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Connie Lo delivered this presentation at the 3rd Annual Electronic Medication Management Conference 2014. This conference is the nation’s only event to look solely at electronic prescribing and electronic medication management systems. For more information, please visit http://www.healthcareconferences.com.au/emed14
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EMM System Design Considerations
For The Clinician-System Interface
Connie Lo
eMM Application Specialist
Michael Turner
eMM Project Pharmacist
Rosemary Richman
eMR Project Manager
Information Management and Technology Division
Sydney and South Western Sydney LHDs
Background - Concord Hospital
Integrated Cerner Solutions
– Closed loop medication solution – Inpatient
Electronic prescribing – PowerOrders
Pharmacy review, verification & dispensing – PharmNet
Charting Administration - MAR
Drug database – Multum
Customised Decision Support – Discern Rules
Future - Concord Hospital
Integrated Cerner Solutions
– Closed loop medication solution – Inpatient + Discharge/Outpatient
Electronic prescribing – PowerOrders
Pharmacy review, verification & dispensing – PharmNet
Charting Administration - MAR
Drug database – Multum
Customised Decision Support – Discern Rules + more rules
Medication reconciliation discharge referral
Dispensing system interface – PharmNet to iPharmacy
IV enhancement
The User’s Perspective
Swallow whole
EMM Systems
Home grown versus commercial eMM systems
– Number of home grown systems is decreasing
– Complexity
– Need for interfacing/integration (local, state & national level)
Hard coded versus customisable functionality
– Core functionality
– Standardisation
Best Way to Customise - What’s the Evidence?
Limited evidence in the literature
– Health Information Technology: An Updated Systematic Review
With a Focus on Meaningful Use1
Strong evidence for use of CPOE and CDS however the studies lack
detail on system design and build for both successful and
unsuccessful aspects of implementations
– The Impact of CPOE Medication Systems’ Design Aspects on
Usability, Workflow and Medication Orders2
Study found that many different methods had been used to assess
different system designs. Design elements were reported as either
positive or negative against three categories, ease of use, work flow,
and the effect on the medication order.
1. Jones et al. Ann Intern Med. 2014;160: 48-54
2. Khajouei et al. Methods Inf Med 2010; 49: 3-19
– Failure to utilize functions of an electronic prescribing system and
the subsequent generation of 'technically preventable'
computerized alerts3
– When 'technically preventable' alerts occur, the design-not the
prescriber-has failed4
Design is more important than training in ensure the user uses the
system correctly. System design that doesn’t account for human
factors, may fail to achieve the desired outcomes and may lead to
unintended consequences.
3. Baysari et al. J Am Med Inform Assoc 2012;19:1003-1
4. Russ et al. J Am Med Inform Assoc 2012;19:1119
Best Way to Customise - What’s the Evidence?
Considerations for Design and Customisation
Usability versus Standardisation
Patient Safety versus User Convenience
Desirability versus Maintenance
Computerising paper processes versus adopting
electronic processes
Consistency
User friendliness and intuitiveness
Medication Orderables
Hide some medication orderables
– Generic/franchise brand products which contain the
drug name (Chemist’s Own, APO, Genrx)
– Metformin (Genrx)
– Products which are generally ordered by brand name
– allantoin/chlorhexidine/hexamidine topical powder
(Medipulv topical powder)
Order Sentences
Limit to ten sentences for selection
Display sequence and grouping
– Common route displayed at the top
– Lowest dose to highest dose
– Sort by dosage form, strength, route, frequency
Use of “information only” order sentences to guide
selection + Discern rule to prevent inadvertent selection
– Anti-venoms, medication reconciliation
Medication Reconciliation
Documenting medication history using generic and brands
Use of “information only” order sentences to guide selection
Rules and Alerts
Clinical decision support
– Consolidate clinical information and alert clinicians
– Customisation of Multum drug-drug interactions
– Digoxin ADE with abnormal electrolyte results
– Cumulative paracetamol dose
‘Not so clinical’ decision support
– Enforce or prevent incorrect workflow
– Warfarin/INR check, weekend warfarin ordering
– Antibiotic start date-time
– Incorrect selection of an ‘information only’ order sentence
Clinical Implications
New errors introduced by the eMM system1
– Selection / ‘click’ errors – MySearch functionality
– Editing errors – Route locked on order modification
– New tasks introduced by eMM system
– Ordering reminders – patch/patch removals - rules
– Default date/times - rules
Automation - safety versus convenience
– Default values / auto-population
– Lessons from aviation
5. Westbrook et al J Am Med Inform Assoc 2013; 20: 1159-1167
Clinician Requests for Design Changes
Apply principles of eMM design and customisation
– Balance of convenience versus patient safety
– Balance of desirability versus ongoing system maintenance
Consider impact on other applications within the EMR
– Shared drop down lists
Consider flow on effects of requested change
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