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