<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)

Despite a Presidential Order in 2004 that launched national incentives for the use of health information technology, specifically the Electronic Health Record (EHR), adoption of the EHR has been slow. This study attempts to quantify factors associated with adoption of the EHR and Computerized Provider Order Entry (CPOE) by combining multiple organizational theories and empirical studies. The study is conducted in two phases. The primary phase of this study identifies and evaluates the effects of external environmental and internal organizational factors on healthcare organizations to adopt the EHR. From secondary data, twelve IVs (df=19) are chosen based on existing models and literature. Logistic regression is used to determine the association between the environmental factors and EHR adoption. The secondary phase of this study examines the adoption of five variations of CPOE using the same IVs from phase one. This EHR component of CPOE is chosen due to its promotion as a solution to help cross the quality chasm (IOM, 2001). Secondary data are analyzed and logistic regression is used to quantify the association between the factors of EHR adoption and CPOE adoption. Eleven of the twelve IVs are significant between the two phases (p<.1). This study uses data from 2009 because the HITECH Act was passed that year and significant government incentives were offered for those health care organizations (HCOs) that meet the qualifications of meaningful use. This study serves as a baseline for future studies, extends the work of other empirical studies, and fills a gap in the literature concerning factors associated with the adoption of the EHR and specific dimensions of CPOE. The Kruse Theory developed is strongly based in literature and reflects complexity commensurate with the health care industry.

Renny Varghese Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting (Under the direction of Russell Toal, Associate Professor) Electronic medical records (EMRs) have become recognized as an important tool for improving patient safety and quality of care. Decision support tools such as alerting functions for patient medication allergies are a key part of reducing the frequency of serious medication problems. Kaiser Permanente Georgia (KPGA) implemented its EMR system in the primary care departments at Kaiser's twelve facilities in the greater metro Atlanta area over a six month period beginning in June 2005 and ending December 2005. The aim of this study is to analyze the impact of the EMR implementation on the number of drug allergy overrides within this large HMO outpatient setting. Research was conducted by comparing the rate of drug allergy overrides during pre and post EMR implementation. The timeline will be six months pre and post implementation. Observing the impact of the incidence rate of drug allergy alerts after the implementation provided insight into the effectiveness of EMRs in reducing contraindicated drug allergies. Results show that the incidence rate of drug allergy overrides per 1,000 filled prescriptions rose by a statistically significant 5.9% (ñ > 0.0002; 95% CI [-1.531, -0.767]) following the implementation. Although results were unexpected, several factors are discussed as to the reason for the increase. Further research is recommended to explore trends in provider behavior, KPGA specific facilities and departments, and in other KP regions and non-KP healthcare settings. INDEX WORDS: electronic medical records, drug allergy overrides, patient safety, medication errors, decision support tools, outpatient setting, primary care, computerized provider order entry

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The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

La prescription électronique, définie comme la saisie et la transmission électronique de diverses données de prescriptions (médicaments, requêtes de laboratoires, imagerie), est une technologie qui promet d’augmenter la productivité de l’exécution d’une prescription, de diminuer les erreurs reliées à l’illisibilité des prescriptions manuscrites et d’améliorer l’usage approprié des médicaments. Toutefois, la réalisation des bénéfices associés à cette technologie dépend grandement du contexte local de l’implantation et la configuration du système, qui doivent être adaptés aux besoins de l’établissement de santé et aux pratiques locales des professionnels. Bien que la prescription électronique soit implantée depuis plus d’une décennie dans plusieurs établissements de santé à travers le monde, il s’agit d’une technologie émergente au Québec et au Canada. Le Centre hospitalier universitaire (CHU) Sainte-Justine est l’un des premiers établissements de santé au Québec qui a implanté un système informatisé d’entrée d’ordonnances (SIEO) en 2019. L’outil, développé par un fournisseur local, a été adapté spécifiquement aux besoins de cet hôpital pédiatrique. Ainsi, l’objectif principal de ce mémoire est d’évaluer les effets de ce SIEO sur la sécurité de l’usage des médicaments. Plus spécifiquement, ce mémoire vise à 1) mesurer et décrire les problèmes liés à l’usage des médicaments avant et après l’implantation du SIEO, 2) identifier les caractéristiques du SIEO qui influencent la sécurité de l’usage des médicaments et 3) formuler des recommandations pour optimiser les bénéfices de l’outil de prescription électronique pour les patients et les utilisateurs. Afin de répondre à ces objectifs, ce travail présente deux études distinctes : 1. Une première analyse heuristique de l’utilisabilité portant spécifiquement sur la vulnérabilité du système a été effectuée en préimplantation du SIEO. Des scénarios visant à identifier les vulnérabilités du système ont été élaborés, puis un score permettant de noter la capacité du système à pallier ces vulnérabilités a été attribué par trois experts indépendants, afin de formuler des recommandations sur le design des fonctionnalités clés de cet outil. 2. Une étude observationnelle pré-post a été menée dans la période précédant l'implantation du système, et suivant l'implantation du système, dans l'unité pilote de pédiatrie générale. L’étude observationnelle est composée de deux volets, soit : a) une analyse des erreurs liées aux prescriptions de médicaments pour un échantillon d’ordonnances rédigées pendant une semaine par une analyse des interventions des pharmaciens et un audit de conformité des prescriptions et b) une analyse pré-post des erreurs liées au circuit du médicament, à partir des rapports d’incidents et accidents déclarés en lien avec le médicament. Les types d'erreurs ont été analysés afin de bien comprendre leur nature, ainsi que le rôle potentiel de la technologie sur la sécurité de l’usage des médicaments. Ces analyses ont été contextualisées par une description des fonctionnalités du SIEO (par l’utilisation d’outils validés pour l’évaluation des SIEO), des flux cliniques (par l’observation directe), et du projet d’implantation (par l’analyse de documents et des discussions avec les parties prenantes) afin de formuler des recommandations visant à optimiser les bénéfices du SIEO. Le premier article rapporte l'analyse de l'utilisabilité (étude 1) et des problèmes liés à la prescription de médicaments (étude 2a). Les résultats suggèrent que le système d’aide à la décision intégré au SIEO ne disposait pas de fonctionnalités recommandées pour limiter les vulnérabilités liées à l’usage de ce type d’outil. Néanmoins, les erreurs de conformité, qui représentaient la majorité des problèmes de prescription avant l’implantation ont été complètement éliminées par le nouveau SIEO. Toutefois, il n’y a pas eu de différence sur les erreurs de dosage et les autres interventions des pharmaciens. Ainsi, les résultats obtenus confirment qu’il est nécessaire de configurer un système d’aide à la décision avancé et adapté aux soins hospitaliers pédiatriques afin de réduire davantage les erreurs cliniques liées aux ordonnances de médicaments. Le deuxième article présente l’analyse des rapports d’incidents et accidents (étude 2b), et vise à estimer les effets du SIEO sur la sécurité de l'usage des médicaments, ainsi que mieux comprendre les erreurs de médicaments dans l’ensemble du processus des soins. L’article met en évidence le rôle important de la prescription électronique dans la simplification des étapes de la relève, de la transmission et de la transcription de la prescription. De plus, l'amélioration de l’utilisabilité de la feuille d’administration des médicaments électronique (FADMe) pourrait contribuer à réduire davantage le nombre d'erreurs liées au médicament. Ces deux articles permettent d’explorer les liens entre les caractéristiques du SIEO et les effets sur la sécurité de l’usage des médicaments, durant l’étape de prescription spécifiquement ainsi qu’à travers l’entièreté du circuit du médicament. Des recommandations sur l’utilisabilité du système et des stratégies de prévention sont présentées afin de réduire les erreurs liées au médicament. / Computerized provider order entry (CPOE), defined as a system used for entering and transmitting orders (e.g., for drugs, imaging, or lab requests) electronically, is a technology that can increase the productivity of order dispensing, reduce errors related to the illegibility of handwritten prescriptions and increase the appropriate use of medication. However, achieving the benefits associated with this technology depends on the local context of the implementation and configuration of the system, which must be adapted to the needs of the healthcare institution and the local practices of the healthcare professionals. Although CPOEs have been implemented for more than a decade in many healthcare institutions worldwide, it is an emerging technology in Quebec and Canada. The Centre hospitalier universitaire (CHU) Sainte-Justine is one of the first healthcare institutions in Quebec to implement a CPOE system in 2019. The CPOE, which was developed by a local vendor, was tailored specifically to meet the needs of the CHU Sainte-Justine's pediatric inpatient population. Thus, this study aims to evaluate the effects of the CPOE on medication safety. More specifically, this study seeks to 1) measure and describe problems related to medication use before and after the implementation of the CPOE, 2) identify the characteristics of the CPOE that influence medication safety, and 3) provide recommendations to optimize the benefits of the CPOE for patients and users. To address these objectives, two studies were conducted: 1. An expert-based heuristic vulnerability analysis of the system was performed to analyze the usability of the CPOE in the pre-implementation phase. Scenarios to identify system vulnerabilities were developed, and a score to rate the CPOE's ability to address these vulnerabilities was assigned by three independent experts to make recommendations on the design of the CPOE's key features. 2. A pre-post observational study was conducted prior to and following the CPOE implementation in the general pediatrics unit. The observational study included two components: a) An analysis of medication orders problems for a sample of prescriptions ordered for one week through the documentation of pharmacists’ interventions and a prescription conformity audit; b) An analysis of medication-related incident and accident reports throughout the year in pre and post implementation. The types of errors were described to understand their nature, as well as the potential role of technology on the safety of medication use. The analyses were contextualized with descriptions of the CPOE features (through the use of validated tools for CPOE evaluation), clinical workflows (through direct observation) and implementation project (through secondary document analysis and discussions with stakeholders) in order to make recommendations to improve medication safety. The first article covers the vulnerability analysis (study 1) and the medication orders problems at the prescribing step (study 2a). The results show that the clinical decision support system (CDSS) integrated into the CPOE lacked the recommended features to identify pediatric order errors. Conformity errors, which accounted for most prescribing errors, were completely eliminated by the prescriber implementation. However, there was no difference in dosing errors and other pharmacist interventions. Thus, the results obtained from these two components suggest the need to configure an advanced CDSS tailored to pediatric hospital care to further reduce clinical errors. The second article, focused on the analysis of incident and accident reports (study 2b), aims to estimate the impacts of the electronic prescriber on medication safety, as well as to better understand medication errors in the overall care process. The article highlights the importance of simplifying the acknowledgment, transmission, and transcription steps by implementing a CPOE. Improving the usability of the electronic medication administration record (eMAR) could further reduce medication errors. These two articles explore the relationship between the characteristics of the CPOE and their impact on medication safety, specifically at the prescribing step and throughout the entire medication management process. Recommendations on system usability and other prevention strategies are presented to improve medication safety.