designing and implementing a computerized physician order entry system in the critical care units of a large urban hospital system is an enormous undertaking. With their significant potential to improve health care and significantly reduce errors, the time for computerized physician order entry or physician order management systems is past due. Careful integrated planning is the key to success, requiring multidisciplinary teams at all levels of clinical and administrative management to work together. Articulated from the viewpoint of the Chief Information Officer of Lifespan, a not-for-profit hospital system in Rhode Island, the vision and strategy preceding the information technology plan, understanding the system's current state, the gap analysis between current and future state, and finally, building and implementing the information technology plan are described.

The current medical education system in the world.

PubMed

Nara, Nobuo; Suzuki, Toshiya; Tohda, Shuji

2011-07-04

To contribute to the innovation of the medical education system in Japan, we visited 35 medical schools and 5 institutes in 12 countries of North America, Europe, Australia and Asia in 2008-2010 and observed the education system. We met the deans, medical education committee and administration affairs and discussed about the desirable education system. We also observed the facilities of medical schools.Medical education system shows marked diversity in the world. There are three types of education course; non-graduate-entry program(non-GEP), graduate-entry program(GEP) and mixed program of non-GEP and GEP. Even in the same country, several types of medical schools coexist. Although the education methods are also various among medical schools, most of the medical schools have introduced tutorial system based on PBL or TBL and simulation-based learning to create excellent medical physicians. The medical education system is variable among countries depending on the social environment. Although the change in education program may not be necessary in Japan, we have to innovate education methods; clinical training by clinical clerkship must be made more developed to foster the training of the excellent clinical physicians, and tutorial education by PBL or TBL and simulation-based learning should be introduced more actively.

Using the nursing process to implement a Y2K computer application.

PubMed

Hobbs, C F; Hardinge, T T

2000-01-01

Because of the coming year 2000, the need was assessed to upgrade the order entry system at many hospitals. At Somerset Medical Center, a training team divided the transition into phases and used a modified version of the nursing process to implement the new program. The entire process required fewer than 6 months and was relatively problem-free. This successful transition was aided by the nursing process, training team, and innovative educational techniques.

Security and confidentiality of health information systems: implications for physicians.

PubMed

Dorodny, V S

1998-01-01

Adopting and developing the new generation of information systems will be essential to remain competitive in a quality conscious health care environment. These systems enable physicians to document patient encounters and aggregate the information from the population they treat, while capturing detailed data on chronic medical conditions, medications, treatment plans, risk factors, severity of conditions, and health care resource utilization and management. Today, the knowledge-based information systems should offer instant, around-the-clock access for the provider, support simple order entry, facilitate data capture and retrieval, and provide eligibility verification, electronic authentication, prescription writing, security, and reporting that benchmarks outcomes management based upon clinical/financial decisions and treatment plans. It is an integral part of any information system to incorporate and integrate transactional (financial/administrative) information, as well as analytical (clinical/medical) data in a user-friendly, readily accessible, and secure form. This article explores the technical, financial, logistical, and behavioral obstacles on the way to the Promised Land.

Implementing computerized physician order entry: the importance of special people.

PubMed

Ash, Joan S; Stavri, P Zoë; Dykstra, Richard; Fournier, Lara

2003-03-01

To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. The theme we call Special People is explored here in detail. A taxonomy of types of Special People includes administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users. The recognition and nurturing of Special People should be among the highest priorities of those implementing computerized physician order entry. Their education and training must be a goal of teaching programs in health administration and medical informatics.

El Camino Hospital: using health information technology to promote patient safety.

PubMed

Bukunt, Susan; Hunter, Christine; Perkins, Sharon; Russell, Diana; Domanico, Lee

2005-10-01

El Camino Hospital is a leader in the use of health information technology to promote patient safety, including bar coding, computerized order entry, electronic medical records, and wireless communications. Each year, El Camino Hospital's board of directors sets performance expectations for the chief executive officer, which are tied to achievement of local, regional, and national safety and quality standards, including the six Institute of Medicine quality dimensions. He then determines a set of explicit quality goals and measurable actions, which serve as guidelines for the overall hospital. The goals and progress reports are widely shared with employees, medical staff, patients and families, and the public. For safety, for example, the medication error reduction team tracks and reviews medication error rates. The hospital has virtually eliminated transcription errors through its 100% use of computerized physician order entry. Clinical pathways and standard order sets have reduced practice variation, providing a safer environment. Many projects focused on timeliness, such as emergency department wait time, lab turnaround time, and pneumonia time to initial antibiotic. Results have been mixed, with projects most successful when a link was established with patient outcomes, such as in reducing time to percutaneous transluminal coronary angioplasty for patients with acute myocardial infarction.

Radiology reporting: a closed-loop cycle from order entry to results communication.

PubMed

Weiss, David L; Kim, Woojin; Branstetter, Barton F; Prevedello, Luciano M

2014-12-01

With the increasing prevalence of PACS over the past decade, face-to-face image review among health care providers has become a rarity. This change has resulted in increasing dependence on fast and accurate communication in radiology. Turnaround time expectations are now conveyed in minutes rather than hours or even days. Ideal modern radiology communication is a closed-loop cycle with multiple interoperable applications contributing to the final product. The cycle starts with physician order entry, now often performed through the electronic medical record, with clinical decision support to ensure that the most effective imaging study is ordered. Radiology reports are now almost all in electronic format. The majority are produced using speech recognition systems. Optimization of this software use can alleviate some, if not all, of the inherent user inefficiencies in this type of reporting. Integrated third-party software applications that provide data mining capability are extremely helpful in both academic and clinical settings. The closed-loop ends with automated communication of imaging results. Software products for this purpose should facilitate use of levels of alert, automated escalation to providers, and recording of audit trails of reports received. The multiple components of reporting should be completely interoperable with each other, as well as with the PACS, the RIS, and the electronic medical record. This integration will maximize radiologist efficiency and minimize the possibility of communication error. Copyright © 2014. Published by Elsevier Inc.

The Influence of a "Gap Year" on Medical Students

ERIC Educational Resources Information Center

Paterson-Brown, Lucy; Paterson-Brown, Flora; Simon, Elizabeth; Loudon, Joanna; Henderson-Howat, Susanna; Robertson, Josephine; Paterson-Brown, Simon

2015-01-01

This study reports the views of second year medical students from 6 Universities on the value or not of deferring entry to medical school in order to take a "Gap Year" obtained from an anonymous questionnaire. Data were analysed using Fisher's exact test to produce a two tailed P value, with significance defined as p <0.05. A total of…

Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed.

PubMed

Hsu, Chia-Chen; Chou, Chia-Lin; Chen, Tzeng-Ji; Ho, Chin-Chin; Lee, Chung-Yuan; Chou, Yueh-Ching

2015-05-01

Clinical care has become increasingly dependent on computerized physician order entry (CPOE) systems. No study has reported the adverse effect of CPOE on physicians' ability to handwrite prescriptions. This study took advantage of an extensive crash of the CPOE system at a large hospital to assess the completeness, legibility, and accuracy of physicians' handwritten prescriptions. The CPOE system had operated at the outpatient department of an academic medical center in Taiwan since 1993. During an unintentional shutdown that lasted 3.5 hours in 2010, physicians were forced to write prescriptions manually. These handwritten prescriptions, together with clinical medical records, were later audited by clinical pharmacists with respect to 16 fields of the patient's, prescriber's, and drug data. A total of 1418 prescriptions with 3805 drug items were handwritten by 114 to 1369 patients. Not a single prescription had all necessary fields filled in. Although the field of age was most frequently omitted (1282 [90.4%] of 1418 prescriptions) among the patient's data, the field of dosage form was most frequently omitted (3480 [91.5%] of 3805 items) among the drug data. In contrast, the scale of illegibility was rather small. The highest percentage reached only 1.5% (n = 57) in the field of drug frequency. Inaccuracies of strength, dose, and drug name were observed in 745 (19.6%), 517 (13.6%), and 435 (11.4%) prescribed drug items, respectively. The unintentional shutdown of a long-running CPOE system revealed that physicians fail to handwrite flawless prescriptions in the digital era. The contingency plans for computer disasters at health care facilities might include preparation of stand-alone e-prescribing software so that the service delay could be kept to the minimum. However, guidance on prescribing should remain an essential part of medical education. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.

Computer-based physician order entry: the state of the art.

PubMed Central

Sittig, D F; Stead, W W

1994-01-01

Direct computer-based physician order entry has been the subject of debate for over 20 years. Many sites have implemented systems successfully. Others have failed outright or flirted with disaster, incurring substantial delays, cost overruns, and threatened work actions. The rationale for physician order entry includes process improvement, support of cost-conscious decision making, clinical decision support, and optimization of physicians' time. Barriers to physician order entry result from the changes required in practice patterns, roles within the care team, teaching patterns, and institutional policies. Key ingredients for successful implementation include: the system must be fast and easy to use, the user interface must behave consistently in all situations, the institution must have broad and committed involvement and direction by clinicians prior to implementation, the top leadership of the organization must be committed to the project, and a group of problem solvers and users must meet regularly to work out procedural issues. This article reviews the peer-reviewed scientific literature to present the current state of the art of computer-based physician order entry. PMID:7719793

Electronic Chemotherapy Order Entry: A Major Cancer Center's Implementation

PubMed Central

Sklarin, Nancy T.; Granovsky, Svetlana; O'Reilly, Eileen M.; Zelenetz, Andrew D.

2011-01-01

Implementation of a computerized provider order entry system for complex chemotherapy regimens at a large cancer center required intense effort from a multidisciplinary team of clinical and systems experts with experience in all facets of the chemotherapy process. The online tools had to resemble the paper forms used at the time and parallel the successful established process as well as add new functionality. Close collaboration between the institution and the vendor was necessary. This article summarizes the institutional efforts, challenges, and collaborative processes that facilitated universal chemotherapy computerized electronic order entry across multiple sites during a period of several years. PMID:22043182

Electronic Chemotherapy Order Entry: A Major Cancer Center's Implementation.

PubMed

Sklarin, Nancy T; Granovsky, Svetlana; O'Reilly, Eileen M; Zelenetz, Andrew D

2011-07-01

Implementation of a computerized provider order entry system for complex chemotherapy regimens at a large cancer center required intense effort from a multidisciplinary team of clinical and systems experts with experience in all facets of the chemotherapy process. The online tools had to resemble the paper forms used at the time and parallel the successful established process as well as add new functionality. Close collaboration between the institution and the vendor was necessary. This article summarizes the institutional efforts, challenges, and collaborative processes that facilitated universal chemotherapy computerized electronic order entry across multiple sites during a period of several years.

Development of an inpatient operational pharmacy productivity model.

PubMed

Naseman, Ryan W; Lopez, Ben R; Forrey, Ryan A; Weber, Robert J; Kipp, Kris M

2015-02-01

An innovative model for measuring the operational productivity of medication order management in inpatient settings is described. Order verification within a computerized prescriber order-entry system was chosen as the pharmacy workload driver. To account for inherent variability in the tasks involved in processing different types of orders, pharmaceutical products were grouped by class, and each class was assigned a time standard, or "medication complexity weight" reflecting the intensity of pharmacist and technician activities (verification of drug indication, verification of appropriate dosing, adverse-event prevention and monitoring, medication preparation, product checking, product delivery, returns processing, nurse/provider education, and problem-order resolution). The resulting "weighted verifications" (WV) model allows productivity monitoring by job function (pharmacist versus technician) to guide hiring and staffing decisions. A 9-month historical sample of verified medication orders was analyzed using the WV model, and the calculations were compared with values derived from two established models—one based on the Case Mix Index (CMI) and the other based on the proprietary Pharmacy Intensity Score (PIS). Evaluation of Pearson correlation coefficients indicated that values calculated using the WV model were highly correlated with those derived from the CMI-and PIS-based models (r = 0.845 and 0.886, respectively). Relative to the comparator models, the WV model offered the advantage of less period-to-period variability. The WV model yielded productivity data that correlated closely with values calculated using two validated workload management models. The model may be used as an alternative measure of pharmacy operational productivity. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru

PubMed Central

Fraser, Hamish SF; Blaya, Joaquin; Choi, Sharon S; Bonilla, Cesar; Jazayeri, Darius

2006-01-01

The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data. In addition less formal data on the use of the EMR for reporting and research are reviewed. Experience and insights from porting the PIH-EMR to the Philippines, and modifying it to support HIV treatment in Haiti and Rwanda are discussed. We propose that additional data of this sort is valuable in assessing medical information systems especially in resource poor areas. PMID:17238344

Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru.

PubMed

Fraser, Hamish S F; Blaya, Joaquin; Choi, Sharon S; Bonilla, Cesar; Jazayeri, Darius

2006-01-01

The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data. In addition less formal data on the use of the EMR for reporting and research are reviewed. Experience and insights from porting the PIH-EMR to the Philippines, and modifying it to support HIV treatment in Haiti and Rwanda are discussed. We propose that additional data of this sort is valuable in assessing medical information systems especially in resource poor areas.

Impact of an antiretroviral stewardship strategy on medication error rates.

PubMed

Shea, Katherine M; Hobbs, Athena Lv; Shumake, Jason D; Templet, Derek J; Padilla-Tolentino, Eimeira; Mondy, Kristin E

2018-05-02

The impact of an antiretroviral stewardship strategy on medication error rates was evaluated. This single-center, retrospective, comparative cohort study included patients at least 18 years of age infected with human immunodeficiency virus (HIV) who were receiving antiretrovirals and admitted to the hospital. A multicomponent approach was developed and implemented and included modifications to the order-entry and verification system, pharmacist education, and a pharmacist-led antiretroviral therapy checklist. Pharmacists performed prospective audits using the checklist at the time of order verification. To assess the impact of the intervention, a retrospective review was performed before and after implementation to assess antiretroviral errors. Totals of 208 and 24 errors were identified before and after the intervention, respectively, resulting in a significant reduction in the overall error rate ( p < 0.001). In the postintervention group, significantly lower medication error rates were found in both patient admissions containing at least 1 medication error ( p < 0.001) and those with 2 or more errors ( p < 0.001). Significant reductions were also identified in each error type, including incorrect/incomplete medication regimen, incorrect dosing regimen, incorrect renal dose adjustment, incorrect administration, and the presence of a major drug-drug interaction. A regression tree selected ritonavir as the only specific medication that best predicted more errors preintervention ( p < 0.001); however, no antiretrovirals reliably predicted errors postintervention. An antiretroviral stewardship strategy for hospitalized HIV patients including prospective audit by staff pharmacists through use of an antiretroviral medication therapy checklist at the time of order verification decreased error rates. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Driving out errors through tight integration between software and automation.

PubMed

Reifsteck, Mark; Swanson, Thomas; Dallas, Mary

2006-01-01

A clear case has been made for using clinical IT to improve medication safety, particularly bar-code point-of-care medication administration and computerized practitioner order entry (CPOE) with clinical decision support. The equally important role of automation has been overlooked. When the two are tightly integrated, with pharmacy information serving as a hub, the distinctions between software and automation become blurred. A true end-to-end medication management system drives out errors from the dockside to the bedside. Presbyterian Healthcare Services in Albuquerque has been building such a system since 1999, beginning by automating pharmacy operations to support bar-coded medication administration. Encouraged by those results, it then began layering on software to further support clinician workflow and improve communication, culminating with the deployment of CPOE and clinical decision support. This combination, plus a hard-wired culture of safety, has resulted in a dramatically lower mortality and harm rate that could not have been achieved with a partial solution.

Study of advanced atmospheric entry systems for Mars

NASA Technical Reports Server (NTRS)

1978-01-01

Entry system designs are described for various advanced Mars missions including sample return, hard lander, and Mars airplane. The Mars exploration systems for sample return and the hard lander require decleration from direct approach entry velocities of about 6 km/s to terminal velocities consistent with surface landing requirements. The Mars airplane entry system is decelerated from orbit at 4.6 km/s to deployment near the surface. Mass performance characteristics of major elements of the Mass performance characteristics are estimated for the major elements of the required entry systems using Viking technology or logical extensions of technology in order to provide a common basis of comparison for the three entry modes mission mode approaches. The entry systems, although not optimized, are based on Viking designs and reflect current hardware performance capability and realistic mass relationships.

Computerised pathology test order entry reduces laboratory turnaround times and influences tests ordered by hospital clinicians: a controlled before and after study

PubMed Central

Westbrook, J I; Georgiou, A; Dimos, A; Germanos, T

2006-01-01

Objective To assess the impact of a computerised pathology order entry system on laboratory turnaround times and test ordering within a teaching hospital. Methods A controlled before and after study compared test assays ordered from 11 wards two months before (n = 97 851) and after (n = 113 762) the implementation of a computerised pathology order entry system (Cerner Millennium Powerchart). Comparisons were made of laboratory turnaround times, frequency of tests ordered and specimens taken, proportions of patients having tests, average number per patient, and percentage of gentamicin and vancomycin specimens labelled as random. Results Intervention wards experienced an average decrease in turnaround of 15.5 minutes/test assay (range 73.8 to 58.3 minutes; p<0.001). Reductions were significant for prioritised and non‐prioritised tests, and for those done within and outside business hours. There was no significant change in the average number of tests (p = 0.228), or specimens per patient (p = 0.324), and no change in turnaround time for the control ward (p = 0.218). Use of structured order screens enhanced data provided to laboratories. Removing three test assays from the liver function order set resulted in significantly fewer of these tests being done. Conclusions Computerised order entry systems are an important element in achieving faster test results. These systems can influence test ordering patterns through structured order screens, manipulation of order sets, and analysis of real time data to assess the impact of such changes, not possible with paper based systems. The extent to which improvements translate into improved patient outcomes remains to be determined. A potentially limiting factor is clinicians' capacity to respond to, and make use of, faster test results. PMID:16461564

Quality Assessment of Process Measures in Antimicrobial Stewardship: Concordance of Valacyclovir Indication and Automatic Prospective Approval in Computerized Provider Order Entry

PubMed Central

Lee, Tiffany; McCoy, Christopher; Mahoney, Monica V

2017-01-01

Abstract Background The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommend computerized decision support at the time of prescribing as an antimicrobial stewardship (AST) tool. Providing antimicrobial indications during prescribing can optimize infection-specific therapy through appropriate antimicrobial selection, dosing, and frequency. The Leapfrog group identifies this as a quality measure for their report card system. At Beth Israel Deaconess Medical Center (BIDMC), indication-based dosing has been incorporated in the computerized provider order entry (CPOE) system since 2006. At BIDMC, valacyclovir is only approved for the treatment of varicella zoster (VZV) infection or prophylaxis of solid organ transplant (SOT) patients at low risk for cytomegalovirus. These indications bypass the need for AST approval. Accuracy validation of the selected indications has not been formally performed. Methods A retrospective chart review was performed in patients prescribed valacyclovir during an 8-month period in 2016. Electronic medical records, laboratory reports, and pharmacy records were reviewed to identify the suspected/confirmed infection. The primary outcome was the concordance rate of selected CPOE valacyclovir indication compared with suspected/confirmed infection at the time of ordering. The secondary outcome was the proportion of valacyclovir use per institutional protocol. Results Overall, 117 patients were included, with a median age of 57.9 years, 51 (43.6%) were male, and 4 (3.4%) were located in an intensive care unit. Fifty-nine orders (50.4%) selected VZV as the indication, followed by 21 orders (17.9%) for SOT prophylaxis. Of orders with any CPOE indication, only 59/101 (58.4%) were concordant with suspected/confirmed infection. Of the valacyclovir orders with a VZV indication, 37 (62.7%) were concordant. Of the orders with SOT prophylaxis indications, 5 (23.8%) were concordant. Furthermore, only 46 orders (39.3%) were per BIDMC-protocol. Conclusion Concordance of CPOE indication selection and suspected/confirmed infection for valacyclovir was low. Using CPOE to grant automatic prospective approval must be monitored and audited for accuracy if employed as an AST tool. Disclosures All authors: No reported disclosures.

Computer-supported weight-based drug infusion concentrations in the neonatal intensive care unit.

PubMed

Giannone, Gay

2005-01-01

This article addresses the development of a computerized provider order entry (CPOE)-embedded solution for weight-based neonatal drug infusion developed during the transition from a legacy CPOE system to a customized application of a neonatal CPOE product during a hospital-wide information system transition. The importance of accurate fluid management in the neonate is reviewed. The process of tailoring the system that eventually resulted in the successful development of a computer application enabling weight-based medication infusion calculation for neonates within the CPOE information system is explored. In addition, the article provides guidelines on how to customize a vendor solution for hospitals with neonatal intensive care unit.

Accuracy and time requirements of a bar-code inventory system for medical supplies.

PubMed

Hanson, L B; Weinswig, M H; De Muth, J E

1988-02-01

The effects of implementing a bar-code system for issuing medical supplies to nursing units at a university teaching hospital were evaluated. Data on the time required to issue medical supplies to three nursing units at a 480-bed, tertiary-care teaching hospital were collected (1) before the bar-code system was implemented (i.e., when the manual system was in use), (2) one month after implementation, and (3) four months after implementation. At the same times, the accuracy of the central supply perpetual inventory was monitored using 15 selected items. One-way analysis of variance tests were done to determine any significant differences between the bar-code and manual systems. Using the bar-code system took longer than using the manual system because of a significant difference in the time required for order entry into the computer. Multiple-use requirements of the central supply computer system made entering bar-code data a much slower process. There was, however, a significant improvement in the accuracy of the perpetual inventory. Using the bar-code system for issuing medical supplies to the nursing units takes longer than using the manual system. However, the accuracy of the perpetual inventory was significantly improved with the implementation of the bar-code system.

Intelligent Visual Input: A Graphical Method for Rapid Entry of Patient-Specific Data

PubMed Central

Bergeron, Bryan P.; Greenes, Robert A.

1987-01-01

Intelligent Visual Input (IVI) provides a rapid, graphical method of data entry for both expert system interaction and medical record keeping purposes. Key components of IVI include: a high-resolution graphic display; an interface supportive of rapid selection, i.e., one utilizing a mouse or light pen; algorithm simplification modules; and intelligent graphic algorithm expansion modules. A prototype IVI system, designed to facilitate entry of physical exam findings, is used to illustrates the potential advantages of this approach.

Easily configured real-time CPOE Pick Off Tool supporting focused clinical research and quality improvement.

PubMed

Rosenbaum, Benjamin P; Silkin, Nikolay; Miller, Randolph A

2014-01-01

Real-time alerting systems typically warn providers about abnormal laboratory results or medication interactions. For more complex tasks, institutions create site-wide 'data warehouses' to support quality audits and longitudinal research. Sophisticated systems like i2b2 or Stanford's STRIDE utilize data warehouses to identify cohorts for research and quality monitoring. However, substantial resources are required to install and maintain such systems. For more modest goals, an organization desiring merely to identify patients with 'isolation' orders, or to determine patients' eligibility for clinical trials, may adopt a simpler, limited approach based on processing the output of one clinical system, and not a data warehouse. We describe a limited, order-entry-based, real-time 'pick off' tool, utilizing public domain software (PHP, MySQL). Through a web interface the tool assists users in constructing complex order-related queries and auto-generates corresponding database queries that can be executed at recurring intervals. We describe successful application of the tool for research and quality monitoring.

The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.

PubMed

Slight, Sarah P; Seger, Diane L; Franz, Calvin; Wong, Adrian; Bates, David W

2018-06-22

To estimate the national cost of ADEs resulting from inappropriate medication-related alert overrides in the U.S. inpatient setting. We used three different regression models (Basic, Model 1, Model 2) with model inputs taken from the medical literature. A random sample of 40 990 adult inpatients at the Brigham and Women's Hospital (BWH) in Boston with a total of 1 639  294 medication orders was taken. We extrapolated BWH medication orders using 2014 National Inpatient Sample (NIS) data. Using three regression models, we estimated that 29.7 million adult inpatient discharges in 2014 resulted in between 1.02 billion and 1.07 billion medication orders, which in turn generated between 75.1 million and 78.8 million medication alerts, respectively. Taking the basic model (78.8 million), we estimated that 5.5 million medication-related alerts might have been inappropriately overridden, resulting in approximately 196 600 ADEs nationally. This was projected to cost between $871 million and $1.8 billion for treating preventable ADEs. We also estimated that clinicians and pharmacists would have jointly spent 175 000 hours responding to 78.8 million alerts with an opportunity cost of $16.9 million. These data suggest that further optimization of hospitals computerized provider order entry systems and their associated clinical decision support is needed and would result in substantial savings. We have erred on the side of caution in developing this range, taking two conservative cost estimates for a preventable ADE that did not include malpractice or litigation costs, or costs of injuries to patients.

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

PubMed

Weir, Charlene R; Nebeker, Jonathan J R; Hicken, Bret L; Campo, Rebecca; Drews, Frank; Lebar, Beth

2007-01-01

Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system.

Duty hour reform in a shifting medical landscape.

PubMed

Jena, Anupam B; Prasad, Vinay

2013-09-01

The circumstances that led to the death of Libby Zion in 1984 prompted national discussions about the impact of resident fatigue on patient outcomes. Nearly 30 years later, national duty hour reforms largely motivated by patient safety concerns have demonstrated a negligible impact of duty hour reductions on patient mortality. We suggest that the lack of an impact of duty hour reforms on patient mortality is due to a different medical landscape today than existed in 1984. Improvements in quality of care made possible by computerized order entry, automated medication checks, inpatient pharmacists, and increased resident supervision have, among other systemic changes, diminished the adverse impact that resident fatigue is able to have on patient outcomes. Given this new medical landscape, advocacy towards current and future duty hour reforms may be best justified by evidence of the impact of duty hour reform on resident wellbeing, education, and burnout.

Integrated information systems for electronic chemotherapy medication administration.

PubMed

Levy, Mia A; Giuse, Dario A; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K

2011-07-01

Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations.

Evaluation of emergency medical text processor, a system for cleaning chief complaint text data.

PubMed

Travers, Debbie A; Haas, Stephanie W

2004-11-01

Emergency Medical Text Processor (EMT-P) version 1, a natural language processing system that cleans emergency department text (e.g., chst pn, chest pai), was developed to maximize extraction of standard terms (e.g., chest pain). The authors compared the number of standard terms extracted from raw chief complaint (CC) data with that for CC data cleaned with EMT-P and evaluated the accuracy of EMT-P. This cross-sectional observation study included CC text entries for all emergency department visits to three tertiary care centers in 2001. Terms were extracted from CC entries before and after cleaning with EMT-P. Descriptive statistics included number and percentage of all entries (tokens) and all unique entries (types) that matched a standard term from the Unified Medical Language System (UMLS). An expert panel rated the accuracy of the CC-UMLS term matches; inter-rater reliability was measured with kappa. The authors collected 203,509 CC entry tokens, of which 63,946 were unique entry types. For the raw data, 89,337 tokens (44%) and 5,081 types (8%) matched a standard term. After EMT-P cleaning, 168,050 tokens (83%) and 44,430 types (69%) matched a standard term. The expert panel reached consensus on 201 of the 222 CC-UMLS term matches reviewed (kappa=0.69-0.72). Ninety-six percent of the 201 matches were rated equivalent or related. Thirty-eight percent of the nonmatches were found to match UMLS concepts. EMT-P version 1 is relatively accurate, and cleaning with EMT-P improved the CC-UMLS term match rate over raw data. The authors identified areas for improvement in future EMT-P versions and issues to be resolved in developing a standard CC terminology.

The VA Computerized Patient Record — A First Look

PubMed Central

Anderson, Curtis L.; Meldrum, Kevin C.

1994-01-01

In support of its in-house DHCP Physician Order Entry/Results Reporting application, the VA is developing the first edition of a Computerized Patient Record. The system will feature a physician-oriented interface with real time, expert system-based order checking, a controlled vocabulary, a longitudinal repository of patient data, HL7 messaging support, a clinical reminder and warning system, and full integration with existing VA applications including lab, pharmacy, A/D/T, radiology, dietetics, surgery, vitals, allergy tracking, discharge summary, problem list, progress notes, consults, and online physician order entry. PMID:7949886

Using an Evidence-Based Approach to EMR Implementation to Optimize Outcomes and Avoid Unintended Consequences

PubMed Central

Longhurst, Christopher A.; Palma, Jonathan P.; Grisim, Lisa M.; Widen, Eric; Chan, Melanie; Sharek, Paul J.

2013-01-01

Implementation of an electronic medical record (EMR) with computerized physician order entry (CPOE) can provide an important foundation for preventing harm and improving outcomes. Incentivized by the recent economic stimulus initiative, healthcare systems are implementing vendor-based EMR systems at an unprecedented rate. Accumulating evidence suggests that local implementation decisions, rather than the specific EMR product or technology selected, are the primary drivers of the quality improvement performance of these systems. However, limited attention has been paid to effective approaches to EMR implementation. In this case report, we outline the evidence-based approach we used to make EMR implementation decisions in a pragmatic structure intended for replication at other sites. PMID:24771994

Estimates of electronic medical records in U.S. Emergency departments.

PubMed

Geisler, Benjamin P; Schuur, Jeremiah D; Pallin, Daniel J

2010-02-17

Policymakers advocate universal electronic medical records (EMRs) and propose incentives for "meaningful use" of EMRs. Though emergency departments (EDs) are particularly sensitive to the benefits and unintended consequences of EMR adoption, surveillance has been limited. We analyze data from a nationally representative sample of US EDs to ascertain the adoption of various EMR functionalities. We analyzed data from the National Hospital Ambulatory Medical Care Survey, after pooling data from 2005 and 2006, reporting proportions with 95% confidence intervals (95% CI). In addition to reporting adoption of various EMR functionalities, we used logistic regression to ascertain patient and hospital characteristics predicting "meaningful use," defined as a "basic" system (managing demographic information, computerized provider order entry, and lab and imaging results). We found that 46% (95% CI 39-53%) of US EDs reported having adopted EMRs. Computerized provider order entry was present in 21% (95% CI 16-27%), and only 15% (95% CI 10-20%) had warnings for drug interactions or contraindications. The "basic" definition of "meaningful use" was met by 17% (95% CI 13-21%) of EDs. Rural EDs were substantially less likely to have a "basic" EMR system than urban EDs (odds ratio 0.19, 95% CI 0.06-0.57, p = 0.003), and Midwestern (odds ratio 0.37, 95% CI 0.16-0.84, p = 0.018) and Southern (odds ratio 0.47, 95% CI 0.26-0.84, p = 0.011) EDs were substantially less likely than Northeastern EDs to have a "basic" system. EMRs are becoming more prevalent in US EDs, though only a minority use EMRs in a "meaningful" way, no matter how "meaningful" is defined. Rural EDs are less likely to have an EMR than metropolitan EDs, and Midwestern and Southern EDs are less likely to have an EMR than Northeastern EDs. We discuss the nuances of how to define "meaningful use," and the importance of considering not only adoption, but also full implementation and consequences.

Evaluation of STAT medication ordering process in a community hospital.

PubMed

Abdelaziz, Hani; Richardson, Sandra; Walsh, Kim; Nodzon, Jessica; Schwartz, Barbara

2016-01-01

In most health care facilities, problems related to delays in STAT medication order processing time are of common concern. The purpose of this study was to evaluate processing time for STAT orders at Kimball Medical Center. All STAT orders were reviewed to determine processing time; order processing time was also stratified by physician order entry (physician entered (PE) orders vs. non-physician entered (NPE) orders). Collected data included medication ordered, indication, time ordered, time verified by pharmacist, time sent from pharmacy, and time charted as given to the patient. A total of 502 STAT orders were reviewed and 389 orders were included for analysis. Overall, median time was 29 minutes, IQR 16-63; p<0.0001.). The time needed to process NPE orders was significantly less than that needed for PE orders (median 27 vs. 34 minutes; p=0.026). In terms of NPE orders, the median total time required to process STAT orders for medications available in the Automated Dispensing Devices (ADM) was within 30 minutes, while that required to process orders for medications not available in the ADM was significantly greater than 30 minutes. For PE orders, the median total time required to process orders for medications available in the ADM (i.e., not requiring pharmacy involvement) was significantly greater than 30 minutes. [Median time = 34 minutes (p<0.001)]. We conclude that STAT order processing time may be improved by increasing the availability of medications in ADM, and pharmacy involvement in the verification process.

MAPS: The Organization of a Spatial Database System Using Imagery, Terrain, and Map Data

DTIC Science & Technology

1983-06-01

segments which share the same pixel position. Finally, in any largo system, a logical partitioning of the database must be performed in order to avoid...34theodore roosevelt memoria entry 0; entry 1: Virginia ’northwest Washington* 2 en 11" ies for "crossover" for ’theodore roosevelt memor i entry 0

The MEDIGATE graphical user interface for entry of physical findings: design principles and implementation. Medical Examination Direct Iconic and Graphic Augmented Text Entry System.

PubMed

Yoder, J W; Schultz, D F; Williams, B T

1998-10-01

The solution to many of the problems of the computer-based recording of the medical record has been elusive, largely due to difficulties in the capture of those data elements that comprise the records of the Present Illness and of the Physical Findings. Reliable input of data has proven to be more complex than originally envisioned by early work in the field. This has led to more research and development into better data collection protocols and easy to use human-computer interfaces as support tools. The Medical Examination Direct Iconic and Graphic Augmented Text Entry System (MEDIGATE System) is a computer enhanced interactive graphic and textual record of the findings from physical examinations designed to provide ease of user input and to support organization and processing of the data characterizing these findings. The primary design objective of the MEDIGATE System is to develop and evaluate different interface designs for recording observations from the physical examination in an attempt to overcome some of the deficiencies in this major component of the individual record of health and illness.

The Lilongwe Central Hospital Patient Management Information System: A Success in Computer-Based Order Entry Where One Might Least Expect It

PubMed Central

GP, Douglas; RA, Deula; SE, Connor

2003-01-01

Computer-based order entry is a powerful tool for enhancing patient care. A pilot project in the pediatric department of the Lilongwe Central Hospital (LCH) in Malawi, Africa has demonstrated that computer-based order entry (COE): 1) can be successfully deployed and adopted in resource-poor settings, 2) can be built, deployed and sustained at relatively low cost and with local resources, and 3) has a greater potential to improve patient care in developing than in developed countries. PMID:14728338

Reducing Wrong Patient Selection Errors: Exploring the Design Space of User Interface Techniques

PubMed Central

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients’ identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed. PMID:25954415

Reducing wrong patient selection errors: exploring the design space of user interface techniques.

PubMed

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients' identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed.

Managing drugs safely.

PubMed

van den Anker, John N

2005-02-01

There is hard data to show that newborn infants are more likely than adults to experience adverse reactions to drugs. Paradoxically, drug-related legislation to ensure safe and effective drug use in humans neglected neonates until 2002, when the Best Pharmaceuticals Act for Children was signed into law in the USA. The situation for neonates should now catch up with that for adults and neonates will be prescribed more licensed drugs in the near future. If we are to be able to analyze the underlying system errors to improve the safe use of drugs in the studied patient population, reporting of adverse drug events and reactions needs to happen in a blame free environment. In addition, computerized physician order entry will certainly further improve the current situation by preventing errors in ordering, transcribing, verifying, and transmitting medication orders.

Lessons learned from a pharmacy practice model change at an academic medical center.

PubMed

Knoer, Scott J; Pastor, John D; Phelps, Pamela K

2010-11-01

The development and implementation of a new pharmacy practice model at an academic medical center are described. Before the model change, decentralized pharmacists responsible for order entry and verification and clinical specialists were both present on the care units. Staff pharmacists were responsible for medication distribution and sterile product preparation. The decentralized pharmacists handling orders were not able to use their clinical training, the practice model was inefficient, and few clinical services were available during evenings and weekends. A task force representing all pharmacy department roles developed a process and guiding principles for the model change, collected data, and decided on a model. Teams consisting of decentralized pharmacists, decentralized pharmacy technicians, and team leaders now work together to meet patients' pharmacy needs and further departmental safety, quality, and cost-saving goals. Decentralized service hours have been expanded through operational efficiencies, including use of automation (e.g., computerized provider order entry, wireless computers on wheels used during rounds with physician teams). Nine clinical specialist positions were replaced by five team leader positions and four pharmacists functioning in decentralized roles. Additional staff pharmacist positions were shifted into decentralized roles, and the hospital was divided into areas served by teams including five to eight pharmacists. Technicians are directly responsible for medication distribution. No individual's job was eliminated. The new practice model allowed better alignment of staff with departmental goals, expanded pharmacy hours and services, more efficient medication distribution, improved employee engagement, and a staff succession plan.

42 CFR 412.46 - Medical review requirements.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Medical review requirements. 412.46 Section 412.46... Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs § 412.46 Medical... performed, as evidenced by the physician's entries in the patient's medical record, physicians must complete...

42 CFR 412.46 - Medical review requirements.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Medical review requirements. 412.46 Section 412.46... Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs § 412.46 Medical... performed, as evidenced by the physician's entries in the patient's medical record, physicians must complete...

ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration--2014.

PubMed

Pedersen, Craig A; Schneider, Philip J; Scheckelhoff, Douglas J

2015-07-01

The results of the 2014 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are described. A stratified random sample of pharmacy directors at 1435 general and children's medical-surgical hospitals in the United States were surveyed by mail. In this national probability sample survey, the response rate was 29.7%. Ninety-seven percent of hospitals used automated dispensing cabinets in their medication distribution systems, 65.7% of which used individually secured lidded pockets as the predominant configuration. Overall, 44.8% of hospitals used some form of machine-readable coding to verify doses before dispensing in the pharmacy. Overall, 65% of hospital pharmacy departments reported having a cleanroom compliant with United States Pharmacopeia chapter 797. Pharmacists reviewed and approved all medication orders before the first dose was administered, either onsite or by remote order view, except in procedure areas and emergency situations, in 81.2% of hospitals. Adoption rates of electronic health information have rapidly increased, with the widespread use of electronic health records, computer prescriber order entry, barcodes, and smart pumps. Overall, 31.4% of hospitals had pharmacists practicing in ambulatory or primary care clinics. Transitions-of-care services offered by the pharmacy department have generally increased since 2012. Discharge prescription services increased from 11.8% of hospitals in 2012 to 21.5% in 2014. Approximately 15% of hospitals outsourced pharmacy management operations to a contract pharmacy services provider, an increase from 8% in 2011. Health-system pharmacists continue to have a positive impact on improving healthcare through programs that improve the efficiency, safety, and clinical outcomes of medication use in health systems. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Towards meaningful medication-related clinical decision support: recommendations for an initial implementation.

PubMed

Phansalkar, S; Wright, A; Kuperman, G J; Vaida, A J; Bobb, A M; Jenders, R A; Payne, T H; Halamka, J; Bloomrosen, M; Bates, D W

2011-01-01

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

Variation in Formulary Management Practices Within the Department of Veterans Affairs Health Care System.

PubMed

Radomski, Thomas R; Good, Chester B; Thorpe, Carolyn T; Zhao, Xinhua; Marcum, Zachary A; Glassman, Peter A; Lowe, John; Mor, Maria K; Fine, Michael J; Gellad, Walid F

2016-02-01

All Department of Veterans Affairs Medical Centers (VAMCs) operate under a single national drug formulary, yet substantial variation in prescribing and spending exists across facilities. Local management of the national formulary may differ across VAMCs and may be one cause of this variation. To characterize variation in the management of nonformulary medication requests and pharmacy and therapeutics (P&T) committee member perceptions of the formulary environment at VAMCs nationwide. We performed an online survey of the chief of pharmacy and an additional staff pharmacist and physician on the P&T committee at all VAMCs. Respondents were asked questions regarding criteria for use for nonformulary medications, specific procedures for ordering nonformulary medications in general and specific lipid-lowering and diabetes agents, the appeals process, and the formulary environment at their VAMCs. We compared responses across facilities and between chiefs of pharmacy, pharmacists, and physicians. A total of 212 chief pharmacists (n = 80), staff pharmacists (n = 78), and physicians (n = 54) responded, for an overall response rate of 49%. In total, 107/143 (75%) different VAMCs were represented. The majority of VAMCs reported adhering to national criteria for use, with 38 (36%) being very adherent and 69 (65%) being mostly adherent. There was substantial variation between VAMCs regarding how nonformulary drugs were ordered, evaluated, and appealed. The nonformulary lipid-lowering drugs ezetimibe, rosuvastatin, and atorvastatin were viewable to providers in the order entry screen at 67 (63%), 67 (63%), and 64 (60%) VAMCs, respectively. The nonformulary diabetes medication pioglitazone was only viewable at 58 (55%) VAMCs. In the remaining VAMCs, providers could not order these nonformulary drugs through the normal order-entry process. For questions about the formulary environment, physician respondent perceptions differed from those of staff pharmacists and chief pharmacists. Compared with pharmacy chiefs and staff pharmacists, physicians were less likely to agree that providers at their VAMC prescribed too many nonformulary medications (47% and 44% vs. 12%, P < 0.001), more likely to agree that providers must jump through too many hoops to prescribe nonformulary medication (5% and 3% vs. 25%, P < 0.001), and more likely to agree that providers make an effort to convert new patients from nonformulary to formulary lipid-lowering (65% and 73% vs. 94%, P <0.02) and diabetic medications (49% and 50% vs. 88%, P < 0.001). Although the Department of Veterans Affairs (VA) operates under a single national formulary, we found significant differences among VAMCs regarding their management of nonformulary medication requests. We also found differences among formulary leaders regarding their perception of the environment in which their VAMC's formulary is managed. These findings have important implications not just for VA, but for any organization that develops, implements, and manages drug formularies across multiple facilities.

Graduate-entry medical students: older and wiser but not less distressed.

PubMed

Casey, Dion; Thomas, Susan; Hocking, Darren R; Kemp-Casey, Anna

2016-02-01

Australia has a growing number of graduate-entry medical courses. It is known that undergraduate medical students have high levels of psychological distress; however, little is known about graduate-entry medical students. We examined whether graduate-entry medical students had higher levels of psychological distress than the same-age general population. Psychological distress was assessed in 122 graduate-entry medical students in an Australian graduate-entry medical school using the 21-item Depression Anxiety and Stress Scale. Mean scores and the proportion of students with scores in the highly distressed range were compared with non-clinical population norms. Scores were also compared across demographic characteristics. Medical students reported higher mean depression, anxiety and stress scores than the general population and were more likely to score in the moderate to extremely high range for anxiety (45% vs. 13%; p<0.001) and stress (17% vs. 13%; p=0.003). Anxiety and stress were higher in students aged ≥30 years than in younger students. Despite their maturity, graduate-entry students experienced high psychological distress. Anxiety and stress were higher, not lower, with increasing age. Our results suggest that graduate-entry medical students warrant the same level of concern as their school-leaving counterparts. Further interventions to support these students during medical school are warranted. © The Royal Australian and New Zealand College of Psychiatrists 2015.

Analysis of Low Appropriateness Score Exam Trends in Decision Support-based Radiology Order Entry System.

PubMed

Gupta, Supriya; Klein, Kandace; Singh, Anand H; Thrall, James H

2017-05-01

Awareness of imaging utilization increased after implementation of Radiology Order Entry with decision support systems (ROE-DS). Our hypothesis is few exams with low Clinical Appropriateness Score (CAS) on ROE-DS are performed. Clinical indications of exams with CAS less than 3 (9-point scale) were re-reviewed and reports analyzed. Structured Query Language-based query retrieved exams with CAS less than 3 in ROE-DS from January 2007 to December 2011. Reasons provided by physicians for ordering these exams and reports of exams performed were analyzed. For each indication, number of exams ordered and performed was calculated. Statistical significance was assessed using Student's t test and χ 2 analysis (P < .05). From 445,984 exams, 12,615 exams (2.8%) had CAS less than 3, and 7,956 exams (63%) were performed. Reasons for ordering of 12,615 low CAS exams were as follows: Requests by physician specialists without further explanation (4,516 = 35.8%), notation of special clinical circumstances (2,877 = 22.8%), requests by nonphysician staff without further explanation (1,383 = 10.9%), absence of suspected finding on previous modality (1,099 = 8.7%), patient preference (737 = 5.8%), and requests based on radiologists' recommendations (706 = 5.6%). Difference between male and female (male < female) preferences for low CAS exams was statistically significant (P < .01). Imaging outcome was highest for extremity MRI cases (66.7%; P < .01). Less than 3% of exams ordered had low CAS and about two-thirds of these were performed. Most common indication for ordering these exams was physician specialist request based on opinion of medical necessity without specification. Extremity MRI constituted the highest positive findings for low CAS exams performed. Published by Elsevier Inc.

Mechanization of Library Procedures in the Medium-sized Medical Library: IX. Holding Statements in PHILSOM: a Study of their Activity *

PubMed Central

Beckwith, Helen K.

1970-01-01

A study was made of the serial holding statements in PHILSOM over a six-month period, in order to determine the desirability of printing the complete serial holding statements monthly. Attention was given to the frequency of internal and update changes in both active and dead entries. The results indicate that while sufficient activity is observed in active serial entries to warrant their monthly updating, dead serial entries remain constant over this period. This indicates that a large group of PHILSOM entries can be easily identified and isolated, facilitating division and independent updating of the resultant lists. The desirability of such a division, however, must also take into consideration the user's ease in handling such a segmented listing. Images PMID:5439902

Implementation of a simple electronic transfusion alert system decreases inappropriate ordering of packed red blood cells and plasma in a multi-hospital health care system.

PubMed

Smith, Matthew; Triulzi, Darrell J; Yazer, Mark H; Rollins-Raval, Marian A; Waters, Jonathan H; Raval, Jay S

2014-12-01

Prescriber adherence to institutional blood component ordering guidelines can be low. The goal of this study was to decrease red blood cell (RBC) and plasma orders that did not meet institutional transfusion guidelines by using data within the laboratory information system to trigger alerts in the computerized order entry (CPOE) system at the time of order entry. At 10 hospitals within a regional health care system, discernment rules were created for RBC and plasma orders utilizing transfusion triggers of hemoglobin <8 gm/dl and INR >1.6, respectively, with subsequent alert generation that appears within the CPOE system when a prescriber attempts to order RBCs or plasma on a patient whose antecedent laboratory values do not suggest that a transfusion is indicated. Orders and subsequent alerts were tracked for RBCs and plasma over evaluation periods of 15 and 10 months, respectively, along with the hospital credentials of the ordering health care providers (physician or nurse). Alerts triggered which were heeded remained steady and averaged 11.3% for RBCs and 19.6% for plasma over the evaluation periods. Overall, nurses and physicians canceled statistically identical percentages of alerted RBC (10.9% vs. 11.5%; p = 0.78) and plasma (21.3% vs. 18.7%; p = 0.22) orders. Implementing a simple evidence-based transfusion alert system at the time of order entry decreased non-evidence based transfusion orders by both nurse and physician providers. Copyright © 2014 Elsevier Ltd. All rights reserved.

Entry characteristics and performance in a Masters module in Tropical Medicine: a 5-year analysis.

PubMed

Weigel, R; Robinson, D; Stewart, M; Assinder, S

2016-06-01

Postgraduate courses can contribute to better-qualified personnel in resource-limited settings. We aimed to identify how entry characteristics of applicants predict performance in order to provide support measures early. We describe demographic data and end-of-module examination marks of medical doctors who enrolled in a first semester module of two one-year MSc programmes between 2010 and 2014. We used t-tests and one-way anova to compare, and post hoc tests to locate differences of mean marks between categories of entry characteristics in univariate analysis. After exclusion of collinear variables, multiple regression examined the effect of several characteristics in multivariable analysis. Eighty-nine students (47% male) with a mean age of 32 (SD 6.4) years who received their medical degree in the UK (19%), other European (22%), African (35%) or other countries (24%) attended the 3-months module. Their mean mark was 69.1% (SD 10.9). Medical graduates from UK universities achieved significantly higher mean marks than graduates from other countries. Students' age was significantly negatively correlated with the module mark. In multiple linear regression, place of medical degree (β = -0.44, P < 0.001) and time since graduation (β = -0.28, P = 0.007) were strongest predictors of performance, explaining 32% of the variation of mean marks. Students' performance substantially differs based on their entry criteria in this 1st semester module. Non-UK graduates and mature students might benefit from early support. © 2016 John Wiley & Sons Ltd.

Evaluation of STAT medication ordering process in a community hospital

PubMed Central

Walsh., Kim; Schwartz., Barbara

Background: In most health care facilities, problems related to delays in STAT medication order processing time are of common concern. Objective: The purpose of this study was to evaluate processing time for STAT orders at Kimball Medical Center. Methods: All STAT orders were reviewed to determine processing time; order processing time was also stratified by physician order entry (physician entered (PE) orders vs. non-physician entered (NPE) orders). Collected data included medication ordered, indication, time ordered, time verified by pharmacist, time sent from pharmacy, and time charted as given to the patient. Results: A total of 502 STAT orders were reviewed and 389 orders were included for analysis. Overall, median time was 29 minutes, IQR 16–63; p<0.0001.). The time needed to process NPE orders was significantly less than that needed for PE orders (median 27 vs. 34 minutes; p=0.026). In terms of NPE orders, the median total time required to process STAT orders for medications available in the Automated Dispensing Devices (ADM) was within 30 minutes, while that required to process orders for medications not available in the ADM was significantly greater than 30 minutes. For PE orders, the median total time required to process orders for medications available in the ADM (i.e., not requiring pharmacy involvement) was significantly greater than 30 minutes. [Median time = 34 minutes (p<0.001)]. Conclusion: We conclude that STAT order processing time may be improved by increasing the availability of medications in ADM, and pharmacy involvement in the verification process. PMID:27382418

A Mis-recognized Medical Vocabulary Correction System for Speech-based Electronic Medical Record

PubMed Central

Seo, Hwa Jeong; Kim, Ju Han; Sakabe, Nagamasa

2002-01-01

Speech recognition as an input tool for electronic medical record (EMR) enables efficient data entry at the point of care. However, the recognition accuracy for medical vocabulary is much poorer than that for doctor-patient dialogue. We developed a mis-recognized medical vocabulary correction system based on syllable-by-syllable comparison of speech text against medical vocabulary database. Using specialty medical vocabulary, the algorithm detects and corrects mis-recognized medical vocabularies in narrative text. Our preliminary evaluation showed 94% of accuracy in mis-recognized medical vocabulary correction.

Data Mining on Numeric Error in Computerized Physician Order Entry System Prescriptions.

PubMed

Wu, Xue; Wu, Changxu

2017-01-01

This study revealed the numeric error patterns related to dosage when doctors prescribed in computerized physician order entry system. Error categories showed that the '6','7', and '9' key produced a higher incidence of errors in Numpad typing, while the '2','3', and '0' key produced a higher incidence of errors in main keyboard digit line typing. Errors categorized as omission and substitution were higher in prevalence than transposition and intrusion.

Integrated Information Systems for Electronic Chemotherapy Medication Administration

PubMed Central

Levy, Mia A.; Giuse, Dario A.; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K.

2011-01-01

Introduction: Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. Methods: We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. Results: We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Conclusion: Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations. PMID:22043185

A Cognitive Task Analysis of Information Management Strategies in a Computerized Provider Order Entry Environment

PubMed Central

Weir, Charlene R.; Nebeker, Jonathan J.R.; Hicken, Bret L.; Campo, Rebecca; Drews, Frank; LeBar, Beth

2007-01-01

Objective Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. Design Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. Measurements Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. Results Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. Conclusion Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system. PMID:17068345

ALCHEMIST (Anesthesia Log, Charge Entry, Medical Information, and Statistics)

PubMed Central

Covey, M. Carl

1979-01-01

This paper presents an automated system for the handling of charges and information processing within the Anesthesiology department of the University of Arkansas for the Medical Sciences (UAMS). The purpose of the system is to take the place of cumbersome, manual billing procedures and in the process of automated charge generation, to compile a data base of patient data for later use. ALCHEMIST has demonstrated its value by increasing both the speed and the accuracy of generation of patient charges as well as facilitating the compilation of valuable, informative reports containing statistical summaries of all aspects of the UAMS operating wing case load. ALCHEMIST allows for the entry of fifty different sets of information (multiple items in some sets) for a total of 107 separate data elements from the original anesthetic record. All this data is entered as part of the charge entry procedure.

Electronic medical record features and seven quality of care measures in physician offices.

PubMed

Hsiao, Chun-Ju; Marsteller, Jill A; Simon, Alan E

2014-01-01

The effect of electronic medical records (EMRs) on quality of care in physicians' offices is uncertain. This study used the 2008-2009 National Ambulatory Medical Care Survey to examine the relationship between EMRs features and quality in physician offices. The relationship between selected EMRs features and 7 quality measures was evaluated by testing 25 associations in multivariate models. Significant relationships include reminders for guideline-based interventions or screening tests associated with lower odds of inappropriate urinalysis and prescription of antibiotics for upper respiratory infection (URI), prescription order entry associated with lower odds of prescription of antibiotics for URI, and patient problem list associated with higher odds of inappropriate prescribing for elderly patients. EMRs system level was associated with lower odds of blood pressure check, inappropriate urinalysis, and prescription of antibiotics for URI compared with no EMRs. The results show both positive and inverse relationships between EMRs features and quality of care.

A framework for considering business models.

PubMed

Anderson, James G

2003-01-01

Information technology (IT) such as computerized physician order entry, computer-based decision support and alerting systems, and electronic prescribing can reduce medical errors and improve the quality of health care. However, the business value of these systems is frequently questioned. At present a number of barriers exist to realizing the potential of IT to improve quality of care. Some of these barriers are: the ineffectiveness of existing error reporting systems, low investment in IT infrastructure, legal impediments to reforms, and the difficulty in demonstrating a sufficient return on investment to justify expenditures for quality improvement. This paper provides an overview of these issues, a framework for considering business models, and examples of successful implementations of IT to improve quality of patient care.

Medical student satisfaction, coping and burnout in direct-entry versus graduate-entry programmes.

PubMed

DeWitt, Dawn; Canny, Benedict J; Nitzberg, Michael; Choudri, Jennifer; Porter, Sarah

2016-06-01

There is ongoing debate regarding the optimal length of medical training, with concern about the cost of prolonged training. Two simultaneous tracks currently exist in Australia: direct entry from high school and graduate entry for students with a bachelor degree. Medical schools are switching to graduate entry based on maturity, academic preparedness and career-choice surety. We tested the assumption that graduate entry is better by exploring student preferences, coping, burnout, empathy and alcohol use. From a potential pool of 2188 participants, enrolled at five Australian medical schools, a convenience sample of 688 (31%) first and second year students completed a survey in the middle of the academic year. Participants answered questions about demographics, satisfaction and coping and completed three validated instruments. Over 90% of students preferred their own entry-type, though more graduate-entry students were satisfied with their programme (82.4% versus 65.3%, p < 0.001). There was no difference between graduate-entry and direct-entry students in self-reported coping or in the proportion of students meeting criteria for burnout (50.7% versus 51.2%). Direct-entry students rated significantly higher for empathy (concern, p = 0.022; personal distress, p = 0.031). Graduate-entry students reported significantly more alcohol use and hazardous drinking (30.0% versus 22.8%; p = 0.017). Our multi-institution data confirm that students are generally satisfied with their choice of entry pathway and do not confirm significant psychosocial benefits of graduate entry. Overall, our data suggest that direct-entry students cope with the workload and psychosocial challenges of medical school, in the first 2 years, as well as graduate-entry students. Burnout and alcohol use should be addressed in both pathways. Despite studies showing similar academic outcomes, and higher total costs, more programmes in Australia are becoming graduate entry. Further research on non-cognitive issues and outcomes is needed so that universities, government funders and the medical profession can decide whether graduate entry, direct entry, or a mix, is ideal. © 2016 John Wiley & Sons Ltd.

Utilization management in radiology, part 2: perspectives and future directions.

PubMed

Duszak, Richard; Berlin, Jonathan W

2012-10-01

Increased utilization of medical imaging in the early part of the last decade has resulted in numerous efforts to reduce associated spending. Recent initiatives have focused on managing utilization with radiology benefits managers and real-time order entry decision support systems. Although these approaches might seem mutually exclusive and their application to radiology appears unique, the historical convergence and broad acceptance of both programs within the pharmacy sector may offer parallels for their potential future in medical imaging. In this second installment of a two-part series, anticipated trends in radiology utilization management are reviewed. Perspectives on current and future potential roles of radiologists in such initiatives are discussed, particularly in light of emerging physician payment models. Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.

75 FR 48387 - Self-Regulatory Organizations; Chicago Board Options Exchange, Incorporated; Notice of Filing and...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-10

... of the PULSe order entry workstation and to make a technical correction to the numbering of the text in the fees schedule. The PULSe workstation is a front-end order entry system designed for use with...\\ In conjunction with the launch of the PULSe workstation, the Exchange waived various fees. To...

The Effect of Automated Alerts on Provider Ordering Behavior in an Outpatient Setting

PubMed Central

Steele, Andrew W; Eisert, Sheri; Witter, Joel; Lyons, Pat; Jones, Michael A; Gabow, Patricia; Ortiz, Eduardo

2005-01-01

Background Computerized order entry systems have the potential to prevent medication errors and decrease adverse drug events with the use of clinical-decision support systems presenting alerts to providers. Despite the large volume of medications prescribed in the outpatient setting, few studies have assessed the impact of automated alerts on medication errors related to drug–laboratory interactions in an outpatient primary-care setting. Methods and Findings A primary-care clinic in an integrated safety net institution was the setting for the study. In collaboration with commercial information technology vendors, rules were developed to address a set of drug–laboratory interactions. All patients seen in the clinic during the study period were eligible for the intervention. As providers ordered medications on a computer, an alert was displayed if a relevant drug–laboratory interaction existed. Comparisons were made between baseline and postintervention time periods. Provider ordering behavior was monitored focusing on the number of medication orders not completed and the number of rule-associated laboratory test orders initiated after alert display. Adverse drug events were assessed by doing a random sample of chart reviews using the Naranjo scoring scale. The rule processed 16,291 times during the study period on all possible medication orders: 7,017 during the pre-intervention period and 9,274 during the postintervention period. During the postintervention period, an alert was displayed for 11.8% (1,093 out of 9,274) of the times the rule processed, with 5.6% for only “missing laboratory values,” 6.0% for only “abnormal laboratory values,” and 0.2% for both types of alerts. Focusing on 18 high-volume and high-risk medications revealed a significant increase in the percentage of time the provider stopped the ordering process and did not complete the medication order when an alert for an abnormal rule-associated laboratory result was displayed (5.6% vs. 10.9%, p = 0.03, Generalized Estimating Equations test). The provider also increased ordering of the rule-associated laboratory test when an alert was displayed (39% at baseline vs. 51% during post intervention, p < 0.001). There was a non-statistically significant difference towards less “definite” or “probable” adverse drug events defined by Naranjo scoring (10.3% at baseline vs. 4.3% during postintervention, p = 0.23). Conclusion Providers will adhere to alerts and will use this information to improve patient care. Specifically, in response to drug–laboratory interaction alerts, providers will significantly increase the ordering of appropriate laboratory tests. There may be a concomitant change in adverse drug events that would require a larger study to confirm. Implementation of rules technology to prevent medication errors could be an effective tool for reducing medication errors in an outpatient setting. PMID:16128621

Current Integration of Dissection in Medical Education in Australia and New Zealand: Challenges and Successes

ERIC Educational Resources Information Center

Bouwer, Hope Ellen; Valter, Krisztina; Webb, Alexandra Louise

2016-01-01

The reduced use of dissection associated with the introduction of integrated systems problem-based learning curricula, graduate-entry programs and medical school expansion is a frequent topic of discussion and debate in modern medical training. The purpose of this study was to investigate the impact of these changes to the medical education…

Quantifying medical student clinical experiences via an ICD Code Logging App.

PubMed

Rawlins, Fred; Sumpter, Cameron; Sutphin, Dean; Garner, Harold R

2018-03-01

The logging of ICD Diagnostic, Procedure and Drug codes is one means of tracking the experience of medical students' clinical rotations. The goal is to create a web-based computer and mobile application to track the progress of trainees, monitor the effectiveness of their training locations and be a means of sampling public health status. We have developed a web-based app in which medical trainees make entries via a simple and quick interface optimized for both mobile devices and personal computers. For each patient interaction, users enter ICD diagnostic, procedure, and drug codes via a hierarchical or search entry interface, as well as patient demographics (age range and gender, but no personal identifiers), and free-text notes. Users and administrators can review and edit input via a series of output interfaces. The user interface and back-end database are provided via dual redundant failover Linux servers. Students master the interface in ten minutes, and thereafter complete entries in less than one minute. Five hundred-forty 3rd year VCOM students each averaged 100 entries in the first four week clinical rotation. Data accumulated in various Appalachian clinics and Central American medical mission trips has demonstrated the public health surveillance utility of the application. PC and mobile apps can be used to collect medical trainee experience in real time or near real-time, quickly, and efficiently. This system has collected 75,596 entries to date, less than 2% of trainees have needed assistance to become proficient, and medical school administrators are using the various summaries to evaluate students and compare different rotation sites. Copyright © 2017. Published by Elsevier B.V.

Improving adherence to the Epic Beacon ambulatory workflow.

PubMed

Chackunkal, Ellen; Dhanapal Vogel, Vishnuprabha; Grycki, Meredith; Kostoff, Diana

2017-06-01

Computerized physician order entry has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Epic's Beacon Oncology Information System of computerized physician order entry and electronic medication administration was implemented in Henry Ford Health System's ambulatory oncology infusion centers on 9 November 2013. Since that time, compliance to the infusion workflow had not been assessed. The objective of this study was to optimize the current workflow and improve the compliance to this workflow in the ambulatory oncology setting. This study was a retrospective, quasi-experimental study which analyzed the composite workflow compliance rate of patient encounters from 9 to 23 November 2014. Based on this analysis, an intervention was identified and implemented in February 2015 to improve workflow compliance. The primary endpoint was to compare the composite compliance rate to the Beacon workflow before and after a pharmacy-initiated intervention. The intervention, which was education of infusion center staff, was initiated by ambulatory-based, oncology pharmacists and implemented by a multi-disciplinary team of pharmacists and nurses. The composite compliance rate was then reassessed for patient encounters from 2 to 13 March 2015 in order to analyze the effects of the determined intervention on compliance. The initial analysis in November 2014 revealed a composite compliance rate of 38%, and data analysis after the intervention revealed a statistically significant increase in the composite compliance rate to 83% ( p < 0.001). This study supports a pharmacist-initiated educational intervention can improve compliance to an ambulatory, oncology infusion workflow.

An Assessment of the Application of Pharma Cloud System to the National Health Insurance Program of Taiwan and the Result in Hospitals.

PubMed

Yan, Yu-Hua; Lu, Chen-Luan

2016-01-01

National Health Insurance Administration established Pharma Cloud System in July 2014. The purpose is to decrease therapeutic duplications and enhance public medication safety. Comparison will be made among individual hospitals and the administering branches of National Health Insurance Bureau (NHIB) on the statistical data on the inquiry of the cloud medication history record system to understand the result of the installation and advocacy of this system. The results show (1) there were 2,329,846 entries of data collected from the branches of the NHIB from 2015 on cloud medication history record and 50,224 entries of data from individual hospitals. (2) The inquiry rate at the branches of the NHIB was 43.2% from January to April, 2015 and at individual hospitals was 18.8%. (3) The improvement rate at the branches of the NHIB was 32.5% and at the individual hospitals was 47.0% from January to April, 2015.

Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients.

PubMed

Fischer, Michael A; Solomon, Daniel H; Teich, Jonathan M; Avorn, Jerry

2003-11-24

Many hospitalized patients continue to receive intravenous medications longer than necessary. Earlier conversion from the intravenous to the oral route could increase patient safety and comfort, reduce costs, and facilitate earlier discharge from the hospital without compromising clinical care. We examined the effect of a computer-based intervention to prompt physicians to switch appropriate patients from intravenous to oral medications. This study was performed at Brigham and Women's Hospital, an academic tertiary care hospital at which all medications are ordered online. We targeted 5 medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. We used the hospital's computerized order entry system to prompt physicians to convert appropriate intravenous medications to the oral route. We measured the total use of the targeted medications via each route in the 4 months before and after the implementation of the intervention. We also measured the rate at which physicians responded to the intervention when prompted. The average intravenous defined daily dose declined by 11.1% (P =.002) from the preintervention to the postintervention period, while the average oral defined daily dose increased by 3.7% (P =.002). Length of stay, case-mix index, and total drug use at the hospital increased during the study period. The average total monthly use of the intravenous preparation of all of the targeted medications declined in the 4 months after the intervention began, compared with the 4 months before. In 35.6% of 1045 orders for which a prompt was generated, the physician either made a conversion from the intravenous to the oral version or canceled the order altogether. Computer-generated reminders can produce a substantial reduction in excessive use of targeted intravenous medications. As online prescribing becomes more common, this approach can be used to reduce excess use of intravenous medications, with potential benefits in patient comfort, safety, and cost.

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation

PubMed Central

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade

2018-01-01

Background A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan. Objective This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. Methods A CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter. Results The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians’ responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. Conclusions The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient’s medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required. PMID:29351893

Pre-post evaluation of physicians' satisfaction with a redesigned electronic medical record system.

PubMed

Jaspers, Monique W M; Peute, Linda W P; Lauteslager, Arnaud; Bakker, Piet J M

2008-01-01

Physicians' acceptance of Electronic Medical Record Systems (EMRs) is closely related to their usability. Knowledge about end-users' opinions on usability of an EMR system may contribute to planning for the next phase of the usability cycle of the system. A demand for integration of new functionalities, such as computerized order entry and an electronic patient status led to redesign of our EMR system, which had been in use for over 8 years at the Academic Medical Center of Amsterdam. The aim of this study was to understand whether the redesigned EMR system was an improvement of the earlier EMR and which system aspects accounted for user satisfaction and which did not. We conducted a formative pre- and post usability evaluation of our former and redesigned EMR system. For the assessment of both system versions' usability, we distributed two standardized usability questionnaires among 150 clinicians who routinely had used the older EMR system and had been working with its newer version for 6 weeks. Though overall user satisfaction was relatively high for both EMR systems, screen layout and interaction structure proved less easy to work with in the newer EMR system. The new EMR system however was more appreciated because of its enhanced functionality, capabilities and likeable user-interface. The results point to a number of actions that might be useful in future usability improvement efforts of our EMR system and other EMRs.

Incorporating medication indications into the prescribing process.

PubMed

Kron, Kevin; Myers, Sara; Volk, Lynn; Nathan, Aaron; Neri, Pamela; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Karmiy, Sam; McCord, Sarah; Seoane-Vazquez, Enrique; Eguale, Tewodros; Rodriguez-Monguio, Rosa; Bates, David W; Schiff, Gordon

2018-04-19

The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, including avoiding look-alike/sound-alike errors, facilitating selection of drugs of choice, aiding in communication among the healthcare team, bolstering patient understanding and adherence, and organizing medication lists to facilitate medication reconciliation. Although strongly supported by pharmacists, multiple prior attempts to encourage prescribers to include the indication on prescriptions have not been successful. We convened 6 expert panels to consult high-level stakeholders on system design considerations and requirements necessary for building and implementing an indications-based computerized prescriber order-entry (CPOE) system. We summarize our findings from the 6 expert stakeholder panels, including rationale, literature findings, potential benefits, and challenges of incorporating indications into the prescribing process. Based on this stakeholder input, design requirements for a new CPOE interface and workflow have been identified. The emergence of universal electronic prescribing and content knowledge vendors has laid the groundwork for incorporating indications into the CPOE prescribing process. As medication prescribing moves in the direction of inclusion of the indication, it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Extracting and standardizing medication information in clinical text - the MedEx-UIMA system.

PubMed

Jiang, Min; Wu, Yonghui; Shah, Anushi; Priyanka, Priyanka; Denny, Joshua C; Xu, Hua

2014-01-01

Extraction of medication information embedded in clinical text is important for research using electronic health records (EHRs). However, most of current medication information extraction systems identify drug and signature entities without mapping them to standard representation. In this study, we introduced the open source Java implementation of MedEx, an existing high-performance medication information extraction system, based on the Unstructured Information Management Architecture (UIMA) framework. In addition, we developed new encoding modules in the MedEx-UIMA system, which mapped an extracted drug name/dose/form to both generalized and specific RxNorm concepts and translated drug frequency information to ISO standard. We processed 826 documents by both systems and verified that MedEx-UIMA and MedEx (the Python version) performed similarly by comparing both results. Using two manually annotated test sets that contained 300 drug entries from medication list and 300 drug entries from narrative reports, the MedEx-UIMA system achieved F-measures of 98.5% and 97.5% respectively for encoding drug names to corresponding RxNorm generic drug ingredients, and F-measures of 85.4% and 88.1% respectively for mapping drug names/dose/form to the most specific RxNorm concepts. It also achieved an F-measure of 90.4% for normalizing frequency information to ISO standard. The open source MedEx-UIMA system is freely available online at http://code.google.com/p/medex-uima/.

77 FR 9902 - Privacy Act of 1974; System of Records

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-21

... effective on March 22, 2012 unless comments are received that would result in a contrary determination... or status, name, Social Security Number (SSN), gender, medical diagnosis, medical condition, special...: Delete entry and replace with ``Paper records in file folders and electronic storage media...

Health innovation for patient safety improvement.

PubMed

Sellappans, Renukha; Chua, Siew Siang; Tajuddin, Nur Amani Ahmad; Mei Lai, Pauline Siew

2013-01-01

Medication error has been identified as a major factor affecting patient safety. Many innovative efforts such as Computerised Physician Order Entry (CPOE), a Pharmacy Information System, automated dispensing machines and Point of Administration Systems have been carried out with the aim of improving medication safety. However, areas remain that require urgent attention. One main area will be the lack of continuity of care due to the breakdown of communication between multiple healthcare providers. Solutions may include consideration of "health smart cards" that carry vital patient medical information in the form of a "credit card" or use of the Malaysian identification card. However, costs and technical aspects associated with the implementation of this health smart card will be a significant barrier. Security and confidentiality, on the other hand, are expected to be of primary concern to patients. Challenges associated with the implementation of a health smart card might include physician buy-in for use in his or her everyday practice. Training and technical support should also be available to ensure the smooth implementation of this system. Despite these challenges, implementation of a health smart card moves us closer to seamless care in our country, thereby increasing the productivity and quality of healthcare.

Novel Representation of Clinical Information in the ICU

PubMed Central

Pickering, B.W.; Herasevich, V.; Ahmed, A.; Gajic, O.

2010-01-01

The introduction of electronic medical records (EMR) and computerized physician order entry (CPOE) into the intensive care unit (ICU) is transforming the way health care providers currently work. The challenge facing developers of EMR’s is to create products which add value to systems of health care delivery. As EMR’s become more prevalent, the potential impact they have on the quality and safety, both negative and positive, will be amplified. In this paper we outline the key barriers to effective use of EMR and describe the methodology, using a worked example of the output. AWARE (Ambient Warning and Response Evaluation), is a physician led, electronic-environment enhancement program in an academic, tertiary care institution’s ICU. The development process is focused on reducing information overload, improving efficiency and eliminating medical error in the ICU. PMID:23616831

Medication errors in the emergency department: a systems approach to minimizing risk.

PubMed

Peth, Howard A

2003-02-01

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.

Using a Scripted Data Entry Process to Transfer Legacy Immunization Data While Transitioning Between Electronic Medical Record Systems

PubMed Central

Michel, J.; Hsiao, A.; Fenick, A.

2014-01-01

Summary Background Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion. Objectives We sought to transfer immunization data from two of our health system’s soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility. Methods We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Control’s CVX immunization codes we developed a bridge between immunization identifiers within our system’s EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review. Results We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data – 500,906 records – just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data – 1,695 records – was migrated using the same process with minimal additional effort. Conclusions Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR. PMID:24734139

Risk factors associated with academic difficulty in an Australian regionally located medical school.

PubMed

Malau-Aduli, Bunmi S; O'Connor, Teresa; Ray, Robin A; van der Kruk, Yolanda; Bellingan, Michelle; Teague, Peta-Ann

2017-12-28

Despite the highly selective admission processes utilised by medical schools, a significant cohort of medical students still face academic difficulties and are at a higher risk of delayed graduation or outright dismissal. This study used survival analysis to identify the non-academic and academic risk factors (and their relative risks) associated with academic difficulty at a regionally located medical school. Retrospective non-academic and academic entry data for all medical students who were enrolled at the time of the study (2009-2014) were collated and analysed. Non-academic variables included age at commencement of studies, gender, Indigenous status, origin, first in family to go to University (FIF), non-English speaking background (NESB), socio-economic status (SES) and rurality expressed as Australian Standard Geographical Classification-Remoteness Area (ASGC-RA). Academic variables included tertiary entrance exam score expressed as overall position (OP) and interview score. In addition, post-entry mid- and end-of-year summative assessment data in the first and second years of study were collated. The results of the survival analysis indicated that FIF, Indigenous and very remote backgrounds, as well as low post-entry Year 1 (final) and Year 2 (mid-year and final) examination scores were strong risk factors associated with academic difficulty. A high proportion of the FIF students who experienced academic difficulty eventually failed and exited the medical program. Further exploratory research will be required to identify the specific needs of this group of students in order to develop appropriate and targeted academic support programs for them. This study has highlighted the need for medical schools to be proactive in establishing support interventions/strategies earlier rather than later, for students experiencing academic difficulty because, the earlier such students can be flagged, the more likely they are able to obtain positive academic outcomes.

Evaluation and Certification of Computerized Provider Order Entry Systems

PubMed Central

Classen, David C.; Avery, Anthony J.; Bates, David W.

2007-01-01

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance. PMID:17077453

Evaluation and certification of computerized provider order entry systems.

PubMed

Classen, David C; Avery, Anthony J; Bates, David W

2007-01-01

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance.

Electronic Documentation Support Tools and Text Duplication in the Electronic Medical Record

ERIC Educational Resources Information Center

Wrenn, Jesse

2010-01-01

In order to ease the burden of electronic note entry on physicians, electronic documentation support tools have been developed to assist in note authoring. There is little evidence of the effects of these tools on attributes of clinical documentation, including document quality. Furthermore, the resultant abundance of duplicated text and…

ContextD: an algorithm to identify contextual properties of medical terms in a Dutch clinical corpus.

PubMed

Afzal, Zubair; Pons, Ewoud; Kang, Ning; Sturkenboom, Miriam C J M; Schuemie, Martijn J; Kors, Jan A

2014-11-29

In order to extract meaningful information from electronic medical records, such as signs and symptoms, diagnoses, and treatments, it is important to take into account the contextual properties of the identified information: negation, temporality, and experiencer. Most work on automatic identification of these contextual properties has been done on English clinical text. This study presents ContextD, an adaptation of the English ConText algorithm to the Dutch language, and a Dutch clinical corpus. We created a Dutch clinical corpus containing four types of anonymized clinical documents: entries from general practitioners, specialists' letters, radiology reports, and discharge letters. Using a Dutch list of medical terms extracted from the Unified Medical Language System, we identified medical terms in the corpus with exact matching. The identified terms were annotated for negation, temporality, and experiencer properties. To adapt the ConText algorithm, we translated English trigger terms to Dutch and added several general and document specific enhancements, such as negation rules for general practitioners' entries and a regular expression based temporality module. The ContextD algorithm utilized 41 unique triggers to identify the contextual properties in the clinical corpus. For the negation property, the algorithm obtained an F-score from 87% to 93% for the different document types. For the experiencer property, the F-score was 99% to 100%. For the historical and hypothetical values of the temporality property, F-scores ranged from 26% to 54% and from 13% to 44%, respectively. The ContextD showed good performance in identifying negation and experiencer property values across all Dutch clinical document types. Accurate identification of the temporality property proved to be difficult and requires further work. The anonymized and annotated Dutch clinical corpus can serve as a useful resource for further algorithm development.

Power User Interface

NASA Technical Reports Server (NTRS)

Pfister, Robin; McMahon, Joe

2006-01-01

Power User Interface 5.0 (PUI) is a system of middleware, written for expert users in the Earth-science community, PUI enables expedited ordering of data granules on the basis of specific granule-identifying information that the users already know or can assemble. PUI also enables expert users to perform quick searches for orderablegranule information for use in preparing orders. PUI 5.0 is available in two versions (note: PUI 6.0 has command-line mode only): a Web-based application program and a UNIX command-line- mode client program. Both versions include modules that perform data-granule-ordering functions in conjunction with external systems. The Web-based version works with Earth Observing System Clearing House (ECHO) metadata catalog and order-entry services and with an open-source order-service broker server component, called the Mercury Shopping Cart, that is provided separately by Oak Ridge National Laboratory through the Department of Energy. The command-line version works with the ECHO metadata and order-entry process service. Both versions of PUI ultimately use ECHO to process an order to be sent to a data provider. Ordered data are provided through means outside the PUI software system.

Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics

PubMed Central

Bleeker, Sacha E; Derksen-Lubsen, Gerarda; van Ginneken, Astrid M; van der Lei, Johan; Moll, Henriëtte A

2006-01-01

Background Whereas an electronic medical record (EMR) system can partly address the limitations, of paper-based documentation, such as fragmentation of patient data, physical paper records missing and poor legibility, structured data entry (SDE, i.e. data entry based on selection of predefined medical concepts) is essential for uniformity of data, easier reporting, decision support, quality assessment, and patient-oriented clinical research. The aim of this project was to explore whether a previously developed generic (i.e. content independent) SDE application to support the structured documentation of narrative data (called OpenSDE) can be used to model data obtained at history taking and physical examination of a broad specialty. Methods OpenSDE was customized for the broad domain of general pediatrics: medical concepts and its descriptors from history taking and physical examination were modeled into a tree structure. Results An EMR system allowing structured recording (OpenSDE) of pediatric narrative data was developed. Patient history is described by 20 main concepts and physical examination by 11. In total, the thesaurus consists of about 1800 items, used in 8648 nodes in the tree with a maximum depth of 9 levels. Patient history contained 6312 nodes, and physical examination 2336. User-defined entry forms can be composed according to individual needs, without affecting the underlying data representation. The content of the tree can be adjusted easily and sharing records among different disciplines is possible. Data that are relevant in more than one context can be accessed from multiple branches of the tree without duplication or ambiguity of data entry via "shortcuts". Conclusion An expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination. For further evaluation in other environments, the tree structure for general pediatrics is available at the Erasmus MC Web site (in Dutch, translation into English in progress) [1]. The generic OpenSDE application is available at the OpenSDE Web site [2]. PMID:16839414

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

PubMed

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade; Liu, Chien-Tsai

2018-01-19

A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients' integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients' medication records prescribed by different health care facilities across Taiwan. This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. A CDS engine was developed that can download patients' up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians' responses to handling the alerts for each encounter. The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians' responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient's medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required. ©Cheng-Yi Yang, Yu-Sheng Lo, Ray-Jade Chen, Chien-Tsai Liu. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 19.01.2018.

National Survey of Neonatal Intensive Care Unit Medication Safety Practices.

PubMed

Greenberg, Rachel G; Smith, P Brian; Bose, Carl; Clark, Reese H; Cotten, C Michael; DeRienzo, Chris

2018-06-15

 We conducted a detailed survey to identify medication safety practices among a large network of United States neonatal intensive care units (NICUs).  We created a 53-question survey to assess 300 U.S. NICU's demographics, medication safety practices, adverse drug event (ADE) reporting, and ADE response plans.  Among the 164 (55%) NICUs that responded to the survey, more than 85% adhered to practices including use of electronic health records, computerized physician order entry, and clinical decision support; fewer reported adopting barcoding, formal safety surveys, and formal culture training; 137 of 164 (84%) developed at least one NICU-specific order-set with a median of 10 order-sets.  Among our survey of 164 NICUs, we found that many safety practices remain unused. Understanding safety practice variation is critical to prevent ADEs and other negative infant outcomes. Future efforts should focus on linking safety practices identified from our survey with ADEs and infant outcomes. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Clinical Information Systems Integration in New York City's First Mobile Stroke Unit.

PubMed

Kummer, Benjamin R; Lerario, Michael P; Navi, Babak B; Ganzman, Adam C; Ribaudo, Daniel; Mir, Saad A; Pishanidar, Sammy; Lekic, Tim; Williams, Olajide; Kamel, Hooman; Marshall, Randolph S; Hripcsak, George; Elkind, Mitchell S V; Fink, Matthew E

2018-01-01

Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied. The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts. NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction. Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field. The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts. Schattauer GmbH Stuttgart.

Electronic Ordering System Improves Postoperative Pain Management After Total Knee or Hip Arthroplasty

PubMed Central

Chiu, T.; Wolfe, S.; Magid, S.

2015-01-01

Summary Objectives The authors investigated the impact of computerized provider order entry (CPOE) on the delivery times of analgesia and subsequent patient outcomes. We hypothesized that patients would report less pain and use less pain medications compared with the previous paper-based system. Methods Two groups of patients after a total hip (THA) or knee arthroplasty (TKA) were retrospectively compared: one comprising 106 patients when the paper-based ordering system was in effect (conventional group), and one comprising 96 patients after CPOE was installed (electronic group). All patients received a regional anaesthetic at surgery (combined spinal-epidural). TKA patients also received a single-injection femoral nerve block. After transfer to the postoperative anaesthesia care unit (PACU), a patient-controlled epidural analgesia (PCEA) infusion was initiated. The following data was collected from the PACU record: time to initiation of analgesia, visual analog scale (VAS) pain scores at initiation of analgesia and hourly for the first postoperative day (POD), volume of pain medication used, length of stay (LOS) in the PACU and the hospital. Results The time to initiation of analgesia from arrival in the PACU was significantly lower in the electronic group compared to the conventional group (24.5 ± 28.3 minutes vs. 51.1 ± 26.2 minutes; mean ± SD, p < 0.001), as were VAS pain scores (0.82 ± 1.08 vs. 1.5 ± 1.52, p < 0.001) and the volume of PCEA needed to control pain (27.9 ± 20.2 ml vs. 34.8 ± 20.3 ml, p = 0.001) at 4 hours postoperatively. PACU LOS and hospital LOS did not significantly differ in the two groups. Conclusions After implementation of CPOE, patients received their postoperative analgesia faster, had less pain, and required less medication. PMID:26448800

Impact of real-time notification of Clostridium difficile test results and early initiation of effective antimicrobial therapy.

PubMed

Polen, Christian B; Judd, William R; Ratliff, Patrick D; King, Gregory S

2018-05-01

Clostridium difficile is a prominent nosocomial pathogen and is the most common causative organism of health care-associated diarrhea. To our knowledge, no studies have investigated the impact of real-time notification of culture results with rapid antimicrobial stewardship program (ASP) intervention in the setting of C difficile infection (CDI). The purpose of this study was to assess the impact of real-time notification of detection of toxigenic C difficile by DNA amplification results in patients with confirmed CDI. This is a single-center, retrospective cohort study at a 433-bed tertiary medical center in central Kentucky. The study consisted of 2 arms: patients treated for CDI prior to implementation of real-time provider notification and patients postimplementation. The primary outcome was time to initiation of effective antimicrobial therapy. The median time to initiation of effective antimicrobial therapy decreased from 5.75 hours in the preimplementation cohort to 2.05 hours in the postimplementation cohort (P = .001). ASP intervention also resulted in a shorter time from detection of CDI to order entry of effective antimicrobial therapy in the patient's electronic medical record (3.0 vs 0.6 hours; P = .001). The implementation of a real-time notification system to alert a pharmacist-led ASP of toxigenic CDI resulted in statistically significant shorter times to order entry and subsequent initiation of effective antimicrobial therapy and contact precautions. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Clinicians' views on displaying cost information to increase clinician cost-consciousness.

PubMed

Kruger, Jenna F; Chen, Alice Hm; Rybkin, Alex; Leeds, Kiren; Frosch, Dominick L; Goldman, Elizabeth

2014-01-01

To evaluate 1) clinician attitudes towards incorporating cost information into decision making when ordering imaging studies; and 2) clinician reactions to the display of Medicare reimbursement information for imaging studies at clinician electronic order entry. Focus group study with inductive thematic analysis. We conducted focus groups of primary care clinicians and subspecialty physicians (nephrology, pulmonary, and neurology) (N = 50) who deliver outpatient care in 12 hospital-based clinics and community health centers in an urban safety net health system. We analyzed focus group transcripts using an inductive framework to identify emergent themes and illustrative quotations. Clinicians believed that their knowledge of healthcare costs was low and wanted access to relevant cost information for reference. However, many clinicians believed it was inappropriate and unethical to consider costs in individual patient care decisions. Among clinicians' negative reactions toward displaying costs at order entry, 4 underlying themes emerged: 1) belief that ordering is already limited to clinically necessary tests; 2) importance of prioritizing responsibility to patients above that to the healthcare system; 3) concern about worsening healthcare disparities; and 4) perceived lack of accountability for healthcare costs in the system. Although clinicians want relevant cost information, many voiced concerns about displaying cost information at clinician order entry in safety net health systems. Alternative approaches to increasing cost-consciousness may be more acceptable to clinicians.

Academic performance and career choices of older medical students at the University of Otago.

PubMed

Shelker, William; Belton, Alison; Glue, Paul

2011-11-25

To compare the academic performance and postgraduate career choices of a cohort of medical students who are older and more life experienced at time of medical school entry ("Other Category" students) with students admitted through standard entry admission pathways. Examination performance, graduation rates, postgraduate specialisation and geographical location were compared between Other Category students and students entering via Standard Entry admission (including competitive first year entry and competitive graduate entry immediately after completing a Bachelor's degree). Compared with Standard Entry students, Other Category students had equivalent examination pass rates, significantly higher rates of distinction passes in examinations in Year 2 (OR 1.86; 95% CI 1.05, 3.29; p=0.03) and Year 5 (OR 2.36; 95% CI 1.27, 4.37; p=0.005), and equivalent graduation rates. Retention of Other Category graduates in New Zealand was 14% higher than Standard Entry students over 10 years post-graduation (p<0.0001), and a higher proportion had specialised in General Practice (p=0.04). Compared with Standard Entry students, Other Category medical students had higher rates of distinction grades in examination results, higher rates of retention in NZ post-graduation, and a higher proportion taking up general practice as a specialty. These findings may be relevant in planning for recruitment and training of the future medical workforce in New Zealand.

Extracting and standardizing medication information in clinical text – the MedEx-UIMA system

PubMed Central

Jiang, Min; Wu, Yonghui; Shah, Anushi; Priyanka, Priyanka; Denny, Joshua C.; Xu, Hua

2014-01-01

Extraction of medication information embedded in clinical text is important for research using electronic health records (EHRs). However, most of current medication information extraction systems identify drug and signature entities without mapping them to standard representation. In this study, we introduced the open source Java implementation of MedEx, an existing high-performance medication information extraction system, based on the Unstructured Information Management Architecture (UIMA) framework. In addition, we developed new encoding modules in the MedEx-UIMA system, which mapped an extracted drug name/dose/form to both generalized and specific RxNorm concepts and translated drug frequency information to ISO standard. We processed 826 documents by both systems and verified that MedEx-UIMA and MedEx (the Python version) performed similarly by comparing both results. Using two manually annotated test sets that contained 300 drug entries from medication list and 300 drug entries from narrative reports, the MedEx-UIMA system achieved F-measures of 98.5% and 97.5% respectively for encoding drug names to corresponding RxNorm generic drug ingredients, and F-measures of 85.4% and 88.1% respectively for mapping drug names/dose/form to the most specific RxNorm concepts. It also achieved an F-measure of 90.4% for normalizing frequency information to ISO standard. The open source MedEx-UIMA system is freely available online at http://code.google.com/p/medex-uima/. PMID:25954575

A study of renal function influence by integrating cloud-based manometers and physician order entry systems.

PubMed

Lin, Yuh-Feng; Sheng, Li-Huei; Wu, Mei-Yi; Zheng, Cai-Mei; Chang, Tian-Jong; Li, Yu-Chuan; Huang, Yu-Hui; Lu, Hsi-Peng

2014-12-01

No evidence exists from randomized trials to support using cloud-based manometers integrated with available physician order entry systems for tracking patient blood pressure (BP) to assist in the control of renal function deterioration. We investigated how integrating cloud-based manometers with physician order entry systems benefits our outpatient chronic kidney disease patients compared with typical BP tracking systems. We randomly assigned 36 chronic kidney disease patients to use cloud-based manometers integrated with physician order entry systems or typical BP recording sheets, and followed the patients for 6 months. The composite outcome was that the patients saw improvement both in BP and renal function. We compared the systolic and diastolic BP (SBP and DBP), and renal function of our patients at 0 months, 3 months, and 6 months after using the integrated manometers and typical BP monitoring sheets. Nighttime SBP and DBP were significantly lower in the study group compared with the control group. Serum creatinine level in the study group improved significantly compared with the control group after the end of Month 6 (2.83 ± 2.0 vs. 4.38 ± 3.0, p = 0.018). Proteinuria improved nonsignificantly in Month 6 in the study group compared with the control group (1.05 ± 0.9 vs. 1.90 ± 1.3, p = 0.09). Both SBP and DBP during the nighttime hours improved significantly in the study group compared with the baseline. In pre-end-stage renal disease patients, regularly monitoring BP by integrating cloud-based manometers appears to result in a significant decrease in creatinine and improvement in nighttime BP control. Estimated glomerular filtration rate and proteinuria were found to be improved nonsignificantly, and thus, larger population and longer follow-up studies may be needed.

Implementation of computerized physician order entry in National Guard Hospitals: assessment of critical success factors.

PubMed

Altuwaijri, Majid M; Bahanshal, Abdullah; Almehaid, Mona

2011-09-01

The purpose of this study is to describe the needs, process and experience of implementing a computerized physician order entry (CPOE) system in a leading healthcare organization in Saudi Arabia. The National Guard Health Affairs (NGHA) deployed the CPOE in a pilot department, which was the intensive care unit (ICU) in order to assess its benefits and risks and to test the system. After the CPOE was implemented in the ICU area, a survey was sent to the ICU clinicians to assess their perception on the importance of 32 critical success factors (CSFs) that was acquired from the literature. The project team also had several meetings to gather lessons learned from the pilot project in order to utilize them for the expansion of the project to other NGHA clinics and hospitals. The results of the survey indicated that the selected CSFs, even though they were developed with regard to international settings, are very much applicable for the pilot area. The top three CSFs rated by the survey respondents were: The "before go-live training", the adequate clinical resources during implementation, and the ordering time. After the assessment of the survey and the lessons learned from the pilot project, NGHA decided that the potential benefits of the CPOE are expected to be greater the risks expected. The project was then expanded to cover all NGHA clinics and hospitals in a phased approach. Currently, the project is in its final stages and expected to be completed by the end of 2011. The role of CPOE systems is very important in hospitals in order to reduce medication errors and to improve the quality of care. In spite of their great benefits, many studies suggest that a high percentage of these projects fail. In order to increase the chances of success and due to the fact that CPOE is a clinical system, NGHA implemented the system first in a pilot area in order to test the system without putting patients at risk and to learn from mistakes before expanding the system to other areas. As a result of the pilot project, NGHA developed a list of CSFs to increase the likelihood of project success for the expansion of the system to other clinics and hospitals. The authors recommend a future study for the CPOE implementation to be done that covers the implementation in all the four NGHA hospitals. The results of the study can then be generalized to other hospitals in Saudi Arabia.

Nature or nurture: the effect of undergraduate rural clinical rotations on pre-existent rural career choice likelihood as measured by the SOMERS Index.

PubMed

Somers, George T; Spencer, Ryan J

2012-04-01

Do undergraduate rural clinical rotations increase the likelihood of medical students to choose a rural career once pre-existent likelihood is accounted for? A prospective, controlled quasi-experiment using self-paired scores on the SOMERS Index of rural career choice likelihood, before and after 3 years of clinical rotations in either mainly rural or mainly urban locations. Monash University medical school, Australia. Fifty-eight undergraduate-entry medical students (35% of the 2002 entry class). The SOMERS Index of rural career choice likelihood and its component indicators. There was an overall decline in SOMERS Index score (22%) and in each of its components (12-41%). Graduating students who attended rural rotations were more likely to choose a rural career on graduation (difference in SOMERS score: 24.1 (95% CI, 15.0-33.3) P<0.0001); however, at entry, students choosing rural rotations had an even greater SOMERS score (difference: 27.1 (95% CI, 18.2-36.1) P<0.0001). Self-paired pre-post reductions in likelihood were not affected by attending mainly rural or urban rotations, nor were there differences based on rural background alone or sex. While rural rotations are an important component of undergraduate medical training, it is the nature of the students choosing to study in rural locations rather than experiences during the course that is the greater influence on rural career choice. In order to improve the rural medical workforce crisis, medical schools should attract more students with pre-existent likelihood to choose a rural career. The SOMERS Index was found to be a useful tool for this quantitative analysis. © 2012 The Authors. Australian Journal of Rural Health © 2012 National Rural Health Alliance Inc.

Using A3 thinking to improve the STAT medication process.

PubMed

Manojlovich, Milisa; Chase, Valerie J; Mack, Megan; Conroy, Meghan K; Belanger, Karen; Zawol, Debbie; Corr, Karen M; Fowler, Karen E; Viglianti, Elizabeth

2014-08-01

Although the term STAT conveys a sense of urgency, it is sometimes used to circumvent a system that may be too slow to accomplish tasks in a timely manner. We describe a quality-improvement project undertaken by a US Department of Veterans Affairs (VA) hospital to improve the STAT medication process. We adapted A3 Thinking, a problem-solving process common in Lean organizations, to our problem. In the discovery phase, a color-coded flow map of the existing process was constructed, and a real-time STAT order was followed in a modified "Go to the Gemba" exercise. In the envisioning phase, the team brainstormed to come up with as many improvement ideas as possible, which were then prioritized based on the anticipated effort and impact. The team then identified initial experiments to be carried out in the experimentation phase; each experiment followed a standard Plan-Do-Study-Act cycle. On average, the number of STAT medications ordered per month decreased by 9.5%. The average time from STAT order entry to administration decreased by 21%, and time from medication delivery to administration decreased by 26%. Improvements were also made in technician awareness of STAT medications and nurse notification of STAT medication delivery. Adapting A3 Thinking for process improvement was a low-cost/low-tech option for a VA facility. The A3 Thinking process led to a better understanding of the meaning of STAT across disciplines, and promoted a collaborative culture in which other hospital-wide problems may be addressed in the future. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

The surgical learning and instructional portfolio: what residents at a single institution are learning.

PubMed

Webb, Travis P; Merkley, Taylor R

2011-03-01

The Accreditation Council for Graduate Medical Education (ACGME) Learning Portfolio is recommended as a tool to develop and document reflective, practice-based learning and improvement. There is no consensus regarding the appropriate content of a learning portfolio in medical education. Studying lessons selected for inclusion in their learning portfolios by surgical trainees could help identify useful subject matter for this purpose. Each month, all residents in our surgery residency program submit entries into their individual Surgical Learning and Instructional Portfolio (SLIP). The SLIP entries from July 2008 to 2009 (n = 420) were deidentified and randomized using a random number generator. We conducted a thematic content analysis of 50 random portfolio entries to identify lessons learned. Two independent raters analyzed the "3 lessons learned" portion of the portfolio entries and identified themes and subthemes using the constant comparative method used in grounded theory. The collaborative coding process resulted in theme saturation after the identification of 7 themes and their subthemes. Themes in decreasing order of frequency included complications, disease epidemiology, disease presentation, surgical management of disease, medical management of disease, operative techniques, and pathophysiology. Junior residents chose to focus on a broad array of foundational topics including disease presentation, epidemiology, and overall management of diseases, whereas postgraduate year-4 (PGY-4) and PGY-5 residents most frequently chose to focus on complications as learning points. Lessons learned reflect perceived needs of the trainees based on training year. When given a template to follow, junior and senior residents choose to reflect on different subject matter to meet their learning goals.

The Surgical Learning and Instructional Portfolio: What Residents at a Single Institution Are Learning

PubMed Central

Webb, Travis P; Merkley, Taylor R

2011-01-01

Background The Accreditation Council for Graduate Medical Education (ACGME) Learning Portfolio is recommended as a tool to develop and document reflective, practice-based learning and improvement. There is no consensus regarding the appropriate content of a learning portfolio in medical education. Studying lessons selected for inclusion in their learning portfolios by surgical trainees could help identify useful subject matter for this purpose. Methods Each month, all residents in our surgery residency program submit entries into their individual Surgical Learning and Instructional Portfolio (SLIP). The SLIP entries from July 2008 to 2009 (n = 420) were deidentified and randomized using a random number generator. We conducted a thematic content analysis of 50 random portfolio entries to identify lessons learned. Two independent raters analyzed the “3 lessons learned” portion of the portfolio entries and identified themes and subthemes using the constant comparative method used in grounded theory. Results The collaborative coding process resulted in theme saturation after the identification of 7 themes and their subthemes. Themes in decreasing order of frequency included complications, disease epidemiology, disease presentation, surgical management of disease, medical management of disease, operative techniques, and pathophysiology. Junior residents chose to focus on a broad array of foundational topics including disease presentation, epidemiology, and overall management of diseases, whereas postgraduate year-4 (PGY-4) and PGY-5 residents most frequently chose to focus on complications as learning points. Conclusions Lessons learned reflect perceived needs of the trainees based on training year. When given a template to follow, junior and senior residents choose to reflect on different subject matter to meet their learning goals. PMID:22379531

Development Of A Combined Sensor System For Atmospheric Entry Missions

NASA Astrophysics Data System (ADS)

Preci, A.; Eswein, N.; Herdrich, G.; Fasoulas, S.; Roser, H.-P.; Auweter-Kurtz, M.

2011-05-01

The payload COMPARE is developed at the Institute of Space Systems for various entry scenarios. It was previously laid out for a Mars entry mission and afterwards redesigned for the German Aerospace Centre suborbital re-entry mission SHEFEX II, which had its successful roll-out in July 2010 and is due to be launched in September 2011. The sensor system aims to simultaneously measure the temperature of the thermal protection shield, the radiation from the plasma and the pressure. The most recent development of COMPARE is a combined sensor system for ablative thermal protection systems enabling a separation of the radiative heat flux from the total heat flux. Furthermore, it enables also the detection of specific species in the plasma by measuring the radiative heat flux at a defined wavelength range. In the frame of an ESA funded project a breadboard has been build and tested in a plasma wind tunnel in order to prove the feasibility of such a sensor system for upcoming entry missions. Results of these measurements are presented in this work.

76 FR 33794 - Self-Regulatory Organizations; Chicago Stock Exchange, Incorporated; Notice of Filing and...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-09

... types and indications that are eligible for entry to and accepted by the Matching System. The Exchange... Exchange with the ability to determine on an order type by order type basis which orders and indications... Rule 43.2 relating to the types of orders handled on the CBOE's Screen Based Trading System (``SBT...

Computerized Orders with Standardized Concentrations Decrease Dispensing Errors of Continuous Infusion Medications for Pediatrics

PubMed Central

Sowan, Azizeh K.; Vaidya, Vinay U.; Soeken, Karen L.; Hilmas, Elora

2010-01-01

OBJECTIVES The use of continuous infusion medications with individualized concentrations may increase the risk for errors in pediatric patients. The objective of this study was to evaluate the effect of computerized prescriber order entry (CPOE) for continuous infusions with standardized concentrations on frequency of pharmacy processing errors. In addition, time to process handwritten versus computerized infusion orders was evaluated and user satisfaction with CPOE as compared to handwritten orders was measured. METHODS Using a crossover design, 10 pharmacists in the pediatric satellite within a university teaching hospital were given test scenarios of handwritten and CPOE order sheets and asked to process infusion orders using the pharmacy system in order to generate infusion labels. Participants were given three groups of orders: five correct handwritten orders, four handwritten orders written with deliberate errors, and five correct CPOE orders. Label errors were analyzed and time to complete the task was recorded. RESULTS Using CPOE orders, participants required less processing time per infusion order (2 min, 5 sec ± 58 sec) compared with time per infusion order in the first handwritten order sheet group (3 min, 7 sec ± 1 min, 20 sec) and the second handwritten order sheet group (3 min, 26 sec ± 1 min, 8 sec), (p<0.01). CPOE eliminated all error types except wrong concentration. With CPOE, 4% of infusions processed contained errors, compared with 26% of the first group of handwritten orders and 45% of the second group of handwritten orders (p<0.03). Pharmacists were more satisfied with CPOE orders when compared with the handwritten method (p=0.0001). CONCLUSIONS CPOE orders saved pharmacists' time and greatly improved the safety of processing continuous infusions, although not all errors were eliminated. pharmacists were overwhelmingly satisfied with the CPOE orders PMID:22477811

The evolution of the market for commercial computerized physician order entry and computerized decision support systems for prescribing.

PubMed

Mozaffar, Hajar; Williams, Robin; Cresswell, Kathrin; Morrison, Zoe; Bates, David W; Sheikh, Aziz

2016-03-01

To understand the evolving market of commercial off-the-shelf Computerized Physician Order Entry (CPOE) and Computerized Decision Support (CDS) applications and its effects on their uptake and implementation in English hospitals. Although CPOE and CDS vendors have been quick to enter the English market, uptake has been slow and uneven. To investigate this, the authors undertook qualitative ethnography of vendors and adopters of hospital CPOE/CDS systems in England. The authors collected data from semi-structured interviews with 11 individuals from 4 vendors, including the 2 most entrenched suppliers, and 6 adopter hospitals, and 21 h of ethnographic observation of 2 user groups, and 1 vendor event. The research and analysis was informed by insights from studies of the evolution of technology fields and the emergence of generic COTS enterprise solutions. Four key themes emerged: (1) adoption of systems that had been developed outside of England, (2) vendors' configuration and customization strategies, (3) localized adopter practices vs generic systems, and (4) unrealistic adopter demands. Evidence for our over-arching finding concerning the current immaturity of the market was derived from vendors' strategies, adopters' reactions to the technology, and policy makers' incomplete insights. The CPOE/CDS market in England is still in an emergent phase. The rapid entrance of diverse products, triggered by federal policy initiatives, has resulted in premature adoption of systems that do not yet adequately meet the needs of hospitals. Vendors and adopters lacked understanding of how to design and implement generic solutions to meet diverse user needs. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion.

PubMed

Patel, Vijay M; Rains, Anna W; Clark, Christopher T

2016-01-01

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

Management of laboratory data and information exchange in the electronic health record.

PubMed

Wilkerson, Myra L; Henricks, Walter H; Castellani, William J; Whitsitt, Mark S; Sinard, John H

2015-03-01

In the era of the electronic health record, the success of laboratories and pathologists will depend on effective presentation and management of laboratory information, including test orders and results, and effective exchange of data between the laboratory information system and the electronic health record. In this third paper of a series that explores empowerment of pathology in the era of the electronic health record, we review key elements of managing laboratory information within the electronic health record and examine functional issues pertinent to pathologists and laboratories in the exchange of laboratory information between electronic health records and both anatomic and clinical pathology laboratory information systems. Issues with electronic order-entry and results-reporting interfaces are described, and considerations for setting up these interfaces are detailed in tables. The role of the laboratory medical director as mandated by the Clinical Laboratory Improvement Amendments of 1988 and the impacts of discordance between laboratory results and their display in the electronic health record are also discussed.

The impact of closed-loop electronic medication management on time to first dose: a comparative study between paper and digital hospital environments.

PubMed

Austin, Jodie A; Smith, Ian R; Tariq, Amina

2018-01-22

Closed-loop electronic medication management systems (EMMS) are recognised as an effective intervention to improve medication safety, yet evidence of their effectiveness in hospitals is limited. Few studies have compared medication turnaround time for a closed-loop electronic versus paper-based medication management environment. To compare medication turnaround times in a paper-based hospital environment with a digital hospital equipped with a closed-loop EMMS, consisting of computerised physician order entry, profiled automated dispensing cabinets packaged with unit dose medications and barcode medication administration. Data were collected during 2 weeks at three private hospital sites (one with closed-loop EMMS) within the same organisation network in Queensland, Australia. Time between scheduled and actual administration times was analysed for first dose of time-critical and non-critical medications located on the ward or sourced via pharmacy. Medication turnaround times at the EMMS site were less compared to the paper-based sites (median, IQR: 35 min, 8-57 min versus 120 min, 30-180 min, P < 0.001). For time-critical medications, 77% were administered within 60 min of scheduled time at the EMMS site versus 38% for the paper-based sites. Similar difference was observed for non-critical medications, 80% were administered within 60 min of their scheduled time at the EMMS site versus 41% at the paper-based facilities. The study indicates medication turnaround times utilising a closed-loop EMMS are less compared to paper-based systems. This improvement may be attributable to increased accessibility of medications using automated dispensing cabinets and electronic medication administration records flagging tasks to nurses in real time. © 2018 Royal Pharmaceutical Society.

Leveraging Health Information Technology to Improve Quality in Federal Healthcare.

PubMed

Weigel, Fred K; Switaj, Timothy L; Hamilton, Jessica

2015-01-01

Healthcare delivery in America is extremely complex because it is comprised of a fragmented and nonsystematic mix of stakeholders, components, and processes. Within the US healthcare structure, the federal healthcare system is poised to lead American medicine in leveraging health information technology to improve the quality of healthcare. We posit that through developing, adopting, and refining health information technology, the federal healthcare system has the potential to transform federal healthcare quality by managing the complexities associated with healthcare delivery. Although federal mandates have spurred the widespread use of electronic health records, other beneficial technologies have yet to be adopted in federal healthcare settings. The use of health information technology is fundamental in providing the highest quality, safest healthcare possible. In addition, health information technology is valuable in achieving the Agency for Healthcare Research and Quality's implementation goals. We conducted a comprehensive literature search using the Google Scholar, PubMed, and Cochrane databases to identify an initial list of articles. Through a thorough review of the titles and abstracts, we identified 42 articles as having relevance to health information technology and quality. Through our exclusion criteria of currency of the article, citation frequency, applicability to the federal health system, and quality of research supporting conclusions, we refined the list to 11 references from which we performed our analysis. The literature shows that the use of computerized physician order entry has significantly increased accurate medication dosage and decreased medication errors. The use of clinical decision support systems have significantly increased physician adherence to guidelines, although there is little evidence that indicates any significant correlation to patient outcomes. Research shows that interoperability and usability are continuing challenges for implementation. The Veterans Administration is the only entity within the federal health system that has published research on the use of health information technology to improve quality. The federal healthcare system has existing systems in place with computerized physician order entry systems and clinical decision support systems, but these should be advanced. Particular focus and attention should be placed on data mining capabilities, integrating the electronic health record across all aspects of care, using the electronic health record to improve quality at the point of care, and developing interoperable and usable health information technology.

The process of development of a prioritization tool for a clinical decision support build within a computerized provider order entry system: Experiences from St Luke's Health System.

PubMed

Wolf, Matthew; Miller, Suzanne; DeJong, Doug; House, John A; Dirks, Carl; Beasley, Brent

2016-09-01

To establish a process for the development of a prioritization tool for a clinical decision support build within a computerized provider order entry system and concurrently to prioritize alerts for Saint Luke's Health System. The process of prioritizing clinical decision support alerts included (a) consensus sessions to establish a prioritization process and identify clinical decision support alerts through a modified Delphi process and (b) a clinical decision support survey to validate the results. All members of our health system's physician quality organization, Saint Luke's Care as well as clinicians, administrators, and pharmacy staff throughout Saint Luke's Health System, were invited to participate in this confidential survey. The consensus sessions yielded a prioritization process through alert contextualization and associated Likert-type scales. Utilizing this process, the clinical decision support survey polled the opinions of 850 clinicians with a 64.7 percent response rate. Three of the top rated alerts were approved for the pre-implementation build at Saint Luke's Health System: Acute Myocardial Infarction Core Measure Sets, Deep Vein Thrombosis Prophylaxis within 4 h, and Criteria for Sepsis. This study establishes a process for developing a prioritization tool for a clinical decision support build within a computerized provider order entry system that may be applicable to similar institutions. © The Author(s) 2015.

Aerodynamic and Aerothermal TPS Instrumentation Reference Guide

NASA Technical Reports Server (NTRS)

Woollard, Bryce A.; Braun, Robert D.; Bose, Deepack

2016-01-01

The hypersonic regime of planetary entry combines the most severe environments that an entry vehicle will encounter with the greatest amount of uncertainty as to the events unfolding during that time period. This combination generally leads to conservatism in the design of an entry vehicle, specifically that of the thermal protection system (TPS). Each planetary entry provides a valuable aerodynamic and aerothermal testing opportunity; the utilization of this opportunity is paramount in better understanding how a specific entry vehicle responds to the demands of the hypersonic entry environment. Previous efforts have been made to instrument entry vehicles in order to collect data during the entry period and reconstruct the corresponding vehicle response. The purpose of this paper is to cumulatively document past TPS instrumentation designs for applicable planetary missions, as well as to list pertinent results and any explainable shortcomings.

Entry, Descent and Landing Systems Analysis: Exploration Class Simulation Overview and Results

NASA Technical Reports Server (NTRS)

DwyerCianciolo, Alicia M.; Davis, Jody L.; Shidner, Jeremy D.; Powell, Richard W.

2010-01-01

NASA senior management commissioned the Entry, Descent and Landing Systems Analysis (EDL-SA) Study in 2008 to identify and roadmap the Entry, Descent and Landing (EDL) technology investments that the agency needed to make in order to successfully land large payloads at Mars for both robotic and exploration or human-scale missions. The year one exploration class mission activity considered technologies capable of delivering a 40-mt payload. This paper provides an overview of the exploration class mission study, including technologies considered, models developed and initial simulation results from the EDL-SA year one effort.

Obstetrics and gynaecology as a career choice: a cohort study of canadian medical students.

PubMed

Scott, Ian M; Nasmith, Trudy; Gowans, Margot C; Wright, Bruce J; Brenneis, Fraser R

2010-11-01

to describe the characteristics of medical students interested in obstetrics and gynaecology and to build a model that predicts which of these students will choose obstetrics and gynaecology as their career. students were surveyed in 2002, 2003, and 2004 at the commencement of their medical studies. Data were collected on career choice, attitudes to practice, and demographics at medical school entry and on career choice at medical school exit. three items present at entry to medical school were predictive of students ultimately choosing a career in obstetrics and gynaecology: having this career as one of their first three career choices at entry (having it as their first choice was the strongest predictor), being female, and desiring a narrow scope of practice. students choosing a career in obstetrics and gynaecology have attributes at medical school entry that differentiate them from students interested in other specialties. Identifying these attributes may guide education in and recruitment to obstetrics and gynaecology.

SU-E-T-544: A Radiation Oncology-Specific Multi-Institutional Federated Database: Initial Implementation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hendrickson, K; Phillips, M; Fishburn, M

Purpose: To implement a common database structure and user-friendly web-browser based data collection tools across several medical institutions to better support evidence-based clinical decision making and comparative effectiveness research through shared outcomes data. Methods: A consortium of four academic medical centers agreed to implement a federated database, known as Oncospace. Initial implementation has addressed issues of differences between institutions in workflow and types and breadth of structured information captured. This requires coordination of data collection from departmental oncology information systems (OIS), treatment planning systems, and hospital electronic medical records in order to include as much as possible the multi-disciplinary clinicalmore » data associated with a patients care. Results: The original database schema was well-designed and required only minor changes to meet institution-specific data requirements. Mobile browser interfaces for data entry and review for both the OIS and the Oncospace database were tailored for the workflow of individual institutions. Federation of database queries--the ultimate goal of the project--was tested using artificial patient data. The tests serve as proof-of-principle that the system as a whole--from data collection and entry to providing responses to research queries of the federated database--was viable. The resolution of inter-institutional use of patient data for research is still not completed. Conclusions: The migration from unstructured data mainly in the form of notes and documents to searchable, structured data is difficult. Making the transition requires cooperation of many groups within the department and can be greatly facilitated by using the structured data to improve clinical processes and workflow. The original database schema design is critical to providing enough flexibility for multi-institutional use to improve each institution s ability to study outcomes, determine best practices, and support research. The project has demonstrated the feasibility of deploying a federated database environment for research purposes to multiple institutions.« less

Capturing Accurate and Useful Information on Medication-Related Telenursing Triage Calls.

PubMed

Lake, R; Li, L; Baysari, M; Byrne, M; Robinson, M; Westbrook, J I

2016-01-01

Registered nurses providing telenursing triage and advice services record information on the medication related calls they handle. However the quality and consistency of these data were rarely examined. Our aim was to examine medication related calls made to the healthdirect advice service in November 2014, to assess their basic characteristics and how the data entry format influenced information collected and data consistency. Registered nurses selected the patient question type from a range of categories, and entered the medications involved in a free text field. Medication names were manually extracted from the free text fields. We also compared the selected patient question type with the free text description of the call, in order to gauge data consistency. Results showed that nurses provided patients with advice on medication-related queries in a timely matter (the median call duration of 9 minutes). From 1835 calls, we were able to identify and classify 2156 medications into 384 generic names. However, in 204 cases (11.2% of calls) no medication name was entered. A further 308 (15.0%) of the medication names entered were not identifiable. When we compared the selected patient question with the free text description of calls, we found that these were consistent in 63.27% of cases. Telenursing and triage advice services provide a valuable resource to the public with quick and easily accessible advice. To support nurses provide quality services and record accurate information about the queries, appropriate data entry format and design would be beneficial.

Re-entry experiences of Black men living with HIV/AIDS after release from prison: Intersectionality and implications for care.

PubMed

Sun, Shufang; Crooks, Natasha; Kemnitz, Rebecca; Westergaard, Ryan P

2018-06-12

Both the HIV epidemic and incarceration disproportionately affect Black men in the United States. A critical period for incarcerated Black men living with HIV/AIDS is re-entry into the community, which is often associated with adverse health outcomes. Additionally, Black men living with HIV/AIDS involved in the criminal justice system are burdened by multiple, intersecting disadvantaged identities and social positions. This study aimed to examine community re-entry experiences among Black men living with HIV/AIDS from an intersectional perspective. In-depth, semi-structured interviews were conducted with 16 incarcerated Black men in Wisconsin, at pre-release from prison and six months after re-entry. Thematic analysis guided by intersectionality theory was used to analyze interview transcripts. Seven emerged themes included Intersectional Identities and Social Positions, Family Support, Neighborhood Violence, Relationship with Law Enforcement, Employment, Mental Health Concerns, and Medical Care and Medication Management. Intersecting identities and social positions interact with factors at multiple levels to inform health and HIV care. A conceptual framework was developed to illustrate relationships among themes. Findings demonstrate the relevance of intersectionality theory in HIV care with Black men involved in criminal justice system. Incorporating a social-ecological perspective into intersectionality framework could be useful in theoretical and empirical research. Disenfranchised communities may particularly benefit from interventions that address community- and systemic-level issues. Copyright © 2018 Elsevier Ltd. All rights reserved.

Human resources for health in Peru: recent trends (2007-2013) in the labour market for physicians, nurses and midwives.

PubMed

Jimenez, M Michelle; Bui, Anthony L; Mantilla, Eduardo; Miranda, J Jaime

2017-09-21

Most analyses of gaps in human resources for health (HRH) do not consider training and the transition of graduates into the labour market. This study aims to explore the labour market for Peru's recent medical, nursing, and midwifery graduates as well as their transition into employment in the Ministry of Health's (MOH) system. Data from four different datasets, covering 2007-2013, was used to characterize the patterns of recently trained physicians, nurses, midwives, and postgraduate-trained physicians that enter employment in the MOH system, and scenario analyses were used to describe how this rate of entry needs to adapt in order to fill current HRH shortages. HRH graduates have been increasing from 2007 to 2011, but the proportions that enter employment in the MOH system 2 years later range from 8 to 45% and less than 10% of newly trained medical specialists. Scenario analyses indicate that the gap for physicians and nurses will be met in 2027 and 2024, respectively, while midwives in 2017. However, if the number of HRH graduates entering the MOH system doubles, these gaps could be filled as early as 2020 for physicians and 2019 for nurses. In this latter scenario, the MOH system would still only utilize 56% of newly qualified physicians, 74% of nurses, and 66% of midwives available in the labour market. At 2013 training rates, Peru has the number of physicians, nurses, and midwives it needs to address HRH shortages and meet estimated HRH gaps in the national MOH system during the next decade. However, a significant number of newly qualified health professionals do not work for the MOH system within 2 years of graduation. These analyses highlight the importance of building adequate incentive structures to improve the entry and retention of HRH into the public sector.

Development of Thermal Protection Materials for Future Mars Entry, Descent and Landing Systems

NASA Technical Reports Server (NTRS)

Cassell, Alan M.; Beck, Robin A. S.; Arnold, James O.; Hwang, Helen; Wright, Michael J.; Szalai, Christine E.; Blosser, Max; Poteet, Carl C.

2010-01-01

Entry Systems will play a crucial role as NASA develops the technologies required for Human Mars Exploration. The Exploration Technology Development Program Office established the Entry, Descent and Landing (EDL) Technology Development Project to develop Thermal Protection System (TPS) materials for insertion into future Mars Entry Systems. An assessment of current entry system technologies identified significant opportunity to improve the current state of the art in thermal protection materials in order to enable landing of heavy mass (40 mT) payloads. To accomplish this goal, the EDL Project has outlined a framework to define, develop and model the thermal protection system material concepts required to allow for the human exploration of Mars via aerocapture followed by entry. Two primary classes of ablative materials are being developed: rigid and flexible. The rigid ablatives will be applied to the acreage of a 10x30 m rigid mid L/D Aeroshell to endure the dual pulse heating (peak approx.500 W/sq cm). Likewise, flexible ablative materials are being developed for 20-30 m diameter deployable aerodynamic decelerator entry systems that could endure dual pulse heating (peak aprrox.120 W/sq cm). A technology Roadmap is presented that will be used for facilitating the maturation of both the rigid and flexible ablative materials through application of decision metrics (requirements, key performance parameters, TRL definitions, and evaluation criteria) used to assess and advance the various candidate TPS material technologies.

Woven Thermal Protection System (WTPS) a Novel Approach to Meet NASA's Most Demanding Reentry Missions

NASA Technical Reports Server (NTRS)

Stackpoole, Mairead

2014-01-01

NASA's future robotic missions to Venus and outer planets, namely, Saturn, Uranus, Neptune, result in extremely high entry conditions that exceed the capabilities of current mid-density ablators (PICA or Avcoat). Therefore mission planners assume the use of a fully dense carbon phenolic heat shield similar to what was flown on Pioneer Venus and Galileo. Carbon phenolic (CP) is a robust Thermal Protection System (TPS) however its high density and thermal conductivity constrain mission planners to steep entries, high heat fluxes, pressures and short entry durations, in order for CP to be feasible from a mass perspective. The high entry conditions pose certification challenges in existing ground based test facilities. In 2012 the Game Changing Development Program in NASA's Space Technology Mission Directorate funded NASA ARC to investigate the feasibility of a Woven Thermal Protection System (WTPS) to meet the needs of NASA's most challenging entry missions. This presentation will summarize maturation of the WTPS project.

Assessing and comparing the usability of Chinese EHRs used in two Peking University hospitals to EHRs used in the US: A method of RUA.

PubMed

Xu, Lufei; Wen, Dong; Zhang, Xingting; Lei, Jianbo

2016-05-01

The objective of this study was to investigate the usability level of Chinese hospital Electronic Health Records (EHRs) by assessing the completion times of EHRs for seven "meaningful use (MU)" relevant tasks conducted at two Chinese tertiary hospitals and comparing the results to those of relevant research conducted in US EHRs. Using Rapid Usability Assessment (RUA) developed by the National Center for Cognitive Informatics and Decision Making (NCCD), the usability of EHRs from two Peking University hospitals was assessed using a three-step Keystroke Level Model (KLM) in a laboratory environment. (1) The total EHR task completion time for 7 MU relevant test tasks showed no significant differences between the two Chinese EHRs and their US counterparts, in which the time for thinking was relatively large and comprised 35.6% of the total time. The time for the electronic physician order was the largest. (2) For specific tasks, the mean completion times of the 2 hospital EHR systems spent on recording, modifying and searching (RMS) the medication orders were similar to those for the RMS radioactive tests; the mean time spent on the RMS laboratory test orders were much less. (3) There were 85 usability problems identified in the 2 hospital EHR systems. In Chinese EHRs, a substantial amount of time is required to complete tasks relevant to MU targets and many preventable usability problems can be discovered. The task completion time of the 2 Chinese EHR systems was a little shorter than in the 5 reported US EHR systems, while the differences in smoking status and CPOE tasks were obvious; one main reason for these differences was the use of structured data entry. The efficiency of Chinese and US EHRs was not significantly different. The key to improving the efficiency of both systems lies in expediting the Computerized physician order entry (CPOE) task. Many usability problems can be identified using heuristic assessments and improved by corresponding actions. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Graduate medical students' perception of obstetrics and gynaecology as a future career specialty.

PubMed

Ismail, S I M F; Kevelighan, E H

2014-05-01

The aim of this study was to explore the perceptions of graduate-entry medical students of obstetrics and gynaecology as a specialty, in order to understand how to increase its appeal to them, and therefore enhance recruitment to the specialty. A total of 90 questionnaires were returned out of 145 questionnaires distributed to years 2 and 4 graduate-entry medical students (62% response rate). Although fewer than 4% of respondents are considering the specialty as their career choice, more than half of the respondents would consider the specialty as a second option, which shows that there is room to persuade them to have a second look. Gender was the only factor that significantly affected views regarding obstetrics and gynaecology. There is a need for more information about the specialty and its training opportunities and exposure to areas of special interest and subspecialisation, as well as role models, rather than focussing on labour ward in timetables. Areas of apprehension about the specialty, such as the risk of litigation, need to be aired and addressed through career days, as well as formal tutorials within teaching programmes.

A multicenter study of outcome in systemic lupus erythematosus. I. Entry variables as predictors of prognosis.

PubMed

Ginzler, E M; Diamond, H S; Weiner, M; Schlesinger, M; Fries, J F; Wasner, C; Medsger, T A; Ziegler, G; Klippel, J H; Hadler, N M; Albert, D A; Hess, E V; Spencer-Green, G; Grayzel, A; Worth, D; Hahn, B H; Barnett, E V

1982-06-01

A retrospective study of factors influencing survival in 1,103 patients with systemic lupus erythematosus (SLE) was carried out at 9 university centers diverse in geographic, socioeconomic, and racial characteristics. The mortality and disease characteristics of the patients at study entry varied widely among centers. The survival rates from the time patients with a diagnosis of SLE were first evaluated at the participating center was 90% at 1 year, 77% at 5 years, and 71% at 10 years. Patients with a serum creatinine greater than 3 mg/dl at study entry had the lowest survival rates: 48%, 29%, and 12% at 1, 5, and 10 years, respectively. Survival rate also correlated independently with the entry hematocrit, degree of proteinuria, number of preliminary American Rheumatism Association criteria for SLE satisfied, and source of funding of medical care. When data were corrected for socioeconomic status, race/ethnic origin did not significantly influence survival. Survival rates varied widely at different participating institutions, generally due to differences in disease severity. Place of treatment was independently associated with survival only in the second year after study entry. Disease duration before study entry did not account for the differences in disease severity.

Evaluation in a competency-based educational system.

PubMed

May, B J

1977-01-01

Competency-based curricula have been implemented at the Medical College of Georgia to prepare students to meet entry level competencies as physical therapists and physical therapist assistants. Criteria-referenced evaluations are used to determine if students have achieved the desired competencies. Performance is measured against the criteria and not other students. The process of developing the system currently in use at the Medical College of Georgia is delineated in some detail and some of the advantages of the system for physical therapy education are discussed.

31 CFR 357.20 - Securities account in Legacy Treasury Direct ®.

Code of Federal Regulations, 2011 CFR

2011-07-01

... number. (c) If a bill is transferred from one Legacy Treasury Direct account to another, the price shown...-ENTRY TREASURY BONDS, NOTES AND BILLS HELD IN TREASURY/RESERVE AUTOMATED DEBT ENTRY SYSTEM (TRADES) AND... securities portfolio associated with an account master record. (c) Account master record. In order for a...

31 CFR 357.20 - Securities account in Legacy Treasury Direct ®.

Code of Federal Regulations, 2014 CFR

2014-07-01

... number. (c) If a bill is transferred from one Legacy Treasury Direct account to another, the price shown... BOOK-ENTRY TREASURY BONDS, NOTES AND BILLS HELD IN TREASURY/RESERVE AUTOMATED DEBT ENTRY SYSTEM (TRADES... the securities portfolio associated with an account master record. (c) Account master record. In order...

31 CFR 357.20 - Securities account in Legacy Treasury Direct ®.

Code of Federal Regulations, 2013 CFR

2013-07-01

... number. (c) If a bill is transferred from one Legacy Treasury Direct account to another, the price shown...-ENTRY TREASURY BONDS, NOTES AND BILLS HELD IN TREASURY/RESERVE AUTOMATED DEBT ENTRY SYSTEM (TRADES) AND... securities portfolio associated with an account master record. (c) Account master record. In order for a...

31 CFR 357.20 - Securities account in Legacy Treasury Direct ®.

Code of Federal Regulations, 2012 CFR

2012-07-01

... number. (c) If a bill is transferred from one Legacy Treasury Direct account to another, the price shown...-ENTRY TREASURY BONDS, NOTES AND BILLS HELD IN TREASURY/RESERVE AUTOMATED DEBT ENTRY SYSTEM (TRADES) AND... securities portfolio associated with an account master record. (c) Account master record. In order for a...

A programmable rules engine to provide clinical decision support using HTML forms.

PubMed

Heusinkveld, J; Geissbuhler, A; Sheshelidze, D; Miller, R

1999-01-01

The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser.

Effect of an Electronic Health Record on the Culture of an Outpatient Medical Oncology Practice in a Four-Hospital Integrated Health Care System: 5-Year Experience

PubMed Central

Brockstein, Bruce; Hensing, Thomas; Carro, George W.; Obel, Jennifer; Khandekar, Janardan; Kaminer, Lynne; Van De Wege, Christine; de Wilton Marsh, Robert

2011-01-01

The electronic health record (EHR) was adopted into the NorthShore University HealthSystem, a four-hospital integrated health system located in suburban Chicago, in 2003. By 2005, all chemotherapy and medicine order entry was conducted through the EHR, completing the incorporation of a fully paperless EHR in our hospital-based oncology practice in both the inpatient and outpatient settings. The use of the EHR has dramatically changed our practice environment by improving efficiency, patient safety, research productivity, and operations, while allowing evaluation of adherence to established quality measures and incorporation of new quality improvement initiatives. The reach of the EHR has been substantial and has influenced every aspect of care at our institution over the short period since its implementation. In this article, we describe subjective and objective measures, outcomes, and achievements of our 5-year EHR experience. PMID:22043197

Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system

PubMed Central

Coleman, Jamie J; Hodson, James; Thomas, Sarah K; Brooks, Hannah L; Ferner, Robin E

2015-01-01

Background A computerized physician order entry (CPOE) system with embedded clinical decision support can reduce medication errors in hospitals, but might increase the time taken to generate orders. Aims We aimed to quantify the effects of temporal (month, day of week, hour of shift) and other factors (grade of doctor, prior experience with the system, alert characteristics, and shift type) on the time taken to generate a prescription order. Setting A large university teaching hospital using a locally developed CPOE system with an extensive audit database. Design We retrospectively analyzed prescription orders from the audit database between August 2011 and July 2012. Results The geometric mean time taken to generate a prescription order within the CPOE system was 11.75 s (95% CI 11.72 to 11.78). Time to prescribe was most affected by the display of high-level (24.59 s (24.43 to 24.76); p<0.001) or previously unseen (18.87 s (18.78 to 18.96); p<0.001) alerts. Prescribers took significantly less time at weekends (11.29 s (11.23 to 11.35)) than on weekdays (11.88 s (11.84 to 11.91); p<0.001), in the first (11.25 s (11.16 to 11.34); p<0.001) and final (11.56 s (11.47 to 11.66); p<0.001) hour of their shifts, and after the first month of using the system. Conclusions The display of alerts, prescribing experience, system familiarity, and environment all affect the time taken to generate a prescription order. Our study reinforces the need for appropriate alerts to be presented to individuals at an appropriate place in the workflow, in order to improve prescribing efficiency. PMID:25074989

Woven Thermal Protection System (WTPS) a Novel Approach to Meet Nasa's Most Demanding Reentry Missions

NASA Technical Reports Server (NTRS)

Stackpoole, Margaret M.; Ellerby, Donald T.; Gasch, Matt; Ventkatapathy, Ethiraj; Beerman, Adam; Boghozian, Tane; Gonzales, Gregory; Feldman, Jay; Peterson, Keith; Prabhu, Dinesh

2014-01-01

NASA's future robotic missions to Venus and other planets, namely, Saturn, Uranus, Neptune, result in extremely high entry conditions that exceed the capabilities of current mid density ablators (PICA or Avcoat). Therefore mission planners assume the use of a fully dense carbon phenolic heatshield similar to what was flown on Pioneer Venus and Galileo. Carbon phenolic is a robust TPS, however, its high density and thermal conductivity constrain mission planners to steep entries, high fluxes, pressures and short entry durations, in order for CP to be feasible from a mass perspective. The high entry conditions pose certification challenges in existing ground based test facilities. In 2012 the Game Changing Development Program in NASA's Space Technology Mission Directorate funded NASA ARC to investigate the feasibility of a Woven Thermal Protection System to meet the needs of NASA's most challenging entry missions. This presentation will summarize the maturation of the WTPS project.

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions.

PubMed

Bedouch, Pierrick; Tessier, Alexandre; Baudrant, Magalie; Labarere, José; Foroni, Luc; Calop, Jean; Bosson, Jean-Luc; Allenet, Benoît

2012-08-01

To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward. A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full-time on-ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug-related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis. The 448 pharmacists' interventions concerned: non-conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37-22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16-37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20-33.29), P < 0.01]. When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist-physician communication is needed. © 2011 Blackwell Publishing Ltd.

A Pharmacy Blueprint for Electronic Medical Record Implementation Success

PubMed Central

Bach, David S.; Risko, Kenneth R.; Farber, Margo S.; Polk, Gregory J.

2015-01-01

Objective: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. Method: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. Results: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. Conclusion: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success. PMID:26405340

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.

PubMed

Shulman, Rob; Singer, Mervyn; Goldstone, John; Bellingan, Geoff

2005-10-05

The study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit. Details of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospital's 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review. The total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71). Introduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE.

Graphical tool for navigation within the semantic network of the UMLS metathesaurus on a locally installed database.

PubMed

Frankewitsch, T; Prokosch, H U

2000-01-01

Knowledge in the environment of information technologies is bound to structured vocabularies. Medical data dictionaries are necessary for uniquely describing findings like diagnoses, procedures or functions. Therefore we decided to locally install a version of the Unified Medical Language System (UMLS) of the U.S. National Library of Medicine as a repository for defining entries of a medical multimedia database. Because of the requirement to extend the vocabulary in concepts and relations between existing concepts a graphical tool for appending new items to the database has been developed: Although the database is an instance of a semantic network the focus on single entries offers the opportunity of reducing the net to a tree within this detail. Based on the graph theorem, there are definitions of nodes of concepts and nodes of knowledge. The UMLS additionally offers the specification of sub-relations, which can be represented, too. Using this view it is possible to manage these 1:n-Relations in a simple tree view. On this background an explorer like graphical user interface has been realised to add new concepts and define new relationships between those and existing entries for adapting the UMLS for specific purposes such as describing medical multimedia objects.

Develop and Implement an Integrated Enterprise Information System for a Computer-Integrated Apparel Enterprise (CIAE).

DTIC Science & Technology

1998-01-24

the Apparel Manufacturing Architecture (AMA), a generic architecture for an apparel enterprise. ARN-AIMS consists of three modules - Order Processing , Order...Tracking and Shipping & Invoicing. The Order Processing Module is designed to facilitate the entry of customer orders for stock and special

Analytic Development of a Reference Profile for the First Entry in a Skip Atmospheric Entry

NASA Technical Reports Server (NTRS)

Garcia-Llama, Eduardo

2010-01-01

This note shows that a feasible reference drag profile for the first entry portion of a skip entry can be generated as a polynomial expression of the velocity. The coefficients of that polynomial are found through the resolution of a system composed of m + 1 equations, where m is the degree of the drag polynomial. It has been shown that a minimum of five equations (m = 4) are required to establish the range and the initial and final conditions on velocity and flight path angle. It has been shown that at least one constraint on the trajectory can be imposed through the addition of one extra equation in the system, which must be accompanied by the increase in the degree of the drag polynomial. In order to simplify the resolution of the system of equations, the drag was considered as being a probability density function of the velocity, with the velocity as a distribution function of the drag. Combining this notion with the introduction of empirically derived constants, it has been shown that the system of equations required to generate the drag profile can be successfully reduced to a system of linear algebraic equations. For completeness, the resulting drag profiles have been flown using the feedback linearization method of differential geometric control as a guidance law with the error dynamics of a second order homogeneous equation in the form of a damped oscillator. Satisfactory results were achieved when the gains in the error dynamics were changed at a certain point along the trajectory that is dependent on the velocity and the curvature of the drag as a function of the velocity. Future work should study the capacity to update the drag profile in flight when dispersions are introduced. Also, future studies should attempt to link the first entry, as presented and controlled in this note, with a more standard control concept for the second entry, such as the Apollo entry guidance, to try to assess the overall skip entry performance. A guidance law that includes an integral feedback term, as is the case in the actual Space Shuttle entry guidance and as is proposed in Ref 29, could be tried in future studies to assess whether its use results in an improvement of the tracking performance, and to evaluate the design needs when determining the control gains.

Performance analysis of different database in new internet mapping system

NASA Astrophysics Data System (ADS)

Yao, Xing; Su, Wei; Gao, Shuai

2017-03-01

In the Mapping System of New Internet, Massive mapping entries between AID and RID need to be stored, added, updated, and deleted. In order to better deal with the problem when facing a large number of mapping entries update and query request, the Mapping System of New Internet must use high-performance database. In this paper, we focus on the performance of Redis, SQLite, and MySQL these three typical databases, and the results show that the Mapping System based on different databases can adapt to different needs according to the actual situation.

Tracking reflective practice-based learning by medical students during an ambulatory clerkship.

PubMed

Thomas, Patricia A; Goldberg, Harry

2007-11-01

To explore the use of web and palm digital assistant (PDA)-based patient logs to facilitate reflective learning in an ambulatory medicine clerkship. Thematic analysis of convenience sample of three successive rotations of medical students' patient log entries. Johns Hopkins University School of Medicine. MS3 and MS4 students rotating through a required block ambulatory medicine clerkship. Students are required to enter patient encounters into a web-based log system during the clerkship. Patient-linked entries included an open text field entitled, "Learning Need." Students were encouraged to use this field to enter goals for future study or teaching points related to the encounter. The logs of 59 students were examined. These students entered 3,051 patient encounters, and 51 students entered 1,347 learning need entries (44.1% of encounters). The use of the "Learning Need" field was not correlated with MS year, gender or end-of-clerkship knowledge test performance. There were strong correlations between the use of diagnostic thinking comments and observations of therapeutic relationships (Pearson's r=.42, p<0.001), and between diagnostic thinking and primary interpretation skills (Pearson's r=.60, p<0.001), but not between diagnostic thinking and factual knowledge (Pearson's r =.10, p=.46). We found that when clerkship students were cued to reflect on each patient encounter with the electronic log system, student entries grouped into categories that suggested different levels of reflective thinking. Future efforts should explore the use of such entries to encourage and track habits of reflective practice in the clinical curriculum.

Entry, Descent and Landing Systems Analysis Study: Phase 1 Report

NASA Technical Reports Server (NTRS)

DwyerCianciolo, Alicia M.; Davis, Jody L.; Komar, David R.; Munk, Michelle M.; Samareh, Jamshid A.; Powell, Richard W.; Shidner, Jeremy D.; Stanley, Douglas O.; Wilhite, Alan W.; Kinney, David J.;

76 FR 37826 - Public Land Order No. 7773; Emergency Withdrawal of Public and National Forest System Lands...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-28

...] Public Land Order No. 7773; Emergency Withdrawal of Public and National Forest System Lands, Coconino and... Forest System lands from location and entry under the 1872 Mining Law for a period of 6 months under the... described above aggregate approximately 1,010,776 acres public and National Forest System lands in Coconino...

75 FR 57061 - Public Land Order No. 7749; Extension of Public Land Order Nos. 6801 and 6812; Arizona

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-17

... National Forest System lands from location or entry under the United States mining laws (30 U.S.C. chapter... Service Coronado National Forest Office, Federal Building, 300 West Congress Street, Tucson, Arizona 85701.... Public Land Order No. 6801 (55 FR 38550, (1990)) that withdrew 61.356 acres of National Forest System...

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration--2011.

PubMed

Pedersen, Craig A; Schneider, Philip J; Scheckelhoff, Douglas J

2012-05-01

Results of the 2011 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented. A stratified random sample of pharmacy directors at 1401 general and children's medical-surgical hospitals in the United States were surveyed by mail. In this national probability sample survey, the response rate was 40.1%. Decentralization of the medication-use system continues, with 40% of hospitals using a decentralized system and 58% of hospitals planning to use a decentralized model in the future. Automated dispensing cabinets were used by 89% of hospitals, robots were used by 11%, carousels were used in 18%, and machine-readable coding was used in 34% of hospitals to verify doses before dispensing. Overall, 65% of hospitals had a United States Pharmacopeia chapter 797 compliant cleanroom for compounding sterile preparations. Medication administration records (MARs) have become increasingly computerized, with 67% of hospitals using electronic MARs. Bar-code-assisted medication administration was used in 50% of hospitals, and 68% of hospitals had smart infusion pumps. Health information is becoming more electronic, with 67% of hospitals having partially or completely implemented an electronic health record and 34% of hospitals having computerized prescriber order entry. The use of these technologies has substantially increased over the past year. The average number of full-time equivalent staff per 100 occupied beds averaged 17.5 for pharmacists and 15.0 for technicians. Directors of pharmacy reported declining vacancy rates for pharmacists. Pharmacists continue to improve medication use at the dispensing and administration steps of the medication-use system. The adoption of new technology is changing the philosophy of medication distribution, and health information is rapidly becoming electronic.

Medical informatics in medical research - the Severe Malaria in African Children (SMAC) Network's experience.

PubMed

Olola, C H O; Missinou, M A; Issifou, S; Anane-Sarpong, E; Abubakar, I; Gandi, J N; Chagomerana, M; Pinder, M; Agbenyega, T; Kremsner, P G; Newton, C R J C; Wypij, D; Taylor, T E

2006-01-01

Computers are widely used for data management in clinical trials in the developed countries, unlike in developing countries. Dependable systems are vital for data management, and medical decision making in clinical research. Monitoring and evaluation of data management is critical. In this paper we describe database structures and procedures of systems used to implement, coordinate, and sustain data management in Africa. We outline major lessons, challenges and successes achieved, and recommendations to improve medical informatics application in biomedical research in sub-Saharan Africa. A consortium of experienced research units at five sites in Africa in studying children with disease formed a new clinical trials network, Severe Malaria in African Children. In December 2000, the network introduced an observational study involving these hospital-based sites. After prototyping, relational database management systems were implemented for data entry and verification, data submission and quality assurance monitoring. Between 2000 and 2005, 25,858 patients were enrolled. Failure to meet data submission deadline and data entry errors correlated positively (correlation coefficient, r = 0.82), with more errors occurring when data was submitted late. Data submission lateness correlated inversely with hospital admissions (r = -0.62). Developing and sustaining dependable DBMS, ongoing modifications to optimize data management is crucial for clinical studies. Monitoring and communication systems are vital in multi-center networks for good data management. Data timeliness is associated with data quality and hospital admissions.

Security of medical multimedia.

PubMed

Tzelepi, S; Pangalos, G; Nikolacopoulou, G

2002-09-01

The application of information technology to health care has generated growing concern about the privacy and security of medical information. Furthermore, data and communication security requirements in the field of multimedia are higher. In this paper we describe firstly the most important security requirements that must be fulfilled by multimedia medical data, and the security measures used to satisfy these requirements. These security measures are based mainly on modern cryptographic and watermarking mechanisms as well as on security infrastructures. The objective of our work is to complete this picture, exploiting the capabilities of multimedia medical data to define and implement an authorization model for regulating access to the data. In this paper we describe an extended role-based access control model by considering, within the specification of the role-permission relationship phase, the constraints that must be satisfied in order for the holders of the permission to use those permissions. The use of constraints allows role-based access control to be tailored to specifiy very fine-grained and flexible content-, context- and time-based access control policies. Other restrictions, such as role entry restriction also can be captured. Finally, the description of system architecture for a secure DBMS is presented.

Effects of Age, Gender and Educational Background on Strength of Motivation for Medical School

ERIC Educational Resources Information Center

Kusurkar, Rashmi; Kruitwagen, Cas; ten Cate, Olle; Croiset, Gerda

2010-01-01

The aim of this study was to determine the effects of selection, educational background, age and gender on strength of motivation to attend and pursue medical school. Graduate entry (GE) medical students (having Bachelor's degree in Life Sciences or related field) and Non-Graduate Entry (NGE) medical students (having only completed high school),…

A Comparison of the Perceptions of Laboratory Directors and Medical Technology Educators Toward Career-Entry Competencies for Associate and Baccalaureate Degree Laboratory Technology Graduates.

ERIC Educational Resources Information Center

Buccelli, Pamela

A study compared the perceptions of Pennsylvania laboratory directors and medical technology educators relative to career-entry competencies for associate degree medical laboratory technicians (MLTs) and baccalaureate medical technology (MT) graduates. A 55-item competency questionnaire was administered to 265 hospital laboratory directors and 40…

Standard Generalized Markup Language for self-defining structured reports.

PubMed

Kahn, C E

1999-01-01

Structured reporting is the process of using standardized data elements and predetermined data-entry formats to record observations. The Standard Generalized Markup Language (SGML; International Standards Organization (ISO) 8879:1986)--an open, internationally accepted standard for document interchange was used to encode medical observations acquired in an Internet-based structured reporting system. The resulting report is self-documenting: it includes a definition of its allowable data fields and values encoded as a report-specific SGML document type definition (DTD). The data-entry forms, DTD, and report document instances are based on report specifications written in a simple, SGML-based language designed for that purpose. Reporting concepts can be linked with those of external vocabularies such as the Unified Medical Language System (UMLS) Metathesaurus. The use of open standards such as SGML is an important step in the creation of open, universally comprehensible structured reports.

The development and evaluation of a new coding system for medical records.

PubMed

Papazissis, Elias

2014-01-01

The present study aims to develop a simple, reliable and easy tool enabling clinicians to codify the major part of individualized medical details (patient history and findings of physical examination) quickly and easily in routine medical practice, by entering data to a purpose-built software application, using structure data elements and detailed medical illustrations. We studied medical records of 9,320 patients and we extracted individualized medical details. We recorded the majority of symptoms and the majority of findings of physical examination into the system, which was named IMPACT® (Intelligent Medical Patient Record and Coding Tool). Subsequently the system was evaluated by clinicians, based on the examination of 1206 patients. The evaluation results showed that IMPACT® is an efficient tool, easy to use even under time-pressing conditions. IMPACT® seems to be a promising tool for illustration-guided, structured data entry of medical narrative, in electronic patient records.

System Level Aerothermal Testing for the Adaptive Deployable Entry and Placement Technology (ADEPT)

NASA Technical Reports Server (NTRS)

Cassell, Alan; Gorbunov, Sergey; Yount, Bryan; Prabhu, Dinesh; de Jong, Maxim; Boghozian, Tane; Hui, Frank; Chen, Y.-K.; Kruger, Carl; Poteet, Carl;

Do hospitals cross-subsidize?

PubMed Central

David, Guy; Lindrooth, Richard C.; Helmchen, Lorens A.; Burns, Lawton R.

2017-01-01

Despite its salience as a regulatory tool to ensure the delivery of unprofitable medical services, cross-subsidization of services within hospital systems has been notoriously difficult to detect and quantify. We use repeated shocks to a profitable service in the market for hospital-based medical care to test for cross-subsidization of unprofitable services. Using patient-level data from general short-term hospitals in Arizona and Colorado before and after entry by cardiac specialty hospitals, we study how incumbent hospitals adjusted their provision of three uncontested services that are widely considered to be unprofitable. We estimate that the hospitals most exposed to entry reduced their provision of psychiatric, substance-abuse, and trauma care services at a rate of about one uncontested-service admission for every four cardiac admissions they stood to lose. Although entry by single-specialty hospitals may adversely affect the provision of unprofitable uncontested services, these findings warrant further evaluation of service-line cross-subsidization as a means to finance them. PMID:25062300

A programmable rules engine to provide clinical decision support using HTML forms.

PubMed Central

Heusinkveld, J.; Geissbuhler, A.; Sheshelidze, D.; Miller, R.

1999-01-01

The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser. Images Figure 1 PMID:10566470

Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a Pediatric Intensive Care Unit.

PubMed

Balasuriya, Lilanthi; Vyles, David; Bakerman, Paul; Holton, Vanessa; Vaidya, Vinay; Garcia-Filion, Pamela; Westdorp, Joan; Sanchez, Christine; Kurz, Rhonda

2017-09-01

An enhanced dose range checking (DRC) system was developed to evaluate prescription error rates in the pediatric intensive care unit and the pediatric cardiovascular intensive care unit. An enhanced DRC system incorporating "soft" and "hard" alerts was designed and implemented. Practitioner responses to alerts for patients admitted to the pediatric intensive care unit and the pediatric cardiovascular intensive care unit were retrospectively reviewed. Alert rates increased from 0.3% to 3.4% after "go-live" (P < 0.001). Before go-live, all alerts were soft alerts. In the period after go-live, 68% of alerts were soft alerts and 32% were hard alerts. Before go-live, providers reduced doses only 1 time for every 10 dose alerts. After implementation of the enhanced computerized physician order entry system, the practitioners responded to soft alerts by reducing doses to more appropriate levels in 24.7% of orders (70/283), compared with 10% (3/30) before go-live (P = 0.0701). The practitioners deleted orders in 9.5% of cases (27/283) after implementation of the enhanced DRC system, as compared with no cancelled orders before go-live (P = 0.0774). Medication orders that triggered a soft alert were submitted unmodified in 65.7% (186/283) as compared with 90% (27/30) of orders before go-live (P = 0.0067). After go-live, 28.7% of hard alerts resulted in a reduced dose, 64% resulted in a cancelled order, and 7.4% were submitted as written. Before go-live, alerts were often clinically irrelevant. After go-live, there was a statistically significant decrease in orders that were submitted unmodified and an increase in the number of orders that were reduced or cancelled.

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two ‘early adopter’ hospitals

PubMed Central

Cresswell, Kathrin M; Bates, David W; Williams, Robin; Morrison, Zoe; Slee, Ann; Coleman, Jamie; Robertson, Ann; Sheikh, Aziz

2014-01-01

Objective To understand the medium-term consequences of implementing commercially procured computerized physician order entry (CPOE) and clinical decision support (CDS) systems in ‘early adopter’ hospitals. Materials and methods In-depth, qualitative case study in two hospitals using a CPOE or a CDS system for at least 2 years. Both hospitals had implemented commercially available systems. Hospital A had implemented a CPOE system (with basic decision support), whereas hospital B invested additional resources in a CDS system that facilitated order entry but which was integrated with electronic health records and offered more advanced CDS. We used a combination of documentary analysis of the implementation plans, audiorecorded semistructured interviews with system users, and observations of strategic meetings and systems usage. Results We collected 11 documents, conducted 43 interviews, and conducted a total of 21.5 h of observations. We identified three major themes: (1) impacts on individual users, including greater legibility of prescriptions, but also some accounts of increased workloads; (2) the introduction of perceived new safety risks related to accessibility and usability of hardware and software, with users expressing concerns that some problems such as duplicate prescribing were more likely to occur; and (3) realizing organizational benefits through secondary uses of data. Conclusions We identified little difference in the medium-term consequences of a CPOE and a CDS system. It is important that future studies investigate the medium- and longer-term consequences of CPOE and CDS systems in a wider range of hospitals. PMID:24431334

Usability of a mobile electronic medical record prototype: a verbal protocol analysis.

PubMed

Wu, Robert C; Orr, M Scott; Chignell, Mark; Straus, Sharon E

2008-06-01

Point of care access to electronic medical records may provide clinicians with the information they want when they need it and may in turn improve patient safety. Yet providing an electronic medical record on handheld devices presents many usability challenges, and it is unclear whether clinicians will use them. An iterative design process for the development and evaluation of a prototype of a mobile electronic medical record was performed. Usability sessions were conducted in which physicians were asked to 'think aloud' while working through clinical scenarios using the prototype. Verbal protocol analysis, which consists of coding utterances, was conducted on the transcripts from the sessions and common themes were extracted. Usability sessions were held with five family physicians and four internists with varying levels of computer expertise. Physicians were able to use the device to complete 52 of 54 required tasks. Users commented that it was intuitive (9/9), would increase accessibility (5/9) but for them to use it, it would need the system to be fast and time-saving (5/9). Users had difficulty entering information (5/9) and reading the screen (4/9). In terms of functionality, users had concerns about completeness of information (6/9), details of ordering (5/9) and desired billing functionality (5/9) and integration with other systems (4/9). While physicians can use mobile electronic medical records in realistic scenarios, certain requirements likely need to be met including a fast system with easy data selection, easy data entry and improved display before widespread adoption occurs.

Classification of medication incidents associated with information technology.

PubMed

Cheung, Ka-Chun; van der Veen, Willem; Bouvy, Marcel L; Wensing, Michel; van den Bemt, Patricia M L A; de Smet, Peter A G M

2014-02-01

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals. The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary. The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process. From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital. A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

SAM: speech-aware applications in medicine to support structured data entry.

PubMed Central

Wormek, A. K.; Ingenerf, J.; Orthner, H. F.

1997-01-01

In the last two years, improvement in speech recognition technology has directed the medical community's interest to porting and using such innovations in clinical systems. The acceptance of speech recognition systems in clinical domains increases with recognition speed, large medical vocabulary, high accuracy, continuous speech recognition, and speaker independence. Although some commercial speech engines approach these requirements, the greatest benefit can be achieved in adapting a speech recognizer to a specific medical application. The goals of our work are first, to develop a speech-aware core component which is able to establish connections to speech recognition engines of different vendors. This is realized in SAM. Second, with applications based on SAM we want to support the physician in his/her routine clinical care activities. Within the STAMP project (STAndardized Multimedia report generator in Pathology), we extend SAM by combining a structured data entry approach with speech recognition technology. Another speech-aware application in the field of Diabetes care is connected to a terminology server. The server delivers a controlled vocabulary which can be used for speech recognition. PMID:9357730

PubMed Central

Labrecque, Michel; Drouin, Jean; Latulippe, Louis

1987-01-01

The physicians on staff at the Family Medicine Unit of the Medical Centre of Laval University evaluated the quality of medical treatment by a method of control involving objective criteria. This study is based on 88 entries in the medical records of patients who were seen for the dispensing of oral contraceptives. The information contained in these entries was compared to criteria published in the 1985 Canadian Report on Oral Contraceptives. On average, each record contained 60%-80% of the criteria, depending on the type of visit. For each criterion analysed separately, the proportion of entries corresponding to the norm varies between 6% and 95%. Overall, the quality of the entries is good. The standard to be attained is correspondence with the recommendations set out in the 1985 PMID:21263877

78 FR 33855 - Merchant Mariner Medical Advisory Committee: Intercessional Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-05

... Medical Evaluation Report and CG-719K/E, Merchant Mariner Evaluation of Fitness for Entry Level Ratings..., Merchant Mariner Evaluation of Fitness for Entry Level Ratings. (4) Closing remarks. Day 2 The agenda for...

Mapping proteins to disease terminologies: from UniProt to MeSH

PubMed Central

Mottaz, Anaïs; Yip, Yum L; Ruch, Patrick; Veuthey, Anne-Lise

2008-01-01

Background Although the UniProt KnowledgeBase is not a medical-oriented database, it contains information on more than 2,000 human proteins involved in pathologies. However, these annotations are not standardized, which impairs the interoperability between biological and clinical resources. In order to make these data easily accessible to clinical researchers, we have developed a procedure to link diseases described in the UniProtKB/Swiss-Prot entries to the MeSH disease terminology. Results We mapped disease names extracted either from the UniProtKB/Swiss-Prot entry comment lines or from the corresponding OMIM entry to the MeSH. Different methods were assessed on a benchmark set of 200 disease names manually mapped to MeSH terms. The performance of the retained procedure in term of precision and recall was 86% and 64% respectively. Using the same procedure, more than 3,000 disease names in Swiss-Prot were mapped to MeSH with comparable efficiency. Conclusions This study is a first attempt to link proteins in UniProtKB to the medical resources. The indexing we provided will help clinicians and researchers navigate from diseases to genes and from genes to diseases in an efficient way. The mapping is available at: . PMID:18460185

Development and Assessment of a Medication Safety Measurement Program in a Long-Term Care Pharmacy.

PubMed

Hertig, John B; Hultgren, Kyle E; Parks, Scott; Rondinelli, Rick

2016-02-01

Medication errors continue to be a major issue in the health care system, including in long-term care facilities. While many hospitals and health systems have developed methods to identify, track, and prevent these errors, long-term care facilities historically have not invested in these error-prevention strategies. The objective of this study was two-fold: 1) to develop a set of medication-safety process measures for dispensing in a long-term care pharmacy, and 2) to analyze the data from those measures to determine the relative safety of the process. The study was conducted at In Touch Pharmaceuticals in Valparaiso, Indiana. To assess the safety of the medication-use system, each step was documented using a comprehensive flowchart (process flow map) tool. Once completed and validated, the flowchart was used to complete a "failure modes and effects analysis" (FMEA) identifying ways a process may fail. Operational gaps found during FMEA were used to identify points of measurement. The research identified a set of eight measures as potential areas of failure; data were then collected on each one of these. More than 133,000 medication doses (opportunities for errors) were included in the study during the research time frame (April 1, 2014, and ended on June 4, 2014). Overall, there was an approximate order-entry error rate of 15.26%, with intravenous errors at 0.37%. A total of 21 errors migrated through the entire medication-use system. These 21 errors in 133,000 opportunities resulted in a final check error rate of 0.015%. A comprehensive medication-safety measurement program was designed and assessed. This study demonstrated the ability to detect medication errors in a long-term pharmacy setting, thereby making process improvements measureable. Future, larger, multi-site studies should be completed to test this measurement program.

77 FR 28647 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing and Immediate...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-15

... calculating the ratio between (i) entered orders, weighted by the distance of the order from the national best... with an ``Order Entry Ratio'' of more than 100. The Order Entry Ratio is calculated, and the Excess Order Fee imposed, on a monthly basis. For each MPID, the Order Entry Ratio is the ratio of (i) the MPID...

Prevalence of genitalia malformation in Iranian children: findings of a nationwide screening survey at school entry.

PubMed

Armanian, Amir-Mohammad; Kelishadi, Roya; Ardalan, Gelayol; Taslimi, Mahnaz; Taheri, Majzoubeh; Motlagh, Mohammad-Esmaeil

2014-01-01

Ambiguous genitalia is a hereditary disorder that usually requires early attention and detection. The discovery of ambiguous genitalia in a neonate is situation that could be difficult to manage, not only because of complications such as salt-losing, but also due to the importance of sex determination before psychological gender could be established. Awareness of the prevalence of ambiguous genitalia can affect the attitude and consideration of physicians and related medical personnel about disease in different communities. So in this study, the prevalence of ambiguous genitalia and undescended testes (UDT) in Iran was reported. This national study was conducted in 2009-2010 as part of the routine screening examinations at school entry in Iran. The physical examinations were performed for students at entry to three school levels by physicians and medical personnel. Execution and conduction of this program was the duty of the University of Medical Sciences in each province. On average, the prevalence of ambiguous genitalia was 0.04% at national level (0.03%, 0.05%, and 0.03% at 6, 12, and 15 year olds, respectively). The prevalence of ambiguous genitalia was not significantly different according to age group and living area. The average of UDT) prevalence in the whole country was 0.13%. The prevalence of UDT was higher at elementary school level than in the other two levels. Although the prevalence of genitalia abnormalities was not high in the school students in Iran, given the importance of the issue and in order to find the ambiguous genitalia or UDT, medical examinations and parental notification should be taken seriously at an earlier age.

Entry-level dietitians' salaries and benefits: comparisons with those of other selected health care professionals.

PubMed

Loushine, S K; Vaden, A G

1985-10-01

Data on salaries and fringe benefits of entry-level hospital dietitians were provided by surveys sent to personnel administrators in seven Midwestern states. In September 1982, the annual mean salary offered to dietitians awaiting registration was +16,472, whereas that for entry-level registered dietitians (R.D.s) was +17,250. In the smallest hospitals, annual mean salaries for R.D.s were lowest; non-metropolitan salaries were 2.8% lower than the metropolitan salaries. The salaries of entry-level R.D.s increased 54% from 1977 to 1982, while the Consumer Price Index (CPl), North Central, increased 59.7%. Salaries for selected entry-level health professionals ranked in decreasing order as follows: pharmacist, physical therapist, occupational therapist, social worker, staff nurse, dietitian, medical technologist, and respiratory therapist. Nationally, the entry-level dietitian's mean annual salary was +630 higher than that of the Midwestern dietitian. The increase in the national CPl from 1977 to 1982 was 57%, while the increase in the dietitian's salary was 48%. Leave time generally included 12 sick days, 2 weeks' vacation, 6 holidays, and 3 personal days per year. Employers contribute various amounts to life, health, and dental insurance costs. Discounts often were permitted on various hospital services. More than 80% of the hospitals surveyed provided some reimbursement for continuing education, and 74% permitted educational leaves of absence.

Comparison of indexing times among articles from medical, nursing, and pharmacy journals.

PubMed

Rodriguez, Ryan W

2016-04-15

Results of an analysis of the times to indexing of articles published in medical, nursing, and pharmacy journals are reported. MEDLINE data were retrieved for articles published in selected general practice medical, nursing, and pharmacy journals and entered into the PubMed system in 2012 and 2013. Collected data included PubMed entry date, date of indexing with Medical Subject Headings (MeSH) terms, and publication characteristics. Survival analysis was performed to assess the primary outcome of time to indexing. Cox proportional hazards models were developed to assess the effect of healthcare discipline and source journal on the primary outcome. Data were collected for 19,259 articles, of which 78.7%, 12.6%, and 8.7% originated from medical, nursing, and pharmacy journals, respectively. For medical, pharmacy, and nursing journals, 97.8%, 90.8%, and 50.1% of articles, respectively, were indexed within one year of PubMed entry; the corresponding median (interquartile range) times to indexing were 52 (20-68), 186 (150-246), and 252 (168-301) days. Unadjusted hazard ratios derived from Cox models indicated that indexing within one year was significantly less likely for articles published in pharmacy or nursing journals versus medical journals and for articles from all evaluated journals versus a designated reference publication (New England Journal of Medicine). Analysis of major medical, nursing, and pharmacy journals found that articles from nursing and pharmacy journals were indexed with MeSH terms more slowly than articles from medical journals. Journal identity was significantly associated with time to indexing. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Mission Sizing and Trade Studies for Low Ballistic Coefficient Entry Systems to Venus

NASA Technical Reports Server (NTRS)

Dutta, Soumyo; Smith, Brandon; Prabhu, Dinesh; Venkatapathy, Ethiraj

2012-01-01

The U.S and the U.S.S.R. have sent seventeen successful atmospheric entry missions to Venus. Past missions to Venus have utilized rigid aeroshell systems for entry. This rigid aeroshell paradigm sets performance limitations since the size of the entry vehicle is constrained by the fairing diameter of the launch vehicle. This has limited ballistic coefficients (beta) to well above 100 kg/m2 for the entry vehicles. In order to maximize the science payload and minimize the Thermal Protection System (TPS) mass, these missions have entered at very steep entry flight path angles (gamma). Due to Venus thick atmosphere and the steep-gamma, high- conditions, these entry vehicles have been exposed to very high heat flux, very high pressures and extreme decelerations (upwards of 100 g's). Deployable aeroshells avoid the launch vehicle fairing diameter constraint by expanding to a larger diameter after the launch. Due to the potentially larger wetted area, deployable aeroshells achieve lower ballistic coefficients (well below 100 kg/m2), and if they are flown at shallower flight path angles, the entry vehicle can access trajectories with far lower decelerations (50-60 g's), peak heat fluxes (400 W/cm2) and peak pressures. The structural and TPS mass of the shallow-gamma, low-beta deployables are lower than their steep-gamma, high-beta rigid aeroshell counterparts at larger diameters, contributing to lower areal densities and potentially higher payload mass fractions. For example, at large diameters, deployables may attain aeroshell areal densities of 10 kg/m2 as opposed to 50 kg/m2 for rigid aeroshells. However, the low-beta, shallow-gamma paradigm also raises issues, such as the possibility of skip-out during entry. The shallow-gamma could also increase the landing footprint of the vehicle. Furthermore, the deployable entry systems may be flexible, so there could be fluid-structure interaction, especially in the high altitude, low-density regimes. The need for precision in guidance, navigation and control during entry also has to be better understood. This paper investigates some of the challenges facing the design of a shallow-gamma, low-beta entry system.

Crossing the quality chasm: the role of information technology departments.

PubMed

Weir, Charlene R; Hicken, Bret L; Rappaport, Hank Steven; Nebeker, Jonathan R

2006-01-01

Integrating information technology (IT) into medical settings is considered essential to transforming hospitals into 21st-century health care institutions. Yet the role of IT departments in maximizing the effectiveness of information systems is not well understood. This article reports a 3-round Delphi panel of Veterans Administration personnel experienced with provider order entry electronic systems. In round 1, 35 administrative, clinical, and IT personnel answered 10 open-ended questions about IT strategies and structures that best support successful transformation. In round 2, panelists rated item importance and ranked proposed strategies. In round 3, panelists received aggregate feedback and rerated the items. Four domains emerged from round 1: IT organization, IT performance monitoring, user-support activities, and core IT responsibilities (eg, computer security, training). In rounds 2 and 3, IT performance monitoring was rated the most important, closely followed by clinical support. Strategies associated with each domain are identified and discussed.

EntrySat: A 3U CubeStat to study the reentry atmospheric environment

NASA Astrophysics Data System (ADS)

Anthony, Sournac; Raphael, Garcia; David, Mimoun; Jeremie, Chaix

2016-04-01

ISAE France Entrysat has for main scientific objective the study of uncontrolled atmospheric re-entry. This project, is developed by ISAE in collaboration with ONERA and University of Toulouse, is funded by CNES, in the overall frame of the QB50 project. This nano-satellite is a 3U Cubesat measuring 34*10*10 cm3, similar to secondary debris produced during the break up of a spacecraft. EntrySat will collect the external and internal temperatures, pressure, heat flux, attitude variations and drag force of the satellite between ≈150 and 90 km before its destruction in the atmosphere, and transmit them during the re-entry using the IRIDIUM satellite network. The result will be compared with the computations of MUSIC/FAST, a new 6-degree of freedom code developed by ONERA to predict the trajectory of space debris. In order to fulfil the scientific objectives, the satellite will acquire 18 re-entry sensors signals, convert them and compress them, thanks to an electronic board developed by ISAE students in cooperation with EREMS. In order to transmit these data every second during the re-entry phase, the satellite will use an IRIDIUM connection. In order to keep a stable enough attitudes during this phase, a simple attitude orbit and control system using magnetotorquers and an inertial measurement unit (IMU) is developed at ISAE by students. A commercial GPS board is also integrated in the satellite into Entry Sat to determine its position and velocity which are necessary during the re-entry phase. This GPS will also be used to synchronize the on-board clock with the real-time UTC data. During the orbital phase (≈2 year) EntrySat measurements will be recorded transmitted through a more classical "UHF/VHF" connection. Preference for presentation: Poster Most suitable session: Author for correspondence: Dr Raphael F. Garcia ISAE 10, ave E. Belin, 31400 Toulouse, France Raphael.GARCIA@isae.fr +33 5 61 33 81 14

75 FR 41886 - Public Land Order No. 7744; Withdrawal of National Forest System Land for Inyan Kara Area; WY

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-19

... National Forest System land other than the mining laws (30 U.S.C. Ch. 2). 3. This withdrawal will expire 20... Order No. 7744; Withdrawal of National Forest System Land for Inyan Kara Area; WY AGENCY: Bureau of Land... Forest System land from location and entry under the United States mining laws for a period of 20 years...

Childhood cancer survivors' school (re)entry: Australian parents' perceptions.

PubMed

McLoone, J K; Wakefield, C E; Cohn, R J

2013-07-01

Starting or returning to school after intense medical treatment can be academically and socially challenging for childhood cancer survivors. This study aimed to evaluate the school (re)entry experience of children who had recently completed cancer treatment. Forty-two semi-structured telephone interviews were conducted to explore parents' perceptions of their child's (re)entry to school after completing treatment (23 mothers, 19 fathers, parent mean age 39.5 years; child mean age 7.76 years). Interviews were analysed using the framework of Miles and Huberman and emergent themes were organised using QSR NVivo8. Parents closely monitored their child's school (re)entry and fostered close relationships with their child's teacher to ensure swift communication of concerns should they arise. The most commonly reported difficulty related to aspects of peer socialisation; survivors either displayed a limited understanding of social rules such as turn taking, or related more to older children or teachers relative to their peers. Additionally, parents placed a strong emphasis on their child's overall personal development, above academic achievement alone. Improved parent, clinician and teacher awareness of the importance of continued peer socialisation during the treatment period is recommended in order to limit the ongoing ramifications this may have on school (re)entry post-treatment completion. © 2013 John Wiley & Sons Ltd.

A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities

PubMed Central

Rose, Roderick A.; Lanier, Paul

2017-01-01

The child welfare system is an access point for children’s mental health services. Psychiatric residential treatment facilities (PRTFs) are the most restrictive, and most expensive setting for children to receive long-term care. Given the high rates of behavioral health concerns among maltreated children in out-of-home care, research is needed to examine the factors that predict entry in PRTFs among children investigated for maltreatment. This exploratory study used cross-sector administrative records linked across multiple systems, including child welfare records and Medicaid claims, from a single state over a five-year period (n = 105,982). Cox proportional hazards modeling was used to predict entry into a PRTF. After controlling for many factors, PRTF entry was predicted by diagnosis code indicating a trauma-related condition, antipsychotic medication prescriptions, and entry into lower levels of out-of-home care, supporting the view that youth are admitted to PRTFs largely due to clinical need. However, PRTF admission is also associated with characteristics of their experiences with the social service system, primarily foster care placement stability and permanency. Implications for practice and research are discussed. PMID:28956825

[The electronic health record: computerised provider order entry and the electronic instruction document as new functionalities].

PubMed

Derikx, Joep P M; Erdkamp, Frans L G; Hoofwijk, A G M

2013-01-01

An electronic health record (EHR) should provide 4 key functionalities: (a) documenting patient data; (b) facilitating computerised provider order entry; (c) displaying the results of diagnostic research; and (d) providing support for healthcare providers in the clinical decision-making process.- Computerised provider order entry into the EHR enables the electronic receipt and transfer of orders to ancillary departments, which can take the place of handwritten orders.- By classifying the computer provider order entries according to disorders, digital care pathways can be created. Such care pathways could result in faster and improved diagnostics.- Communicating by means of an electronic instruction document that is linked to a computerised provider order entry facilitates the provision of healthcare in a safer, more efficient and auditable manner.- The implementation of a full-scale EHR has been delayed as a result of economic, technical and legal barriers, as well as some resistance by physicians.

75 FR 72855 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing and Immediate...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-26

... . NASDAQ has safeguards in place to protect the market from inadvertent entry of large orders. Each member that requests connectivity through an order entry port is required to specify the maximum order size... and procedures in place to ensure the proper entry and monitoring of orders entered into NASDAQ...

Building an automated problem list based on natural language processing: lessons learned in the early phase of development.

PubMed

Solti, Imre; Aaronson, Barry; Fletcher, Grant; Solti, Magdolna; Gennari, John H; Cooper, Melissa; Payne, Tom

2008-11-06

Detailed problem lists that comply with JCAHO requirements are important components of electronic health records. Besides improving continuity of care electronic problem lists could serve as foundation infrastructure for clinical trial recruitment, research, biosurveillance and billing informatics modules. However, physicians rarely maintain problem lists. Our team is building a system using MetaMap and UMLS to automatically populate the problem list. We report our early results evaluating the application. Three physicians generated gold standard problem lists for 100 cardiology ambulatory progress notes. Our application had 88% sensitivity and 66% precision using a non-modified UMLS dataset. The systemâs misses concentrated in the group of ambiguous problem list entries (Chi-square=27.12 p<0.0001). In addition to the explicit entries, the notes included 10% implicit entry candidates. MetaMap and UMLS are readily applicable to automate the problem list. Ambiguity in medical documents has consequences for performance evaluation of automated systems.

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

PubMed

Bubalo, Joseph; Warden, Bruce A; Wiegel, Joshua J; Nishida, Tess; Handel, Evelyn; Svoboda, Leanne M; Nguyen, Lam; Edillo, P Neil

2014-12-01

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors. This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care. The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the antineoplastic population, benefit from many other technologies may have to be inferred based on data from other patient populations. As health systems begin to widely adopt and implement new technologies it is important to critically assess their effectiveness in improving patient safety. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

International Organization for Migration: experience on the need for medical evacuation of refugees during the Kosovo crisis in 1999.

PubMed

Szilard, Istvan; Cserti, Arpad; Hoxha, Ruhija; Gorbacheva, Olga; O'Rourke, Thomas

2002-04-01

The International Organization for Migration (IOM) developed and implemented a three-month project entitled Priority Medical Screening of Kosovar Refugees in Macedonia, within the Humanitarian Evacuation Program (HEP) for Kosovar refugees from FR Yugoslavia, which was adopted in May 1999. The project was based on an agreement with the office of United Nations High Commission for Refugees (UNHCR) and comprised the entry of registration data of refugees with medical condition (Priority Medical Database), and classification (Priority Medical Screening) and medical evacuation of refugees (Priority Medical Evacuation) in Macedonia. To realize the Priority Medical Screening project plan, IOM developed and set up a Medical Database linked to IOM/UNHCR HEP database, recruited and trained a four-member data entry team, worked out and set up a referral system for medical cases from the refugee camps, and established and staffed medical contact office for refugees in Skopje and Tetovo. Furthermore, it organized and staffed a mobile medical screening team, developed and implemented the system and criteria for the classification of referred medical cases, continuously registered and classified the incoming medical reports, contacted regularly the national delegates and referred to them the medically prioritized cases asking for acceptance and evacuation, and co-operated and continuously exchanged the information with UNHCR Medical Co-ordination and HEP team. Within the timeframe of the project, 1,032 medical cases were successfully evacuated for medical treatment to 25 host countries throughout the world. IOM found that those refugees suffering from health problems, who at the time of the termination of the program were still in Macedonia and had not been assisted by the project, were not likely to have been priority one cases, whose health problems could be solved only in a third country. The majority of these vulnerable people needed social rather than medical care and assistance a challenge that international aid agencies needed to address in Macedonia and will need to address elsewhere.

78 FR 3928 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Order Disapproving Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-17

... system protocol, to the NASDAQ matching engine or to the NASDAQ router as needed to complete the... Order application to the order entry gateway of NASDAQ's matching engine, but the amount of time gained... proposal represents another example of the blurring borders between exchanges and broker-dealers, and...

A parenteral nutrition use survey with gap analysis.

PubMed

Boullata, Joseph I; Guenter, Peggi; Mirtallo, Jay M

2013-03-01

Parenteral nutrition (PN) is a high-alert medication for which safe practice guidelines are available. Recent adverse events associated with PN have been widely reported. A survey of current practices was indicated as new guidelines are being considered. A web-based survey consisting of 70 items was made available for the month of August 2011. Respondents provided answers to questions that addressed all aspects of the PN use process. There were a total of 895 respondents to the survey, including dietitians, nurses, pharmacists, and physicians. They predominantly represented hospital settings (89%), with 44% from academic institutions. Most organizations use a once-daily PN admixture with 21% outsourcing preparation. Electronic PN order entry is available in one-third of organizations, and the use of standardized order sets prevails. Unfortunately, electronic interfaces between computer systems remain infrequent, meaning that at least one transcription step is required by most in the PN use process. There are a wide variety of methods for ordering PN components, many of which are inconsistent with safe practices. Most organizations dedicate a pharmacist to review the PN orders, many of which require clarifications. Documentation at each step of the PN use process with oversight to identify deviations from best practice recommendations is infrequent. A significant proportion (44%) does not track PN-related medication errors. The survey data are a valuable snapshot of current practices with PN. Poor compliance with some of the safe practice guidelines continues. This will help guide new safety initiatives for the PN use process.

HL7 Structured Product Labeling - electronic prescribing information for provider order entry decision support.

PubMed

Schadow, Gunther

2005-01-01

Prescribing errors are an important cause of adverse events, and lack of knowledge of the drug is a root cause for prescribing errors. The FDA is issuing new regulations that will make the drug labels much more useful not only to physicians, but also to computerized order entry systems that support physicians to practice safe prescribing. For this purpose, FDA works with HL7 to create the Structured Product Label (SPL) standard that includes a document format as well as a drug knowledge representation, this poster introduces the basic concepts of SPL.

Micromechanical Characterization and Testing of Carbon Based Woven Thermal Protection Materials

NASA Technical Reports Server (NTRS)

Agrawal, Parul; Pham, John T.; Arnold, James O.; Peterson, Keith; Venkatapathy, Ethiraj

2013-01-01

Woven thermal protection system (TPS) materials are one of the enabling technologies for mechanically deployable hypersonic decelerator systems. These materials can be simultaneously used for thermal protection and as structural load bearing members during the entry, descent and landing operations. In order to ensure successful thermal and structural performance during the atmospheric entry, it is important to characterize the properties of these materials, once they have been subjected to entry like conditions. The present paper focuses on mechanical characteristics of pre-and post arc-jet tested woven TPS samples at different scales. It also presents the observations from scanning electron microscope and computed tomography images, and explains the changes in microstructure after being subjected to combined thermal-mechanical loading environments.

A Comparison of Two Skip Entry Guidance Algorithms

NASA Technical Reports Server (NTRS)

Rea, Jeremy R.; Putnam, Zachary R.

2007-01-01

The Orion capsule vehicle will have a Lift-to-Drag ratio (L/D) of 0.3-0.35. For an Apollo-like direct entry into the Earth's atmosphere from a lunar return trajectory, this L/D will give the vehicle a maximum range of about 2500 nm and a maximum crossrange of 216 nm. In order to y longer ranges, the vehicle lift must be used to loft the trajectory such that the aerodynamic forces are decreased. A Skip-Trajectory results if the vehicle leaves the sensible atmosphere and a second entry occurs downrange of the atmospheric exit point. The Orion capsule is required to have landing site access (either on land or in water) inside the Continental United States (CONUS) for lunar returns anytime during the lunar month. This requirement means the vehicle must be capable of flying ranges of at least 5500 nm. For the L/D of the vehicle, this is only possible with the use of a guided Skip-Trajectory. A skip entry guidance algorithm is necessary to achieve this requirement. Two skip entry guidance algorithms have been developed: the Numerical Skip Entry Guidance (NSEG) algorithm was developed at NASA/JSC and PredGuid was developed at Draper Laboratory. A comparison of these two algorithms will be presented in this paper. Each algorithm has been implemented in a high-fidelity, 6 degree-of-freedom simulation called the Advanced NASA Technology Architecture for Exploration Studies (ANTARES). NASA and Draper engineers have completed several monte carlo analyses in order to compare the performance of each algorithm in various stress states. Each algorithm has been tested for entry-to-target ranges to include direct entries and skip entries of varying length. Dispersions have been included on the initial entry interface state, vehicle mass properties, vehicle aerodynamics, atmosphere, and Reaction Control System (RCS). Performance criteria include miss distance to the target, RCS fuel usage, maximum g-loads and heat rates for the first and second entry, total heat load, and control system saturation. The comparison of the performance criteria has led to a down select and guidance merger that will take the best ideas from each algorithm to create one skip entry guidance algorithm for the Orion vehicle.

Entry to medical schools with 'A' level in mathematics rather than biology.

PubMed

Spurgin, C B

1975-09-01

The majority of British medical schools now accept for their shortest courses students who have mathematics at A level in place of the former requirement of biology A level. Only a small fraction of the entry, less than one-fifth, enters this way, in spite of statements by most medical schools that they make no distinction between those with mathematics and those with biology when making conditional offers of places. There is no evidence that those without biology are at a disadvantage in the courses. If the prospects of entry without A level biology were better publicized medical schools would have a wider field of possibly abler entrants, and pupils entering sixth forms could defer for a year a choice between a medical (or dental) career and one involving physical science, engineering, or other mathematics-based university education.

Experience with DICOM for the clinical specialties in the healthcare enterprise

NASA Astrophysics Data System (ADS)

Kuzmak, Peter M.; Dayhoff, Ruth E.

2003-05-01

DICOM is a success for radiology and cardiology and it is now beginning to be used for other clinical specialties. The US Department of Veterans Affairs has been instrumental in promoting this technological advancement. We have worked with a number of non-radiology imaging vendors over the past several years, encouraging them to support DICOM, providing requirement specifications, validating their implementations, installing their products, and integrating their systems with the VA healthcare enterprise. We require each new non-radiology vendor to support the DICOM Modality Worklist and Storage services, as specified in the IHE Technical Framework, and insist that they perform validation testing with us over the Internet before installing at a VA site. Three years ago we began working with commercial DICOM image acquisition applications in ophthalmology and endoscopy. Today we are interfacing with six vendors in ophthalmology, six in dental, and two in endoscopy. Getting imaging modality vendors to support DICOM is only part of the story, however. We have also developed the capabilities of the VistA hospital information system to properly handle DICOM interfaces to the different clinical specialties. The workflow in the clinical specialties is different than that of radiology, and is much more diverse. We designed the VistA DICOM image acquisition and display interface to use the generic order entry, result entry, result reporting, and appointment scheduling applications of our hospital information system, which are common to other hospital information systems, in order to maintain existing clinical workflow, minimize operational disruptions, simplify training, and win user acceptance. This software is now being field tested with dental and ophthalmology systems at a large number of VA medical centers. We have learned several things from this field test. The DICOM Modality Worklist and Storage services can be successfully used for image acquisition in the clinical specialties, although the specifications for some of the clinical specialty image types need to be enhanced. Special consideration needs to be given to the healthcare provider workflow in order to support DICOM requirements and to minimize change. The clinical specialties handle a large number of different kinds of requests, and imaging procedures may comprise only a small subset, which may need to be isolated out for efficient operation of DICOM Modality Worklist. The clinical specialties will acquire a large volume of images. Our goal is to incorporate all of the patient"s data into the electronic medical record and DICOM is making this easier for everyone. The work involved in extending DICOM to the clinical specialties and integrating them with the hospital information systems continues to be an ongoing and worthwhile challenge.

Which students will choose a career in psychiatry?

PubMed

Gowans, Margot C; Wright, Bruce J; Brenneis, Fraser R; Scott, Ian M

2011-10-01

In Canada, availability of and access to mental health professionals is limited. Only 6.6% of practising physicians are psychiatrists, a situation unlikely to improve in the foreseeable future. Identifying student characteristics present at medical school entry that predict a subsequent psychiatry residency choice could allow targeted recruiting or support to students early on in their careers, in turn creating a supply of psychiatry-oriented residency applicants. Between 2002 and 2004, data were collected from students in 15 Canadian medical school classes within 2 weeks of commencement of their medical studies. Surveys included questions on career preferences, attitudes, and demographics. Students were followed through to graduation and entry data linked anonymously with residency choice data. Logistic regression was used to identify early predictors of a psychiatry residency choice. Students (n = 1502) (77.4% of those eligible) contributed to the final analysis, with 5.3% naming psychiatry as their preferred residency career. When stated career interest in psychiatry at medical school entry was not included in a regression model, an exit career choice in psychiatry was predicted by a student's desire for prestige, lesser interest in medical compared with social problems, low hospital orientation, and not volunteering in sports. When an entry career interest in psychiatry was included in the model, this variable became the only predictor of an exit career choice in psychiatry. While experience and attitudes at medical school entry can predict whether students will chose a psychiatry career, the strongest predictor is an early career interest in psychiatry.

Data Entry Skills in a Computer-based Spread Sheet Amongst Postgraduate Medical Students: A Simulation Based Descriptive Assessment.

PubMed

Khan, Amir Maroof; Shah, Dheeraj; Chatterjee, Pranab

2014-07-01

In India, research work in the form of a thesis is a mandatory requirement for the postgraduate (PG) medical students. Data entry in a computer-based spread sheet is one of the important basic skills for research, which has not yet been studied. This study was conducted to assess the data entry skills of the 2(nd) year PG medical students of a medical college of North India. A cross-sectional, descriptive study was conducted among 111 second year PG students by using four simulated filled case record forms and a computer-based spread sheet in which data entry was to be carried out. On a scale of 0-10, only 17.1% of the students scored more than seven. The specific sub-skills that were found to be lacking in more than half of the respondents were as follows: Inappropriate coding (93.7%), long variable names (51.4%), coding not being done for all the variables (76.6%), missing values entered in a non-uniform manner (84.7%) and two variables entered in the same column in the case of blood pressure reading (80.2%). PG medical students were not found to be proficient in data entry skill and this can act as a barrier to do research. This being a first of its kind study in India, more research is needed to understand this issue and then include this yet neglected aspect in teaching research methodology to the medical students.

SHEFEX - the vehicle and sub-systems for a hypersonic re-entry flight experiment

NASA Astrophysics Data System (ADS)

Turner, John; Hörschgen, Marcus; Turner, Peter; Ettl, Josef; Jung, Wolfgang; Stamminger, Andreas

2005-08-01

The purpose of the Sharp Edge Flight Experiment (SHEFEX) is to investigate the aerodynamic behaviour and thermal problems of an unconventional shape for re-entry vehicles, comprising multi-facetted surfaces with sharp edges. The main object of this experiment is the correlation of numerical analysis with real flight data in terms of the aerodynamic effects and structural concept for the thermal protection system (TPS). The Mobile Rocket Base of the German Aerospace Center (DLR) is responsible for the test flight of SHEFEX on a two stage unguided solid propellant sounding rocket which is required to provide a velocity of the order of March 7 for more than 30 seconds during atmospheric re-entry. This paper discusses the problems associated with the mission requirements and the solutions developed for the vehicle and sub-systems.

Competencies of Career-Entry Medical Technology Graduates of Lyceum of Batangas: Basis for Enhancement of the Internship Training Program

ERIC Educational Resources Information Center

Valdez, Anacleta P.

2010-01-01

The role of medical technologists in the years due to changes in the laboratory environment. curriculum is needed to prepare graduates for changes in laboratory medicine. It is the ultimate goal of the College to prepare students for career entry positions as medical technology professionals. The curriculum should be designed to prepare the…

Can social semantic web techniques foster collaborative curriculum mapping in medicine?

PubMed

Spreckelsen, Cord; Finsterer, Sonja; Cremer, Jan; Schenkat, Hennig

2013-08-15

Curriculum mapping, which is aimed at the systematic realignment of the planned, taught, and learned curriculum, is considered a challenging and ongoing effort in medical education. Second-generation curriculum managing systems foster knowledge management processes including curriculum mapping in order to give comprehensive support to learners, teachers, and administrators. The large quantity of custom-built software in this field indicates a shortcoming of available IT tools and standards. The project reported here aims at the systematic adoption of techniques and standards of the Social Semantic Web to implement collaborative curriculum mapping for a complete medical model curriculum. A semantic MediaWiki (SMW)-based Web application has been introduced as a platform for the elicitation and revision process of the Aachen Catalogue of Learning Objectives (ACLO). The semantic wiki uses a domain model of the curricular context and offers structured (form-based) data entry, multiple views, structured querying, semantic indexing, and commenting for learning objectives ("LOs"). Semantic indexing of learning objectives relies on both a controlled vocabulary of international medical classifications (ICD, MeSH) and a folksonomy maintained by the users. An additional module supporting the global checking of consistency complements the semantic wiki. Statements of the Object Constraint Language define the consistency criteria. We evaluated the application by a scenario-based formative usability study, where the participants solved tasks in the (fictional) context of 7 typical situations and answered a questionnaire containing Likert-scaled items and free-text questions. At present, ACLO contains roughly 5350 operational (ie, specific and measurable) objectives acquired during the last 25 months. The wiki-based user interface uses 13 online forms for data entry and 4 online forms for flexible searches of LOs, and all the forms are accessible by standard Web browsers. The formative usability study yielded positive results (median rating of 2 ("good") in all 7 general usability items) and produced valuable qualitative feedback, especially concerning navigation and comprehensibility. Although not asked to, the participants (n=5) detected critical aspects of the curriculum (similar learning objectives addressed repeatedly and missing objectives), thus proving the system's ability to support curriculum revision. The SMW-based approach enabled an agile implementation of computer-supported knowledge management. The approach, based on standard Social Semantic Web formats and technology, represents a feasible and effectively applicable compromise between answering to the individual requirements of curriculum management at a particular medical school and using proprietary systems.

Orion Entry Monitor

NASA Technical Reports Server (NTRS)

Smith, Kelly M.

2016-01-01

NASA is scheduled to launch the Orion spacecraft atop the Space Launch System on Exploration Mission 1 in late 2018. When Orion returns from its lunar sortie, it will encounter Earth's atmosphere with speeds in excess of 11 kilometers per second, and Orion will attempt its first precision-guided skip entry. A suite of flight software algorithms collectively called the Entry Monitor has been developed in order to enhance crew situational awareness and enable high levels of onboard autonomy. The Entry Monitor determines the vehicle capability footprint in real-time, provides manual piloting cues, evaluates landing target feasibility, predicts the ballistic instantaneous impact point, and provides intelligent recommendations for alternative landing sites if the primary landing site is not achievable. The primary engineering challenges of the Entry Monitor is in the algorithmic implementation in making a highly reliable, efficient set of algorithms suitable for onboard applications.

17 CFR 10.7 - Date of entry of orders.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 17 Commodity and Securities Exchanges 1 2010-04-01 2010-04-01 false Date of entry of orders. 10.7 Section 10.7 Commodity and Securities Exchanges COMMODITY FUTURES TRADING COMMISSION RULES OF PRACTICE General Provisions § 10.7 Date of entry of orders. In computing any period of time involving the date of...

Venus In Situ Explorer Mission design using a mechanically deployed aerodynamic decelerator

NASA Astrophysics Data System (ADS)

Smith, B.; Venkatapathy, E.; Wercinski, P.; Yount, B.; Prabhu, D.; Gage, P.; Glaze, L.; Baker, C.

The Venus In Situ Explorer (VISE) Mission addresses the highest priority science questions within the Venus community outlined in the National Research Council's Decadal Survey. The heritage Venus atmospheric entry system architecture, a 45° sphere-cone rigid aeroshell with a carbon phenolic thermal protection system, may no longer be the preferred entry system architecture compared to other viable alternatives being explored at NASA. A mechanically-deployed aerodynamic decelerator, known as the Adaptive Deployable Entry and Placement Technology (ADEPT), is an entry system alternative that can provide key operational benefits and risk reduction compared to a rigid aeroshell. This paper describes a mission feasibility study performed with the objectives of identifying potential adverse interactions with other mission elements and establishing requirements on decelerator performance. Feasibility is assessed through a launch-to-landing mission design study where the Venus Intrepid Tessera Lander (VITaL), a VISE science payload designed to inform the Decadal Survey results, is repackaged from a rigid aeroshell into the ADEPT decelerator. It is shown that ADEPT reduces the deceleration load on VITaL by an order of magnitude relative to a rigid aeroshell. The more benign entry environment opens up the VISE mission design environment for increased science return, reduced risk, and reduced cost. The ADEPT-VITAL mission concept of operations is presented and details of the entry vehicle structures and mechanisms are given. Finally, entry aerothermal analysis is presented that defines the operational requirements for a revolutionary structural-TPS material employed by ADEPT: three-dimensionally woven carbon cloth. Ongoing work to mitigate key risks identified in this feasibility study is presented.

Safe use of electronic health records and health information technology systems: trust but verify.

PubMed

Denham, Charles R; Classen, David C; Swenson, Stephen J; Henderson, Michael J; Zeltner, Thomas; Bates, David W

2013-12-01

We will provide a context to health information technology systems (HIT) safety hazards discussions, describe how electronic health record-computer prescriber order entry (EHR-CPOE) simulation has already identified unrecognized hazards in HIT on a national scale, helping make EHR-CPOE systems safer, and we make the case for all stakeholders to leverage proven methods and teams in HIT performance verification. A national poll of safety, quality improvement, and health-care administrative leaders identified health information technology safety as the hazard of greatest concern for 2013. Quality, HIT, and safety leaders are very concerned about technology performance risks as addressed in the Health Information Technology and Patient Safety report of the Institute of Medicine; and these are being addressed by the Office of the National Coordinator of HIT of the U.S. Dept. of Human Services in their proposed plans. We describe the evolution of postdeployment testing of HIT performance, including the results of national deployment of Texas Medical Institute of Technology's electronic health record computer prescriber order entry (TMIT EHR-CPOE) Flight Simulator verification test that is addressed in these 2 reports, and the safety hazards of concern to leaders. A global webinar for health-care leaders addressed the top patient safety hazards in the areas of leadership, practices, and technologies. A poll of 76 of the 221 organizations participating in the webinar revealed that HIT hazards were the participants' greatest concern of all 30 hazards presented. Of those polled, 89% rated HIT patient/data mismatches in EHRs and HIT systems as a 9 or 10 on a scale of 1 to 10 as a hazard of great concern. Review of a key study of postdeployment testing of the safety performance of operational EHR systems with CPOE implemented in 62 hospitals, using the TMIT EHR-CPOE simulation tool, showed that only 53% of the medication orders that could have resulted in fatalities were detected. The study also showed significant variability in the performance of specific EHR vendor systems, with the same vendor product scoring as high as a 75% detection score in one health-care organization, and the same vendor system scoring below 10% in another health-care organization. HIT safety hazards should be taken very seriously, and the need for proven, robust, and regular postdeployment performance verification measurement of EHR system operations in every health-care organization is critical to ensure that these systems are safe for every patient. The TMIT EHR-CPOE flight simulator is a well-tested and scalable tool that can be used to identify performance gaps in EHR and other HIT systems. It is critical that suppliers, providers, and purchasers of health-care partner with HIT stakeholders and leverage the existing body of work, as well as expert teams and collaborative networks to make care safer; and public-private partnerships to accelerate safety in HIT. A global collaborative is already underway incorporating a "trust but verify" philosophy.

Information technologies in education of medical students at the university of sarajevo.

PubMed

Masic, Izet; Karcic, Emina; Hodzic, Ajla; Mulic, Smaila

2014-08-01

Information and communication technology have brought about many changes in medical education and practice, especially in the field of diagnostics. During the academic year 2013/2014, at Faculty of Medicine, University of Sarajevo, students in the final year of the study were subjected to examination which aim was to determine how medical students in Bosnia and Herzegovina subjectively assessing their skills for using computers, have gained insight into the nature of Information Technology's (IT) education and possessive knowledge. The survey was conducted voluntary by anonymous questionnaire consisting of 27 questions, divided into five categories, which are collecting facts about student's: sex, age, year of entry, computer skills, possessing the same, the use of the Internet, the method of obtaining currently knowledge and recommendations of students in order to improve their IT training. According to the given parameters, indicate an obvious difference in the level of knowledge, use and practical application of Information Technology's knowledge among students of the Bologna process to the students educated under the old system in favor of the first ones. Based on a comparison of similar studies conducted in Croatia, Sri Lanka, Pakistan and Denmark, it was observed that the level of knowledge of students of the Medical Faculty in Sarajevo was of equal height or greater than in these countries.

Discovering disease associations by integrating electronic clinical data and medical literature.

PubMed

Holmes, Antony B; Hawson, Alexander; Liu, Feng; Friedman, Carol; Khiabanian, Hossein; Rabadan, Raul

2011-01-01

Electronic health record (EHR) systems offer an exceptional opportunity for studying many diseases and their associated medical conditions within a population. The increasing number of clinical record entries that have become available electronically provides access to rich, large sets of patients' longitudinal medical information. By integrating and comparing relations found in the EHRs with those already reported in the literature, we are able to verify existing and to identify rare or novel associations. Of particular interest is the identification of rare disease co-morbidities, where the small numbers of diagnosed patients make robust statistical analysis difficult. Here, we introduce ADAMS, an Application for Discovering Disease Associations using Multiple Sources, which contains various statistical and language processing operations. We apply ADAMS to the New York-Presbyterian Hospital's EHR to combine the information from the relational diagnosis tables and textual discharge summaries with those from PubMed and Wikipedia in order to investigate the co-morbidities of the rare diseases Kaposi sarcoma, toxoplasmosis, and Kawasaki disease. In addition to finding well-known characteristics of diseases, ADAMS can identify rare or previously unreported associations. In particular, we report a statistically significant association between Kawasaki disease and diagnosis of autistic disorder.

Discovering Disease Associations by Integrating Electronic Clinical Data and Medical Literature

PubMed Central

Holmes, Antony B.; Hawson, Alexander; Liu, Feng; Friedman, Carol; Khiabanian, Hossein; Rabadan, Raul

2011-01-01

Electronic health record (EHR) systems offer an exceptional opportunity for studying many diseases and their associated medical conditions within a population. The increasing number of clinical record entries that have become available electronically provides access to rich, large sets of patients' longitudinal medical information. By integrating and comparing relations found in the EHRs with those already reported in the literature, we are able to verify existing and to identify rare or novel associations. Of particular interest is the identification of rare disease co-morbidities, where the small numbers of diagnosed patients make robust statistical analysis difficult. Here, we introduce ADAMS, an Application for Discovering Disease Associations using Multiple Sources, which contains various statistical and language processing operations. We apply ADAMS to the New York-Presbyterian Hospital's EHR to combine the information from the relational diagnosis tables and textual discharge summaries with those from PubMed and Wikipedia in order to investigate the co-morbidities of the rare diseases Kaposi sarcoma, toxoplasmosis, and Kawasaki disease. In addition to finding well-known characteristics of diseases, ADAMS can identify rare or previously unreported associations. In particular, we report a statistically significant association between Kawasaki disease and diagnosis of autistic disorder. PMID:21731656

Attitude determination with three-axis accelerometer for emergency atmospheric entry

NASA Technical Reports Server (NTRS)

Garcia-Llama, Eduardo (Inventor)

2012-01-01

Two algorithms are disclosed that, with the use of a 3-axis accelerometer, will be able to determine the angles of attack, sideslip and roll of a capsule-type spacecraft prior to entry (at very high altitudes, where the atmospheric density is still very low) and during entry. The invention relates to emergency situations in which no reliable attitude and attitude rate are available. Provided that the spacecraft would not attempt a guided entry without reliable attitude information, the objective of the entry system in such case would be to attempt a safe ballistic entry. A ballistic entry requires three controlled phases to be executed in sequence: First, cancel initial rates in case the spacecraft is tumbling; second, maneuver the capsule to a heat-shield-forward attitude, preferably to the trim attitude, to counteract the heat rate and heat load build up; and third, impart a ballistic bank or roll rate to null the average lift vector in order to prevent prolonged lift down situations. Being able to know the attitude, hence the attitude rate, will allow the control system (nominal or backup, automatic or manual) to cancel any initial angular rates. Also, since a heat-shield forward attitude and the trim attitude can be specified in terms of the angles of attack and sideslip, being able to determine the current attitude in terms of these angles will allow the control system to maneuver the vehicle to the desired attitude. Finally, being able to determine the roll angle will allow for the control of the roll ballistic rate during entry.

A Low Cost Micro-Computer Based Local Area Network for Medical Office and Medical Center Automation

PubMed Central

Epstein, Mel H.; Epstein, Lynn H.; Emerson, Ron G.

1984-01-01

A Low Cost Micro-computer based Local Area Network for medical office automation is described which makes use of an array of multiple and different personal computers interconnected by a local area network. Each computer on the network functions as fully potent workstations for data entry and report generation. The network allows each workstation complete access to the entire database. Additionally, designated computers may serve as access ports for remote terminals. Through “Gateways” the network may serve as a front end for a large mainframe, or may interface with another network. The system provides for the medical office environment the expandability and flexibility of a multi-terminal mainframe system at a far lower cost without sacrifice of performance.

Applying World Wide Web technology to the study of patients with rare diseases.

PubMed

de Groen, P C; Barry, J A; Schaller, W J

1998-07-15

Randomized, controlled trials of sporadic diseases are rarely conducted. Recent developments in communication technology, particularly the World Wide Web, allow efficient dissemination and exchange of information. However, software for the identification of patients with a rare disease and subsequent data entry and analysis in a secure Web database are currently not available. To study cholangiocarcinoma, a rare cancer of the bile ducts, we developed a computerized disease tracing system coupled with a database accessible on the Web. The tracing system scans computerized information systems on a daily basis and forwards demographic information on patients with bile duct abnormalities to an electronic mailbox. If informed consent is given, the patient's demographic and preexisting medical information available in medical database servers are electronically forwarded to a UNIX research database. Information from further patient-physician interactions and procedures is also entered into this database. The database is equipped with a Web user interface that allows data entry from various platforms (PC-compatible, Macintosh, and UNIX workstations) anywhere inside or outside our institution. To ensure patient confidentiality and data security, the database includes all security measures required for electronic medical records. The combination of a Web-based disease tracing system and a database has broad applications, particularly for the integration of clinical research within clinical practice and for the coordination of multicenter trials.

Predictors of re-entry into the child protection system in Singapore: a cumulative ecological-transactional risk model.

PubMed

Li, Dongdong; Chu, Chi Meng; Ng, Wei Chern; Leong, Wai

2014-11-01

This study examines the risk factors of re-entry for 1,750 child protection cases in Singapore using a cumulative ecological-transactional risk model. Using administrative data, the present study found that the overall percentage of Child Protection Service (CPS) re-entry in Singapore is 10.5% based on 1,750 cases, with a range from 3.9% (within 1 year) to 16.5% (within 8 years after case closure). One quarter of the re-entry cases were observed to occur within 9 months from case closure. Seventeen risk factors, as identified from the extant literature, were tested for their utility to predict CPS re-entry in this study using a series of Cox regression analyses. A final list of seven risk factors (i.e., children's age at entry, case type, case closure result, duration of case, household income, family size, and mother's employment status) was used to create a cumulative risk score. The results supported the cumulative risk model in that higher risk score is related to higher risk of CPS re-entry. Understanding the prevalence of CPS re-entry and the risk factors associated with re-entry is the key to informing practice and policy in a culturally relevant way. The results from this study could then be used to facilitate critical case management decisions in order to enhance positive outcomes of families and children in Singapore's care system. Copyright © 2014 Elsevier Ltd. All rights reserved.

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

PubMed

Halbesleben, Jonathon R B; Savage, Grant T; Wakefield, Douglas S; Wakefield, Bonnie J

2010-01-01

Health care organizations have redesigned existing and implemented new work processes intended to improve patient safety. As a consequence of these process changes, there are now intentionally designed "blocks" or barriers that limit how specific work actions, such as ordering and administering medication, are to be carried out. Health care professionals encountering these designed barriers can choose to either follow the new process, engage in workarounds to get past the block, or potentially repeat work (rework). Unfortunately, these workarounds and rework may lead to other safety concerns. The aim of this study was to examine rework and workarounds in hospital medication administration processes. Observations and semistructured interviews were conducted with 58 nurses from four hospital intensive care units focusing on the medication administration process. Using the constant comparative method, we analyzed the observation and interview data to develop themes regarding rework and workarounds. From this analysis, we developed an integrated process map of the medication administration process depicting blocks. A total of 12 blocks were reported by the participants. Based on the analysis, we categorized them as related to information exchange, information entry, and internal supply chain issues. Whereas information exchange and entry blocks tended to lead to rework, internal supply chain issues were more likely to lead to workarounds. A decentralized pharmacist on the unit may reduce work flow blocks (and, thus, workarounds and rework). Work process redesign may further address the problems of workarounds and rework.

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

PubMed

Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M

2002-01-01

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Measuring value for money: a scoping review on economic evaluation of health information systems.

PubMed

Bassi, Jesdeep; Lau, Francis

2013-01-01

To explore how key components of economic evaluations have been included in evaluations of health information systems (HIS), to determine the state of knowledge on value for money for HIS, and provide guidance for future evaluations. We searched databases, previously collected papers, and references for relevant papers published from January 2000 to June 2012. For selection, papers had to: be a primary study; involve a computerized system for health information processing, decision support, or management reporting; and include an economic evaluation. Data on study design and economic evaluation methods were extracted and analyzed. Forty-two papers were selected and 33 were deemed high quality (scores ≥ 8/10) for further analysis. These included 12 economic analyses, five input cost analyses, and 16 cost-related outcome analyses. For HIS types, there were seven primary care electronic medical records, six computerized provider order entry systems, five medication management systems, five immunization information systems, four institutional information systems, three disease management systems, two clinical documentation systems, and one health information exchange network. In terms of value for money, 23 papers reported positive findings, eight were inconclusive, and two were negative. We found a wide range of economic evaluation papers that were based on different assumptions, methods, and metrics. There is some evidence of value for money in selected healthcare organizations and HIS types. However, caution is needed when generalizing these findings. Better reporting of economic evaluation studies is needed to compare findings and build on the existing evidence base we identified.

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument.

PubMed

Sittig, Dean F; Ash, Joan S; Guappone, Ken P; Campbell, Emily M; Dykstra, Richard H

2008-07-01

To determine what "average" clinicians in organizations that were about to implement Computer-based Provider Order Entry (CPOE) were expecting to occur, we conducted an open-ended, semi-structured survey at three community hospitals. We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately 5 min to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to. Our survey findings did not reveal any overly negative, critical, problematic, or striking sets of concerns. However, from the standpoint of unintended consequences, we found that clinicians were anticipating only a few of the events, emotions, and process changes that are likely to result from CPOE. The results of such an open-ended survey may prove useful in helping CPOE leaders to understand user perceptions and predictions about CPOE, because it can expose issues about which more communication, or discussion, is needed. Using the survey, implementation strategies and management techniques outlined in this paper, any chief information officer (CIO) or chief medical information officer (CMIO) should be able to adequately assess their organization's CPOE readiness, make the necessary mid-course corrections, and be prepared to deal with the currently identified unintended consequences of CPOE should they occur.

[Study of the Application of Mobile Medical Technology in Construction of Grading Diagnosis and Treatment System].

PubMed

Zhu, Wenwu; Shen, Yihong; Zhen, Hui; Yang, Xiaohe; Hu, Kai

2018-02-08

The combination of mobile medical technology and the grading diagnosis and treatment system (GDTS) can stimulate the allocation of medical resources, reduce medical cost and improve public health significantly. Firstly we summarize development features of mobile medical technology in foreign and domestic market, then we study the application model of mobile medical application in GDTS with field research data and analyzes its advantage and shortage. Finally, we propose four measures for further developing mobile medical application in the GDTS:the government departments should formulate policies and industry standards of products as soon as possible to meet requirement of market; service providers should take the hospitals as core role to achieve mutual benefit and win-win situation; take the daily monitoring of chronic diseases as an entry point to build profitable business model; enhance publicity to promote public health awareness.

Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals.

PubMed

Leung, Alexander A; Schiff, Gordon; Keohane, Carol; Amato, Mary; Simon, Steven R; Cadet, Bismarck; Coffey, Michael; Kaufman, Nathan; Zimlichman, Eyal; Seger, Diane L; Yoon, Catherine; Bates, David W

2013-10-01

Adverse drug events (ADEs) are common among hospitalized patients with renal impairment. To determine whether computerized physician order entry (CPOE) systems with clinical decision support capabilities reduce the frequency of renally related ADEs in hospitals. Quasi-experimental study of 1590 adult patients with renal impairment who were admitted to 5 community hospitals in Massachusetts from January 2005 to September 2010, preimplementation and postimplementation of CPOE. Varying levels of clinical decision support, ranging from basic CPOE only (sites 4 and 5), rudimentary clinical decision support (sites 1 and 2), and advanced clinical decision support (site 3). Primary outcome was the rate of preventable ADEs from nephrotoxic and/or renally cleared medications. Similarly, secondary outcomes were the rates of overall ADEs and potential ADEs. There was a 45% decrease in the rate of preventable ADEs following implementation (8.0/100 vs 4.4/100 admissions; P < 0.01), and the impact was related to the level of decision support. Basic CPOE was not associated with any significant benefit (4.6/100 vs 4.3/100 admissions; P = 0.87). There was a nonsignificant decrease in preventable ADEs with rudimentary clinical decision support (9.1/100 vs 6.4/100 admissions; P = 0.22). However, substantial reduction was seen with advanced clinical decision support (12.4/100 vs 0/100 admissions; P = 0.01). Despite these benefits, a significant increase in potential ADEs was found for all systems (55.5/100 vs 136.8/100 admissions; P < 0.01). Vendor-developed CPOE with advanced clinical decision support can reduce the occurrence of preventable ADEs but may be associated with an increase in potential ADEs. © 2013 Society of Hospital Medicine.

Ordering the Senses in a Monolingual Dictionary Entry.

ERIC Educational Resources Information Center

Gold, David L.

1986-01-01

Reviews issues to be considered in determining the order of meanings for a lexeme in a dictionary entry and compares techniques for deciding order. Types of ordering include importance, frequency, logical ordering, dominant meaning, syntactic, and historical. (MSE)

The MeSH translation maintenance system: structure, interface design, and implementation.

PubMed

Nelson, Stuart J; Schopen, Michael; Savage, Allan G; Schulman, Jacque-Lynne; Arluk, Natalie

2004-01-01

The National Library of Medicine (NLM) produces annual editions of the Medical Subject Headings (MeSH). Translations of MeSH are often done to make the vocabulary useful for non-English users. However, MeSH translators have encountered difficulties with entry vocabulary as they maintain and update their translation. Tracking MeSH changes and updating their translations in a reasonable time frame is cumbersome. NLM has developed and implemented a concept-centered vocabulary maintenance system for MeSH. This system has been extended to create an interlingual database of translations, the MeSH Translation Maintenance System (MTMS). This database allows continual updating of the translations, as well as facilitating tracking of the changes within MeSH from one year to another. The MTMS interface uses a Web-based design with multiple colors and fonts to indicate concepts needing translation or review. Concepts for which there is no exact English equivalent can be added. The system software encourages compliance with the Unicode standard in order to ensure that character sets with native alphabets and full orthography are used consistently.

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding.

PubMed

MacKay, Mark; Anderson, Collin; Boehme, Sabrina; Cash, Jared; Zobell, Jeffery

2016-04-01

The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors. © 2015 American Society for Parenteral and Enteral Nutrition.

[se-atlas - the health service information platform for people with rare diseases : Supporting research on medical care institutions and support groups].

PubMed

Haase, Johanna; Wagner, Thomas O F; Storf, Holger

2017-05-01

se-atlas - the health service information platform for rare diseases - is part of the German National Action Plan for People with Rare Diseases and is funded by the German Federal Ministry of Health. The objective of se-atlas as a web-based platform is to illustrate those medical care institutions that are linked to rare diseases, in a transparent and user-friendly way. The website provides an overview of medical care institutions and support groups focusing on rare diseases in Germany. The primary target groups of se-atlas are affected patients, their relatives and physicians but can also include non-medical professionals and the general public. In order to make it easier to look up medical care institutions or support groups and optimize the search results displayed, various strategies are being developed and evaluated. Hence, the allocation of diseases to appropriate medical care institutions and support groups is currently a main focus. Since its launch in 2015, se-atlas has grown continuously and now incorporates five times more entries than were included 20 months prior. Among this data are the current rare diseases centres in Germany, which play a major role in providing patient-centred healthcare by acting as primary contact points for people with rare diseases. Further expansion and maintenance of the data base raises several organisational and software-related challenges. For one, the data should be completed by adding more high-quality information, while not neglecting the existing entries and maintaining their high level of quality in the long term.

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

PubMed

Chan, Julie; Shojania, Kaveh G; Easty, Anthony C; Etchells, Edward E

2011-05-01

Application of user-centred design principles to Computerized provider order entry (CPOE) systems may improve task efficiency, usability or safety, but there is limited evaluative research of its impact on CPOE systems. 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). 27 staff physicians, residents and medical students. Sunnybrook Health Sciences Centre, an academic hospital in Toronto, Canada. 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 randomized. Users received individual training for the CPOE Test format only. Completion time (efficiency), requests for assistance (usability), and errors in the submitted orders (safety). 27 study participants completed 108 order sets. Mean task times were: User Centred Design format 273 s, Paper format 293 s (p=0.73 compared to UCD format), and CPOE Test format 637 s (p<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<0.01). There were no significant differences in number of errors between formats. 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.

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

PubMed Central

Chan, Julie; Shojania, Kaveh G; Easty, Anthony C

2011-01-01

Background Application of user-centred design principles to Computerized 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 27staff physicians, residents and medical students. Setting Sunnybrook Health Sciences Centre, an academic hospital in Toronto, Canada. 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 randomized. 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 s, Paper format 293 s (p=0.73 compared to UCD format), and CPOE Test format 637 s (p<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<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. PMID:21486886

The role of local terminologies in electronic health records. The HEGP experience.

PubMed

Daniel-Le Bozec, Christel; Steichen, Olivier; Dart, Thierry; Jaulent, Marie-Christine

2007-01-01

Despite decades of work, there is no universally accepted standard medical terminology and no generally usable terminological tools have yet emerged. The local dictionary of concepts of the Georges Pompidou European Hospital (HEGP) is a Terminological System (TS) designed to support clinical data entry. It covers 93 data entry forms and contains definitions and synonyms of more than 5000 concepts, sometimes linked to reference terminologies such as ICD-10. In this article, we evaluate to which extend SNOMED CT could fully replace or rather be mapped to the local terminology system. We first describe the local dictionary of concepts of HEGP according to some published TS characterization framework. Then we discuss the specific role that a local terminology system plays with regards to reference terminologies.

The journey from precontemplation to action: Transitioning between electronic medical record systems.

PubMed

Bentley, Thomas; Rizer, Milisa; McAlearney, Ann Scheck; Mekhjian, Hagop; Siedler, Monica; Sharp, Karen; Teater, Phyllis; Huerta, Timothy

2016-01-01

Health care organizations, in response to federal programs, have sought to identify electronic medical record (EMR) strategies that align well with their visions for success. Little exists in the literature discussing the transition from one EMR strategy to another. The analysis and planning process used by a major academic medical center in its journey to adopt a new strategy was described in this study. We use the transtheoretical model of change to frame the five phases through which the organization transitioned from a best-of-breed system to an enterprise system. We explore the five phases of change from the perspective of a maturing approach to new technology adoption. Data collection included archival retrieval and review as well as interviews with key stakeholders. Although there was always a focus on some enterprise capabilities such as computerized physician order entry, the emphasis on EMR selection tended to be driven by specialty requirements. Focusing on the patient across the continuum of care, as opposed to focusing on excessive requirements by clinical specialties, was essential in forming and deploying a vision for the new EMR. This research outlines a successful pathway used by an organization that had invested heavily in EMR technology and was faced with evaluating whether to continue that investment or start with a new platform. Rather than focusing on the technology alone, efforts to reframe the discussion to one that focused on the patient resulted in less resistance to change.

Optimizing radiologist e-prescribing of CT oral contrast agent using a protocoling portal.

PubMed

Wasser, Elliot J; Galante, Nicholas J; Andriole, Katherine P; Farkas, Cameron; Khorasani, Ramin

2013-12-01

The purpose of this study is to quantify the time expenditure associated with radiologist ordering of CT oral contrast media when using an integrated protocoling portal and to determine radiologists' perceptions of the ordering process. This prospective study was performed at a large academic tertiary care facility. Detailed timing information for CT inpatient oral contrast orders placed via the computerized physician order entry (CPOE) system was gathered over a 14-day period. Analyses evaluated the amount of physician time required for each component of the ordering process. Radiologists' perceptions of the ordering process were assessed by survey. Descriptive statistics and chi-square analysis were performed. A total of 96 oral contrast agent orders were placed by 13 radiologists during the study period. The average time necessary to create a protocol for each case was 40.4 seconds (average range by subject, 20.0-130.0 seconds; SD, 37.1 seconds), and the average total time to create and sign each contrast agent order was 27.2 seconds (range, 10.0-50.0 seconds; SD, 22.4 seconds). Overall, 52.5% (21/40) of survey respondents indicated that radiologist entry of oral contrast agent orders improved patient safety. A minority of respondents (15% [6/40]) indicated that contrast agent order entry was either very or extremely disruptive to workflow. Radiologist e-prescribing of CT oral contrast agents using CPOE can be embedded in a protocol workflow. Integration of health IT tools can help to optimize user acceptance and adoption.

Analysis of Management Control Techniques for the Data Processing Department at the Navy Finance Center, Cleveland, Ohio.

DTIC Science & Technology

1983-03-01

Sysiem are: Order processinq coordinators Order processing management Credit and collections Accounts receivable Support management Admin ianagemenr...or sales secretary, then by order processing (OP). Phone-in orders go directly to OP. The infor- mation is next Transcribed onto an order entry... ORDER PROCESSING : The central systems validate The order items and codes t!, processing them against the customer file, the prodicT or PA? ts file, and

76 FR 13004 - Self-Regulatory Organizations; C2 Options Exchange, Incorporated; Notice of Filing and Immediate...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-09

... Schedule to reduce an away-market routing fee and extend a fee waiver related to the PULSe workstation. The... waiver related to the PULSe workstation. By way of background, the PULSe workstation is a front-end order entry system designed for use with respect to orders that may be sent to the trading systems of C2. In...

[MEDRISK--an expert system for medical risk assessment].

PubMed

Mayer-Ohly, E; Regenauer, A

1995-10-01

The Munich Reinsurance Company has developed a rule-based expert system for assessing substandard risk in life, disability and accidental death benefit. It is one of the most comprehensive medical expert systems yet conceived and currently includes entries for over 7500 impairment terms. Based on the most up-to-date insurance medical knowledge MEDRISK allows underwriters, irrespective of their level of experience, to process both simple and highly complex cases. The system which takes account of the interactive effect that can exist between different impairments as well as the influence which occupational factors can exert, always produces consistent and case-specific decisions. The number of impairments and types of insurance included in MEDRISK can be expanded. After tests at Munich Re and at a number of insurance companies, the system ist now ready to be launched in German speaking markets.

A decision-supported outpatient practice system.

PubMed Central

Barrows, R. C.; Allen, B. A.; Smith, K. C.; Arni, V. V.; Sherman, E.

1996-01-01

We describe a Decision-supported Outpatient Practice (DOP) system developed and now in use at the Columbia-Presbyterian Medical Center. DOP is an automated ambulatory medical record system that integrates in-patient and ambulatory care data, and incorporates active and passive decision support mechanisms with a view towards improving the quality of primary care. Active decision support occurs in the form of event-driven reminders created within a remote clinical information system with its central data repository and decision support system (DSS). Novel features of DOP include patient specific health maintenance task lists calculated by the remote DSS. uses of a semantically structured controlled medical vocabulary to support clinical results review and provider data entry, and exploitation of an underlying ambulatory data model that provides for an explicit record of evolution of insight regarding patient management. Benefits, challenges, and plans are discussed. PMID:8947774

Teleform scannable data entry: an efficient method to update a community-based medical record? Community care coordination network Database Group.

PubMed Central

Guerette, P.; Robinson, B.; Moran, W. P.; Messick, C.; Wright, M.; Wofford, J.; Velez, R.

1995-01-01

Community-based multi-disciplinary care of chronically ill individuals frequently requires the efforts of several agencies and organizations. The Community Care Coordination Network (CCCN) is an effort to establish a community-based clinical database and electronic communication system to facilitate the exchange of pertinent patient data among primary care, community-based and hospital-based providers. In developing a primary care based electronic record, a method is needed to update records from the field or remote sites and agencies and yet maintain data quality. Scannable data entry with fixed fields, optical character recognition and verification was compared to traditional keyboard data entry to determine the relative efficiency of each method in updating the CCCN database. PMID:8563414

Optimizing the user interface of a data entry module for an electronic patient record for cardiac rehabilitation: A mixed method usability approach.

PubMed

van Engen-Verheul, Mariëtte M; Peute, Linda W P; de Keizer, Nicolette F; Peek, Niels; Jaspers, Monique W M

2016-03-01

Cumbersome electronic patient record (EPR) interfaces may complicate data-entry in clinical practice. Completeness of data entered in the EPR determines, among other things, the value of computerized clinical decision support (CCDS). Quantitative usability evaluations can provide insight into mismatches between the system design model of data entry and users' data entry behavior, but not into the underlying causes for these mismatches. Mixed method usability evaluation studies may provide these insights, and thus support generating redesign recommendations for improving an EPR system's data entry interface. To improve the usability of the data entry interface of an EPR system with CCDS in the field of cardiac rehabilitation (CR), and additionally, to assess the value of a mixed method usability approach in this context. Seven CR professionals performed a think-aloud usability evaluation both before (beta-version) and after the redesign of the system. Observed usability problems from both evaluations were analyzed and categorized using Zhang et al.'s heuristic principles of good interface design. We combined the think-aloud usability evaluation of the system's beta-version with the measurement of a new usability construct: users' deviations in action sequence from the system's predefined data entry order sequence. Recommendations for redesign were implemented. We assessed whether the redesign improved CR professionals' (1) task efficacy (with respect to the completeness of data they collected), and (2) task efficiency (with respect to the average number of mouse clicks they needed to complete data entry subtasks). With the system's beta version, 40% of health care professionals' navigation actions through the system deviated from the predefined next system action. The causes for these deviations as revealed by the think-aloud method mostly concerned mismatches between the system design model for data entry action sequences and users expectations of these action sequences, based on their paper-based daily routines. This caused non completion of data entry tasks (31% of main tasks completed), and more navigation actions than minimally required (146% of the minimum required). In the redesigned system the data entry navigational structure was organized in a flexible way around an overview screen to better mimic users' paper-based daily routines of collecting patient data. This redesign resulted in an increased number of completed main tasks (70%) and a decrease in navigation actions (133% of the minimum required). The think-aloud usability evaluation of the redesigned system showed that remaining problems concerned flexibility (e.g., lack of customization options) and consistency (mainly with layout and position of items on the screen). The mixed method usability evaluation was supportive in revealing the magnitude and causes of mismatches between the system design model of data-entry with users' data entry behavior. However, as both task efficacy and efficiency were still not optimal with the redesigned EPR, we advise to perform a cognitive analysis on end users' mental processes and behavior patterns in daily work processes specifically during the requirements analysis phase of development of interactive healthcare information systems. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Determinants of choosing a career in family medicine

PubMed Central

Scott, Ian; Gowans, Margot; Wright, Bruce; Brenneis, Fraser; Banner, Sandra; Boone, Jim

2011-01-01

Background Student choice is an important determinant of the distribution of specialties of practising physicians in many countries. Understanding characteristics at entry into medical school that are associated with the choice of residency in family medicine can assist medical schools in admitting an appropriate mix of students to serve the health care needs of their regions. Methods From 2002 to 2004, we collected data from students in 15 classes at 8 of 16 Canadian medical schools at entry. Surveys included questions on career choice, attitudes to practice and socio-demographic characteristics. We followed students prospectively with these data linked to their residency choice. We used multiple logistic regression analysis to identify entry characteristics that predicted a student’s ultimate career choice in family medicine. Results Of 1941 eligible students in the participating classes, 1542 (79.4%) contributed data to the final analyses. The following 11 entry variables predicted whether a student named family medicine as his or her top residency choice: being older, being engaged or in a long-term relationship, not having parents with postgraduate university education nor having family or close friends practicing medicine, having undertaken voluntary work in a developing nation, not volunteering with elderly people, desire for varied scope of practice, a societal orientation, a lower interest in research, desire for short postgraduate training, and lower preference for medical versus social problems. Interpretation Demographic and attitudinal characteristics at entry into medical school predicted whether students chose a career in family medicine. PMID:20974721

Adherence to the Australian National Inpatient Medication Chart: the efficacy of a uniform national drug chart on improving prescription error.

PubMed

Atik, Alp

2013-10-01

In 2006, the National Inpatient Medication Chart (NIMC) was introduced as a uniform medication chart in Australian public hospitals with the aim of reducing prescription error. The rate of regular medication prescription error in the NIMC was assessed. Data was collected using the NIMC Audit Tool and analyzed with respect to causes of error per medication prescription and per medication chart. The following prescription requirements were assessed: date, generic drug name, route of administration, dose, frequency, administration time, indication, signature, name and contact details. A total of 1877 medication prescriptions were reviewed. 1653 prescriptions (88.07%) had no contact number, 1630 (86.84%) did not have an indication, 1230 and 675 (35.96%) used a drug's trade name. Within 261 medication charts, all had at least one entry, which did not include an indication, 258 (98.85%) had at least one entry, which did not have a contact number and 200 (76.63%) had at least one entry, which used a trade name. The introduction of a uniform national medication chart is a positive step, but more needs to be done to address the root causes of prescription error. © 2012 John Wiley & Sons Ltd.

The US blockade and Cuba's AIDS sanatoria system.

PubMed

Landau, J G

1998-01-01

Cuba's low rate of HIV infection is due to several factors that include early HIV detection campaigns, the sanatoria system, and the U.S. embargo that has restricted sex tourism and drugs. People diagnosed with HIV are scheduled for entry into the sanatoria system within their province. Food and medical care are guaranteed in the sanatoria, as are educational opportunities and work for the unskilled, a powerful incentive in an impoverished nation. Ironically, while the U.S. embargo partly contributes to keeping the HIV infection rate low, it also is severely and adversely affecting public health in Cuba by creating widespread shortages in medical care resources.

Utilization management in radiology, part 1: rationale, history, and current status.

PubMed

Duszak, Richard; Berlin, Jonathan W

2012-10-01

Previous growth in the utilization of medical imaging has led to numerous efforts to reduce associated spending. Although these have historically been directed toward unit cost reductions, recent interest has emerged by various stakeholders in curbing inappropriate utilization. Radiology benefits managers have widespread market penetration and have been promoted largely by the payer community as effective mechanisms to curb increases in imaging volume. The provider community has tended to favor real-time order entry decision support systems. These have demonstrated comparable effectiveness to radiology benefits managers in early projects but currently have only limited market penetration. In this first of a two-part series, the rationale for the development of utilization management programs will be discussed and their history and current status reviewed. Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Design and Evaluation of an Electronic Override Mechanism for Medication Alerts to Facilitate Communication Between Prescribers and Pharmacists.

PubMed

Russ, Alissa L; Chen, Siying; Melton, Brittany L; Saleem, Jason J; Weiner, Michael; Spina, Jeffrey R; Daggy, Joanne K; Zillich, Alan J

2015-07-01

Computerized medication alerts can often be bypassed by entering an override rationale, but prescribers' override reasons are frequently ambiguous to pharmacists who review orders. To develop and evaluate a new override mechanism for adverse reaction and drug-drug interaction alerts. We hypothesized that the new mechanism would improve usability for prescribers and increase the clinical appropriateness of override reasons. A counterbalanced, crossover study was conducted with 20 prescribers in a simulated prescribing environment. We modified the override mechanism timing, navigation, and text entry. Instead of free-text entry, the new mechanism presented prescribers with a predefined set of override reasons. We assessed usability (learnability, perceived efficiency, and usability errors) and used a priori criteria to evaluate the clinical appropriateness of override reasons entered. Prescribers rated the new mechanism as more efficient (Wilcoxon signed-rank test, P = 0.032). When first using the new design, 5 prescribers had difficulty finding the new mechanism, and 3 interpreted the navigation to mean that the alert could not be overridden. The number of appropriate override reasons significantly increased with the new mechanism compared with the original mechanism (median change of 3.0; interquartile range = 3.0; P < 0.0001). When prescribers were given a menu-based choice for override reasons, clinical appropriateness of these reasons significantly improved. Further enhancements are necessary, but this study is an important first step toward a more standardized menu of override choices. Findings may be used to improve communication through e-prescribing systems between prescribers and pharmacists. © The Author(s) 2015.

Design and implementation of the GLIF3 guideline execution engine.

PubMed

Wang, Dongwen; Peleg, Mor; Tu, Samson W; Boxwala, Aziz A; Ogunyemi, Omolola; Zeng, Qing; Greenes, Robert A; Patel, Vimla L; Shortliffe, Edward H

2004-10-01

We have developed the GLIF3 Guideline Execution Engine (GLEE) as a tool for executing guidelines encoded in the GLIF3 format. In addition to serving as an interface to the GLIF3 guideline representation model to support the specified functions, GLEE provides defined interfaces to electronic medical records (EMRs) and other clinical applications to facilitate its integration with the clinical information system at a local institution. The execution model of GLEE takes the "system suggests, user controls" approach. A tracing system is used to record an individual patient's state when a guideline is applied to that patient. GLEE can also support an event-driven execution model once it is linked to the clinical event monitor in a local environment. Evaluation has shown that GLEE can be used effectively for proper execution of guidelines encoded in the GLIF3 format. When using it to execute each guideline in the evaluation, GLEE's performance duplicated that of the reference systems implementing the same guideline but taking different approaches. The execution flexibility and generality provided by GLEE, and its integration with a local environment, need to be further evaluated in clinical settings. Integration of GLEE with a specific event-monitoring and order-entry environment is the next step of our work to demonstrate its use for clinical decision support. Potential uses of GLEE also include quality assurance, guideline development, and medical education.

Use of Order Sets in Inpatient Computerized Provider Order Entry Systems: A Comparative Analysis of Usage Patterns at Seven Sites

PubMed Central

Wright, Adam; Feblowitz, Joshua C.; Pang, Justine E.; Carpenter, James D.; Krall, Michael A.; Middleton, Blackford; Sittig, Dean F.

2012-01-01

Background Many computerized provider order entry (CPOE) systems include the ability to create electronic order sets: collections of clinically-related orders grouped by purpose. Order sets promise to make CPOE systems more efficient, improve care quality and increase adherence to evidence-based guidelines. However, the development and implementation of order sets can be expensive and time-consuming and limited literature exists about their utilization. Methods Based on analysis of order set usage logs from a diverse purposive sample of seven sites with commercially- and internally-developed inpatient CPOE systems, we developed an original order set classification system. Order sets were categorized across seven non-mutually exclusive axes: admission/discharge/transfer (ADT), perioperative, condition-specific, task-specific, service-specific, convenience, and personal. In addition, 731 unique subtypes were identified within five axes: four in ADT (S=4), three in perioperative, 144 in condition-specific, 513 in task-specific, and 67 in service-specific. Results Order sets (n=1,914) were used a total of 676,142 times at the participating sites during a one-year period. ADT and perioperative order sets accounted for 27.6% and 24.2% of usage respectively. Peripartum/labor, chest pain/Acute Coronary Syndrome/Myocardial Infarction and diabetes order sets accounted for 51.6% of condition-specific usage. Insulin, angiography/angioplasty and arthroplasty order sets accounted for 19.4% of task-specific usage. Emergency/trauma, Obstetrics/Gynecology/Labor Delivery and anesthesia accounted for 32.4% of service-specific usage. Overall, the top 20% of order sets accounted for 90.1% of all usage. Additional salient patterns are identified and described. Conclusion We observed recurrent patterns in order set usage across multiple sites as well as meaningful variations between sites. Vendors and institutional developers should identify high-value order set types through concrete data analysis in order to optimize the resources devoted to development and implementation. PMID:22819199

Woven Thermal Protection System Based Heat-shield for Extreme Entry Environments Technology (HEEET)

NASA Technical Reports Server (NTRS)

Ellerby, Donald; Venkatapathy, Ethiraj; Stackpoole, Margaret; Chinnapongse, Ronald; Munk, Michelle; Dillman, Robert; Feldman, Jay; Prabhu, Dinesh; Beerman, Adam

2013-01-01

NASA's future robotic missions utilizing an entry system into Venus and the outer planets, namely, Saturn, Uranus, Neptune, result in extremely high entry conditions that exceed the capabilities of state of the art low to mid density ablators such as PICA or Avcoat. Therefore mission planners typically assume the use of a fully dense carbon phenolic heat shield similar to what was flown on Pioneer Venus and Galileo. Carbon phenolic is a robust TPS material however its high density and relatively high thermal conductivity constrain mission planners to steep entries, with high heat fluxes and pressures and short entry durations, in order for CP to be feasible from a mass perspective. The high entry conditions pose challenges for certification in existing ground based test facilities and the longer-term sustainability of CP will continue to pose challenges. In 2012 the Game Changing Development Program (GCDP) in NASA's Space Technology Mission Directorate funded NASA ARC to investigate the feasibility of a Woven Thermal Protection System (WTPS) to meet the needs of NASA's most challenging entry missions. This project was highly successful demonstrating that a Woven TPS solution compares favorably to CP in performance in simulated reentry environments and provides the opportunity to manufacture graded materials that should result in overall reduced mass solutions and enable a much broader set of missions than does CP. Building off the success of the WTPS project GCDP has funded a follow on project to further mature and scale up the WTPS concept for insertion into future NASA robotic missions. The matured WTPS will address the CP concerns associated with ground based test limitations and sustainability. This presentation will briefly discuss results from the WTPS Project and the plans for WTPS maturation into a heat-shield for extreme entry environment.

Woven Thermal Protection System Based Heat-shield for Extreme Entry Environments Technology (HEEET)

NASA Technical Reports Server (NTRS)

Chinnapongse, Ronald; Ellerbe, Donald; Stackpoole, Maragaret; Venkatapathy, Ethiraj; Beerman, Adam; Feldman, Jay; Peterson Keith; Prabhu, Dinesh; Dillman, Robert; Munk, Michelle

2013-01-01

NASA's future robotic missions utilizing an entry system into Venus and the outer planets, namely, Saturn, Uranus, Neptune, result in extremely severe entry conditions that exceed the capabilities of state of the art low to mid density ablators such as PICA or Avcoat. Therefore mission planners typically assume the use of a fully dense carbon phenolic heat shield similar to what was flown on Pioneer Venus and Galileo. Carbon phenolic (CP) is a robust TPS material however its high density and relatively high thermal conductivity constrain mission planners to steep entries, with high heat fluxes and pressures and short entry durations, in order for CP to be feasible from a mass perspective. The high entry conditions pose challenges for certification in existing ground based test facilities and the longer-­-term sustainability of CP will continue to pose challenges. In 2012 the Game Changing Development Program (GCDP) in NASA's Space Technology Mission Directorate funded NASA ARC to investigate the feasibility of a Woven Thermal Protection System (WTPS) to meet the needs of NASA's most challenging entry missions. This project was highly successful demonstrating that a Woven TPS solution compares favorably to CP in performance in simulated reentry environments and provides the opportunity to manufacture graded materials that should result in overall reduced mass solutions and enable a much broader set of missions than does CP. Building off the success of the WTPS project GCDP has funded a follow on project to further mature and scale up the WTPS concept for insertion into future NASA robotic missions. The matured WTPS will address the CP concerns associated with ground based test limitations and sustainability. This presentation will briefly discuss results from the WTPS Project and the plans for WTPS maturation into a heat-­-shield for extreme entry environment.

Design and Use of a Joint Order Vocabulary Knowledge Representation Tier in a Multi-tier CPOE Architecture

PubMed Central

Rucker, Donald W.; Steele, Andrew W.; Douglas, Ivor S.; Couderc, Carmela A.; Hardel, Gary G.

2006-01-01

Two major barriers to adoption of computerized physician order entry (CPOE) systems are the initial physician effort to learn the system and ongoing time costs to use the system. These barriers stem from the CPOE system’s need to reformulate physician orders into services that can be electronically communicated to ancillary clinical systems such as pharmacy, nursing, lab or radiology as well as to billing systems. Typical CPOE systems use significant custom user interface programming to match the terms used by physicians to order services as well as the aggregation of those orders into order sets with the underlying orderable services. We describe the design and implementation of a commercial CPOE system that has a formal separate intermediate mapping layer to match physician screen vocabulary and ordering behaviors to underlying services, both individually and in groups, supported by powerful search tools. PMID:17238425

NewYork-Presbyterian Hospital: translating innovation into practice.

PubMed

Johnson, Trudy; Currie, Gail; Keill, Patricia; Corwin, Steven J; Pardes, Herbert; Cooper, Mary Reich

2005-10-01

NewYork-Presbyterian (NYP) Hospital, a 2,242-bed not-for-profit academic medical center, was formed by a merger of The New York Hospital and The Presbyterian Hospital in the City of New York. It is also the flagship for the NewYork-Presbyterian Healthcare System, with 37 acute care facilities and 18 others. The hospital embeds safety in the culture through strategic initiatives and enhances service and efficiency using Six Sigma and other techniques to drive adoption of improvements. Goals are selected in alignment with the annual strategic initiatives, which are chosen on the basis of satisfaction surveys, patient and family complaints, community advisory groups, and performance measures, among other sources. A new business intelligence system enables online, dynamic analysis of performance results, replacing static paper reports. Advanced features in the clinical information systems include computerized physician order entry; interactive clinical alerts for decision support; a real-time infection control tracking system; and a clinical data warehouse supporting data mining and analysis for quality improvement, decision making, and education. To achieve clinical, service, and operational excellence, NYP focuses on all Institute of Medicine quality aims.

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility.

PubMed

Elliott, Rohan A; Lee, Cik Yin; Hussainy, Safeera Y

2016-06-01

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Analytic Guidance for the First Entry in a Skip Atmospheric Entry

NASA Technical Reports Server (NTRS)

Garcia-Llama, Eduardo

2007-01-01

This paper presents an analytic method to generate a reference drag trajectory for the first entry portion of a skip atmospheric entry. The drag reference, expressed as a polynomial function of the velocity, will meet the conditions necessary to fit the requirements of the complete entry phase. The generic method proposed to generate the drag reference profile is further simplified by thinking of the drag and the velocity as density and cumulative distribution functions respectively. With this notion it will be shown that the reference drag profile can be obtained by solving a linear algebraic system of equations. The resulting drag profile is flown using the feedback linearization method of differential geometric control as guidance law with the error dynamics of a second order homogeneous equation in the form of a damped oscillator. This approach was first proposed as a revisited version of the Space Shuttle Orbiter entry guidance. However, this paper will show that it can be used to fly the first entry in a skip entry trajectory. In doing so, the gains in the error dynamics will be changed at a certain point along the trajectory to improve the tracking performance.

Care provider order entry (CPOE): a perspective on factors leading to success or to failure.

PubMed

Ozdas, A; Miller, R A

2007-01-01

Authors provide a perspective on factors leading to successful care provider order entry (CPOE) implementations. Viewpoint of authors supported by background literature review. Authors review both benefits and challenges related to CPOE implementation using three guiding principles: (1) a clinical approach to clinical systems, which claims that CPOE implementation is analogous to a "good" clinician delivering care to a patient; (2) a commitment to quality, which advocates that no compromises should be made in implementing system functionality and clinical system content - the highest objective for CPOE implementation is to provide better quality of care and increased safety for patients; (3) a commitment to fairness, as evidenced by respect for individuals and support of local autonomy, which advocates for minimizing disruptions to clinician-users' workflows, and adequate local control over CPOE system design and evolution, including clinical content management. Past experiences with CPOE implementation can inform future installation attempts. Sociocultural factors dominate in determining the success of implementation, and should govern technical factors.

FDA marketing claims, and the practitioner.

PubMed

Runner, Susan

2006-03-01

The Food and Drug Administration (FDA) is the federal agency that is tasked with regulating market entry for medical devices. The laws that govern this process are codified in the Federal Food Drug and Cosmetic Act (the Act) and the regulations are based on this law. The medical device amendments to the Act were instituted in 1976, instituting the methods for classification of medical devices and the format for the premarket review of devices. Information for practitioners on how medical devices come to market, what data are required, how specific claims are cleared, and how the practitioner can give input to the system are critical for the further development of safe and effective medical devices.

Shuttle Entry Air Data System (SEADS) hardware development. Volume 1: Summary

NASA Technical Reports Server (NTRS)

While, D. M.

1983-01-01

Hardware development of the Shuttle Entry Data System (SEADS) is described. The system consists of an array of fourteen pressure ports, installed in an Orbiter nose cap, which, when coupled with existing fuselage mounted static pressure ports permits computation of entry flight parameters. Elements of the system that are described include the following: (1) penetration assemblies to place pressure port openings at the surface of the nose cap; (2) pressure tubes to transmit the surface pressure to transducers; (3) support posts or manifolds to provide support for, and reduce the length of, the individual pressure tubes; (4) insulation for the manifolds; and (5) a SEADS nose cap. Design, analyses, and tests to develop and certify design for flight are described. Specific tests include plasma arc exposure, radiant thermal, vibration, and structural. Volume one summarizes highlights of the program, particularly as they relate to the final design of SEADS. Volume two summarizes all of the Vought responsible activities in essentially a chronological order.

Shuttle Entry Air Data System (SEADS) hardware development. Volume 2: History

NASA Technical Reports Server (NTRS)

While, D. M.

1983-01-01

Hardware development of the Shuttle Entry Air Data System (SEADS) is described. The system consists of an array of fourteen pressure ports, installed in an Orbiter nose cap, which, when coupled with existing fuselage mounted static pressure ports permits computation of entry flight parameters. Elements of the system that are described include the following: (1) penetration assemblies to place pressure port openings at the surface of the nose cap; (2) pressure tubes to transmit the surface pressure to transducers; (3) support posts or manifolds to provide support for, and reduce the length of, the individual pressure tubes; (4) insulation for the manifolds; and (5) a SEADS nose cap. Design, analyses, and tests to develop and certify design for flight are described. Specific tests included plasma arc exposure, radiant thermal, vibration, and structural. Volume one summarizes highlights of the program, particularly as they relate to the final design of SEADS. Volume two summarizes all of the Vought responsible activities in essentially a chronological order.

Evaluation and implementation of chemotherapy regimen validation in an electronic health record.

PubMed

Diaz, Amber H; Bubalo, Joseph S

2014-12-01

Computerized provider order entry of chemotherapy regimens is quickly becoming the standard for prescribing chemotherapy in both inpatient and ambulatory settings. One of the difficulties with implementation of chemotherapy regimen computerized provider order entry lies in verifying the accuracy and completeness of all regimens built in the system library. Our goal was to develop, implement, and evaluate a process for validating chemotherapy regimens in an electronic health record. We describe our experience developing and implementing a process for validating chemotherapy regimens in the setting of a standard, commercially available computerized provider order entry system. The pilot project focused on validating chemotherapy regimens in the adult inpatient oncology setting and adult ambulatory hematologic malignancy setting. A chemotherapy regimen validation process was defined as a result of the pilot project. Over a 27-week pilot period, 32 chemotherapy regimens were validated using the process we developed. Results of the study suggest that by validating chemotherapy regimens, the amount of time spent by pharmacists in daily chemotherapy review was decreased. In addition, the number of pharmacist modifications required to make regimens complete and accurate were decreased. Both physician and pharmacy disciplines showed improved satisfaction and confidence levels with chemotherapy regimens after implementation of the validation system. Chemotherapy regimen validation required a considerable amount of planning and time but resulted in increased pharmacist efficiency and improved provider confidence and satisfaction. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Stability and Change of Medical Specialty Choice, Wright State University School of Medicine. Classes of 1981 and 1982, Report No. 7 [and] Class of 1981, Report No. 4. Program Evaluation Studies. Occasional Papers.

ERIC Educational Resources Information Center

Markert, Ronald J.

Medical specialty choice and reasons for change among those Wright State University students who switched their choice between entry and graduation were studied, based on questionnaire findings. For the class of 1982, 35 of the 70 students chose as their eventual specialty their preference at entry to medical school. Primary care specialties…

Predicting performance of junior doctors: Association of workplace based assessment with demographic characteristics, emotional intelligence, selection scores, and undergraduate academic performance.

PubMed

Carr, Sandra E; Celenza, Antonio; Mercer, Annette M; Lake, Fiona; Puddey, Ian B

2018-01-21

Predicting workplace performance of junior doctors from before entry or during medical school is difficult and has limited available evidence. This study explored the association between selected predictor variables and workplace based performance in junior doctors during their first postgraduate year. Two cohorts of medical students (n = 200) from one university in Western Australia participated in the longitudinal study. Pearson correlation coefficients and multivariate analyses utilizing linear regression were used to assess the relationships between performance on the Junior Doctor Assessment Tool (JDAT) and its sub-components with demographic characteristics, selection scores for medical school entry, emotional intelligence, and undergraduate academic performance. Grade Point Average (GPA) at the completion of undergraduate studies had the most significant association with better performance on the overall JDAT and each subscale. Increased age was a negative predictor for junior doctor performance on the Clinical management subscale and understanding emotion was a predictor for the JDAT Communication subscale. Secondary school performance measured by Tertiary Entry Rank on entry to medical school score predicted GPA but not junior doctor performance. The GPA as a composite measure of ability and performance in medical school is associated with junior doctor assessment scores. Using this variable to identify students at risk of difficulty could assist planning for appropriate supervision, support, and training for medical graduates transitioning to the workplace.

Case study: a health check-up for the corporate IT department.

PubMed

Clark, Frank; Kimmerly, William

2004-01-01

As advances such as the electronic charting, closed-loop medication safety, physician order entry, consumer portals, electronic collaboration, and wireless access become the norm, central IS organizations are finding it difficult to keep pace. This challenge is exacerbated by declining margins, severe cost pressures, increased regulation, and added public scrutiny. Is your centralized IS organization healthy enough to meet the challenges presented by today's complex, demanding, dynamic healthcare delivery environments? How do you know? What factors do you consider?

Mobile computing acceptance grows as applications evolve.

PubMed

Porn, Louis M; Patrick, Kelly

2002-01-01

Handheld devices are becoming more cost-effective to own, and their use in healthcare environments is increasing. Handheld devices currently are being used for e-prescribing, charge capture, and accessing daily schedules and reference tools. Future applications may include education on medications, dictation, order entry, and test-results reporting. Selecting the right handheld device requires careful analysis of current and future applications, as well as vendor expertise. It is important to recognize the technology will continue to evolve over the next three years.

75 FR 43590 - Self-Regulatory Organizations; Notice of Filing and Immediate Effectiveness of Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-26

... PHLX, Inc. Relating to Order Re-Entry July 20, 2010. Pursuant to section 19(b)(1) of the Securities... a system enhancement that automatically re-enters unexecuted contracts when, after trading at the..., upon the written instruction of the member that initially submitted the order, re-submit unexecuted...

17 CFR Appendix A to Part 37 - Guidance on Compliance With Registration Criteria

Code of Federal Regulations, 2011 CFR

2011-04-01

... facility should include the system's trade-matching algorithm and order entry procedures. A submission involving a trade-matching algorithm that is based on order priority factors other than on a best price/earliest time basis should include a brief explanation of the alternative algorithm. (b) A board of trade's...

17 CFR Appendix A to Part 37 - Guidance on Compliance With Registration Criteria

Code of Federal Regulations, 2012 CFR

2012-04-01

... facility should include the system's trade-matching algorithm and order entry procedures. A submission involving a trade-matching algorithm that is based on order priority factors other than on a best price/earliest time basis should include a brief explanation of the alternative algorithm. (b) A board of trade's...

19 CFR 143.35 - Procedure for electronic entry summary.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 19 Customs Duties 2 2012-04-01 2012-04-01 false Procedure for electronic entry summary. 143.35...; DEPARTMENT OF THE TREASURY (CONTINUED) SPECIAL ENTRY PROCEDURES Electronic Entry Filing § 143.35 Procedure for electronic entry summary. In order to obtain entry summary processing electronically, the filer...

19 CFR 143.35 - Procedure for electronic entry summary.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 19 Customs Duties 2 2011-04-01 2011-04-01 false Procedure for electronic entry summary. 143.35...; DEPARTMENT OF THE TREASURY (CONTINUED) SPECIAL ENTRY PROCEDURES Electronic Entry Filing § 143.35 Procedure for electronic entry summary. In order to obtain entry summary processing electronically, the filer...

19 CFR 143.35 - Procedure for electronic entry summary.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 19 Customs Duties 2 2010-04-01 2010-04-01 false Procedure for electronic entry summary. 143.35...; DEPARTMENT OF THE TREASURY (CONTINUED) SPECIAL ENTRY PROCEDURES Electronic Entry Filing § 143.35 Procedure for electronic entry summary. In order to obtain entry summary processing electronically, the filer...

Current status of cardiovascular surgery in Japan, 2013 and 2014: A report based on the Japan Cardiovascular Surgery Database (JCVSD). 1: Mission and history of JCVSD.

PubMed

Takamoto, Shinichi; Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki

2018-01-01

The Japan Cardiovascular Surgery Database (JCVSD) was created in 2000 with the support of the Society of Thoracic Surgeons (STS). The STS database content was translated to Japanese using the same disease criteria and in 2001, data entry for adult cardiac surgeries was initiated online using the University Hospital Medical Information Network (UMIN). In 2008, data entry for congenital heart surgeries was initiated in the congenital section of JCVSD and preoperative expected mortality (JapanSCORE) in adult cardiovascular surgeries was first calculated using the risk model of JCVSD. The Japan Surgical Board system merged with JCVSD in 2011, and all cardiovascular surgical data were registered in the JCVSD from 2012 onward. The reports resulting from the data analyses of the JCVSD will encourage further improvements in the quality of cardiovascular surgeries, patient safety, and medical care in Japan.

Performance analysis of a proposed tightly-coupled medical instrument network based on CAN protocol.

PubMed

Mujumdar, Shantanu; Thongpithoonrat, Pongnarin; Gurkan, D; McKneely, Paul K; Chapman, Frank M; Merchant, Fatima

2010-01-01

Advances in medical devices and health care has been phenomenal during the recent years. Although medical device manufacturers have been improving their instruments, network connection of these instruments still rely on proprietary technologies. Even if the interface has been provided by the manufacturer (e.g., RS-232, USB, or Ethernet coupled with a proprietary API), there is no widely-accepted uniform data model to access data of various bedside instruments. There is a need for a common standard which allows for internetworking with the medical devices from different manufacturers. ISO/IEEE 11073 (X73) is a standard attempting to unify the interfaces of all medical devices. X73 defines a client access mechanism that would be implemented into the communication controllers (residing between an instrument and the network) in order to access/network patient data. On the other hand, MediCAN™ technology suite has been demonstrated with various medical instruments to achieve interfacing and networking with a similar goal in its open standardization approach. However, it provides a more generic definition for medical data to achieve flexibility for networking and client access mechanisms. The instruments are in turn becoming more sophisticated; however, the operation of an instrument is still expected to be locally done by authorized medical personnel. Unfortunately, each medical instrument has its unique proprietary API (application programming interface - if any) to provide automated and electronic access to monitoring data. Integration of these APIs requires an agreement with the manufacturers towards realization of interoperable health care networking. As long as the interoperability of instruments with a network is not possible, ubiquitous access to patient status is limited only to manual entry based systems. This paper demonstrates an attempt to realize an interoperable medical instrument interface for networking using MediCAN technology suite as an open standard.

Internet and cardiovascular research: the present and its future potentials and limits.

PubMed

2002-03-01

The Internet and the World Wide Web have been proposed as tools to improve medical and cardiovascular research. These new technologies have been mainly applied to large-scale clinical trials, with the development of clinical-trial websites. They include tools for the management of some aspects of clinical trials, such as the dissemination of information on trial progress; randomisation and the monitoring processes; the distribution and accountability of study drugs; and remote data-entry. Several clinical-trial websites have been developed in the cardiovascular field over the last few years, but few have been designed to conduct trials fully online. Advantages of such systems include greater interaction between the coordinating centre and investigators, availability of a clean database in a short time, and cost reduction. Website developers need to take care of security issues and to use security tools (data encryption, firewalls, passwords and electronic signatures) in order to prevent unauthorised users from accessing the system and patient data.

Human Mars Entry, Descent and Landing Architectures Study Overview

NASA Technical Reports Server (NTRS)

Polsgrove, Tara T.; Dwyer Cianciolo, Alicia

2016-01-01

Landing humans on Mars will require entry, descent and landing (EDL) capability beyond the current state of the art. Nearly twenty times more delivered payload and an order of magnitude improvement in precision landing capability will be necessary. Several EDL technologies capable of meeting the human class payload delivery requirements are being considered. The EDL technologies considered include low lift-to-drag vehicles like Hypersonic Inflatable Aerodynamic Decelerators (HIAD), Adaptable Deployable Entry and Placement Technology (ADEPT), and mid range lift-to-drag vehicles like rigid aeroshell configurations. To better assess EDL technology options and sensitivities to future human mission design variations, a series of design studies has been conducted. The design studies incorporate EDL technologies with conceptual payload arrangements defined by the Evolvable Mars Campaign to evaluate the integrated system with higher fidelity than have been performed to date. This paper describes the results of the design studies for a lander design using the HIAD, ADEPT and rigid shell entry technologies and includes system and subsystem design details including mass and power estimates. This paper will review the point design for three entry configurations capable of delivering a 20 t human class payload to the surface of Mars.

A Retrospective Evaluation of Remote Pharmacist Interventions in a Telepharmacy Service Model Using a Conceptual Framework

PubMed Central

Murante, Lori J.; Moffett, Lisa M.

2014-01-01

Abstract Objectives: This retrospective cross-sectional study evaluated a telepharmacy service model using a conceptual framework to compare documented remote pharmacist interventions by year, hospital, and remote pharmacist and across rural hospitals with or without an on-site rural hospital pharmacist. Materials and Methods: Documented remote pharmacist interventions for patients at eight rural hospitals in the Midwestern United States during prospective prescription order review/entry from 2008 to 2011 were extracted from RxFusion® database (a home-grown system, i.e., internally developed program at The Nebraska Medical Center (TNMC) for capturing remote pharmacist-documented intervention data). The study authors conceptualized an analytical framework, mapping the 37 classes of remote pharmacist interventions to three broader-level definitions: (a) intervention, eight categories (interaction/potential interaction, contraindication, adverse effects, anticoagulation monitoring, drug product selection, drug regimen, summary, and recommendation), (b) patient medication management, two categories (therapy review and action), and (c) health system-centered medication use process, four categories (prescribing, transcribing and documenting, administering, and monitoring). Frequencies of intervention levels were compared by year, hospital, remote pharmacist, and hospital pharmacy status (with a remote pharmacist and on-site pharmacist or with a remote pharmacist only) using chi-squared test and univariate logistic regression analyses, as appropriate. Results: For 450,000 prescription orders 19,222 remote pharmacist interventions were documented. Frequency of interventions significantly increased each year (36% in 2009, 55% in 2010, and 7% in 2011) versus the baseline year (2008, 3%) when service started. The frequency of interventions also differed significantly across the eight hospitals and 16 remote pharmacists for the three defined intervention levels and categories. Remote pharmacist interventions at hospitals with an on-site and remote pharmacist (n=12,141) versus those with a remote pharmacist alone (n=7,081) were significantly more likely to be (1) patient-centered, (2) related to “actionable” medication management recommendations (unadjusted odds ratio [OR]=1.12), and (3) related to the “transcribing” (OR=1.47) and “prescribing” (OR=1.40) steps of the health system-centered medication use process level (all p<0.01). Conclusions: This is one of the first studies to demonstrate the patient- and health system-centered nature of pharmaceutical care delivered via a telepharmacy service model by evaluating documented remote pharmacist interventions with an analytical framework. PMID:24611489

77 FR 71185 - Privacy Act of 1974; System of Records

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-29

... dependents.'' Categories of records in the system: Delete entry and replace with ``Name, Social Security..., security clearance, spouse information, child information, military records, military orders and expense... collection of spouse and child information to be used for updates to the military member's dependency status...

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

PubMed

Sethuraman, Usha; Kannikeswaran, Nirupama; Murray, Kyle P; Zidan, Marwan A; Chamberlain, James M

2015-06-01

Prescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates. © 2015 by the Society for Academic Emergency Medicine.

Student manual, Book 2: Orientation to occupational safety compliance in DOE

DOE Office of Scientific and Technical Information (OSTI.GOV)

Colley, D.L.

1993-10-01

This is a student hand-book an Occupational Safety Compliance in DOE. Topics include the following: Electrical; materials handling & storage; inspection responsibilities & procedures; general environmental controls; confined space entry; lockout/tagout; office safety, ergonomics & human factors; medical & first aid, access to records; construction safety; injury/illness reporting system; and accident investigation procedures.

Development of a medical module for disaster information systems.

PubMed

Calik, Elif; Atilla, Rıdvan; Kaya, Hilal; Aribaş, Alirıza; Cengiz, Hakan; Dicle, Oğuz

2014-01-01

This study aims to improve a medical module which provides a real-time medical information flow about pre-hospital processes that gives health care in disasters; transferring, storing and processing the records that are in electronic media and over internet as a part of disaster information systems. In this study which is handled within the frame of providing information flow among professionals in a disaster case, to supply the coordination of healthcare team and transferring complete information to specified people at real time, Microsoft Access database and SQL query language were used to inform database applications. System was prepared on Microsoft .Net platform using C# language. Disaster information system-medical module was designed to be used in disaster area, field hospital, nearby hospitals, temporary inhabiting areas like tent city, vehicles that are used for dispatch, and providing information flow between medical officials and data centres. For fast recording of the disaster victim data, accessing to database which was used by health care professionals was provided (or granted) among analysing process steps and creating minimal datasets. Database fields were created in the manner of giving opportunity to enter new data and search old data which is recorded before disaster. Web application which provides access such as data entry to the database and searching towards the designed interfaces according to the login credentials access level. In this study, homepage and users' interfaces which were built on database in consequence of system analyses were provided with www.afmedinfo.com web site to the user access. With this study, a recommendation was made about how to use disaster-based information systems in the field of health. Awareness has been developed about the fact that disaster information system should not be perceived only as an early warning system. Contents and the differences of the health care practices of disaster information systems were revealed. A web application was developed supplying a link between the user and the database to make date entry and data query practices by the help of the developed interfaces.

“Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention”

PubMed Central

2013-01-01

Background We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers. Methods The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011. Results Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year. Conclusions The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision. PMID:23566021

Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names

PubMed Central

Bryan, Rachel; Aronson, Jeffrey K.; ten Hacken, Pius; Williams, Alison; Jordan, Sue

2015-01-01

Background Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’ lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion. Methods and Findings We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion. Conclusions We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors. PMID:26701761

Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names.

PubMed

Bryan, Rachel; Aronson, Jeffrey K; ten Hacken, Pius; Williams, Alison; Jordan, Sue

2015-01-01

Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and 'Tall Man' lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion. We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion. We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors.

Reducing medication errors and increasing patient safety: case studies in clinical pharmacology.

PubMed

Benjamin, David M

2003-07-01

Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the now politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to "prevention" and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is "an act that through ingnorance, deficiency, or accident departs from or fails to achieve what should be done." What should be done is generally known as "the five rights": the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. "System errors" are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the "safety net" that failed. Examples of reengineering the system to make it more "error proof" are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faculty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.

Inclusion of Medical-Legal Issues in Entry-Level Occupational and Physical Therapy Curricula.

ERIC Educational Resources Information Center

Ekelman, Beth A.; Goodman, Glenn; Dal Bello-Haas, Vanina

2000-01-01

Directors of 47 occupational therapy (OT) and 65 physical therapy (PT) accredited entry-level programs responded to a survey by indicating their support for inclusion of medical-legal issues in the curriculum. Only 40% of OT and 52% of PT directors believed lawyers should deliver instruction; most felt their faculty were qualified to teach these…

Development of a Screening Methodology for Entry into Medical Technical Training Courses. Final Report for Period October 1975-April 1977.

ERIC Educational Resources Information Center

Leisey, Sandra A.; Guinn, Nancy

At the request of the Air Force School of Aviation Medicine, a project was initiated to evaluate the current screening process used for entry into three medical technical training courses: Aeromedical Specialist, Environmental Health Specialist, and Physiological Training Specialist. A sample of 1,003 students were administered the General…

Aeronautical engineering, a special bibliography, September 1971 (supplement 10)

NASA Technical Reports Server (NTRS)

1971-01-01

This supplement to Aeronautical Engineering-A Special Bibliography (NASA SP-7037) lists 413 reports, journal articles, and other documents originally announced in September 1971 in Scientific and Technical Aerospace Reports (STAR) or in International Aerospace Abstracts (IAA). The coverage includes documents on the engineering and theoretical aspects of design, construction, evaluation, testing, operation, and performance of aircraft (including aircraft engines) and associated components, equipment, and systems. It also includes research and development in aerodynamics, aeronautics, and ground support equipment for aeronautical vehicles. Each entry in the bibliography consists of a standard bibliographic citation accompanied by an abstract. The listing of the entries is arranged in two major sections, IAA Entries and STAR Entries in that order. The citations and abstracts are reproduced exactly as they appeared originally in IAA or STAR, including the original accession numbers from the respective announcement journals.

Measuring value for money: a scoping review on economic evaluation of health information systems

PubMed Central

Bassi, Jesdeep; Lau, Francis

2013-01-01

Objective To explore how key components of economic evaluations have been included in evaluations of health information systems (HIS), to determine the state of knowledge on value for money for HIS, and provide guidance for future evaluations. Materials and methods We searched databases, previously collected papers, and references for relevant papers published from January 2000 to June 2012. For selection, papers had to: be a primary study; involve a computerized system for health information processing, decision support, or management reporting; and include an economic evaluation. Data on study design and economic evaluation methods were extracted and analyzed. Results Forty-two papers were selected and 33 were deemed high quality (scores ≥8/10) for further analysis. These included 12 economic analyses, five input cost analyses, and 16 cost-related outcome analyses. For HIS types, there were seven primary care electronic medical records, six computerized provider order entry systems, five medication management systems, five immunization information systems, four institutional information systems, three disease management systems, two clinical documentation systems, and one health information exchange network. In terms of value for money, 23 papers reported positive findings, eight were inconclusive, and two were negative. Conclusions We found a wide range of economic evaluation papers that were based on different assumptions, methods, and metrics. There is some evidence of value for money in selected healthcare organizations and HIS types. However, caution is needed when generalizing these findings. Better reporting of economic evaluation studies is needed to compare findings and build on the existing evidence base we identified. PMID:23416247

Information Technologies in Education of Medical Students at the University of Sarajevo

PubMed Central

Masic, Izet; Karcic, Emina; Hodzic, Ajla; Mulic, Smaila

2014-01-01

Introduction: Information and communication technology have brought about many changes in medical education and practice, especially in the field of diagnostics. During the academic year 2013/2014, at Faculty of Medicine, University of Sarajevo, students in the final year of the study were subjected to examination which aim was to determine how medical students in Bosnia and Herzegovina subjectively assessing their skills for using computers, have gained insight into the nature of Information Technology’s (IT) education and possessive knowledge. Material and methods: The survey was conducted voluntary by anonymous questionnaire consisting of 27 questions, divided into five categories, which are collecting facts about student’s: sex, age, year of entry, computer skills, possessing the same, the use of the Internet, the method of obtaining currently knowledge and recommendations of students in order to improve their IT training. Results of the study: According to the given parameters, indicate an obvious difference in the level of knowledge, use and practical application of Information Technology’s knowledge among students of the Bologna process to the students educated under the old system in favor of the first ones. Based on a comparison of similar studies conducted in Croatia, Sri Lanka, Pakistan and Denmark, it was observed that the level of knowledge of students of the Medical Faculty in Sarajevo was of equal height or greater than in these countries. PMID:25395722

76 FR 30417 - Self-Regulatory Organizations; NYSE Arca, Inc.; Notice of Filing and Immediate Effectiveness of...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-25

... Change Amending Rule 7.31(h)(5) To Reduce the Minimum Order Entry Size of a Mid-Point Passive Liquidity... order entry size of a Mid-Point Passive Liquidity Order (``MPL Order'') from 100 shares to one share...

[Information system in the cardio polyclinic].

PubMed

Mihajlović, Marina; Zivković, Marija

2014-03-01

The cardiologic polyclinic information system ensures effective management of business processes in the polyclinic. Medical nurse provides health care to a patient with the support of the information system, which enables recording the patient's identity, admission, participation fee charges, billing for the services provided, patients' orders for noninvasive diagnostic methods, and implementation of diagnostic methods. The nurse enters patient's personal information at every work station, updates the existing records, and has an opportunity to add notes and insights to the results of patient's diagnostic tests and doctors' opinions for patients in the polyclinic. Additionally, the nurse records the services and supplies provided, and these entries are used for billing and service charges. This information is accessible at every work station to authorized persons exclusively. The implementation of the information system enables medical nurses working at the reception desk and in nurses' consulting room to record administrative data and data related to diagnostic analysis at the moment and at the place they happen. A personal password is required to access these data. In this way, the patient admission recording is facilitated, and in case the patient needs to be contacted, communication with him/her is improved, and finally, writing reports and data analysis are simplified. Apart from the advantages, there also are problems such as inadequate staff education and insufficient reliability of the information infrastructure, which if overloaded, can slow down the system, and this is time consuming for both health workers and patients.

Attitudes towards statistics of graduate entry medical students: the role of prior learning experiences

PubMed Central

2014-01-01

Background While statistics is increasingly taught as part of the medical curriculum, it can be an unpopular subject and feedback from students indicates that some find it more difficult than other subjects. Understanding attitudes towards statistics on entry to graduate entry medical programmes is particularly important, given that many students may have been exposed to quantitative courses in their previous degree and hence bring preconceptions of their ability and interest to their medical education programme. The aim of this study therefore is to explore, for the first time, attitudes towards statistics of graduate entry medical students from a variety of backgrounds and focus on understanding the role of prior learning experiences. Methods 121 first year graduate entry medical students completed the Survey of Attitudes toward Statistics instrument together with information on demographics and prior learning experiences. Results Students tended to appreciate the relevance of statistics in their professional life and be prepared to put effort into learning statistics. They had neutral to positive attitudes about their interest in statistics and their intellectual knowledge and skills when applied to it. Their feelings towards statistics were slightly less positive e.g. feelings of insecurity, stress, fear and frustration and they tended to view statistics as difficult. Even though 85% of students had taken a quantitative course in the past, only 24% of students described it as likely that they would take any course in statistics if the choice was theirs. How well students felt they had performed in mathematics in the past was a strong predictor of many of the components of attitudes. Conclusion The teaching of statistics to medical students should start with addressing the association between students’ past experiences in mathematics and their attitudes towards statistics and encouraging students to recognise the difference between the two disciplines. Addressing these issues may reduce students’ anxiety and perception of difficulty at the start of their learning experience and encourage students to engage with statistics in their future careers. PMID:24708762

Attitudes towards statistics of graduate entry medical students: the role of prior learning experiences.

PubMed

Hannigan, Ailish; Hegarty, Avril C; McGrath, Deirdre

2014-04-04

While statistics is increasingly taught as part of the medical curriculum, it can be an unpopular subject and feedback from students indicates that some find it more difficult than other subjects. Understanding attitudes towards statistics on entry to graduate entry medical programmes is particularly important, given that many students may have been exposed to quantitative courses in their previous degree and hence bring preconceptions of their ability and interest to their medical education programme. The aim of this study therefore is to explore, for the first time, attitudes towards statistics of graduate entry medical students from a variety of backgrounds and focus on understanding the role of prior learning experiences. 121 first year graduate entry medical students completed the Survey of Attitudes toward Statistics instrument together with information on demographics and prior learning experiences. Students tended to appreciate the relevance of statistics in their professional life and be prepared to put effort into learning statistics. They had neutral to positive attitudes about their interest in statistics and their intellectual knowledge and skills when applied to it. Their feelings towards statistics were slightly less positive e.g. feelings of insecurity, stress, fear and frustration and they tended to view statistics as difficult. Even though 85% of students had taken a quantitative course in the past, only 24% of students described it as likely that they would take any course in statistics if the choice was theirs. How well students felt they had performed in mathematics in the past was a strong predictor of many of the components of attitudes. The teaching of statistics to medical students should start with addressing the association between students' past experiences in mathematics and their attitudes towards statistics and encouraging students to recognise the difference between the two disciplines. Addressing these issues may reduce students' anxiety and perception of difficulty at the start of their learning experience and encourage students to engage with statistics in their future careers.

Renal Drug Dosing

PubMed Central

Vogel, Erin A.; Billups, Sarah J.; Herner, Sheryl J.

2016-01-01

Summary Objective The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists. Methods This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient’s renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period. Results During the pharmacist- and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist- and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall). Conclusions Prescriber- and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS. PMID:27466041

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

PubMed

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2012-12-01

Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Mechanical Testing of Carbon Based Woven Thermal Protection Materials

NASA Technical Reports Server (NTRS)

Pham, John; Agrawal, Parul; Arnold, James O.; Peterson, Keith; Venkatapathy, Ethiraj

2013-01-01

Three Dimensional Woven thermal protection system (TPS) materials are one of the enabling technologies for mechanically deployable hypersonic decelerator systems. These materials have been shown capable of serving a dual purpose as TPS and as structural load bearing members during entry and descent operations. In order to ensure successful structural performance, it is important to characterize the mechanical properties of these materials prior to and post exposure to entry-like heating conditions. This research focuses on the changes in load bearing capacity of woven TPS materials after being subjected to arcjet simulations of entry heating. Preliminary testing of arcjet tested materials [1] has shown a mechanical degradation. However, their residual strength is significantly more than the requirements for a mission to Venus [2]. A systematic investigation at the macro and microstructural scales is reported here to explore the potential causes of this degradation. The effects of heating on the sizing (an epoxy resin coating used to reduce friction and wear during fiber handling) are discussed as one of the possible causes for the decrease in mechanical properties. This investigation also provides valuable guidelines for margin policies for future mechanically deployable entry systems.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service.

PubMed

Laing, G L; Bruce, J L; Skinner, D L; Allorto, N L; Clarke, D L; Aldous, C

2014-06-01

The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS). Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death). A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high. It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.

The Toxicology Investigators Consortium Case Registry--the 2012 experience.

PubMed

Wiegand, Timothy; Wax, Paul; Smith, Eric; Hart, Katherine; Brent, Jeffrey

2013-12-01

In 2010, the American College of Medical Toxicology (ACMT) established its Case Registry, the Toxicology Investigators Consortium (ToxIC). All cases are entered prospectively and include only suspected and confirmed toxic exposures cared for at the bedside by board-certified or board-eligible medical toxicologists at its participating sites. The primary aims of establishing this Registry include the development of a realtime toxico-surveillance system in order to identify and describe current or evolving trends in poisoning and to develop a research tool in toxicology. ToxIC allows for extraction of data from medical records from multiple sites across a national and international network. All cases seen by medical toxicologists at participating institutions were entered into the database. Information characterizing patients entered in 2012 was tabulated and data from the previous years including 2010 and 2011 were included so that cumulative numbers and trends could be described as well. The current report includes data through December 31st, 2012. During 2012, 38 sites with 68 specific institutions contributed a total of 7,269 cases to the Registry. The total number of cases entered into the Registry at the end of 2012 was 17,681. Emergency departments remained the most common source of consultation in 2012, accounting for 61 % of cases. The most common reason for consultation was for pharmaceutical overdose, which occurred in 52 % of patients including intentional (41 %) and unintentional (11 %) exposures. The most common classes of agents were sedative-hypnotics (1,422 entries in 13 % of cases) non-opioid analgesics (1,295 entries in 12 % of cases), opioids (1,086 entries in 10 % of cases) and antidepressants (1,039 entries in 10 % of cases). N-acetylcysteine (NAC) was the most common antidote administered in 2012, as it was in previous years, followed by the opioid antagonist naloxone, sodium bicarbonate, physostigmine and flumazenil. Anti-crotalid Fab fragments were administered in 109 cases or 82 % of cases in which a snake envenomation occurred. There were 57 deaths reported in the Registry in 2012. The most common associated agent alone or in combination was the non-opioid analgesic acetaminophen, being reported in 10 different cases. Other common agents and agent classes involved in death cases included ethanol, opioids, the anti-diabetic agent metformin, sedatives-hypnotics and cardiovascular agents, in particular amlodipine. There were significant trends identified during 2012. Abuse of over-the-counter medications such as dextromethorphan remains prevalent. Cases involving dextromethorphan continued to be reported at frequencies higher than other commonly abused drugs including many stimulants, phencyclidine, synthetic cannabinoids and designer amphetamines such as bath salts. And, while cases involving synthetic cannabinoids and psychoactive bath salts remained relatively constant from 2011 to 2012 several designer amphetamines and novel psychoactive substances were first reported in the Registry in 2012 including the NBOME compounds or "N-bomb" agents. LSD cases also spiked dramatically in 2012 with an 18-fold increase from 2011 although many of these cases are thought to be ultra-potent designer amphetamines misrepresented as "synthetic" LSD. The 2012 Registry included over 400 Adverse Drug Reactions (ADRs) involving 4 % of all Registry cases with 106 agents causing at least 2 ADRs. Additional data including supportive cares, decontamination, and chelating agent use are also included in the 2012 annual report. The Registry remains a valuable toxico-surveillance and research tool. The ToxIC Registry is a unique tool for identifying and characterizing confirmed cases of significant or potential toxicity or complexity to require bedside care by a medical toxicologist.

Engineering the electronic health record for safety: a multi-level video-based approach to diagnosing and preventing technology-induced error arising from usability problems.

PubMed

Borycki, Elizabeth M; Kushniruk, Andre W; Kuwata, Shigeki; Kannry, Joseph

2011-01-01

Electronic health records (EHRs) promise to improve and streamline healthcare through electronic entry and retrieval of patient data. Furthermore, based on a number of studies showing their positive benefits, they promise to reduce medical error and make healthcare safer. However, a growing body of literature has clearly documented that if EHRS are not designed properly and with usability as an important goal in their design, rather than reducing error, EHR deployment has the potential to actually increase medical error. In this paper we describe our approach to engineering (and reengineering) EHRs in order to increase their beneficial potential while at the same time improving their safety. The approach described in this paper involves an integration of the methods of usability analysis with video analysis of end users interacting with EHR systems and extends the evaluation of the usability of EHRs to include the assessment of the impact of these systems on work practices. Using clinical simulations, we analyze human-computer interaction in real healthcare settings (in a portable, low-cost and high fidelity manner) and include both artificial and naturalistic data collection to identify potential usability problems and sources of technology-induced error prior to widespread system release. Two case studies where the methods we have developed and refined have been applied at different levels of user-computer interaction are described.

MedRapid--medical community & business intelligence system.

PubMed

Finkeissen, E; Fuchs, H; Jakob, T; Wetter, T

2002-01-01

currently, it takes at least 6 months for researchers to communicate their results. This delay is caused (a) by partial lacks of machine support for both representation as well as communication and (b) by media breaks during the communication process. To make an integrated communication between researchers and practitioners possible, a general structure for medical content representation has been set up. The procedure for data entry and quality management has been generalized and implemented in a web-based authoring system. The MedRapid-system supports the medical experts in entering their knowledge into a database. Here, the level of detail is still below that of current medical guidelines representation. However, the symmetric structure for an area-wide medical knowledge representation is highly retrievable and thus can quickly be communicated into daily routine for the improvement of the treatment quality. In addition, other sources like journal articles and medical guidelines can be references within the MedRapid-system and thus be communicated into daily routine. The fundamental system for the representation of medical reference knowledge (from reference works/books) itself is not sufficient for the friction-less communication amongst medical staff. Rather, the process of (a) representing medical knowledge, (b) refereeing the represented knowledge, (c) communicating the represented knowledge, and (d) retrieving the represented knowledge has to be unified. MedRapid will soon support the whole process on one server system.

Data quality in a DRG-based information system.

PubMed

Colin, C; Ecochard, R; Delahaye, F; Landrivon, G; Messy, P; Morgon, E; Matillon, Y

1994-09-01

The aim of this study initiated in May 1990 was to evaluate the quality of the medical data collected from the main hospital of the "Hospices Civils de Lyon", Edouard Herriot Hospital. We studied a random sample of 593 discharge abstracts from 12 wards of the hospital. Quality control was performed by checking multi-hospitalized patients' personal data, checking that each discharge abstract was exhaustive, examining the quality of abstracting, studying diagnoses and medical procedures coding, and checking data entry. Assessment of personal data showed a 4.4% error rate. It was mainly accounted for by spelling mistakes in surnames and first names, and mistakes in dates of birth. The quality of a discharge abstract was estimated according to the two purposes of the medical information system: description of hospital morbidity per patient and Diagnosis Related Group's case mix. Error rates in discharge abstracts were expressed in two ways: an overall rate for errors of concordance between Discharge Abstracts and Medical Records, and a specific rate for errors modifying classification in Diagnosis Related Groups (DRG). For abstracting medical information, these error rates were 11.5% (SE +/- 2.2) and 7.5% (SE +/- 1.9) respectively. For coding diagnoses and procedures, they were 11.4% (SE +/- 1.5) and 1.3% (SE +/- 0.5) respectively. For data entry on the computerized data base, the error rate was 2% (SE +/- 0.5) and 0.2% (SE +/- 0.05). Quality control must be performed regularly because it demonstrates the degree of participation from health care teams and the coherence of the database.(ABSTRACT TRUNCATED AT 250 WORDS)

Timing of entry to care by newly diagnosed HIV cases before and after the 2010 New York State HIV testing law.

PubMed

Gordon, Daniel E; Bian, Fuqin; Anderson, Bridget J; Smith, Lou C

2015-01-01

Prompt entry to care after HIV diagnosis benefits the infected individual and reduces the likelihood of further transmission of the virus. The New York State HIV Testing Law of 2010 requires diagnosing providers to refer persons newly diagnosed with HIV to follow-up medical care. This study used routinely collected HIV-related laboratory data from the New York State HIV surveillance system to assess whether the fraction of newly diagnosed cases entering care within 90 days of diagnosis increased after the implementation of the law. Laboratory data on 23,302 newly diagnosed cases showed that entry to care within 90 days rose steadily from 72.0% in 2007 to 85.4% in 2012. The rise was observed across all race/ethnic groups, ages, transmission risk groups, sexes, and regions of residence. Logistic regression analyses of entry to care pre-law and post-law, controlling for demographic characteristics, transmission risk, and geographic area, indicate that percentage of newly diagnosed cases entering care within 90 days grew more rapidly in the post-law period. This is consistent with a positive effect of the law on entry to care.

42 CFR 35.13 - Entry for negotiation of release or settlement.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 1 2011-10-01 2011-10-01 false Entry for negotiation of release or settlement. 35.13 Section 35.13 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND STATION MANAGEMENT General § 35.13 Entry for negotiation of release...

42 CFR 35.13 - Entry for negotiation of release or settlement.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 1 2013-10-01 2013-10-01 false Entry for negotiation of release or settlement. 35.13 Section 35.13 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND STATION MANAGEMENT General § 35.13 Entry for negotiation of release...

42 CFR 35.13 - Entry for negotiation of release or settlement.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Entry for negotiation of release or settlement. 35.13 Section 35.13 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND STATION MANAGEMENT General § 35.13 Entry for negotiation of release...

42 CFR 35.13 - Entry for negotiation of release or settlement.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 1 2012-10-01 2012-10-01 false Entry for negotiation of release or settlement. 35.13 Section 35.13 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND STATION MANAGEMENT General § 35.13 Entry for negotiation of release...

42 CFR 35.13 - Entry for negotiation of release or settlement.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 1 2014-10-01 2014-10-01 false Entry for negotiation of release or settlement. 35.13 Section 35.13 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND STATION MANAGEMENT General § 35.13 Entry for negotiation of release...

Clinical decision support provided within physician order entry systems: a systematic review of features effective for changing clinician behavior.

PubMed

Kawamoto, Kensaku; Lobach, David F

2003-01-01

Computerized physician order entry (CPOE) systems represent an important tool for providing clinical decision support. In undertaking this systematic review, our objective was to identify the features of CPOE-based clinical decision support systems (CDSSs) most effective at modifying clinician behavior. For this review, two independent reviewers systematically identified randomized controlled trials that evaluated the effectiveness of CPOE-based CDSSs in changing clinician behavior. Furthermore, each included study was assessed for the presence of 14 CDSS features. We screened 10,023 citations and included 11 studies. Of the 10 studies comparing a CPOE-based CDSS intervention against a non-CDSS control group, 7 reported a significant desired change in professional practice. Moreover, meta-regression analysis revealed that automatic provision of the decision support was strongly associated with improved professional practice (adjusted odds ratio, 23.72; 95% confidence interval, 1.75-infiniti). Thus, we conclude that automatic provision of decision support is a critical feature of successful CPOE-based CDSS interventions.

5. DETAIL VIEW OF ADMINISTRATION BUILDING SHOWING PRINCIPAL, EAST, ENTRY. ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

5. DETAIL VIEW OF ADMINISTRATION BUILDING SHOWING PRINCIPAL, EAST, ENTRY. VIEW TO WEST. - VA Medical Center, Aspinwall Division, Administration Building, 5103 Delafield Avenue, Aspinwall, Allegheny County, PA

Electronic security device

DOEpatents

Eschbach, E.A.; LeBlanc, E.J.; Griffin, J.W.

1992-03-17

The present invention relates to a security device having a control box containing an electronic system and a communications loop over which the system transmits a signal. The device is constructed so that the communications loop can extend from the control box across the boundary of a portal such as a door into a sealed enclosure into which access is restricted whereby the loop must be damaged or moved in order for an entry to be made into the enclosure. The device is adapted for detecting unauthorized entries into such enclosures such as rooms or containers and for recording the time at which such entries occur for later reference. Additionally, the device detects attempts to tamper or interfere with the operation of the device itself and records the time at which such events take place. In the preferred embodiment, the security device includes a microprocessor-based electronic system and a detection module capable of registering changes in the voltage and phase of the signal transmitted over the loop. 11 figs.

Electronic security device

DOEpatents

Eschbach, Eugene A.; LeBlanc, Edward J.; Griffin, Jeffrey W.

1992-01-01

The present invention relates to a security device having a control box (12) containing an electronic system (50) and a communications loop (14) over which the system transmits a signal. The device is constructed so that the communications loop can extend from the control box across the boundary of a portal such as a door into a sealed enclosure into which access is restricted whereby the loop must be damaged or moved in order for an entry to be made into the enclosure. The device is adapted for detecting unauthorized entries into such enclosures such as rooms or containers and for recording the time at which such entries occur for later reference. Additionally, the device detects attempts to tamper or interfere with the operation of the device itself and records the time at which such events take place. In the preferred embodiment, the security device includes a microprocessor-based electronic system (50) and a detection module (72) capable of registering changes in the voltage and phase of the signal transmitted over the loop.

78 FR 9749 - Self-Regulatory Organizations; EDGA Exchange, Inc.; Notice of Filing and Immediate Effectiveness...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-11

... physical port that connects to the Exchange's System via 1 gigabyte Fiber circuits; and $1,000 per physical port that connects to the Exchange's System via 10 gigabyte Fiber circuits. In addition, the Exchange...-Members to connect to the Exchange's System \\5\\ for order entry and the receipt of Exchange data, among...

78 FR 9763 - Self-Regulatory Organizations; EDGX Exchange, Inc.; Notice of Filing and Immediate Effectiveness...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-11

... physical port that connects to the Exchange's System via 1 gigabyte Fiber circuits; and $1,000 per physical port that connects to the Exchange's System via 10 gigabyte Fiber circuits. In addition, the Exchange...-Members to connect to the Exchange's System \\5\\ for order entry and the receipt of Exchange data, among...

Automation of Command and Data Entry in a Glovebox Work Volume: An Evaluation of Data Entry Devices

NASA Technical Reports Server (NTRS)

Steele, Marianne K.; Nakamura, Gail; Havens, Cindy; LeMay, Moira

1996-01-01

The present study was designed to examine the human-computer interface for data entry while performing experimental procedures within a glovebox work volume in order to make a recommendation to the Space Station Biological Research Project for a data entry system to be used within the Life Sciences Glovebox. Test subjects entered data using either a manual keypad, similar to a standard computer numerical keypad located within the glovebox work volume, or a voice input system using a speech recognition program with a microphone headset. Numerical input and commands were programmed in an identical manner between the two systems. With both electronic systems, a small trackball was available within the work volume for cursor control. Data, such as sample vial identification numbers, sample tissue weights, and health check parameters of the specimen, were entered directly into procedures that were electronically displayed on a video monitor within the glovebox. A pen and paper system with a 'flip-chart' format for procedure display, similar to that currently in use on the Space Shuttle, was used as a baseline data entry condition. Procedures were performed by a single operator; eight test subjects were used in the study. The electronic systems were tested under both a 'nominal' or 'anomalous' condition. The anomalous condition was introduced into the experimental procedure to increase the probability of finding limitations or problems with human interactions with the electronic systems. Each subject performed five test runs during a test day: two procedures each with voice and keypad, one with and one without anomalies, and one pen and paper procedure. The data collected were both quantitative (times, errors) and qualitative (subjective ratings of the subjects).

Community of Learners: Charting Learning in First Year Graduate Entry Medical Students during Problem-Based Learning (PBL) Study

ERIC Educational Resources Information Center

Orsmond, Paul; Zvauya, R.

2015-01-01

This study considers social learning practices within and outside the overt curriculum. A thematic approach was used to analyse data from six focus group interviews with 11 graduate entry medical students from a UK university over a year of study. The results indicate that: (1) during their first year of study students form a community of learning…

Exam Success at Undergraduate and Graduate-Entry Medical Schools: Is Learning Style or Learning Approach More Important? A Critical Review Exploring Links Between Academic Success, Learning Styles, and Learning Approaches Among School-Leaver Entry ("Traditional") and Graduate-Entry ("Nontraditional") Medical Students.

PubMed

Feeley, Anne-Marie; Biggerstaff, Deborah L

2015-01-01

PHENOMENON: The literature on learning styles over many years has been replete with debate and disagreement. Researchers have yet to elucidate exactly which underlying constructs are measured by the many learning styles questionnaires available. Some academics question whether learning styles exist at all. When it comes to establishing the value of learning styles for medical students, a further issue emerges. The demographics of medical students in the United Kingdom have changed in recent years, so past studies may not be applicable to students today. We wanted to answer a very simple, practical question: what can the literature on learning styles tell us that we can use to help today's medical students succeed academically at medical school? We conducted a literature review to synthesise the available evidence on how two different aspects of learning-the way in which students like to receive information in a learning environment (termed learning "styles") and the motivations that drive their learning (termed learning "approaches")-can impact on medical students' academic achievement. Our review confirms that although learning "styles" do not correlate with exam performance, learning "approaches" do: those with "strategic" and "deep" approaches to learning (i.e., motivated to do well and motivated to learn deeply respectively) perform consistently better in medical school examinations. Changes in medical school entrant demographics in the past decade have not altered these correlations. Optimistically, our review reveals that students' learning approaches can change and more adaptive approaches may be learned. Insights: For educators wishing to help medical students succeed academically, current evidence demonstrates that helping students develop their own positive learning approach using "growth mind-set" is a more effective (and more feasible) than attempting to alter students' learning styles. This conclusion holds true for both "traditional" and graduate-entry medical students.

Who wants to be a surgeon? Patterns of medical student career choice.

PubMed

Shirley, Otis C; Addison, Ben; Poole, Phillippa

2014-11-07

NZ needs a surgical workforce with the capacity to meet the increasing health demands of an aging population. This study determined longitudinal patterns of medical student interest in a surgical career and factors influencing that choice. We studied medical students entering the Auckland medical programme from 2006-2008 who completed an entry and exit questionnaire on career intentions. Four notional groups were created, depending on the level of interest at entry and at exit. Demographic factors for each category were compared. Analysis of influencing factors was also undertaken. Of 488 students, 310 (64%) completed both an entry and exit questionnaire. Over 50% of students had a strong interest in a surgical career at entry, dropping to 26% at exit. The 'Never Evers' (No interest at entry /No interest at exit) made up 39%,'Divergers' (Strong/No) 35%, 'Die Hards' (Strong/Strong) 18%, and 'Convertibles' (No/Strong) 8%. Less interest in a surgical career was seen among female (P=0.001) and older students (P=0.017). Influencing factors differentiating the 'Die Hards' from the 'Divergers' were work hours and flexibility (less influence among 'Die Hards'), with procedural nature and consultants/mentors (higher). There is a significant reduction in interest in a surgical career over the course of the undergraduate programme, especially among female and older students. Yet the level appears sufficient for available training places. Consultant role models are an important career influence. Lack of flexibility in work and training programmes continue to provide challenges in creating a diverse surgical workforce.

HPV vaccination: Pilot study assessing characteristics of high and low performing primary care offices.

PubMed

Lollier, Allison; Rodriguez, Elisa M; Saad-Harfouche, Frances G; Widman, Christy A; Mahoney, Martin C

2018-06-01

This pilot study was undertaken to identify characteristics and approaches (e.g., social, behavioral, and/or systems factors) which differentiate primary care medical offices achieving higher rates of HPV vaccination. Eligible primary care practice sites providing care to adolescent patients were recruited within an eight county region of western New York State between June 2016 and July 2016. Practice sites were categorized as higher (n = 3) or lower performing (n = 2) based on three dose series completion rates for HPV vaccinations among females aged 13-17 years. Interviewer administered surveys were completed with office staff (n = 37) and focused on understanding approaches to adolescent vaccination. Results were summarized using basic descriptive statistics. Higher performing offices reported more full-time clinical staff (median = 25 vs. 9.5 in lower performing clinics), larger panels of patients ages 11-17 years (median = 3541 vs. 925) and completion of NYSIIS data entry within two weeks of vaccination. (less than a month vs. two). Staff in higher performing offices reviewed medical charts prior to scheduled visits (100% vs. 50) and identified their office vaccine champion as a physician and/or a nurse manager (75% vs. 22%). Also, staffs from higher performing offices were more likely to report the combination of having an office vaccine champion, previewing charts and using standing orders. These preliminary findings support future research examining implementation of organizational processes including identifying a vaccine champion, using standing orders and previewing medical charts prior to office visits as strategies to increase rates of HPV vaccination in primary care offices.

Aerodynamic Interactions of Propulsive Deceleration and Reaction Control System Jets on Mars-Entry Aeroshells

NASA Astrophysics Data System (ADS)

Alkandry, Hicham

Future missions to Mars, including sample-return and human-exploration missions, may require alternative entry, descent, and landing technologies in order to perform pinpoint landing of heavy vehicles. Two such alternatives are propulsive deceleration (PD) and reaction control systems (RCS). PD can slow the vehicle during Mars atmospheric descent by directing thrusters into the incoming freestream. RCS can provide vehicle control and steering by inducing moments using thrusters on the hack of the entry capsule. The use of these PD and RCS jets, however, involves complex flow interactions that are still not well understood. The fluid interactions induced by PD and RCS jets for Mars-entry vehicles in hypersonic freestream conditions are investigated using computational fluid dynamics (CFD). The effects of central and peripheral PD configurations using both sonic and supersonic jets at various thrust conditions are examined in this dissertation. The RCS jet is directed either parallel or transverse to the freestream flow at different thrust conditions in order to examine the effects of the thruster orientation with respect to the center of gravity of the aeroshell. The physical accuracy of the computational method is also assessed by comparing the numerical results with available experimental data. The central PD configuration decreases the drag force acting on the entry capsule due to a shielding effect that prevents mass and momentum in the hypersonic freestream from reaching the aeroshell. The peripheral PD configuration also decreases the drag force by obstructing the flow around the aeroshell and creating low surface pressure regions downstream of the PD nozzles. The Mach number of the PD jets, however, does not have a significant effect on the induced fluid interactions. The reaction control system also alters the flowfield, surface, and aerodynamic properties of the aeroshell, while the jet orientation can have a significant effect on the control effectiveness of the RCS.

Impact of a Graduate Entry Programme on a medical school library service.

PubMed

Martin, Sam

2003-03-01

The aim of this study was to compare the use of library facilities by first year undergraduate medical students and Graduate Entry Programme students (GEP). More specifically it tried to determine which library services (if any) were more frequently used by GEP so that this could be taken into account in future Information Services planning. A questionnaire on the use of Library and Information Services was posted to all first year GEP students and undergraduates on the 5-year course. In addition, user statistics of library entry and borrowing were collated from gate readings and the library Unicorn management system. Overall, GEP students were found to make a greater daily/weekly use of library facilities than undergraduates on the 5-year course. The facilities most used by both sets of students were essential texts, e-mail, PCs and study facilities. Computer Aided Learning packages, journals and video facilities were least used. However, on a daily/weekly basis GEP students made 74% more use of journals (P < 0.01), 59% more use of e-journals (P < 0.05), 36% more use photocopiers (P < 0.05), 42% more use of printers (P < 0.05), 56% more use of the library catalogue (P < 0.05) and 50% more use of databases (P < 0.05). This difference in use should be taken into account by LIS providers as there is expected to be an increase in fast-track graduate courses offered by medical schools throughout the UK.

Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6.

PubMed

Mathers, Jonathan; Sitch, Alice; Marsh, Jennifer L; Parry, Jayne

2011-02-22

To determine whether new programmes developed to widen access to medicine in the United Kingdom have produced more diverse student populations. Population based cross sectional analysis. 31 UK universities that offer medical degrees. 34,407 UK medical students admitted to university in 2002-6. Age, sex, socioeconomic status, and ethnicity of students admitted to traditional courses and newer courses (graduate entry courses (GEC) and foundation) designed to widen access and increase diversity. The demographics of students admitted to foundation courses were markedly different from traditional, graduate entry, and pre-medical courses. They were less likely to be white and to define their background as higher managerial and professional. Students on the graduate entry programme were older than students on traditional courses (25.5 v 19.2 years) and more likely to be white (odds ratio 3.74, 95% confidence interval 3.27 to 4.28; P<0.001) than those on traditional courses, but there was no difference in the ratio of men. Students on traditional courses at newer schools were significantly older by an average of 2.53 (2.41 to 2.65; P<0.001) years, more likely to be white (1.55, 1.41 to 1.71; P<0.001), and significantly less likely to have higher managerial and professional backgrounds than those at established schools (0.67, 0.61 to 0.73; P<0.001). There were marked differences in demographics across individual established schools offering both graduate entry and traditional courses. The graduate entry programmes do not seem to have led to significant changes to the socioeconomic profile of the UK medical student population. Foundation programmes have increased the proportion of students from under-represented groups but numbers entering these courses are small.

Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds.

PubMed

Miller, Daniel F; Fortier, Christopher R; Garrison, Kelli L

2011-02-01

Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors. To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR). Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted. Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time. BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology. © 2011 SAGE Publications.

A Cross-site Qualitative Study of Physician Order Entry

PubMed Central

Ash, Joan S.; Gorman, Paul N.; Lavelle, Mary; Payne, Thomas H.; Massaro, Thomas A.; Frantz, Gerri L.; Lyman, Jason A.

2003-01-01

Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals. Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data. Measurements: Patterns and themes concerning perceptions of POE were identified. Results: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions. Conclusion: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied. PMID:12595408

Hospital pharmacy practice in Saudi Arabia: Prescribing and transcribing in the Riyadh region

PubMed Central

Alsultan, Mohammed S.; Khurshid, Fowad; Salamah, Heba J.; Mayet, Ahmed Y.; Al-jedai, Ahmed H.

2011-01-01

Purpose The purpose of this survey is to outline pharmacy services in hospitals on a regional level in the Kingdom of Saudi Arabia. Methods A modified-American Society of Health-System Pharmacists (ASHP) survey questionnaire as pertinent to Saudi Arabia was used to conduct a national survey. After discussing with the pharmacy directors of 48 hospitals in the Riyadh region over the phone on the survey’s purpose, the questionnaires were personally delivered and collected upon completion. The hospital lists were drawn from the Ministry of Health hospital database. Results Twenty-nine hospitals participated in the survey giving a response rate of 60.4%. Approximately 60% of the hospitals which participated in the survey required prior approval for the use of non-formulary medications. About 83.3% of hospitals reviewed compliance with clinical practice guidelines and 72.7% hospitals reported that pharmacists are also actively involved in these activities. Pharmacists in more than 95% of hospitals provided consultations on drug information. A staff pharmacist routinely answering questions was the most frequently cited (74.1%) method by which objective drug information was provided to prescribers. Electronic drug information resources were available in 77.7% of hospitals, although internet use is not widely available to hospital pharmacists, with only 58.6% of hospitals providing pharmacist access to the internet. About, 34.5% of hospitals had computerized prescriber order entry (CPOE) systems with clinical decision-support systems (CDSSs) and 51.9% of the hospitals had electronic medical record (EMR) system. Conclusion Hospital pharmacists are increasingly using electronic technologies to improve prescribing and transcribing of medications in Saudi Arabia. PMID:23960794

Effectiveness of a real-time clinical decision support system for computerized physician order entry of plasma orders.

PubMed

Yazer, Mark H; Triulzi, Darrell J; Reddy, Vivek; Waters, Jonathan H

2013-12-01

We investigated the effect of implementing adaptive plasma ordering criteria in the computerized physician order entry (CPOE) system, with alerts that were automatically generated if the recipient's antecedent international normalized ratio (INR) did not meet the institutional criteria. In a regional health care system consisting of 11 hospitals using a common CPOE, data on the number of plasma orders and alerts that were generated were collected over a 4-month period before prescribers were required to select an indication for plasma. When adaptive ordering was implemented prescribers had to choose from prepopulated indications for plasma: INR of 1.6 or greater with bleeding, INR of 1.6 or greater before an invasive procedure, therapeutic exchange, massive transfusion, and other. Regardless of the antecedent INR the alert did not trigger if massive transfusion or plasmapheresis was selected. Information on prescribers and recipients was collected during this 5-month period. In the 4-month period before the adaptive alerts were implemented, 42.9% of the plasma orders generated an alert; in the 5-month period thereafter the alert rate was significantly lower at 27.9% (p < 0.0001). The percentage of heeded alerts increased during the adaptive alert period (24.3% vs. 17.1%, respectively, p = 0.004). A significant percentage (45%) of other plasma orders were for periprocedure or bleeding patients whose antecedent INR was less than 1.6. There were significant differences in prescriber specialties among those who ordered plasma using the other indication compared to all plasma orders. Electronic interventions improve compliance with plasma guidelines but as implemented are not sufficient to completely curtail non-evidence-based ordering. © 2013 American Association of Blood Banks.

Demographic attributes and knowledge acquisition among graduate-entry medical students.

PubMed

Finucane, Paul; Flannery, Denise; McGrath, Deirdre; Saunders, Jean

2013-01-01

Recent changes to undergraduate (basic) medical education in Ireland have linked an expansion of student numbers with wide-ranging reforms. Medical schools have broadened access by admitting more mature students from diverse backgrounds and have increased their international student numbers. This has resulted in major changes to the demographic profile of students at Irish medical schools. To determine whether the demographic characteristics of students impact on their academic performance and specifically on their rate of knowledge acquisition. As a formative assessment exercise, we administered a progress test to all students twice each year during a 4 year graduate-entry medical programme. We compared scores over time between students from different age cohorts, of different gender, of different nationalities and from different academic backgrounds. In the 1143 tests taken by 285 students to date, there were no significant differences in the rate of knowledge acquisition between the various groups. Early in the course, students from a non-biological science background performed less well than others but outperformed their peers by the time of graduation. Neither age, gender, nationality nor academic background impacts on the rate of knowledge acquisition among graduate-entry medical students.

Passive vs. Parachute System Architecture for Robotic Sample Return Vehicles

NASA Technical Reports Server (NTRS)

Maddock, Robert W.; Henning, Allen B.; Samareh, Jamshid A.

2016-01-01

The Multi-Mission Earth Entry Vehicle (MMEEV) is a flexible vehicle concept based on the Mars Sample Return (MSR) EEV design which can be used in the preliminary sample return mission study phase to parametrically investigate any trade space of interest to determine the best entry vehicle design approach for that particular mission concept. In addition to the trade space dimensions often considered (e.g. entry conditions, payload size and mass, vehicle size, etc.), the MMEEV trade space considers whether it might be more beneficial for the vehicle to utilize a parachute system during descent/landing or to be fully passive (i.e. not use a parachute). In order to evaluate this trade space dimension, a simplified parachute system model has been developed based on inputs such as vehicle size/mass, payload size/mass and landing requirements. This model works in conjunction with analytical approximations of a mission trade space dataset provided by the MMEEV System Analysis for Planetary EDL (M-SAPE) tool to help quantify the differences between an active (with parachute) and a passive (no parachute) vehicle concept.

Trajectory Guidance for Mars Robotic Precursors: Aerocapture, Entry, Descent, and Landing

NASA Technical Reports Server (NTRS)

Sostaric, Ronald R.; Zumwalt, Carlie; Garcia-Llama, Eduardo; Powell, Richard; Shidner, Jeremy

2011-01-01

Future crewed missions to Mars require improvements in landed mass capability beyond that which is possible using state-of-the-art Mars Entry, Descent, and Landing (EDL) systems. Current systems are capable of an estimated maximum landed mass of 1-1.5 metric tons (MT), while human Mars studies require 20-40 MT. A set of technologies were investigated by the EDL Systems Analysis (SA) project to assess the performance of candidate EDL architectures. A single architecture was selected for the design of a robotic precursor mission, entitled Exploration Feed Forward (EFF), whose objective is to demonstrate these technologies. In particular, inflatable aerodynamic decelerators (IADs) and supersonic retro-propulsion (SRP) have been shown to have the greatest mass benefit and extensibility to future exploration missions. In order to evaluate these technologies and develop the mission, candidate guidance algorithms have been coded into the simulation for the purposes of studying system performance. These guidance algorithms include aerocapture, entry, and powered descent. The performance of the algorithms for each of these phases in the presence of dispersions has been assessed using a Monte Carlo technique.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.

PubMed

Page, N; Baysari, M T; Westbrook, J I

2017-09-01

To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems. PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness. Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits. The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system. Copyright © 2017 Elsevier B.V. All rights reserved.

Evaluation of real-time clinical decision support systems for platelet and cryoprecipitate orders.

PubMed

Collins, Ryan A; Triulzi, Darrell J; Waters, Jonathan H; Reddy, Vivek; Yazer, Mark H

2014-01-01

To evaluate cryoprecipitate and platelet ordering practices after the implementation of real-time clinical decision support systems (CDSSs) in a computerized physician order entry (CPOE) system. Uniform platelet and cryoprecipitate transfusion thresholds were implemented at 11 hospitals in a regional health care system with a common CPOE system. Over 6 months, a variety of information was collected on the ordering physicians and the number of alerts generated by the CDSSs when these products were ordered outside of the institutional guidelines. There were 1,889 orders for platelets and 152 orders for cryoprecipitate placed in 6 months. Of these, 1,102 (58.3%) platelet and 74 (48.7%) cryoprecipitate orders triggered an alert. The proportion of orders canceled after an alert was generated ranged from 13.5% to 17.9% for platelets and 0% to 50.0% for cryoprecipitate orders. CDSS alerts reduce, but do not eliminate, platelet and cryoprecipitate transfusions that do not meet institutional guidelines.

21 CFR 26.80 - Entry into force, amendment, and termination.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 1 2010-04-01 2010-04-01 false Entry into force, amendment, and termination. 26... EUROPEAN COMMUNITY âFrameworkâ Provisions § 26.80 Entry into force, amendment, and termination. (a) The...) inspections, and medical devices shall enter into force on the first day of the second month following the...

High-Value, Cost-Conscious Care: Iterative Systems-Based Interventions to Reduce Unnecessary Laboratory Testing.

PubMed

Sadowski, Brett W; Lane, Alison B; Wood, Shannon M; Robinson, Sara L; Kim, Chin Hee

2017-09-01

Inappropriate testing contributes to soaring healthcare costs within the United States, and teaching hospitals are vulnerable to providing care largely for academic development. Via its "Choosing Wisely" campaign, the American Board of Internal Medicine recommends avoiding repetitive testing for stable inpatients. We designed systems-based interventions to reduce laboratory orders for patients admitted to the wards at an academic facility. We identified the computer-based order entry system as an appropriate target for sustainable intervention. The admission order set had allowed multiple routine tests to be ordered repetitively each day. Our iterative study included interventions on the automated order set and cost displays at order entry. The primary outcome was number of routine tests controlled for inpatient days compared with the preceding year. Secondary outcomes included cost savings, delays in care, and adverse events. Data were collected over a 2-month period following interventions in sequential years and compared with the year prior. The first intervention led to 0.97 fewer laboratory tests per inpatient day (19.4%). The second intervention led to sustained reduction, although by less of a margin than order set modifications alone (15.3%). When extrapolating the results utilizing fees from the Centers for Medicare and Medicaid Services, there was a cost savings of $290,000 over 2 years. Qualitative survey data did not suggest an increase in care delays or near-miss events. This series of interventions targeting unnecessary testing demonstrated a sustained reduction in the number of routine tests ordered, without adverse effects on clinical care. Published by Elsevier Inc.

Changes, disruption and innovation: An investigation of the introduction of new health information technology in a microbiology laboratory.

PubMed

Toouli, George; Georgiou, Andrew; Westbrook, Johanna

2012-01-01

It is expected that health information technology (HIT) will deliver a safer, more efficient and effective health care system. The aim of this study was to undertake a qualitative and video-ethnographic examination of the impact of information technologies on work processes in the reception area of a Microbiology Department, to ascertain what changed, how it changed and the impact of the change. The setting for this study was the microbiology laboratory of a large tertiary hospital in Sydney. The study consisted of qualitative (interview and focus group) data and observation sessions for the period August 2005 to October 2006 along with video footage shot in three sessions covering the original system and the two stages of the Cerner implementation. Data analysis was assisted by NVivo software and process maps were produced from the video footage. There were two laboratory information systems observed in the video footage with computerized provider order entry introduced four months later. Process maps highlighted the large number of pre data entry steps with the original system whilst the newer system incorporated many of these steps in to the data entry stage. However, any time saved with the new system was offset by the requirement to complete some data entry of patient information not previously required. Other changes noted included the change of responsibilities for the reception staff and the physical changes required to accommodate the increased activity around the data entry area. Implementing a new HIT is always an exciting time for any environment but ensuring that the implementation goes smoothly and with minimal trouble requires the administrator and their team to plan well in advance for staff training, physical layout and possible staff resource reallocation.

76 FR 75900 - Notice of Application for Withdrawal Extension and Opportunity for Public Meeting; Wyoming

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-05

... of National Forest System land in the Shoshone National Forest from mining in order to protect the... of National Forest System land in the Shoshone National Forest from location and entry under the... of Land Management, Interior. ACTION: Notice. SUMMARY: The United States Forest Service (USFS) has...

76 FR 62881 - Self-Regulatory Organizations; Chicago Board Options Exchange, Incorporated: Notice of Filing and...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-11

..., the PULSe workstation is a front-end order entry system designed for use with respect to orders that... reasonable in that it is designed to help attract and encourage use of the PULSe workstation. The Exchange... amend its Fees Schedule as it relates to the PULSe workstation. The text of the proposed rule change is...

The Causes of Attrition in Initial Entry Rotary Wing Training

DTIC Science & Technology

1979-01-01

often, did not as often feel they were educationally prepared for the program, and had significantly lower peer ratings. Attritees and non- attritees did...Rucker as those of E’s. SE’s had less education than Non-E’s by about .01 one year. E’s had more medical problems since they joined .10 the Army. Birth...order showed little difference as did place NA* of origin, living accommodations, size of community of origin, or parents ’ occupation. E’s did not list

Computerizing medical records in Japan.

PubMed

Yasunaga, Hideo; Imamura, Tomoaki; Yamaki, Shintaro; Endo, Hiroyoshi

2008-10-01

The present study reports the current status of computerizing medical records in Japan. In 2001, the Ministry of Health, Labour and Welfare formulated the Grand Design for the Development of Information Systems in the Healthcare and Medical Fields. The Grand Design stated a numerical target for "spreading the use of electronic medical records (EMR) in at least 60% of Japan's hospitals with 400 or more beds by 2006." The objective of this study was to examine the extent to which EMR and order entry systems (OES) have been adopted as of February 2007 and to evaluate the Japanese government's policy regarding the computerization of medical records. We conducted a postal survey targeting medical institutions throughout Japan. In February 2007, we mailed self-administered questionnaires to all 1574 hospitals with 300 or more beds, and to a random selection of 1000 hospitals with less than 300 beds in addition to 4000 clinics. Responses were received from 812 (51.6%), 504 (50.5%), and 1769 (44.8%), respectively. We asked questions concerning: (i) the extent to which EMR and OES had been introduced; (ii) the reasons why certain institutions had not introduced EMR and (iii) the subjective evaluation of the efficacy and cost-effectiveness of EMR. The percentage of institutions that had introduced EMR as of February 2007 was 10.0% for hospitals and 10.1% for clinics. Even the percentage for hospitals with 400 or more beds was just 31.2%, illustrating that the government's target had not been reached. The most common reason given for not introducing EMR was: "The cost is high" which was observed in 82.0% of hospitals. It was considered that the introduction of EMR could improve 'inter-hospital networks', and 'time efficiency for physicians' by around 45% and 25% of hospitals, respectively. Healthcare information computerization in Japan is behind schedule because the introductory costs are high. For the computerization of healthcare information to be further promoted, prices of EMR systems should be lowered to a level which individual hospitals can afford. Furthermore, the communication between EMR systems should be further standardized to secure functional and semantic interoperability in Japan.

Power selective optical filter devices and optical systems using same

DOEpatents

Koplow, Jeffrey P

2014-10-07

In an embodiment, a power selective optical filter device includes an input polarizer for selectively transmitting an input signal. The device includes a wave-plate structure positioned to receive the input signal, which includes at least one substantially zero-order, zero-wave plate. The zero-order, zero-wave plate is configured to alter a polarization state of the input signal passing in a manner that depends on the power of the input signal. The zero-order, zero-wave plate includes an entry and exit wave plate each having a fast axis, with the fast axes oriented substantially perpendicular to each other. Each entry wave plate is oriented relative to a transmission axis of the input polarizer at a respective angle. An output polarizer is positioned to receive a signal output from the wave-plate structure and selectively transmits the signal based on the polarization state.

The Unparalleled Systems Engineering of MSL's Backup Entry, Descent, and Landing System: Second Chance

NASA Technical Reports Server (NTRS)

Roumeliotis, Chris; Grinblat, Jonathan; Reeves, Glenn

2013-01-01

Second Chance (SECC) was a bare bones version of Mars Science Laboratory's (MSL) Entry Descent & Landing (EDL) flight software that ran on Curiosity's backup computer, which could have taken over swiftly in the event of a reset of Curiosity's prime computer, in order to land her safely on Mars. Without SECC, a reset of Curiosity's prime computer would have lead to catastrophic mission failure. Even though a reset of the prime computer never occurred, SECC had the important responsibility as EDL's guardian angel, and this responsibility would not have seen such success without unparalleled systems engineering. This paper will focus on the systems engineering behind SECC: Covering a brief overview of SECC's design, the intense schedule to use SECC as a backup system, the verification and validation of the system's "Do No Harm" mandate, the system's overall functional performance, and finally, its use on the fateful day of August 5th, 2012.

Where are the bariatric bypass ads? The answer, my friend, is bloomin' on the Web.

PubMed

Botvin, Judith D

2003-01-01

If you look up bariatric, or gastric bypass surgery on the Internet, you'll find 9,000 entries or more, depending on the search engine used. Some of these, but not all, are from hospitals and healthcare systems, most of which have more requests than they can handle. We look at the publicity for bariatric surgery presented by St. Cloud Hospital in St. Cloud, Minn.; Holy Name Hospital, Teaneck, N.J.; Kuakini Medical Center, Honolulu, Hawaii; and Cincinnati Children's Medical Center, Cincinnati, Ohio.

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

PubMed

Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa

2013-01-01

To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

Development of a data entry auditing protocol and quality assurance for a tissue bank database.

PubMed

Khushi, Matloob; Carpenter, Jane E; Balleine, Rosemary L; Clarke, Christine L

2012-03-01

Human transcription error is an acknowledged risk when extracting information from paper records for entry into a database. For a tissue bank, it is critical that accurate data are provided to researchers with approved access to tissue bank material. The challenges of tissue bank data collection include manual extraction of data from complex medical reports that are accessed from a number of sources and that differ in style and layout. As a quality assurance measure, the Breast Cancer Tissue Bank (http:\\\\www.abctb.org.au) has implemented an auditing protocol and in order to efficiently execute the process, has developed an open source database plug-in tool (eAuditor) to assist in auditing of data held in our tissue bank database. Using eAuditor, we have identified that human entry errors range from 0.01% when entering donor's clinical follow-up details, to 0.53% when entering pathological details, highlighting the importance of an audit protocol tool such as eAuditor in a tissue bank database. eAuditor was developed and tested on the Caisis open source clinical-research database; however, it can be integrated in other databases where similar functionality is required.

77 FR 60917 - Trinexapac-ethyl; Pesticide Tolerances

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-05

... ``hog, meat by-products'' in order to correct inadvertent errors in the final rule tolerance table for...'' is revised to ``hog, meat by-products.'' V. Statutory and Executive Order Reviews This final rule... alphabetical order an entry for ``Hog, meat by-products''. 0 iii. Revising the entries for ``Wheat, forage...

Operationalizing a bedside pen entry notebook clinical database system in consultation-liaison psychiatry.

PubMed

Hammer, J S; Strain, J J; Friedberg, A; Fulop, G

1995-05-01

No current system of computerized data entry of clinical information in consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to achieve accurate, complete, systematic collection of discrete variables and data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand-held Notebook computer with Windows PEN ENTRY MICROCARES capabilities has permitted one-time direct entry of data at the time of collection at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axis III diagnoses may be selected from a "look-up" which at the same time automatically assigns the appropriate code and diagnostic-related groups, (DRG) number. A patient narrative can be typed at the nurse's station, a chart note printed for the medical record, and the MICRO-CARES literature database perused with the printing of selected citations, abstracts, and in some cases experts' commentaries for the consultee. The consultant's documentation time is halved using the NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software, with the advantage of more accurate and complete data description than with the traditional handwritten consultation records. Consultees preferred typewritten in contrast to handwritten notes. The cost of the hardware (about $2000) is less than that of an optical scanner, and it permits report generation and archival searches at the nurses' station without returning to the C-L office for scanning. Radio frequency or ethernet download from the Notebook permits direct data transfer to th C-L office archive computer.

Impact of providing fee data on laboratory test ordering: a controlled clinical trial.

PubMed

Feldman, Leonard S; Shihab, Hasan M; Thiemann, David; Yeh, Hsin-Chieh; Ardolino, Margaret; Mandell, Steven; Brotman, Daniel J

2013-05-27

Inpatient care providers often order laboratory tests without any appreciation for the costs of the tests. To determine whether we could decrease the number of laboratory tests ordered by presenting providers with test fees at the time of order entry in a tertiary care hospital, without adding extra steps to the ordering process. Controlled clinical trial. Tertiary care hospital. All providers, including physicians and nonphysicians, who ordered laboratory tests through the computerized provider order entry system at The Johns Hopkins Hospital. We randomly assigned 61 diagnostic laboratory tests to an "active" arm (fee displayed) or to a control arm (fee not displayed). During a 6-month baseline period (November 10, 2008, through May 9, 2009), we did not display any fee data. During a 6-month intervention period 1 year later (November 10, 2009, through May 9, 2010), we displayed fees, based on the Medicare allowable fee, for active tests only. We examined changes in the total number of orders placed, the frequency of ordered tests (per patient-day), and total charges associated with the orders according to the time period (baseline vs intervention period) and by study group (active test vs control). For the active arm tests, rates of test ordering were reduced from 3.72 tests per patient-day in the baseline period to 3.40 tests per patient-day in the intervention period (8.59% decrease; 95% CI, -8.99% to -8.19%). For control arm tests, ordering increased from 1.15 to 1.22 tests per patient-day from the baseline period to the intervention period (5.64% increase; 95% CI, 4.90% to 6.39%) (P < .001 for difference over time between active and control tests). Presenting fee data to providers at the time of order entry resulted in a modest decrease in test ordering. Adoption of this intervention may reduce the number of inappropriately ordered diagnostic tests.

Current and emerging business models in the health care information technology industry: a view from wall street.

PubMed

Frank, Seth

2003-01-01

When we think about health care IT, we don't just think about clinical automation with the movement to computerized physician order entry (CPOE), but also the need to upgrade legacy financial and administrative systems to interact with clinical systems. Technology acceptance by physicians remains low, and computer use by physicians for data entry and analysis remains minimal. We expect this trend to change, and expect increased automation to represent gradual change. The HCIT space is dynamic, with many opportunities, but also many challenges. The unique nature of the end market buyers, existing business models, and nature of the technology makes this a challenging but dynamic area for equity investment.

A comprehensive inpatient discharge system.

PubMed Central

O'Connell, E. M.; Teich, J. M.; Pedraza, L. A.; Thomas, D.

1996-01-01

Our group has developed a computer system that supports all phases of the inpatient discharge process. The system fills in most of the physician's discharge order form and the nurse's discharge abstract, using information available from sign-out, order entry, scheduling, and other databases. It supplies information for referrals to outside institutions, and provides a variety of instruction materials for patients. Discharge forms can be completed in advance, so that the patient is not waiting for final paperwork. Physicians and nurses can work on their components independently, rather than in series. Response to the system has been very favorable. PMID:8947755

Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.

PubMed

Moran, John; Scanlon, Dennis

2013-01-01

In response to the Institute of Medicine's To Err Is Human report on the prevalence of medical errors, the Leapfrog Group, an organization that promotes hospital safety and quality, established a voluntary hospital survey assessing compliance with several safety standards. Using data from the period 2002-07, we conducted the first longitudinal assessment of how hospitals in specific cities and states initially selected by Leapfrog progressed on public reporting and adoption of standards requiring the use of computerized drug order entry and hospital intensivists. Overall, little progress was observed. Reporting rates were unchanged over the study period. Adoption of computerized drug order entry increased from 2.94 percent to 8.13 percent, and intensivist staffing increased from 14.74 percent to 21.40 percent. These findings should not be viewed as an indictment of Leapfrog but may reflect various challenges. For example, hospitals faced no serious threats to their market share if purchasers shifted business away from those that either didn't report data or didn't meet the standards. In the absence of mandatory reporting, policy makers might need to act to address these challenges to ensure improvements in quality.

Market entry and exit by biotech and device companies funded by venture capital.

PubMed

Burns, Lawton R; Housman, Michael G; Robinson, Charles A

2009-01-01

Start-up companies in the biotechnology and medical device sectors are important sources of health care innovation. This paper describes the role of venture capital in supporting these companies and charts the growth in venture capital financial support. The paper then uses longitudinal data to describe market entry and exit by these companies. Similar factors are associated with entry and exit in the two sectors. Entries and exits in one sector also appear to influence entry in the other. These findings have important implications for developing innovative technologies and ensuring competitive markets in the life sciences.

Effect of adding piperacillin-tazobactam to automated dispensing cabinets on promptness of first-dose antibiotics in hospitalized patients.

PubMed

Lo, Amy; Zhu, Juanqi Nikki; Richman, Mark; Joo, Julianne; Chan, Patrick

2014-10-01

Significant improvements in order-to-administration times for critical first doses of i.v. antibiotic therapy through the use of automated dispensing cabinets (ADCs) are reported. In a retrospective pre-post analysis conducted at a large academic medical center, pharmacy and medical records were reviewed to evaluate average times to administration of first doses of i.v. piperacillin-tazobactam therapy during designated periods before and after the addition of selected i.v. antibiotics to ADCs on patient care units. Inpatients who received a specified i.v. piperacillin-tazobactam formulation were included in the analysis. The primary endpoint was the total time from prescribing to administration; the impact of ADC use on other time intervals (e.g., from scanning of orders to administration, from pharmacist verification and release of orders to administration) was also evaluated. A total of 121 subjects were included in the preimplementation (n = 65) and postimplementation (n = 56) samples. There was a significant 1.7-hour reduction in the mean ± S.D. order-to-administration time (from 4.5 ± 4.1 to 2.9 ± 2.5 hours, p = 0.009) for piperacillin-tazobactam first doses with the use of ADCs. Subgroup analyses showed significant reductions in the mean ± S.D. scan-to-administration time (from 3.3 ± 3.4 to 1.7 ± 1.5 hours, p = 0.001) and release-to-administration time (from 2.4 ± 2.4 to 1.4 ± 1.5 hours, p = 0.034). The addition of a piperacillin-tazobactam product and other commonly used i.v. antibiotics to ADCs was associated with a significantly reduced order-to-administration time for piperacillin-tazobactam first doses. This change was accounted for by a significant reduction in the time between order entry and drug administration. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Examination of changes in pathology tests ordered by Diagnosis-Related Group (DRGs) following CPOE introduction.

PubMed

Vecellio, Elia; Georgiou, Andrew; Toouli, George; Eigenstetter, Alex; Li, Ling; Wilson, Roger; Westbrook, Johanna I

2013-01-01

Electronic test ordering, via the Electronic Medical Record (EMR), which incorporates computerised provider order entry (CPOE), is widely considered as a useful tool to support appropriate pathology test ordering. Diagnosis-related groups (DRGs) are clinically meaningful categories that allow comparisons in pathology utilisation by patient groups by controlling for many potentially confounding variables. This study used DRG data linked to pathology test data to examine changes in rates of test ordering across four years coinciding with the introduction of an EMR in six hospitals in New South Wales, Australia. This method generated a list of high pathology utilisation DRGs. We investigated patients with a Chest pain DRG to examine whether tests rates changed for specific test groups by hospital emergency department (ED) pre- and post-EMR. There was little change in testing rates between EDs or between time periods pre- and post-EMR. This is a valuable method for monitoring the impact of EMR and clinical decision support on test order rates.

Adaptation of a web-based, open source electronic medical record system platform to support a large study of tuberculosis epidemiology

PubMed Central

2012-01-01

Background In 2006, we were funded by the US National Institutes of Health to implement a study of tuberculosis epidemiology in Peru. The study required a secure information system to manage data from a target goal of 16,000 subjects who needed to be followed for at least one year. With previous experience in the development and deployment of web-based medical record systems for TB treatment in Peru, we chose to use the OpenMRS open source electronic medical record system platform to develop the study information system. Supported by a core technical and management team and a large and growing worldwide community, OpenMRS is now being used in more than 40 developing countries. We adapted the OpenMRS platform to better support foreign languages. We added a new module to support double data entry, linkage to an existing laboratory information system, automatic upload of GPS data from handheld devices, and better security and auditing of data changes. We added new reports for study managers, and developed data extraction tools for research staff and statisticians. Further adaptation to handle direct entry of laboratory data occurred after the study was launched. Results Data collection in the OpenMRS system began in September 2009. By August 2011 a total of 9,256 participants had been enrolled, 102,274 forms and 13,829 laboratory results had been entered, and there were 208 users. The system is now entirely supported by the Peruvian study staff and programmers. Conclusions The information system served the study objectives well despite requiring some significant adaptations mid-stream. OpenMRS has more tools and capabilities than it did in 2008, and requires less adaptations for future projects. OpenMRS can be an effective research data system in resource poor environments, especially for organizations using or considering it for clinical care as well as research. PMID:23131180

Development of Supersonic Retro-Propulsion for Future Mars Entry, Descent, and Landing Systems

NASA Technical Reports Server (NTRS)

Edquist, Karl T.; Dyakonov, Artem A.; Shidner, Jeremy D.; Studak, Joseph W.; Tiggers, Michael A.; Kipp, Devin M.; Prakash, Ravi; Trumble, Kerry A.; Dupzyk, Ian C.; Korzun, Ashley M.

2010-01-01

Recent studies have concluded that Viking-era entry system technologies are reaching their practical limits and must be succeeded by new methods capable of delivering large payloads (greater than 10 metric tons) required for human exploration of Mars. One such technology, termed Supersonic Retro-Propulsion, has been proposed as an enabling deceleration technique. However, in order to be considered for future NASA flight projects, this technology will require significant maturation beyond its current state. This paper proposes a roadmap for advancing the component technologies to a point where Supersonic Retro-Propulsion can be reliably used on future Mars missions to land much larger payloads than are currently possible using Viking-based systems. The development roadmap includes technology gates that are achieved through testing and/or analysis, culminating with subscale flight tests in Earth atmosphere that demonstrate stable and controlled flight. The component technologies requiring advancement include large engines capable of throttling, computational models for entry vehicle aerodynamic/propulsive force and moment interactions, aerothermodynamic environments modeling, entry vehicle stability and control methods, integrated systems engineering and analyses, and high-fidelity six degree-of-freedom trajectory simulations. Quantifiable metrics are also proposed as a means to gage the technical progress of Supersonic Retro-Propulsion. Finally, an aggressive schedule is proposed for advancing the technology through sub-scale flight tests at Earth by 2016.

Generic entry, reformulations and promotion of SSRIs in the US.

PubMed

Huskamp, Haiden A; Donohue, Julie M; Koss, Catherine; Berndt, Ernst R; Frank, Richard G

2008-01-01

Previous research has shown that a manufacturer's promotional strategy for a brand name drug is typically affected by generic entry. However, little is known about how newer strategies to extend patent life, including product reformulation introduction or obtaining approval to market for additional clinical indications, influence promotion. To examine the relationships among promotional expenditures, generic entry, reformulation entry and new indication approval. We used quarterly data on national product-level promotional spending (including expenditures for physician detailing and direct-to-consumer advertising [DTCA], and the retail value of free samples distributed in physician offices) for selective serotonin reuptake inhibitors (SSRIs) over the period 1997-2004. We estimated econometric models of detailing, DTCA and total quarterly promotional expenditures as a function of the timing of generic entry, entry of new product formulations and US FDA approval for new clinical indications for existing medications in the SSRI class. Expenditures by pharmaceutical manufacturers for promotion of antidepressant medications was the main outcome measure. Over the period 1997-2004, there was considerable variation in the composition of promotional expenditures across the SSRIs. Promotional expenditures for the original brand molecule decreased dramatically when a reformulation of the molecule was introduced. Promotional spending (both total and detailing alone) for a specific molecule was generally lower after generic entry than before, although the effect of generic entry on promotional spending appears to be closely linked with the choice of product reformulation strategy pursued by the manufacturer. Detailing expenditures for Paxil were increased after the manufacturer received FDA approval to market the drug for generalized anxiety disorder (GAD), while the likelihood of DTCA outlays for the drug was not changed. In contrast, FDA approval to market Paxil and Zoloft for social anxiety disorder (SAD) did not affect the manufacturers' detailing expenditures but did result in a greater likelihood of DTCA outlays. The introduction of new product formulations appears to be a common strategy for attempting to extend market exclusivity for medications facing impending generic entry. Manufacturers who introduced a reformulation before generic entry shifted most promotion dollars from the original brand to the reformulation long before generic entry, and in some cases manufacturers appeared to target a particular promotion type for a given indication. Given the significant impact that pharmaceutical promotion has on demand for prescription drugs in the US, these findings have important implications for prescription drug spending and public health.

Post-Secondary Education and Rural-Urban Migration

ERIC Educational Resources Information Center

Synge, J.

1974-01-01

This study examined education and career plans of Scottish rural youth who entered post-secondary education in order to determine the extent to which the educational system offers rural youth not only specific training but only entry to the urban labour market. (Author/RK)

Usability Evaluation at the Point-of-Care: A Method to Identify User Information Needs in CPOE Applications

PubMed Central

Washburn, Jeff; Fiol, Guilherme Del; Rocha, Roberto A.

2006-01-01

Point of care usability evaluation may help identify information needs that occur during the process of providing care. We describe the process of using usability-specific recording software to record Computerized Physician Order Entry (CPOE) ordering sessions on admitted adult and pediatric patients at two urban tertiary hospitals in the Intermountain Healthcare system of hospitals. PMID:17238756

76 FR 2741 - Self-Regulatory Organizations; C2 Options Exchange, Incorporated: Notice of Filing and Immediate...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-14

... is to extend a fee waiver related to the PULSe workstation. By way of background, the PULSe workstation is a front-end order entry system designed for use with respect to orders that may be sent to the... extend a fee waiver related to the PULSe workstation. The text of the proposed rule change is available...

78 FR 16731 - Self-Regulatory Organizations; NYSE Arca, Inc.; Notice of Filing and Immediate Effectiveness of...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-18

... International Securities Exchange offers PRECISE TRADE as a means for users to enter orders and Chicago Board... users to develop their own internal front-end order entry systems and may provide savings to users in.../NASDAQOMXPHLXTools/PlatformViewer.asp?selectednode=chp%5F1%5F4&manual=%2Fnasdaqomxphlx%2Fphlx%2Fphlx%2Drulesbrd%2F...

Guide for Program Planning: Medical Laboratory Technician.

ERIC Educational Resources Information Center

Kahler, Carol, Ed.; And Others

Prepared by the American Association of Junior Colleges and the National Council on Medical Technology Education, this guide discusses programs for career-entry supportive medical laboratory personnel which have been cooperatively planned by junior college personnel and the medical community, particularly pathologists and medical technologists.…

Mars2020 Entry, Descent, and Landing Instrumentation (MEDLI2): Science Objectives and Instrument Requirements

NASA Technical Reports Server (NTRS)

Bose, Deepak; White, Todd; Schoenenberger, Mark; Karlgaard, Chris; Wright, Henry

2015-01-01

NASAs exploration and technology roadmaps call for capability advancements in Mars entry, descent, and landing (EDL) systems to enable increased landed mass, a higher landing precision, and a wider planetary access. It is also recognized that these ambitious EDL performance goals must be met while maintaining a low mission risk in order to pave the way for future human missions. As NASA is engaged in developing new EDL systems and technologies via testing at Earth, instrumentation of existing Mars missions is providing valuable engineering data for performance improvement, risk reduction, and an improved definition of entry loads and environment. The most notable recent example is the Mars Entry, Descent and Landing Instrument (MEDLI) suite hosted by Mars Science Laboratory for its entry in Aug 2012. The MEDLI suite provided a comprehensive dataset for Mars entry aerodynamics, aerothermodynamics and thermal protection system (TPS) performance. MEDLI data has since been used for unprecedented reconstruction of aerodynamic drag, vehicle attitude, in-situ atmospheric density, aerothermal heating, and transition to turbulence, in-depth TPS performance and TPS ablation. [1,2] In addition to validating predictive models, MEDLI data has demonstrated extra margin available in the MSL forebody TPS, which can potentially be used to reduce vehicle parasitic mass. The presentation will introduce a follow-on MEDLI instrumentation suite (called MEDLI2) that is being developed for Mars-2020 mission. MEDLI2 has an enhanced scope that includes backshell instrumentation, a wider forebody coverage, and instruments that specifically target supersonic aerodynamics. Similar to MEDLI, MEDLI2 uses thermal plugs with embedded thermocouples and ports through the TPS to measure surface pressure. MEDLI2, however, also includes heat flux sensors in the backshell and a low range pressure transducer to measure afterbody pressure.

A prospective audit of a nurse independent prescribing within critical care.

PubMed

Carberry, Martin; Connelly, Sarah; Murphy, Jennifer

2013-05-01

To determine the prescribing activity of different staff groups within intensive care unit (ICU) and combined high dependency unit (HDU), namely trainee and consultant medical staff and advanced nurse practitioners in critical care (ANPCC); to determine the number and type of prescription errors; to compare error rates between prescribing groups and to raise awareness of prescribing activity within critical care. The introduction of government legislation has led to the development of non-medical prescribing roles in acute care. This has facilitated an opportunity for the ANPCC working in critical care to develop a prescribing role. The audit was performed over 7 days (Monday-Sunday), on rolling days over a 7-week period in September and October 2011 in three ICUs. All drug entries made on the ICU prescription by the three groups, trainee medical staff, ANPCCs and consultant anaesthetists, were audited once for errors. Data were collected by reviewing all drug entries for errors namely, patient data, drug dose, concentration, rate and frequency, legibility and prescriber signature. A paper data collection tool was used initially; data was later entered onto a Microsoft Access data base. A total of 1418 drug entries were audited from 77 patient prescription Cardexes. Error rates were reported as, 40 errors in 1418 prescriptions (2·8%): ANPCC errors, n = 2 in 388 prescriptions (0·6%); trainee medical staff errors, n = 33 in 984 (3·4%); consultant errors, n = 5 in 73 (6·8%). The error rates were significantly different for different prescribing groups (p < 0·01). This audit shows that prescribing error rates were low (2·8%). Having the lowest error rate, the nurse practitioners are at least as effective as other prescribing groups within this audit, in terms of errors only, in prescribing diligence. National data is required in order to benchmark independent nurse prescribing practice in critical care. These findings could be used to inform research and role development within the critical care. © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

PubMed Central

Sacchi, L.; Lanzola, G.; Viani, N.

2015-01-01

Summary Objectives This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. Methods We considered papers published on scientific journals, by querying PubMed and Web of Science™. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. Results We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. Conclusions Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large. PMID:26293857

Computerised Order Entry Systems and Pathology Services - A Synthesis of the Evidence

PubMed Central

Georgiou, Andrew; Westbrook, Johanna I

2006-01-01

Computerised Physician Order Entry (CPOE) systems have been promoted in Australia and internationally for their potential to improve the quality of care. The existing research of the effect of CPOE on pathology laboratories has been variable, pointing to the potential to increase efficiency and effectiveness and contribute to enhancing the quality of patient care on the one hand, while leading to significant disruptions in work organisation with a negative impact on departmental relations on the other hand. In this paper we provide an overview of the research evidence about the impact of CPOE on four areas associated with pathology services; a) efficiency of the ordering process, e.g. test turnaround times, b) effectiveness as measured by test ordering volumes and test order appropriateness, c) quality of care, particularly its effects on patient care and d) work organisation patterns, which can be severely disrupted by CPOE. We discuss the possible ramifications of CPOE and offer three broad, but important recommendations for pathology laboratories, based on our own research experience investigating CPOE implementations over three years. Firstly, pathology laboratories need to be active participants in planning the implementation of CPOE. Secondly, the importance of building a firm organisational foundation for the introduction of the new system that includes openness and responsiveness to feedback. And thirdly, the implementation process needs to be underpinned by a strong commitment to a multi-method evaluation at every stage of the process to be able to measure the impact of the system on work practices and outcomes. PMID:17077878

Computerized provider order entry systems - Research imperatives and organizational challenges facing pathology services.

PubMed

Georgiou, Andrew; Westbrook, Johanna; Braithwaite, Jeffrey

2010-07-13

Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.

A diffusion of innovations model of physician order entry.

PubMed

Ash, J S; Lyman, J; Carpenter, J; Fournier, L

2001-01-01

To interpret the results of a cross-site study of physician order entry (POE) in hospitals using a diffusion of innovations theory framework. Qualitative study using observation, focus groups, and interviews. Data were analyzed by an interdisciplinary team of researchers using a grounded approach to identify themes. Themes were then interpreted using classical Diffusion of Innovations (DOI) theory as described by Rogers [1]. Four high level themes were identified: organizational issues; clinical and professional issues; technology implementation issues; and issues related to the organization of information and knowledge. Further analysis using the DOI framework indicated that POE is an especially complex information technology innovation when one considers communication, time, and social system issues in addition to attributes of the innovation itself. Implementation strategies for POE should be designed to account for its complex nature. The ideal would be a system that is both customizable and integrated with other parts of the information system, is implemented with maximum involvement of users and high levels of support, and is surrounded by an atmosphere of trust and collaboration.

78 FR 48752 - Self-Regulatory Organizations; NASDAQ OMX BX, Inc.; Notice of Filing of Proposed Rule Change to...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-09

... particular MPID has been made by calculating the ratio between (i) entered orders, weighted by the distance... in part. The fee has been imposed on MPIDs with an ``Order Entry Ratio'' of more than 100. The Order Entry Ratio is calculated, and the Excess Order Fee imposed, on a monthly basis. BX is now proposing to...

Bridging the gap between informatics and medicine upon medical school entry: Implementing a course on the Applicative Use of ICT.

PubMed

Milic, Natasa M; Ilic, Nikola; Stanisavljevic, Dejana M; Cirkovic, Andja M; Milin, Jelena S; Bukumiric, Zoran M; Milic, Nikola V; Savic, Marko D; Ristic, Sara M; Trajkovic, Goran Z

2018-01-01

Education is undergoing profound changes due to permanent technological innovations. This paper reports the results of a pilot study aimed at developing, implementing and evaluating the course, "Applicative Use of Information and Communication Technologies (ICT) in Medicine," upon medical school entry. The Faculty of Medicine, University of Belgrade, introduced a curriculum reform in 2014 that included the implementation of the course, "Applicative Use of ICT in Medicine" for first year medical students. The course was designed using a blended learning format to introduce the concepts of Web-based learning environments. Data regarding student knowledge, use and attitudes towards ICT were prospectively collected for the classes of 2015/16 and 2016/17. The teaching approach was supported by multimedia didactic materials using Moodle LMS. The overall quality of the course was also assessed. The five level Likert scale was used to measure attitudes related to ICT. In total, 1110 students were assessed upon medical school entry. A small number of students (19%) had previous experience with e-learning. Students were largely in agreement that informatics is needed in medical education, and that it is also useful for doctors (4.1±1.0 and 4.1±0.9, respectively). Ability in informatics and use of the Internet in education in the adjusted multivariate regression model were significantly associated with positive student attitudes toward ICT. More than 80% of students stated that they had learned to evaluate medical information and would use the Internet to search medical literature as an additional source for education. The majority of students (77%) agreed that a blended learning approach facilitates access to learning materials and enables time independent learning (72%). Implementing the blended learning course, "Applicative Use of ICT in Medicine," may bridge the gap between medicine and informatics upon medical school entry. Students displayed positive attitudes towards using ICT and gained adequate skills necessary to function effectively in an information-rich environment.

Bridging the gap between informatics and medicine upon medical school entry: Implementing a course on the Applicative Use of ICT

PubMed Central

Ilic, Nikola; Stanisavljevic, Dejana M.; Cirkovic, Andja M.; Milin, Jelena S.; Bukumiric, Zoran M.; Milic, Nikola V.; Savic, Marko D.; Ristic, Sara M.; Trajkovic, Goran Z.

2018-01-01

Education is undergoing profound changes due to permanent technological innovations. This paper reports the results of a pilot study aimed at developing, implementing and evaluating the course, "Applicative Use of Information and Communication Technologies (ICT) in Medicine," upon medical school entry. The Faculty of Medicine, University of Belgrade, introduced a curriculum reform in 2014 that included the implementation of the course, “Applicative Use of ICT in Medicine” for first year medical students. The course was designed using a blended learning format to introduce the concepts of Web-based learning environments. Data regarding student knowledge, use and attitudes towards ICT were prospectively collected for the classes of 2015/16 and 2016/17. The teaching approach was supported by multimedia didactic materials using Moodle LMS. The overall quality of the course was also assessed. The five level Likert scale was used to measure attitudes related to ICT. In total, 1110 students were assessed upon medical school entry. A small number of students (19%) had previous experience with e-learning. Students were largely in agreement that informatics is needed in medical education, and that it is also useful for doctors (4.1±1.0 and 4.1±0.9, respectively). Ability in informatics and use of the Internet in education in the adjusted multivariate regression model were significantly associated with positive student attitudes toward ICT. More than 80% of students stated that they had learned to evaluate medical information and would use the Internet to search medical literature as an additional source for education. The majority of students (77%) agreed that a blended learning approach facilitates access to learning materials and enables time independent learning (72%). Implementing the blended learning course, "Applicative Use of ICT in Medicine," may bridge the gap between medicine and informatics upon medical school entry. Students displayed positive attitudes towards using ICT and gained adequate skills necessary to function effectively in an information-rich environment. PMID:29684042

Top ten challenges when interfacing a laboratory information system to an electronic health record: Experience at a large academic medical center.

PubMed

Petrides, Athena K; Tanasijevic, Milenko J; Goonan, Ellen M; Landman, Adam B; Kantartjis, Michalis; Bates, David W; Melanson, Stacy E F

2017-10-01

Recent U.S. government regulations incentivize implementation of an electronic health record (EHR) with computerized order entry and structured results display. Many institutions have also chosen to interface their EHR to their laboratory information system (LIS). Reported long-term benefits include increased efficiency and improved quality and safety. In order to successfully implement an interfaced EHR-LIS, institutions must plan years in advance and anticipate the impact of an integrated system. It can be challenging to fully understand the technical, workflow and resource aspects and adequately prepare for a potentially protracted system implementation and the subsequent stabilization. We describe the top ten challenges that we encountered in our clinical laboratories following the implementation of an interfaced EHR-LIS and offer suggestions on how to overcome these challenges. This study was performed at a 777-bed, tertiary care center which recently implemented an interfaced EHR-LIS. Challenges were recorded during EHR-LIS implementation and stabilization and the authors describe the top ten. Our top ten challenges were selection and harmonization of test codes, detailed training for providers on test ordering, communication with EHR provider champions during the build process, fluid orders and collections, supporting specialized workflows, sufficient reports and metrics, increased volume of inpatient venipunctures, adequate resources during stabilization, unanticipated changes to laboratory workflow and ordering specimens for anatomic pathology. A few suggestions to overcome these challenges include regular meetings with clinical champions, advanced considerations of reports and metrics that will be needed, adequate training of laboratory staff on new workflows in the EHR and defining all tests including anatomic pathology in the LIS. EHR-LIS implementations have many challenges requiring institutions to adapt and develop new infrastructures. This article should be helpful to other institutions facing or undergoing a similar endeavor. Copyright © 2017 Elsevier B.V. All rights reserved.

Reconciling disparate information in continuity of care documents: Piloting a system to consolidate structured clinical documents.

PubMed

Hosseini, Masoud; Jones, Josette; Faiola, Anthony; Vreeman, Daniel J; Wu, Huanmei; Dixon, Brian E

2017-10-01

Due to the nature of information generation in health care, clinical documents contain duplicate and sometimes conflicting information. Recent implementation of Health Information Exchange (HIE) mechanisms in which clinical summary documents are exchanged among disparate health care organizations can proliferate duplicate and conflicting information. To reduce information overload, a system to automatically consolidate information across multiple clinical summary documents was developed for an HIE network. The system receives any number of Continuity of Care Documents (CCDs) and outputs a single, consolidated record. To test the system, a randomly sampled corpus of 522 CCDs representing 50 unique patients was extracted from a large HIE network. The automated methods were compared to manual consolidation of information for three key sections of the CCD: problems, allergies, and medications. Manual consolidation of 11,631 entries was completed in approximately 150h. The same data were automatically consolidated in 3.3min. The system successfully consolidated 99.1% of problems, 87.0% of allergies, and 91.7% of medications. Almost all of the inaccuracies were caused by issues involving the use of standardized terminologies within the documents to represent individual information entries. This study represents a novel, tested tool for de-duplication and consolidation of CDA documents, which is a major step toward improving information access and the interoperability among information systems. While more work is necessary, automated systems like the one evaluated in this study will be necessary to meet the informatics needs of providers and health systems in the future. Copyright © 2017 Elsevier Inc. All rights reserved.

School re-entry of the pediatric heart transplant recipient.

PubMed

Weil, Constance M; Rodgers, S; Rubovits, S

2006-12-01

Pediatric cardiac transplant has become increasingly frequent in the last decade and survival rates have improved remarkably. Outcome research on this population suggests that the majority of children have the capacity for healthy adaptation although 25-40% have been shown to have some type of psychiatric difficulties. As school plays a major role in these children's lives, early intervention and close liaison with schools is indicated to reduce psychological morbidity, enhance adaptation within the school environment and enhance overall adjustment. This paper proposes a model for a school re-entry program for this population. The school re-entry program is aimed at children who are undergoing cardiac transplant and will be entering or re-entering the school system. They may range in academic age from preschool to college level and have been attending private or public schools with placements in regular education programs, regular education programs with resource support, special education programs, and alternative school programs. Others may not have been attending school because of the severity of their medical condition and have been receiving in-home tutoring. Each child is offered school re-entry assistance by a multi-disciplinary team composed of members from the Cardiology Transplant Service. The re-entry program includes cognitive and psychosocial assessment, liaison with the child's school pre- and post-transplant, academic planning and provision of academic, emotional, and behavioral support before, during, and immediately after transplant, a school re-entry visit, and an ongoing school consultation. The goal is to address issues necessary for a successful school re-entry including appropriate academic placement and support, psychosocial adjustment, education of school personnel and ongoing health needs of the student. The next step is to formally evaluate the efficacy of this program in successful school re-entry.

24 CFR 350.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Security) maintained in the Book-entry System, as set forth in Federal Reserve Bank Operating Circulars. (b...: Book-entry Ginnie Mae Security. A Ginnie Mae Security issued or maintained in the Book-entry System... Reserve Banks. Book-entry System. The automated book-entry system operated by the Federal Reserve Banks...

3. DETAIL VIEW OF THE MAIN ENTRY OF BUILDING 13, ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

3. DETAIL VIEW OF THE MAIN ENTRY OF BUILDING 13, SHOWING THE ORIGINAL LIGHT FIXTURES AND THE EGYPTIAN MOTIF DECORATION; LOOKING SSW. (Ryan) - Veterans Administration Medical Center, Building No. 13, Old State Route 13 West, Marion, Williamson County, IL

Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies

PubMed Central

Cross, Dori A; Boukus, Ellyn R; Cohen, Genna R

2011-01-01

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 physician practice and pharmacy experiences 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 organizations between February and September 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 e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions. PMID:22101907

78 FR 76642 - Public Land Order No. 7822; Partial Revocation of Secretarial Order Dated May 2, 1919; Wyoming

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-18

... closed to settlement, sale, location, or entry under the general land laws, including the United States mining laws, until the Bureau of Land Management completes a planning review. Order By virtue of the... withdrew lands from settlement, sale location, or entry under the general land laws, including the United...

Structured physician order entry for trauma CT: value in improving clinical information transfer and billing efficiency.

PubMed

Wortman, Jeremy R; Goud, Asha; Raja, Ali S; Marchello, Dana; Sodickson, Aaron

2014-12-01

The purpose of this study was to measure the effects of use of a structured physician order entry system for trauma CT on the communication of clinical information and on coding practices and reimbursement efficiency. This study was conducted between April 1, 2011, and January 14, 2013, at a level I trauma center with 59,000 annual emergency department visits. On March 29, 2012, a structured order entry system was implemented for head through pelvis trauma CT, so-called pan-scan CT. This study compared the following factors before and after implementation: communication of clinical signs and symptoms and mechanism of injury, primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code category, success of reimbursement, and time required for successful reimbursement for the examination. Chi-square statistics were used to compare all categoric variables before and after the intervention, and the Wilcoxon rank sum test was used to compare billing cycle times. A total of 457 patients underwent pan-scan CT in 2734 distinct examinations. After the intervention, there was a 62% absolute increase in requisitions containing clinical signs or symptoms (from 0.4% to 63%, p<0.0001) and a 99% absolute increase in requisitions providing mechanism of injury (from 0.4% to 99%, p<0.0001). There was a 19% absolute increase in primary ICD-9-CM codes representing clinical signs or symptoms (from 2.9% to 21.8%, p<0.0001), and a 7% absolute increase in reimbursement success for examinations submitted to insurance carriers (from 83.0% to 89.7%, p<0.0001). For reimbursed studies, there was a 14.7-day reduction in mean billing cycle time (from 68.4 days to 53.7 days, p=0.008). Implementation of structured physician order entry for trauma CT was associated with significant improvement in the communication of clinical history to radiologists. The improvement was also associated with changes in coding practices, greater billing efficiency, and an increase in reimbursement success.

Research and development for Onboard Navigation (ONAV) ground based expert/trainer system: ONAV entry expert system code

NASA Technical Reports Server (NTRS)

Bochsler, Daniel C.

1988-01-01

A complete listing is given of the expert system rules for the Entry phase of the Onboard Navigation (ONAV) Ground Based Expert Trainer System for aircraft/space shuttle navigation. These source listings appear in the same format as utilized and required by the C Language Integrated Production System (CLIPS) expert system shell which is the basis for the ONAV entry system. A schematic overview is given of how the rules are organized. These groups result from a partitioning of the rules according to the overall function which a given set of rules performs. This partitioning was established and maintained according to that established in the knowledge specification document. In addition, four other groups of rules are specified. The four groups (control flow, operator inputs, output management, and data tables) perform functions that affect all the other functional rule groups. As the name implies, control flow ensures that the rule groups are executed in the order required for proper operation; operator input rules control the introduction into the CLIPS fact base of various kinds of data required by the expert system; output management rules control the updating of the ONAV expert system user display screen during execution of the system; and data tables are static information utilized by many different rule sets gathered in one convenient place.

The more it changes; the more it remains the same: a Foucauldian analysis of Canadian policy documents relevant to student selection for medical school.

PubMed

Razack, Saleem; Lessard, David; Hodges, Brian D; Maguire, Mary H; Steinert, Yvonne

2014-05-01

Calls to increase the demographic representativeness of medical classes to better reflect the diversity of society are part of a growing international trend. Despite this, entry into medical school remains highly competitive and exclusive of marginalized groups. To address these questions, we conducted a Foucauldian discourse analysis of 15 publically available policy documents from the websites of Canadian medical education regulatory bodies, using the concepts of "excellence" (institutional or in an applicant), "diversity," and "equity" to frame the analysis. In most documents, there were appeals to broaden definitions of institutional excellence to include concerns for greater social accountability. Equity concerns tended to be represented as needing to be dealt with by people in positions of authority in order to counter a "hidden curriculum." Diversity was represented as an object of value, situated within a discontinuous history. As a rhetorical strategy, documents invoked complex societal shifts to promote change toward a more humanistic medical education system and profession. "Social accountability" was reified as an all-encompassing solution to most issues of representation. Although the policy documents proclaimed rootedness in an ethos of improving the societal responsiveness of the medical profession, our analysis takes a more critical stance towards the discourses identified. On the basis of our research findings, we question whether these calls may contribute to the maintenance of the specific power relations they seek to address. These conclusions lead us to consider the possibility that the discourses represented in the documents might be reframed to take into account issues of power distribution and its productive and reproductive features. A reframing of discourses could potentially generate greater inclusiveness in policy development processes, and afford disadvantaged and marginalized groups more participatory roles in the discussion.

General physicians: born or made? The use of a tracking database to answer medical workforce questions.

PubMed

Poole, P; McHardy, K; Janssen, A

2009-07-01

The aim of the study was to use a tracking database to investigate the perceived influence of various factors on career choices of New Zealand medical graduates and to examine specifically whether experiences at medical school may have an effect on a decision to become a general physician. Questionnaires were distributed to medical students in the current University of Auckland programme at entry and exit points. The surveys have been completed by two entry cohorts and an exit one since 2006. The response rates were 70 and 88% in the entry and exit groups, respectively. More than 75% of exiting students reported an interest in pursuing a career in general internal medicine. In 42%, this is a 'strong interest' in general medicine compared with 23% in the entry cohort (P < 0.0001). There is correlation between a positive experience in a clinical rotation and the reported level of interest in that specialty with those indicating a good experience likely to specify career intentions in that area. Having a positive experience in a clinical rotation, positive role models and flexibility in training are the most influential factors affecting career decisions in Auckland medical students. Only 11% of study respondents reported that student loan burden has a significant influence on career decisions. Quality experiences on attachments seem essential for undergraduates to promote interest in general medicine. There is potential for curriculum design and clinical experiences to be formulated to promote the 'making' of these doctors. Tracking databases will assist in answering some of these questions.

Intelligent retrieval of medical images from the Internet

NASA Astrophysics Data System (ADS)

Tang, Yau-Kuo; Chiang, Ted T.

1996-05-01

The object of this study is using Internet resources to provide a cost-effective, user-friendly method to access the medical image archive system and to provide an easy method for the user to identify the images required. This paper describes the prototype system architecture, the implementation, and results. In the study, we prototype the Intelligent Medical Image Retrieval (IMIR) system as a Hypertext Transport Prototype server and provide Hypertext Markup Language forms for user, as an Internet client, using browser to enter image retrieval criteria for review. We are developing the intelligent retrieval engine, with the capability to map the free text search criteria to the standard terminology used for medical image identification. We evaluate retrieved records based on the number of the free text entries matched and their relevance level to the standard terminology. We are in the integration and testing phase. We have collected only a few different types of images for testing and have trained a few phrases to map the free text to the standard medical terminology. Nevertheless, we are able to demonstrate the IMIR's ability to search, retrieve, and review medical images from the archives using general Internet browser. The prototype also uncovered potential problems in performance, security, and accuracy. Additional studies and enhancements will make the system clinically operational.

Maximum proton kinetic energy and patient-generated neutron fluence considerations in proton beam arc delivery radiation therapy.

PubMed

Sengbusch, E; Pérez-Andújar, A; DeLuca, P M; Mackie, T R

2009-02-01

Several compact proton accelerator systems for use in proton therapy have recently been proposed. Of paramount importance to the development of such an accelerator system is the maximum kinetic energy of protons, immediately prior to entry into the patient, that must be reached by the treatment system. The commonly used value for the maximum kinetic energy required for a medical proton accelerator is 250 MeV, but it has not been demonstrated that this energy is indeed necessary to treat all or most patients eligible for proton therapy. This article quantifies the maximum kinetic energy of protons, immediately prior to entry into the patient, necessary to treat a given percentage of patients with rotational proton therapy, and examines the impact of this energy threshold on the cost and feasibility of a compact, gantry-mounted proton accelerator treatment system. One hundred randomized treatment plans from patients treated with IMRT were analyzed. The maximum radiological pathlength from the surface of the patient to the distal edge of the treatment volume was obtained for 180 degrees continuous arc proton therapy and for 180 degrees split arc proton therapy (two 90 degrees arcs) using CT# profiles from the Pinnacle (Philips Medical Systems, Madison, WI) treatment planning system. In each case, the maximum kinetic energy of protons, immediately prior to entry into the patient, that would be necessary to treat the patient was calculated using proton range tables for various media. In addition, Monte Carlo simulations were performed to quantify neutron production in a water phantom representing a patient as a function of the maximum proton kinetic energy achievable by a proton treatment system. Protons with a kinetic energy of 240 MeV, immediately prior to entry into the patient, were needed to treat 100% of patients in this study. However, it was shown that 90% of patients could be treated at 198 MeV, and 95% of patients could be treated at 207 MeV. Decreasing the proton kinetic energy from 250 to 200 MeV decreases the total neutron energy fluence produced by stopping a monoenergetic pencil beam in a water phantom by a factor of 2.3. It is possible to significantly lower the requirements on the maximum kinetic energy of a compact proton accelerator if the ability to treat a small percentage of patients with rotational therapy is sacrificed. This decrease in maximum kinetic energy, along with the corresponding decrease in neutron production, could lower the cost and ease the engineering constraints on a compact proton accelerator treatment facility.

[Errors in medicine. Causes, impact and improvement measures to improve patient safety].

PubMed

Waeschle, R M; Bauer, M; Schmidt, C E

2015-09-01

The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental.The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures.Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing information on dosage, pharmacological interactions, side effects and contraindications of medications.The major challenges for quality and risk management, for the heads of departments and the executive board is the implementation and support of the described actions and a sustained guidance of the staff involved in the modification management process. The global trigger tool is suitable for improving transparency and objectifying the frequency of medical errors.

Neural Network Assisted Inverse Dynamic Guidance for Terminally Constrained Entry Flight

PubMed Central

Chen, Wanchun

2014-01-01

This paper presents a neural network assisted entry guidance law that is designed by applying Bézier approximation. It is shown that a fully constrained approximation of a reference trajectory can be made by using the Bézier curve. Applying this approximation, an inverse dynamic system for an entry flight is solved to generate guidance command. The guidance solution thus gotten ensures terminal constraints for position, flight path, and azimuth angle. In order to ensure terminal velocity constraint, a prediction of the terminal velocity is required, based on which, the approximated Bézier curve is adjusted. An artificial neural network is used for this prediction of the terminal velocity. The method enables faster implementation in achieving fully constrained entry flight. Results from simulations indicate improved performance of the neural network assisted method. The scheme is expected to have prospect for further research on automated onboard control of terminal velocity for both reentry and terminal guidance laws. PMID:24723821

Pediatrician-experienced barriers in the medical care for refugee children in the Netherlands.

PubMed

Baauw, A; Rosiek, S; Slattery, B; Chinapaw, M; van Hensbroek, M Boele; van Goudoever, J B; Kist-van Holthe, J

2018-04-20

Pediatricians in the Netherlands have been confronted with high numbers of refugee children in their daily practice. Refugee children have been recognized as an at-risk population because they may have an increased burden of physical and mental health conditions, and their caretakers may experience barriers in gaining access to the Dutch health care system. The aim of the study was to gain insight into the barriers in the health care for refugee children perceived by pediatricians by analyzing logistical problems reported through the Dutch Pediatric Surveillance Unit, an online system where pediatricians can report predefined conditions. Pediatricians reported 68 cases of barriers in health care ranging from mild to severe impact on the health outcome of refugee children, reported from November 2015 till January 2017. Frequent relocation of children between asylum seeker centers was mentioned in 28 of the reports on lack of continuity of care. Unknown medical history (21/68) and poor handoffs of medical records resulting in poor communication between health professionals (17/68) contributed to barriers to provide good medical care for refugee children, as did poor health literacy (17/68) and cultural differences (5/68). Frequent relocations and the unknown medical history were reported most frequently as barriers impacting the delivery of health care to refugee children. To overcome these barriers, the Committee of International Child Health of the Dutch Society of Pediatrics recommends stopping the frequent relocations, improving medical assessment upon entry in the Netherlands, improving handoff of medical records, and improving the health literacy of refugee children and their families. What is Known: • Pediatricians in the Netherlands are confronted with high numbers of refugee children • Refugee children represent a population that is especially at risk due to their increased burden of physical and mental health conditions What is New: • Refugee children experience barriers in accessing medical care • To start overcoming these barriers, we recommend that frequent relocations be stopped, health assessment upon entry in the Netherlands be improved, medical handoffs be improved, and that the refugees be empowered by increasing their health literacy.

An Automated System for Generating Situation-Specific Decision Support in Clinical Order Entry from Local Empirical Data

ERIC Educational Resources Information Center

Klann, Jeffrey G.

2011-01-01

Clinical Decision Support is one of the only aspects of health information technology that has demonstrated decreased costs and increased quality in healthcare delivery, yet it is extremely expensive and time-consuming to create, maintain, and localize. Consequently, a majority of health care systems do not utilize it, and even when it is…

Can Social Semantic Web Techniques Foster Collaborative Curriculum Mapping In Medicine?

PubMed Central

Finsterer, Sonja; Cremer, Jan; Schenkat, Hennig

2013-01-01

Background Curriculum mapping, which is aimed at the systematic realignment of the planned, taught, and learned curriculum, is considered a challenging and ongoing effort in medical education. Second-generation curriculum managing systems foster knowledge management processes including curriculum mapping in order to give comprehensive support to learners, teachers, and administrators. The large quantity of custom-built software in this field indicates a shortcoming of available IT tools and standards. Objective The project reported here aims at the systematic adoption of techniques and standards of the Social Semantic Web to implement collaborative curriculum mapping for a complete medical model curriculum. Methods A semantic MediaWiki (SMW)-based Web application has been introduced as a platform for the elicitation and revision process of the Aachen Catalogue of Learning Objectives (ACLO). The semantic wiki uses a domain model of the curricular context and offers structured (form-based) data entry, multiple views, structured querying, semantic indexing, and commenting for learning objectives (“LOs”). Semantic indexing of learning objectives relies on both a controlled vocabulary of international medical classifications (ICD, MeSH) and a folksonomy maintained by the users. An additional module supporting the global checking of consistency complements the semantic wiki. Statements of the Object Constraint Language define the consistency criteria. We evaluated the application by a scenario-based formative usability study, where the participants solved tasks in the (fictional) context of 7 typical situations and answered a questionnaire containing Likert-scaled items and free-text questions. Results At present, ACLO contains roughly 5350 operational (ie, specific and measurable) objectives acquired during the last 25 months. The wiki-based user interface uses 13 online forms for data entry and 4 online forms for flexible searches of LOs, and all the forms are accessible by standard Web browsers. The formative usability study yielded positive results (median rating of 2 (“good”) in all 7 general usability items) and produced valuable qualitative feedback, especially concerning navigation and comprehensibility. Although not asked to, the participants (n=5) detected critical aspects of the curriculum (similar learning objectives addressed repeatedly and missing objectives), thus proving the system’s ability to support curriculum revision. Conclusions The SMW-based approach enabled an agile implementation of computer-supported knowledge management. The approach, based on standard Social Semantic Web formats and technology, represents a feasible and effectively applicable compromise between answering to the individual requirements of curriculum management at a particular medical school and using proprietary systems. PMID:23948519

The Future of Access Technology for Blind and Visually Impaired People.

ERIC Educational Resources Information Center

Schreier, E. M.

1990-01-01

This article describes potential use of new technological products and services by blind/visually impaired people. Items discussed include computer input devices, public telephones, automatic teller machines, airline and rail arrival/departure displays, ticketing machines, information retrieval systems, order-entry terminals, optical character…

A Crisis in Competency: The Strategic and Ethical Imperative to Assessing New Graduate Nurses' Clinical Reasoning.

PubMed

Kavanagh, Joan M; Szweda, Christine

The aim of the study was to assess entry-level competency and practice readiness of newly graduated nurses. Literature on success of new graduates focuses primarily on National Council of State Boards of Nursing Licensure Examination (NCLEX-RN) pass rates, creating a false and incomplete picture of practice readiness. Posthire and prestart Performance-Based Development System assessments were administered to more than 5,000 newly graduated nurses at a large midwestern academic medical center between July 2010 and July 2015. Aggregate baseline data indicate that only 23 percent of newly graduated nurses demonstrate entry-level competencies and practice readiness. New data suggest that we are losing ground in the quest for entry-level competency. Graduates often are underprepared to operate in the complex field of professional practice where increased patient acuity and decreased length of stay, coupled with a lack of deep learning in our academic nursing programs, have exacerbated a crisis in competency.

3. DETAIL VIEW OF S ENTRY DOOR TO BUILDING 8, ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

3. DETAIL VIEW OF S ENTRY DOOR TO BUILDING 8, SHOWING ONE OF THE ORIGINAL LIGHT FIXTURES AND THE EGYPTIAN MOTIF DECORATION; LOOKING N (Ryan) - Veterans Administration Medical Center, Building No. 8, Old State Route 13 West, Marion, Williamson County, IL

Emergency Medical Services Program Guide.

ERIC Educational Resources Information Center

Georgia Univ., Athens. Dept. of Vocational Education.

This program guide contains the standard emergency medical services curriculum for technical institutes in Georgia. The curriculum encompasses the minimum competencies required for entry-level workers in the emergency medical services field, and includes job skills in six emergency medical services divisions outlined in the national curriculum:…

A medical informatics perspective on clinical decision support systems. Findings from the yearbook 2013 section on decision support.

PubMed

Bouaud, J; Lamy, J-B

2013-01-01

To summarize excellent research and to select best papers published in 2012 in the field of computer-based decision support in healthcare. A bibliographic search focused on clinical decision support systems (CDSSs) and computer provider order entry was performed, followed by a double-blind literature review. The review process yielded six papers, illustrating various aspects of clinical decision support. The first paper is a systematic review of CDSS intervention trials in real settings, and considers different types of possible outcomes. It emphasizes the heterogeneity of studies and confirms that CDSSs can improve process measures but that evidence lacks for other types of outcomes, especially clinical or economic. Four other papers tackle the safety of drug prescribing and show that CDSSs can be efficient in reducing prescription errors. The sixth paper exemplifies the growing role of ontological resources which can be used for several applications including decision support. CDSS research has to be continuously developed and assessed. The wide variety of systems and of interventions limits the understanding of factors of success of CDSS implementations. A standardization in the characterization of CDSSs and of intervention trial reporting will help to overcome this obstacle.

Evolution of a Patient Information Management System in a Local Area Network Environment at Loyola University of Chicago Medical Center

PubMed Central

Price, Ronald N; Chandrasekhar, Arcot J; Tamirisa, Balaji

1990-01-01

The Department of Medicine at Loyola University Medical Center (LUMC) of Chicago has implemented a local area network (LAN) based Patient Information Management System (PIMS) as part of its integrated departmental database management system. PIMS consists of related database applications encompassing demographic information, current medications, problem lists, clinical data, prior events, and on-line procedure results. Integration into the existing departmental database system permits PIMS to capture and manipulate data in other departmental applications. Standardization of clinical data is accomplished through three data tables that verify diagnosis codes, procedures codes and a standardized set of clinical data elements. The modularity of the system, coupled with standardized data formats, allowed the development of a Patient Information Protocol System (PIPS). PIPS, a userdefinable protocol processor, provides physicians with individualized data entry or review screens customized for their specific research protocols or practice habits. Physician feedback indicates that the PIMS/PIPS combination enhances their ability to collect and review specific patient information by filtering large amount of clinical data.

Validating a multiple mini-interview question bank assessing entry-level reasoning skills in candidates for graduate-entry medicine and dentistry programmes.

PubMed

Roberts, Chris; Zoanetti, Nathan; Rothnie, Imogene

2009-04-01

The multiple mini-interview (MMI) was initially designed to test non-cognitive characteristics related to professionalism in entry-level students. However, it may be testing cognitive reasoning skills. Candidates to medical and dental schools come from diverse backgrounds and it is important for the validity and fairness of the MMI that these background factors do not impact on their scores. A suite of advanced psychometric techniques drawn from item response theory (IRT) was used to validate an MMI question bank in order to establish the conceptual equivalence of the questions. Bias against candidate subgroups of equal ability was investigated using differential item functioning (DIF) analysis. All 39 questions had a good fit to the IRT model. Of the 195 checklist items, none were found to have significant DIF after visual inspection of expected score curves, consideration of the number of applicants per category, and evaluation of the magnitude of the DIF parameter estimates. The question bank contains items that have been studied carefully in terms of model fit and DIF. Questions appear to measure a cognitive unidimensional construct, 'entry-level reasoning skills in professionalism', as suggested by goodness-of-fit statistics. The lack of items exhibiting DIF is encouraging in a contemporary high-stakes admission setting where candidates of diverse personal, cultural and academic backgrounds are assessed by common means. This IRT approach has potential to provide assessment designers with a quality control procedure that extends to the level of checklist items.

Thermal Testing of Woven TPS Materials in Extreme Entry Environments

NASA Technical Reports Server (NTRS)

Gonzales, G.; Stackpoole, M.

2014-01-01

NASAs future robotic missions to Venus and outer planets, namely, Saturn, Uranus, Neptune, result in extremely high entry conditions that exceed the capabilities of current mid density ablators (PICA or Avcoat). Therefore mission planners assume the use of a fully dense carbon phenolic heatshield similar to what was flown on Pioneer Venus and Galileo. Carbon phenolic (CP) is a robust TPS however its high density and thermal conductivity constrain mission planners to steep entries, high heat fluxes, high pressures and short entry durations, in order for CP to be feasible from a mass perspective. In 2012 the Game Changing Development Program in NASAs Space Technology Mission Directorate funded NASA ARC to investigate the feasibility of a Woven Thermal Protection System to meet the needs of NASAs most challenging entry missions. The high entry conditions pose certification challenges in existing ground based test facilities. Recent updates to NASAs IHF and AEDCs H3 high temperature arcjet test facilities enable higher heatflux (2000 Wcm2) and high pressure (5 atm) testing of TPS. Some recent thermal tests of woven TPS will be discussed in this paper. These upgrades have provided a way to test higher entry conditions of potential outer planet and Venus missions and provided a baseline against carbon phenolic material. The results of these tests have given preliminary insight to sample configuration and physical recession profile characteristics.

39 CFR 761.8 - Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

Code of Federal Regulations, 2010 CFR

2010-07-01

... 39 Postal Service 1 2010-07-01 2010-07-01 false Servicing book-entry Postal Service securities... POSTAL SERVICE POSTAL SERVICE DEBT OBLIGATIONS; DISBURSEMENT POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.8 Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

39 CFR 761.8 - Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

Code of Federal Regulations, 2012 CFR

2012-07-01

... 39 Postal Service 1 2012-07-01 2012-07-01 false Servicing book-entry Postal Service securities... POSTAL SERVICE POSTAL SERVICE DEBT OBLIGATIONS; DISBURSEMENT POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.8 Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

39 CFR 761.8 - Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

Code of Federal Regulations, 2014 CFR

2014-07-01

... 39 Postal Service 1 2014-07-01 2014-07-01 false Servicing book-entry Postal Service securities... POSTAL SERVICE POSTAL SERVICE DEBT OBLIGATIONS; DISBURSEMENT POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.8 Servicing book-entry Postal Service securities; payment of interest, payment at maturity or upon...

Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students?

PubMed

Hayes, K; Feather, A; Hall, A; Sedgwick, P; Wannan, G; Wessier-Smith, A; Green, T; McCrorie, P

2004-11-01

The transition to full-time clinical studies holds anxieties for most medical students. While graduate entry medical education has only recently begun in the UK, the parallel undergraduate and graduate entry MBBS courses taught at our school allowed us to study how 2 differently prepared groups perceived this vital time at a comparable stage in their training. An anonymous questionnaire collected demographic data and graded anxiety in 13 statements relating to starting full-time clinical attachments. Two open questions allowed free text comment on the most positive and negative influences perceived during this time. Both a statistical analysis and a qualitative assessment were performed to compare the 2 groups of students. The 2 groups were similar with respect to gender but the graduate entry students were significantly older. The graduate entry students were significantly less anxious about most aspects of the transition period compared to the undergraduates. These course differences remained after adjusting for age and sex. When adjusted for course and age, male students expressed less anxiety. The main positive qualitative statements related to continual clinical and communication skills training in the graduate entry group. The main qualitative concerns in both groups related to 'fitting in' and perceived lack of factual knowledge. These data support the early introduction of clinical skills teaching, backed up by a fully integrated clinically relevant curriculum with continued assessment, in preparing students and reducing levels of anxiety before they start full-time clinical attachments. These course design differences appear to be more important than any differences in maturity between the 2 groups.

A Fast Proceduere for Optimizing Thermal Protection Systems of Re-Entry Vehicles

NASA Astrophysics Data System (ADS)

Ferraiuolo, M.; Riccio, A.; Tescione, D.; Gigliotti, M.

The aim of the present work is to introduce a fast procedure to optimize thermal protection systems for re-entry vehicles subjected to high thermal loads. A simplified one-dimensional optimization process, performed in order to find the optimum design variables (lengths, sections etc.), is the first step of the proposed design procedure. Simultaneously, the most suitable materials able to sustain high temperatures and meeting the weight requirements are selected and positioned within the design layout. In this stage of the design procedure, simplified (generalized plane strain) FEM models are used when boundary and geometrical conditions allow the reduction of the degrees of freedom. Those simplified local FEM models can be useful because they are time-saving and very simple to build; they are essentially one dimensional and can be used for optimization processes in order to determine the optimum configuration with regard to weight, temperature and stresses. A triple-layer and a double-layer body, subjected to the same aero-thermal loads, have been optimized to minimize the overall weight. Full two and three-dimensional analyses are performed in order to validate those simplified models. Thermal-structural analyses and optimizations are executed by adopting the Ansys FEM code.

Generic Entry, Reformulations, and Promotion of SSRIs

PubMed Central

Donohue, Julie M.; Koss, Catherine; Berndt, Ernst R.; Frank, Richard G.

2009-01-01

Background Previous research has shown that a manufacturer’s promotional strategy for a brand-name drug is typically affected by generic entry. However, little is known about how newer strategies to extend patent life, including product reformulation introduction or obtaining approval to market for additional clinical indications, influence promotion. Objective To examine the relationship between promotional expenditures, generic entry, reformulation entry, and new indication approval. Study Design/Setting We used quarterly data on national product-level promotional spending (including expenditures for physician detailing and direct-to-consumer advertising (DTCA), and the retail value of free samples distributed in physician offices) for selective serotonin reuptake inhibitors (SSRIs) over the period 1997 through 2004. We estimated econometric models of detailing, DTCA, and total quarterly promotional expenditures as a function of the timing of generic entry, entry of new product formulations, and Food and Drug Administration (FDA) approval for new clinical indications for existing medications in the SSRI class. Main Outcome Measure Expenditures by pharmaceutical manufacturers for promotion of antidepressant medications. Results Over the period 1997–2004, there was considerable variation in the composition of promotional expenditures across the SSRIs. Promotional expenditures for the original brand molecule decreased dramatically when a reformulation of the molecule was introduced. Promotional spending (both total and detailing alone) for a specific molecule was generally lower after generic entry than before, although the effect of generic entry on promotional spending appears to be closely linked with the choice of product reformulation strategy pursued by the manufacturer. Detailing expenditures for Paxil were increased after the manufacturer received FDA approval to market the drug for generalized anxiety disorder (GAD), while the likelihood of DTCA outlays for the drug was not changed. In contrast, FDA approval to market Paxil and Zoloft for social anxiety disorder (SAD) did not affect the manufacturers’ detailing expenditures but did result in a greater likelihood of DTCA outlays. Conclusion The introduction of new product formulations appears to be a common strategy for attempting to extend market exclusivity for medications facing impending generic entry. Manufacturers that introduced a reformulation before generic entry shifted most promotion dollars from the original brand to the reformulation long before generic entry, and in some cases manufacturers appeared to target a particular promotion type for a given indication. Given the significant impact pharmaceutical promotion has on demand for prescription drugs, these findings have important implications for prescription drug spending and public health. PMID:18563951

Evidence that electronic health records can promote physician counseling for healthy behaviors.

PubMed

Bae, Jaeyong; Hockenberry, Jason M; Rask, Kimberly J; Becker, Edmund R

Health behavior counseling services may help patients manage chronic conditions effectively and slow disease progression. Studies show, however, that many providers fail to provide these services because of time constraints and inability to tailor counseling to individual patient needs. Electronic health records (EHRs) have the potential to increase appropriate counseling by providing pertinent patient information at the point of care and clinical decision support. This study estimates the impact of select EHR functionalities on the rate of health behavior counseling provided during primary care visits. Multivariable regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to examine whether eight EHR components representing four core functionalities of EHR systems were correlated with the rate of health behavior counseling services. Propensity score matching was used to control for confounding factors given the use of observational data. To address concerns that EHR may only lead to improved documentation of counseling services and not necessarily improved care, the association of EHR functionalities with prescriptions for smoking cessation medications was also estimated. The use of an EHR system with health information and data, order entry and management, result management, decision support, and a notification system for abnormal test results was associated with an approximately 25% increase in the probability of health behavior counseling delivered. Clinical reminders were associated with more health behavior counseling services when available in combination with patient problem lists. The laboratory results viewer was also associated with more counseling services when implemented with a notification system for abnormal results. An EHR system with key supportive functionalities can enhance delivery of preventive health behavior counseling services in primary care settings. Meaningful use criteria should be evaluated to ensure that they encourage the adoption of EHR systems with those functionalities shown to improve clinical care.

Etiquette for medical students' email communication with faculty members: a single-institution study.

PubMed

Kim, Do-Hwan; Yoon, Hyun Bae; Yoo, Dong-Mi; Lee, Sang-Min; Jung, Hee-Yeon; Kim, Seog Ju; Shin, Jwa-Seop; Lee, Seunghee; Yim, Jae-Joon

2016-04-27

Email is widely used as a means of communication between faculty members and students in medical education because of its practical and educational advantages. However, because of the distinctive nature of medical education, students' inappropriate email etiquette may adversely affect their learning as well as faculty members' perception of them. Little data on medical students' competency in professional email writing is available; therefore, this study explored the strengths and weaknesses of medical students' email etiquette and factors that contribute to professional email writing. A total of 210 emails from four faculty members at Seoul National University College of Medicine were collected. An evaluation criteria and a scoring rubric were developed based on the various email-writing guidelines. The rubric comprised 10 items, including nine items for evaluation related to the email components and one item for the assessment of global impression of politeness. Three evaluators independently assessed all emails according to the criteria. Students were identified as being 61.0% male and 52.8% were in the undergraduate-entry program. The sum of each component score was 62.21 out of 100 and the mean value for global impression was 2.6 out of 4. The results demonstrated that students' email etiquettes remained low-to-mediocre for most criteria, except for readability and honorifics. Three criteria, salutation (r=0.668), closing (r=0.653), and sign-off (r=0.646), showed a strong positive correlation with the global impression of politeness. Whether a student entered a graduate-entry program or an undergraduate-entry program significantly contributed to professional email writing after other variables were controlled. Although students in the graduate-entry program demonstrated a relatively superior level of email etiquette, the majority of medical students did not write emails professionally. Educating all medical students in email etiquette may well contribute to the improvement of student-faculty relationships as well as their email writing.

[Information management in multicenter studies: the Brazilian longitudinal study for adult health].

PubMed

Duncan, Bruce Bartholow; Vigo, Álvaro; Hernandez, Émerson; Luft, Vivian Cristine; Ahlert, Hubert; Bergmann, Kaiser; Mota, Eduardo

2013-06-01

Information management in large multicenter studies requires a specialized approach. The Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil - Brazilian Longitudinal Study for Adult Health) has created a Datacenter to enter and manage its data system. The aim of this paper is to describe the steps involved, including the information entry, transmission and management methods. A web system was developed in order to allow, in a safe and confidential way, online data entry, checking and editing, as well as the incorporation of data collected on paper. Additionally, a Picture Archiving and Communication System was implemented and customized for echocardiography and retinography. It stores the images received from the Investigation Centers and makes them available at the Reading Centers. Finally, data extraction and cleaning processes were developed to create databases in formats that enable analyses in multiple statistical packages.

Medical Assistant Curriculum.

ERIC Educational Resources Information Center

Jaeger, Mildred

Intended to serve as a guide to school personnel responsible for curriculum development, the course outline is designed to prepare high school students for entry into the medical field as an assistant in a doctor's office. Contents are divided into three areas: medical secretary, medical technician, and doctor's assistant (patient management).…

Entry Guidance for the Reusable Launch Vehicle

NASA Technical Reports Server (NTRS)

Lu, Ping

1999-01-01

The X-33 Advanced Technology Demonstrator is a half-scale prototype developed to test the key technologies needed for a full-scale single-stage reusable launch vehicle (RLV). The X-33 is a suborbital vehicle that will be launched vertically, and land horizontally. The goals of this research were to develop an alternate entry guidance scheme for the X-33 in parallel to the actual X-33 entry guidance algorithms, provide comparative and complementary study, and identify potential new ways to improve entry guidance performance. Toward these goals, the nominal entry trajectory is defined by a piecewise linear drag-acceleration-versus-energy profile, which is in turn obtained by the solution of a semi-analytical parameter optimization problem. The closed-loop guidance is accomplished by tracking the nominal drag profile with primarily bank-angle modulation on-board. The bank-angle is commanded by a single full-envelope nonlinear trajectory control law. Near the end of the entry flight, the guidance logic is switched to heading control in order to meet strict conditions at the terminal area energy management interface. Two methods, one on ground-track control and the other on heading control, were proposed and examined for this phase of entry guidance where lateral control is emphasized. Trajectory dispersion studies were performed to evaluate the effectiveness of the entry guidance algorithms against a number of uncertainties including those in propulsion system, atmospheric properties, winds, aerodynamics, and propellant loading. Finally, a new trajectory-regulation method is introduced at the end as a promising precision entry guidance method. The guidance principle is very different and preliminary application in X-33 entry guidance simulation showed high precision that is difficult to achieve by existing methods.

Communications Blackout Predictions for Atmospheric Entry of Mars Science Laboratory

NASA Technical Reports Server (NTRS)

Morabito, David D.; Edquist, Karl

2005-01-01

The Mars Science Laboratory (MSL) is expected to be a long-range, long-duration science laboratory rover on the Martian surface. MSL will provide a significant milestone that paves the way for future landed missions to Mars. NASA is studying options to launch MSL as early as 2009. MSL will be the first mission to demonstrate the new technology of 'smart landers', which include precision landing and hazard avoidance in order to -land at scientifically interesting sites that would otherwise be unreachable. There are three elements to the spacecraft; carrier (cruise stage), entry vehicle, and rover. The rover will have an X-band direct-to-Earth (DTE) link as well as a UHF proximity link. There is also a possibility of an X-band proximity link. Given the importance of collecting critical event telemetry data during atmospheric entry, it is important to understand the ability of a signal link to be maintained, especially during the period near peak convective heating. The received telemetry during entry (or played back later) will allow for the performance of the Entry-Descent-Landing technologies to be assessed. These technologies include guided entry for precision landing, hazard avoidance, a new sky-crane landing system and powered descent. MSL will undergo an entry profile that may result in a potential communications blackout caused by ionized plasma for short periods near peak heating. The vehicle will use UHF and possibly X-band during the entry phase. The purpose of this report is to quantify or bound the likelihood of any such blackout at UHF frequencies (401 MHz) and X-band frequencies (8.4 GHz). Two entry trajectory scenarios were evaluated: a stressful entry trajectory to quantify an upper-bound for any possible blackout period, and a nominal likely trajectory to quantify likelihood of blackout for such cases.

Predictors of patient entry into alcohol treatment after initial diagnosis.

PubMed

Kirchner, J E; Booth, B M; Owen, R R; Lancaster, A E; Smith, G R

2000-08-01

To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry, must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance-use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included age younger than than 60 (odds ratio [OR] = 4.6), not married (OR = 1.7), primary diagnosis of an alcohol-related disorder (OR = 7.7), diagnosis of a comorbid drug (OR = 4.3) or psychiatric disorder (OR = 3.6), diagnosis by a medical as opposed to a surgical specialty (OR = 6.0), and African American (OR = 1.7).

Terminology Services: Standard Terminologies to Control Health Vocabulary.

PubMed

González Bernaldo de Quirós, Fernán; Otero, Carlos; Luna, Daniel

2018-04-22

Healthcare Information Systems should capture clinical data in a structured and preferably coded format. This is crucial for data exchange between health information systems, epidemiological analysis, quality and research, clinical decision support systems, administrative functions, among others. Structured data entry is an obstacle for the usability of electronic health record (EHR) applications and their acceptance by physicians who prefer to document patient EHRs using "free text". Natural language allows for rich expressiveness but at the same time is ambiguous; it has great dependence on context and uses jargon and acronyms. Although much progress has been made in knowledge and natural language processing techniques, the result is not yet satisfactory enough for the use of free text in all dimensions of clinical documentation. In order to address the trade-off between capturing data with free text and at the same time coding data for computer processing, numerous terminological systems for the systematic recording of clinical data have been developed. The purpose of terminology services consists of representing facts that happen in the real world through database management in order to allow for semantic interoperability and computerized applications. These systems interrelate concepts of a particular domain and provide references to related terms with standards codes. In this way, standard terminologies allow the creation of a controlled medical vocabulary, making terminology services a fundamental component for health data management in the healthcare environment. The Hospital Italiano de Buenos Aires has been working in the development of its own terminology server. This work describes its experience in the field. Georg Thieme Verlag KG Stuttgart.

Meaning-Making among Medical Students: Development of a Quantitative Measure of Self-Authorship

ERIC Educational Resources Information Center

Fallar, Robert

2014-01-01

Preparation for and application to medical school, as well as the subsequent medical training of matriculating students, can have an important impact on psychosocial development. The premedical baccalaureate is the traditional preparation for medical school, although many medical schools also offer a separate entry path through early assurance…

31 CFR 357.0 - Book-entry systems.

Code of Federal Regulations, 2014 CFR

2014-07-01

... General Information § 357.0 Book-entry systems. (a) Treasury securities. Treasury securities are...-entry system is the book-entry system in which Treasury securities are held in a tiered system through securities intermediaries such as financial institutions or brokerage firms. A Treasury security is...

31 CFR 357.0 - Book-entry systems.

Code of Federal Regulations, 2012 CFR

2012-07-01

... General Information § 357.0 Book-entry systems. (a) Treasury securities. Treasury securities are...-entry system is the book-entry system in which Treasury securities are held in a tiered system through securities intermediaries such as financial institutions or brokerage firms. A Treasury security is...

31 CFR 357.0 - Book-entry systems.

Code of Federal Regulations, 2011 CFR

2011-07-01

... General Information § 357.0 Book-entry systems. (a) Treasury securities. Treasury securities are...-entry system is the book-entry system in which Treasury securities are held in a tiered system through securities intermediaries such as financial institutions or brokerage firms. A Treasury security is...

31 CFR 357.0 - Book-entry systems.

Code of Federal Regulations, 2013 CFR

2013-07-01

... General Information § 357.0 Book-entry systems. (a) Treasury securities. Treasury securities are...-entry system is the book-entry system in which Treasury securities are held in a tiered system through securities intermediaries such as financial institutions or brokerage firms. A Treasury security is...

Radiative Heating in MSL Entry: Comparison of Flight Heating Discrepancy to Ground Test and Predictive Models

NASA Technical Reports Server (NTRS)

Cruden, Brett A.; Brandis, Aaron M.; White, Todd R.; Mahzari, Milad; Bose, Deepak

2014-01-01

During the recent entry of the Mars Science Laboratory (MSL), the heat shield was equipped with thermocouple stacks to measure in-depth heating of the thermal protection system (TPS). When only convective heating was considered, the derived heat flux from gauges in the stagnation region was found to be underpredicted by as much as 17 W/sq cm, which is significant compared to the peak heating of 32 W/sq cm. In order to quantify the contribution of radiative heating phenomena to the discrepancy, ground tests and predictive simulations that replicated the MSL entry trajectory were performed. An analysis is carried through to assess the quality of the radiation model and the impact to stagnation line heating. The impact is shown to be significant, but does not fully explain the heating discrepancy.

Usability of a barcode scanning system as a means of data entry on a PDA for self-report health outcome questionnaires: a pilot study in individuals over 60 years of age

PubMed Central

Boissy, Patrick; Jacobs, Karen; Roy, Serge H

2006-01-01

Background Throughout the medical and paramedical professions, self-report health status questionnaires are used to gather patient-reported outcome measures. The objective of this pilot study was to evaluate in individuals over 60 years of age the usability of a PDA-based barcode scanning system with a text-to-speech synthesizer to collect data electronically from self-report health outcome questionnaires. Methods Usability of the system was tested on a sample of 24 community-living older adults (7 men, 17 women) ranging in age from 63 to 93 years. After receiving a brief demonstration on the use of the barcode scanner, participants were randomly assigned to complete two sets of 16 questions using the bar code wand scanner for one set and a pen for the other. Usability was assessed using directed interviews with a usability questionnaire and performance-based metrics (task times, errors, sources of errors). Results Overall, participants found barcode scanning easy to learn, easy to use, and pleasant. Participants were marginally faster in completing the 16 survey questions when using pen entry (20/24 participants). The mean response time with the barcode scanner was 31 seconds longer than traditional pen entry for a subset of 16 questions (p = 0.001). The responsiveness of the scanning system, expressed as first scan success rate, was less than perfect, with approximately one-third of first scans requiring a rescan to successfully capture the data entry. The responsiveness of the system can be explained by a combination of factors such as the location of the scanning errors, the type of barcode used as an answer field in the paper version, and the optical characteristics of the barcode scanner. Conclusion The results presented in this study offer insights regarding the feasibility, usability and effectiveness of using a barcode scanner with older adults as an electronic data entry method on a PDA. While participants in this study found their experience with the barcode scanning system enjoyable and learned to become proficient in its use, the responsiveness of the system constitutes a barrier to wide-scale use of such a system. Optimizing the graphical presentation of the information on paper should significantly increase the system's responsiveness. PMID:17184533

The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan.

PubMed

Long, An-Jim; Chang, Polun

2012-09-01

There is an evidence that pregnant women have been prescribed a significant number of improper medications that could lead to potential damage for a developing fetus due to discontinuity of care. The safety of pregnant women raises public concern and there is a need to identify ways to prevent potential adverse events to the pregnant woman. This study used a health smart card with a clinical reminder system to keep continuous records of general outpatient visits of pregnant women to protect them from potential adverse events caused by improper prescription. The health smart card, issued to all 23 million citizens in Taiwan, was used to work with a Computerized Physician Order Entry (CPOE) implemented at a 700-bed teaching medical center in Taipei to provide the outpatient information of pregnant women. FDA pregnancy risk classification was used to categorize the risk of pregnant women. The log file, combined with the physicians' and patients' profiles, were statistically examined using the Mantel-Haenszel technique to evaluate the impact of system in changing physician's prescription behavior. A total of 441 patients ranged in age from 15 to 50 years with 1114 prescriptions involved in FDA pregnancy risk classification C, D, and X during the study period. 144 reminders (13.1%) were accepted by physicians for further assessment and 100 (69.4%) of them were modified. Non-obstetric physicians in non-emergency setting were more intended to accept reminders (27.8%, 4.9 folds than obstetricians). Reminders triggered on patients in second trimester (15.5%) were accepted by all physicians more than third trimester (OR 1.52, p<0.05). A health smart card armed with CPOE reminder system and well-defined criteria had the potential to decrease harmful medication prescribed to pregnant patients. The results show better conformance for non-obstetric physicians (26%) and when physicians accepted the alerts they are more likely to went back and review their orders (69%). In sum, reminder criteria of FDA pregnancy risk classification C for obstetricians and reminder based on different trimesters is suggested to be refined to improve system acceptability and to decrease improper prescription. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

An evaluation of the success of a surgical resident learning portfolio.

PubMed

Webb, Travis P; Merkley, Taylor R

2012-01-01

Learning portfolios have gained modest acceptance in graduate medical education because of challenges related to user satisfaction, time and resource commitment, and quality assessment. In 2001, the Department of Surgery implemented the Surgical Learning and Instructional Portfolio (SLIP) to help residents develop a case-based portfolio demonstrating practice-based learning. In 2008, the format was changed to a Web-based platform with open viewing of portfolios for all learners. This study was performed to evaluate the SLIP program using resident and faculty perspectives in the domains of satisfaction, compliance, and educational value. Likert scale surveys were distributed to residents to assess satisfaction. Using a semistructured format with subsequent qualitative analysis of the meeting transcript, a focus group discussion was held with the SLIP director, SLIP facilitator, and program coordinator. An analysis of the program compliance was performed by review of SLIP entry dates. Finally, the quality of the SLIP entries (n = 420) was analyzed in a blinded manner using a locally developed standardized SLIP assessment tool. Data analysis was performed using Pearson's correlation and Cronbach's alpha. Residents were satisfied with the program and felt the Web-based format promoted self-reflection. They perceived that time spent was appropriate. Residents also believed they gained medical knowledge of their own specific entry topics but did not learn routinely from others' entries. Faculty asserted that the Web-based platform eased the administrative burden but did not necessarily alter the quality of the SLIP entries. Compliance with the assignment was 100%. SLIP entry analysis demonstrated the reflection and understanding of the topics chosen. However, the overall quality assessment of entries was hindered by suboptimal interrater reliability (inter-rater reliability (IR) = 0.636). The SLIP program allows residents to demonstrate practice-based learning and improvement of medical knowledge. The Web-based format provides transparency and ease of administration. Quality assessment of individual portfolio entries remains a challenge to the widespread adoption of portfolios. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A Change of Heart? British Policies towards Tubercular Refugees during 1959 World Refugee Year.

PubMed

Taylor, Becky

2015-01-01

This article looks at Britain's response to the World Refugee Year (1959-60), and in particular the government's decision to allow entry to refugees with tuberculosis and other chronic illnesses. In doing so, it broke the practice established by the 1920 Aliens' Order which had barred entry to immigrants with a range of medical conditions. This article uses the entry of these sick refugees as an opportunity to explore whether government policy represented as much of a shift in attitude and practice as contemporary accounts suggested. It argues for the importance of setting the reception of tubercular and other 'disabled' refugees in 1959-61 in its very particular historical context, showing it was a case less of the government thinking differently about refugees, and more of how, in a post-Suez context, the government felt obliged to take into account international and public opinion. The work builds on and adds to the growing literature surrounding refugees and disease. It also places the episode within the specificity of the post-war changing epidemiological climate; the creation of the National Health Service; and the welfare state more broadly. In looking at the role of refugee organizations in the Year, the article also contributes to debates over the place of voluntary agencies within British society.

Assessing competency in practice-based learning: a foundation for milestones in learning portfolio entries.

PubMed

Webb, Travis P; Merkley, Taylor R; Wade, Thomas J; Simpson, Deborah; Yudkowsky, Rachel; Harris, Ilene

2014-01-01

Graduate medical education is undergoing a dramatic shift toward competency-based assessment of learners. Competency assessment requires clear definitions of competency and validated assessment methods. The purpose of this study is to identify criteria used by surgical educators to judge competence in Practice-Based Learning and Improvement (PBL&I) as demonstrated in learning portfolios. A total of 6 surgical learning and instructional portfolio entries served as documents to be assessed by 3 senior surgical educators. These faculty members were asked to rate and then identify criteria used to assess PBL&I competency. Individual interviews and group discussions were conducted, recorded, and transcribed to serve as the study dataset. Analysis was performed using qualitative methodology to identify themes for the purpose of defining competence in PBL&I. The assessment themes derived are presented with narrative examples to describe the progression of competency. The collaborative coding process resulted in identification of 7 themes associated with competency in PBL&I related to surgical learning and instructional portfolio entries: (1) self-awareness regarding effect of actions; (2) identification and thorough description of learning goals; (3) cases used as catalyst for reflection; (4) reconceptualization with appropriate use and critique of cited literature; (5) communication skills/completeness of entry template; (6) description of future behavioral change; and (7) engagement in process--identifies as personally relevant. The identified themes are consistent with and complement other criteria emerging from reflective practice literature and experiential learning theory. This study provides a foundation for further development of a tool for assessing learner portfolios consistent with the Accreditation Council for Graduate Medical Education's Next Accreditation System requirements. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Pulmonary drug delivery. Part I: Physiological factors affecting therapeutic effectiveness of aerosolized medications

PubMed Central

Labiris, N R; Dolovich, M B

2003-01-01

As the end organ for the treatment of local diseases or as the route of administration for systemic therapies, the lung is a very attractive target for drug delivery. It provides direct access to disease in the treatment of respiratory diseases, while providing an enormous surface area and a relatively low enzymatic, controlled environment for systemic absorption of medications. As a major port of entry, the lung has evolved to prevent the invasion of unwanted airborne particles from entering into the body. Airway geometry, humidity, mucociliary clearance and alveolar macrophages play a vital role in maintaining the sterility of the lung and consequently are barriers to the therapeutic effectiveness of inhaled medications. In addition, a drug's efficacy may be affected by where in the respiratory tract it is deposited, its delivered dose and the disease it may be trying to treat. PMID:14616418

31 CFR 306.23 - Securities eligible to be held in the Legacy Treasury Direct® Book-entry Securities System.

Code of Federal Regulations, 2011 CFR

2011-07-01

... Legacy Treasury Direct® Book-entry Securities System. 306.23 Section 306.23 Money and Finance: Treasury... Securities eligible to be held in the Legacy Treasury Direct® Book-entry Securities System. (a) Eligible... book-entry securities system. (b) Conversion of Registered Security to book-entry form to be held in...

39 CFR 761.3 - Scope and effect of book-entry procedure.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 39 Postal Service 1 2012-07-01 2012-07-01 false Scope and effect of book-entry procedure. 761.3... POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.3 Scope and effect of book-entry procedure. (a) A Reserve Bank as fiscal agent of the United States acting on behalf of the Postal Service may apply the book...

39 CFR 761.3 - Scope and effect of book-entry procedure.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 39 Postal Service 1 2013-07-01 2013-07-01 false Scope and effect of book-entry procedure. 761.3... POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.3 Scope and effect of book-entry procedure. (a) A Reserve Bank as fiscal agent of the United States acting on behalf of the Postal Service may apply the book...

39 CFR 761.3 - Scope and effect of book-entry procedure.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 39 Postal Service 1 2014-07-01 2014-07-01 false Scope and effect of book-entry procedure. 761.3... POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.3 Scope and effect of book-entry procedure. (a) A Reserve Bank as fiscal agent of the United States acting on behalf of the Postal Service may apply the book...

39 CFR 761.3 - Scope and effect of book-entry procedure.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 39 Postal Service 1 2010-07-01 2010-07-01 false Scope and effect of book-entry procedure. 761.3... POSTAL MONEY ORDERS BOOK-ENTRY PROCEDURES § 761.3 Scope and effect of book-entry procedure. (a) A Reserve Bank as fiscal agent of the United States acting on behalf of the Postal Service may apply the book...

Information management and informatics: need for a modern pathology service.

PubMed

Jones, Rick; O'Connor, John

2004-05-01

Requirements for information technology in pathology now extend well beyond the provision of purely analytical data. With the aim of achieving seamless integration of laboratory data into the total clinical pathway, "informatics"--the art and science of turning data into useful information--is becoming increasingly important in laboratory medicine. Informatics is a powerful tool in pathology--whether in implementing processes for pathology modernization, introducing new diagnostic modalities (e.g. proteomics, genomics), providing timely and evidence-based disease management, or enabling best use of limited and often costly resources. Providing appropriate information to empowered and interested patients--which requires critical assessment of the ever-increasing volume of information available--can also benefit greatly from appropriate use of informatics. General trends in medical informatics are reflected in current priorities for laboratory medicine, including the need for unified electronic records, computerized order entry, data security and recovery, and audit. The increasing demands placed on pathology information systems in the context of wider developmental change in healthcare delivery are explored in this paper.

Manual versus automated coding of free-text self-reported medication data in the 45 and Up Study: a validation study.

PubMed

Gnjidic, Danijela; Pearson, Sallie-Anne; Hilmer, Sarah N; Basilakis, Jim; Schaffer, Andrea L; Blyth, Fiona M; Banks, Emily

2015-03-30

Increasingly, automated methods are being used to code free-text medication data, but evidence on the validity of these methods is limited. To examine the accuracy of automated coding of previously keyed in free-text medication data compared with manual coding of original handwritten free-text responses (the 'gold standard'). A random sample of 500 participants (475 with and 25 without medication data in the free-text box) enrolled in the 45 and Up Study was selected. Manual coding involved medication experts keying in free-text responses and coding using Anatomical Therapeutic Chemical (ATC) codes (i.e. chemical substance 7-digit level; chemical subgroup 5-digit; pharmacological subgroup 4-digit; therapeutic subgroup 3-digit). Using keyed-in free-text responses entered by non-experts, the automated approach coded entries using the Australian Medicines Terminology database and assigned corresponding ATC codes. Based on manual coding, 1377 free-text entries were recorded and, of these, 1282 medications were coded to ATCs manually. The sensitivity of automated coding compared with manual coding was 79% (n = 1014) for entries coded at the exact ATC level, and 81.6% (n = 1046), 83.0% (n = 1064) and 83.8% (n = 1074) at the 5, 4 and 3-digit ATC levels, respectively. The sensitivity of automated coding for blank responses was 100% compared with manual coding. Sensitivity of automated coding was highest for prescription medications and lowest for vitamins and supplements, compared with the manual approach. Positive predictive values for automated coding were above 95% for 34 of the 38 individual prescription medications examined. Automated coding for free-text prescription medication data shows very high to excellent sensitivity and positive predictive values, indicating that automated methods can potentially be useful for large-scale, medication-related research.

How Regrouping Alerts in Computerized Physician Order Entry Layout Influences Physicians' Prescription Behavior: Results of a Crossover Randomized Trial.

PubMed

Wipfli, Rolf; Ehrler, Frederic; Bediang, Georges; Bétrancourt, Mireille; Lovis, Christian

2016-06-02

As demonstrated in several publications, low positive predictive value alerts in computerized physician order entry (CPOE) induce fatigue and may interrupt physicians unnecessarily during prescription of medication. Although it is difficult to increase the consideration of medical alerts by physician through an improvement of their predictive value, another approach consists to act on the way they are presented. The interruption management model inspired us to propose an alternative alert display strategy of regrouping the alerts in the screen layout, as a possible solution for reducing the interruption in physicians' workflow. In this study, we compared 2 CPOE designs based on a particular alert presentation strategy: one design involved regrouping the alerts in a single place on the screen, and in the other, the alerts were located next to the triggering information. Our objective was to evaluate experimentally whether the new design led to fewer interruptions in workflow and if it affected alert handling. The 2 CPOE designs were compared in a controlled crossover randomized trial. All interactions with the system and eye movements were stored for quantitative analysis. The study involved a group of 22 users consisting of physicians and medical students who solved medical scenarios containing prescription tasks. Scenario completion time was shorter when the alerts were regrouped (mean 117.29 seconds, SD 36.68) than when disseminated on the screen (mean 145.58 seconds, SD 75.07; P=.045). Eye tracking revealed that physicians fixated longer on alerts in the classic design (mean 119.71 seconds, SD 76.77) than in the centralized alert design (mean 70.58 seconds, SD 33.53; P=.001). Visual switches between prescription and alert areas, indicating interruption, were reduced with centralized alerts (mean 41.29, SD 21.26) compared with the classic design (mean 57.81, SD 35.97; P=.04). Prescription behavior (ie, prescription changes after alerting), however, did not change significantly between the 2 strategies of display. The After-Scenario Questionnaire (ASQ) that was filled out after each scenario showed that overall satisfaction was significantly rated lower when alerts were regrouped (mean 4.37, SD 1.23) than when displayed next to the triggering information (mean 5.32, SD 0.94; P=.02). Centralization of alerts in a table might be a way to motivate physicians to manage alerts more actively, in a meaningful way, rather than just being interrupted by them. Our study could not provide clear recommendations yet, but provides objective data through a cognitive psychological approach. Future tests should work on standardized scenarios that would enable to not only measure physicians' behavior (visual fixations and handling of alerts) but also validate those actions using clinical criteria.

[Analysis of drug-related problems in a tertiary university hospital in Barcelona (Spain)].

PubMed

Ferrández, Olivia; Casañ, Borja; Grau, Santiago; Louro, Javier; Salas, Esther; Castells, Xavier; Sala, Maria

2018-05-07

To describe drug-related problems identified in hospitalized patients and to assess physicians' acceptance rate of pharmacists' recommendations. Retrospective observational study that included all drug-related problems detected in hospitalized patients during 2014-2015. Statistical analysis included a descriptive analysis of the data and a multivariate logistic regression to evaluate the association between pharmacists' recommendation acceptance rate and the variable of interest. During the study period 4587 drug-related problems were identified in 44,870 hospitalized patients. Main drug-related problems were prescription errors due to incorrect use of the computerized physician order entry (18.1%), inappropriate drug-drug combination (13.3%) and dose adjustment by renal and/or hepatic function (11.5%). Acceptance rate of pharmacist therapy advice in evaluable cases was 81.0%. Medical versus surgical admitting department, specific types of intervention (addition of a new drug, drug discontinuation and correction of a prescription error) and oral communication of the recommendation were associated with a higher acceptance rate. The results of this study allow areas to be identified on which to implement optimization strategies. These include training courses for physicians on the computerized physician order entry, on drugs that need dose adjustment with renal impairment, and on relevant drug interactions. Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Structured product labeling improves detection of drug-intolerance issues.

PubMed

Schadow, Gunther

2009-01-01

This study sought to assess the value of the Health Level 7/U.S. Food and Drug Administration Structured Product Labeling (SPL) drug knowledge representation standard and its associated terminology sources for drug-intolerance (allergy) decision support in computerized provider order entry (CPOE) systems. The Regenstrief Institute CPOE drug-intolerance issue detection system and its knowledge base was compared with a method based on existing SPL label content enriched with knowledge sources used with SPL (NDF-RT/MeSH). Both methods were applied to a large set of drug-intolerance (allergy) records, drug orders, and medication dispensing records covering >50,000 patients over 30 years. The number of drug-intolerance issues detected by both methods was counted, as well as the number of patients with issues, number of distinct drugs, and number of distinct intolerances. The difference between drug-intolerance issues detected or missed by either method was qualitatively analyzed. Although <70% of terms were mapped to SPL, the new approach detected four times as many drug-intolerance issues on twice as many patients. The SPL-based approach is more sensitive and suggests that mapping local dictionaries to SPL, and enhancing the depth and breadth of coverage of SPL content are worth accelerating. The study also highlights specificity problems known to trouble drug-intolerance decision support and suggests how terminology and methods of recording drug intolerances could be improved.

Structured Product Labeling Improves Detection of Drug-intolerance Issues

PubMed Central

Schadow, Gunther

2009-01-01

Objectives This study sought to assess the value of the Health Level 7/U.S. Food and Drug Administration Structured Product Labeling (SPL) drug knowledge representation standard and its associated terminology sources for drug-intolerance (allergy) decision support in computerized provider order entry (CPOE) systems. Design The Regenstrief Institute CPOE drug-intolerance issue detection system and its knowledge base was compared with a method based on existing SPL label content enriched with knowledge sources used with SPL (NDF-RT/MeSH). Both methods were applied to a large set of drug-intolerance (allergy) records, drug orders, and medication dispensing records covering >50,000 patients over 30 years. Measurements The number of drug-intolerance issues detected by both methods was counted, as well as the number of patients with issues, number of distinct drugs, and number of distinct intolerances. The difference between drug-intolerance issues detected or missed by either method was qualitatively analyzed. Results Although <70% of terms were mapped to SPL, the new approach detected four times as many drug-intolerance issues on twice as many patients. Conclusion The SPL-based approach is more sensitive and suggests that mapping local dictionaries to SPL, and enhancing the depth and breadth of coverage of SPL content are worth accelerating. The study also highlights specificity problems known to trouble drug-intolerance decision support and suggests how terminology and methods of recording drug intolerances could be improved. PMID:18952933

Association between learning style preferences and anatomy assessment outcomes in graduate-entry and undergraduate medical students.

PubMed

O'Mahony, Siobhain M; Sbayeh, Amgad; Horgan, Mary; O'Flynn, Siun; O'Tuathaigh, Colm M P

2016-07-08

An improved understanding of the relationship between anatomy learning performance and approaches to learning can lead to the development of a more tailored approach to delivering anatomy teaching to medical students. This study investigated the relationship between learning style preferences, as measured by Visual, Aural, Read/write, and Kinesthetic (VARK) inventory style questionnaire and Honey and Mumford's learning style questionnaire (LSQ), and anatomy and clinical skills assessment performance at an Irish medical school. Additionally, mode of entry to medical school [undergraduate/direct-entry (DEM) vs. graduate-entry (GEM)], was examined in relation to individual learning style, and assessment results. The VARK and LSQ were distributed to first and second year DEM, and first year GEM students. DEM students achieved higher clinical skills marks than GEM students, but anatomy marks did not differ between each group. Several LSQ style preferences were shown to be weakly correlated with anatomy assessment performance in a program- and year-specific manner. Specifically, the "Activist" style was negatively correlated with anatomy scores in DEM Year 2 students (rs = -0.45, P = 0.002). The "Theorist" style demonstrated a weak correlation with anatomy performance in DEM Year 2 (rs = 0.18, P = 0.003). Regression analysis revealed that, among the LSQ styles, the "Activist" was associated with poorer anatomy assessment performance (P < 0.05), while improved scores were associated with students who scored highly on the VARK "Aural" modality (P < 0.05). These data support the contention that individual student learning styles contribute little to variation in academic performance in medical students. Anat Sci Educ 9: 391-399. © 2016 American Association of Anatomists. © 2016 American Association of Anatomists.

Postgraduate surgical education and training in Canada and Australia: each may benefit from the other's experiences.

PubMed

Pollett, William G; Waxman, Bruce P

2012-09-01

Canada and Australia share similar cultural origins and current multicultural societies and demographics but there are differences in climate and sporting pursuits. Surgeons and surgeon teachers similarly share many of the same challenges, but the health care and health-care education systems differ in significant ways. The objective of this review is to detail the different postgraduate surgical training programs with a focus on general surgery and how the programs of each country may benefit from appreciating the experiences of the other. The major differences relate to entry requirements, the role of universities in governance of training, mandatory skills courses in early training, the accreditation process, remuneration for surgical teachers and the impact of private practice. Many of the differences are culturally entrenched in their respective medical systems and unlikely to change substantially. Direct entry into specialty training without an internship per se is now firmly established in Canada just as delayed entry after internship is mandated by the Australian Medical Board. Both recognize the importance of establishing goals and objectives, modular curricular and the emerging role of online educational resources and how these may impact on assessments. The Royal Australasian College of Surgeons is unlikely to cede much responsibility to the universities but alternative academic models are emerging. Private health care in the two countries differs, but there are increasing opportunities for training in the private sector in Australia. In spite of the differences, both provide excellent health care and surgical training opportunities in an environment with significant fiscal, technological and societal challenges. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.