Class of 2009 Abstract / OBJECTIVES: To measure the attitudes of Arizona e-prescribing clinicians regarding (1) the importance of key criteria that may be used in the selection of an e-prescribing system; and (2) their satisfaction with key criteria as implemented within their current e- prescribing system. METHODS: This study utilized a print-based questionnaire. The questionnaire was faxed weekly to clinicians who were registered office-based e-prescribers in Arizona until either a response was received or three fax cycles were completed. Clinicians were asked to rate the importance of each e-prescribing feature on a five-point scale, where 1 was not at all important and 5 was extremely important. For each e-prescribing feature, clinicians were asked to rate their satisfaction with their current e-prescribing system on a seven-point scale, where -3 was very dissatisfied and +3 was very satisfied. Demographic data were collected on practice size, practice type, prescription entry, e-prescribing software vendor and system used, year e-prescribing started, and comments. RESULTS: Questionnaires were completed and returned by 114 clinicians. The overall mean for feature importance and satisfaction was 4.22 and 4.92, respectively. Of the 39 criteria, 9 were categorized as having high importance with low satisfaction; and 14 were categorized as having high importance with high satisfaction. The nine criteria with high importance but low satisfaction were related to vendor support, system cost, lack of e-prescribing features, and unrealized benefits. CONCLUSIONS: Arizona e-prescribers are moderately satisfied with the basic functions provided by their electronic prescribing systems. Their dissatisfaction with electronic prescribing systems may be due to vendor support and system costs.

Class of 2016 Abstract / Objectives: To identify which types of mid-level practitioners have prescribing authority in each state in the United States (US), compare the types of prescriptive authority for scheduled medications for mid-level practitioners, and delineate differences between state and federal requirements for electronic prescribing (e-prescribing) for mid-level practitioners in each state. Methods: A data extraction tool was developed and utilized to collect e-prescribing requirements and mid-level practitioner prescriptive authority from publically accessible state and federal websites. Dependent variables were analyzed using frequencies and percentages. A comparison of regional mid-level practitioner prescriptive authority patterns was conducted. Results: Mid-level practitioner prescriptive authority and e-prescribing requirements were collected from 50 states, the District of Columbia, and the Drug Enforcement Administration (DEA). For e-prescribing requirements, 19 (37%) states listed federal law requirements, 28 (55%) states listed requirements in addition to federal law, and 4 states (8%) did not specify requirements. Overall, over half of the US had more stringent e-prescribing requirements than federal law. States varied in which mid-level practitioners had authority to prescribe controlled substances: 98% of states allow nurse practitioners to prescribe; 96% allow physician assistants; 84% allow optometrists; 14% allow naturopathic doctors; 12% allow registered pharmacists; 8% allow certified nurse midwives, 4% allow homeopathic physicians, medical psychologists, and nursing homes; and 2% allow doctors of oriental medicine, certified chiropractors, clinical nurse specialists and/or advanced practice registered nurses. Conclusions: There are differences in e-prescribing requirements and varying levels of prescriptive authority for mid-level practitioners between US states.

Class of 2017 Abstract / Objectives: To evaluate the perceptions of the pharmacy staff on prescription errors, efficiency, and difficulty of use before and after implementation of a new pharmacy computer system. Subjects: Employees of El Rio Community Health Center outpatient pharmacies located at the Congress, Northwest, and El Pueblo Clinics. Methods: This study was of a retrospective pre-post design. A 5-question survey on error rates and workflow efficiency was distributed to pharmacists and technicians 6 months after a new computer system had been implemented. Participants of the study included employees of El Rio Community Health Center outpatient pharmacies who were employed with El Rio during the time of transition between the old and new computer systems. Results: Questionnaire responses were completed by 10 (41.7%) technicians and 6 (66.7%) pharmacists at three El Rio Clinics. There was an increase in perceived efficiency between the new (Liberty) (n=17, 94.4%) and old (QS1) (n=11, 61.1%) computer systems (p<0.05). There were no significant differences in perceived difficulty of use, most common types of errors, error rates, and time to fix detected errors. Conclusions: While there were no significant differences between Liberty and QS1 in perceived difficulty of use, most common types of errors, error rates, and time to correct detected errors, there was a significant difference in the perceived efficiency, which may have beneficial implications.

Purpose: The purpose of this study is to examine the adoption of e-prescribing by primary care physicians in the Cowichan Valley Community of Practice (COP) who use the same commercial EMR product (Med Access EMR) and to make suggestions on improving adoption. Methods: This study employed a multi-method study design to compare the ideal state of e-prescribing (i.e., the desired e-prescribing features in an EMR) with the possible state (i.e., what the EMR can offer) and the current state of e-prescribing (i.e., what physicians are actually using in practice).The ideal state of e-prescribing was determined using a literature search in MEDLINE, a personal collection, and reference mining.The possible state for e-prescribing was assessed by (1) reviewing the EMR user documentation and (2) reviewing provincial conformance specifications for EMRs (from Physician Information Technology Office (PITO)) and (3) interviewing an EMR vendor representative to confirm features. Based on this review, an e-prescribing assessment tool was then developed and piloted with physicians.The current state of e-prescribing was examined by interviewing physicians using the aforementioned e-prescribing assessment tool and an EMR Adoption Survey. A discussion group then took place to share the study findings and provide feedback on how to improve use of the EMR for prescribing. Results: For the ideal state of e-prescribing, 10 papers were included in the literature search as a part of the search strategy. In total, 104 e-prescribing features were identified in these papers relating to the following categories: patient Information, identification, and data access, current medications/medication history, medication selection, prescribing safety, patient education, monitoring, repeat (renewal) prescribing, computer-user interface, transparency and accountability, security and confidentiality, and interoperability and communication.For the possible state of e-prescribing, the EMR product met 27 of the 33 PITO e-prescribing requirements partially or fully, relating to the following PITO subcategories: generating prescriptions, processing prescriptions, transmitting prescriptions, viewing medications, managing renewals, drug formularies, interaction checking, medication profiles, and reference support. Data pertaining to the current state of e-prescribing adoption were collected from interviews with 12 primary care physicians who represent 17% of the total sample population. On average, the physicians reported using 75% (n=21.7/29) of the e-prescribing features available in the EMR. The e-prescribing features least used were “drug search by class”, “check for patient coverage”, “drug to procedure interaction checking”, and “use of drug monographs”. The average EMR Adoption score for physicians was 3.1 out of 5. A discussion group with six study participants was conducted to validate the findings of the current state and recommendations. Conclusions/ Recommendations: Recruited physicians from the Cowichan Valley COP are using most of the e-prescribing and EMR features available in the Med Access EMR. However, there are several gaps between the ideal, possible, and current state of e-prescribing. These gaps have been addressed through physician-level, policy-related, and technology-related recommendations to (1) help physicians improve use of the EMR for prescribing to achieve the possible state of e-prescribing and (2) guide vendor design and development of e-prescribing features in the EMR to achieve the ideal state of e-prescribing. / Graduate / 0723 / 0566 / 0984 / gurprit@uvic.ca

Class of 2016 Abstract / Objectives: Analyze electronic prescription errors made by a community health center. Determine the time it takes to correct electronic prescription errors in a community pharmacy. Ascertain whether or not a collaborative practice agreement would be beneficial. Methods: The store computer system was used to generate a report of all prescriptions received at a community pharmacy from a community health center during a 6-month period. Using an Excel sheet, one author kept track of how many electronic prescriptions were received, the number and type of errors, and the time it took to get an error corrected. Results: There were 1896 electronic prescriptions sent from a community health center to a community pharmacy; 61 contained an error (3.24%). On average, it took the doctor’s office 111.7 hours to call back and clarify the mistake. Conclusions: There was not a significant amount of prescribing errors that occurred during the data collection period. However, the time it took for the doctor’s office to call back was significant and translates to patients not being able to get their medications on time.

The use of Electronic Prescribing Systems (EPS) has significant potential role in improving patient safety and reducing adverse drug events. However, the introduction of these systems can have negative outcome on delivery of care if healthcare providers are not utilizing regularly and accept it. This study aims to explore paediatrician’s attitude towards electronic prescribing systems as well as understand the possible factors affecting user acceptance at tertiary care using the Technology Acceptance Model (TAM). A qualitative research methodology was applied. Semi-structured interviews were developed according to TAM model and used as primary source of collecting empirical data. Seven research participants were interviewed. The findings of this study had identified factors that are important for paediatrician’s acceptance of EPS systems. Although paediatricians are positive to the usefulness of EPS, it appears that there are some acceptance problems due to ease of use concerns and usability issues of the system. The acceptance of EPS can be improved by leveraging ease of use as well as enhancing training.

Medication is an essential part of health care and enables the prevention andtreatment of many conditions. However, medication errors and drug-relatedproblems (DRP) are frequent and cause suffering for patients and substantial costsfor society. eMedication, defined as information technology (IT) in themedication management process, has the potential to increase quality, efficiencyand safety but can also cause new problems and risks.In this thesis, we have studied the employment of IT in different steps of themedication management process with a focus on the user's perspective. Sweden isone of the leading countries when it comes to ePrescribing, i.e. prescriptionstransferred and stored electronically. We found that ePrescribing is well acceptedand appreciated by pharmacists (Study I) and patients (Study II), but that therewas a need for improvement in several aspects. When the pharmacy market inSweden was re-regulated, four new dispensing systems were developed andimplemented. Soon after the implementation, we found weaknesses related toreliability, functionality, and usability, which could affect patient safety (StudyIII). In the last decade, several county councils in Sweden have implementedshared medication lists within the respective region. We found that physiciansperceived that a regionally shared medication list generally was more complete butoften not accurate (Study IV). Electronic expert support (EES) is a decisionsupport system which analyses patients´ electronically-stored prescriptions in orderto detect potential DRP, i.e. drug-drug interactions, therapy duplication, highdose, and inappropriate drugs for geriatric or pediatric patients. We found thatEES detected potential DRP in most patients with multi-dose drug dispensing inSweden (Study V), and that the majority of alerts were regarded as clinicallyrelevant (Study VI).For an improved eMedication, we need a holistic approach that combinestechnology, users, and organization in implementation and evaluation. The thesissuggests a need for improved sharing of information and support for decisionmaking, coordination, and education, as well as clarification of responsibilitiesamong involved actors in order to employ appropriate IT. We suggestcollaborative strategic work and that the relevant authorities establish guidelinesand requirements for IT in the medication management process. / Läkemedel förbättrar och förlänger livet för många och utgör en väsentlig del av dagens hälso- och sjukvård men om läkemedel tas i fel dos eller kombineras felaktigt med varandra kan behandlingen leda till en försämrad livskvalitet, sjukhusinläggningar och dödsfall. En del av dessa problem skulle kunna förebyggas med rätt information till rätt person vid rätt tidpunkt och i rätt form. Informationsteknik i läkemedelsprocessen har potentialen att öka kvalitet, effektivitet och säkerhet genom att göra information tillgänglig och användbar men kan också innebära problem och risker. Det är dock en stor utmaning att i läkemedelsprocessen föra in effektiva och användbara IT-system som stödjer och inte stör personalen inom sjukvård och på apotek, skyddar den känsliga informationen för obehöriga och dessutom fungerar tillsammans med andra system. Dagens IT-stöd i läkemedelsprocessen är otillräckliga. Till exempel saknar läkare, farmaceuter och patienter ofta tillgång på fullständig och korrekt information om en patients aktuella läkemedel; det händer att fel läkemedel blir utskrivet eller expedierat på apotek; och bristande eller långsamma system skapar frustration hos användarna. Dessutom är det flera delar av läkemedelsprocessen som fortfarande är pappersbaserade. Därför är det viktigt att utvärdera IT-system i läkemedelsprocessen. Vi har studerat IT i olika delar av läkemedelsprocessen, före eller efter införandet, framför allt utifrån användarnas perspektiv. Sverige har lång erfarenhet och tillhör de ledande länderna i världen när det gäller eRecept, det vill säga recept som skickas och lagras elektroniskt. I två studier fann vi att eRecept är väl accepterat och uppskattat av farmaceuter (Studie I) och patienter (Studie II), men att det finns behov av förbättringar. När apoteksmarknaden omreglerades 2009 infördes fyra nya receptexpeditionssystem på apoteken. Vi fann att det efter införandet uppstod problem med användbarhet, tillförlitlighet och funktionalitet som kan ha inneburit en risk för patientsäkerheten (Studie III). I Sverige har man inom flera sjukvårdsregioner infört gemensamma elektroniska läkemedelslistor. I en av studierna kunde vi visa att detta har inneburit en ökad tillgänglighet av information, men att en gemensam lista inte alltid blir mer korrekt och kan innebära en ökad risk att känslig information nås av obehöriga (Studie IV). I två av studierna undersöktes beslutsstödssystemet elektroniskt expertstöd (EES):s potential som stöd för läkare att upptäcka läkemedelsrelaterade problem till exempel om en patient har två olika läkemedel som inte passar ihop, eller ett läkemedel som kanske är olämpligt för en äldre person. Studierna visade att EES gav signaler för potentiella problem hos de flesta patienter med dosdispenserade läkemedel i Sverige (Studie V), och läkarna ansåg att majoriteten av signalerna är kliniskt relevanta och att några av signalerna kan leda till förändringar i läkemedelsbehandlingen (Studie VI). Sammantaget visar avhandlingen att IT-stöd har blivit en naturlig och nödvändig del i läkemedelsprocessen i Sverige men att flera problem är olösta. Vi fann svagheter med användbarhet, tillförlitlighet och funktionalitet i de använda IT-systemen. Patienterna är inte tillräckligt informerade och delaktiga i sin läkemedelsbehandling. Läkare och farmaceuter saknar fullständig och korrekt information om patienters läkemedel, och de har i dagsläget inte tillräckliga beslutsstöd för att förebygga läkemedelsrelaterade problem. Eftersom läkemedelsprocessen är komplex med många aspekter som påverkar utfall behöver vi ett helhetstänkande när vi planerar, utvecklar, implementerar och utvärderar IT-lösningar där vi väger in både tekniska, sociala och organisatoriska aspekter. Avhandlingens resultat visar på ett behov av ökad koordination och utbildning samt förtydligande av ansvaret för inblandade aktörer. Vi föreslår gemensamt strategiskt arbete och att inblandade myndigheter tar fram vägledning och krav för IT i läkemedelsprocessen.

There are 353 NHS hospitals in the United Kingdom, and within these hospitals there is wide variation in the electronic prescribing systems applied. Indeed, only one hospital uses a single system in all of its clinical areas. Medication error is the biggest issue in the health care profession in respect to patient safety—

<p>Integrating laboratory information into prescribing tasks may improve medication safety. This thesis addresses several methodological issues in the progress of two studies: a systematic review of randomized trials addressing the impact of drug-lab safety alerts on adverse drug events and changes in prescribing or lab monitoring and a randomized trial using an electronic survey to compare prescribing decisions in complex clinical scenarios including integrated lab data with those in which the lab data were available on request. The systematic review found 32 studies; 10 addressed multiple drug-lab combinations, and 22 addressed single drug-lab combinations, including 14 targeting anticoagulation. We report a benefit of anticoagulation-related alerts (OR of an adverse event (bleeding or thrombosis) 0.88 (95% CI 0.78-1.00) and improved prescribing in multi-drug studies (OR 2.22, 95% CI 1.19-4.17), but substantial study heterogeneity precluded combining studies of other drugs. Methodological issues addressed in the RCT include medication selection, scenario design, recruitment, and assessment of the representativeness of the sample. We selected medications for study scenarios that are commonly prescribed by Canadian primary care physicians, and are associated with clinically important harm that may be preventable through laboratory monitoring. Data sources included IMS Brogan data on prescribing patterns and the Discharge Abstracts Database (DAD) and the National Ambulatory Care Reporting System (NACRS) from 2006-2007 to 2008-2009. Our study had 148 completed surveys. The study sample differed from the population of Ontario family physicians by gender, and use of electronic medical records. We found no difference in prescribing decisions (OR 1.21, 95% CI 0.84-1.75) between the study groups and no predictors of improved prescribing decisions. The lack of demonstrated impact of integrating lab data into clinical decision-making may be related to the study being underpowered, to a true lack of clinical benefit, or to a lack of discriminatory power in the scenarios.</p> / Master of Science (MSc)

<p>Objectives: (1) to assess whether computer simulation modeling or process modeling have improved medication management systems, including informing the design of e-prescribing systems for Canada, and (2) to build and validate a workflow diagram of the handwritten medication management process in the community setting for Canada and use it to obtain feedback from stakeholders.</p> <p>Methods: A systematic review was conducted to assess whether the modeling techniques have improved medication management systems. A workflow diagram was developed and used to obtain feedback from stakeholders as to where problems exist in the current paper-based process and where information technology might be of help. Analyses were descriptive and qualitative.</p> <p>Results: The systematic review identified 13,376 citations, 8 of which were included in the full data extraction. The review revealed that simulation models of e-prescribing systems have been developed, but their accuracy and usefulness has not been established. One process model had been used to analyze a Canadian medication management system, but no evidence was found that process models had any positive impact on e-prescribing development in Canada.</p> <p>Fifteen stakeholders, including 5 physicians, 5 pharmacists, and 5 members of the public provided feedback using the workflow diagram. All stakeholders agreed that the diagram was a realistic representation of the actual handwritten medication management process, suggesting face validity. The majority of stakeholders identified the most problematic processes as generating the prescription by the physician (9/15 (60.0%)) and drug checking by the physician (6/15 (40.0%)).</p> <p>Conclusions: There is a lack of published evidence on simulation models and process models, and the studies that exist do not suggest any benefit in informing e-prescribing design. We developed and established face validity for a workflow diagram of the paper-based medication management cascade. Stakeholders believed that generating the prescription and drug checking by the physician could be improved by e-prescribing.</p> / Master of Science (MSc)