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Objectives: Several alert systems have been developed to improve the patient safety aspects of clinical information systems (CIS). Most studies have focused on the evaluation of these systems, with little information provided about the methodology leading to system implementation. We propose here an 'agile' business rule design framework (BRDF) supporting both the design of alerts for the validation of drug prescriptions and the incorporation of the end user into the design process., Methods: We analyzed the unified process (UP) design life cycle and defined the activities, subactivities, actors and UML artifacts that could be used to enhance the agility of the proposed framework. We then applied the proposed framework to two different sets of data in the context of the Georges Pompidou University Hospital (HEGP) CIS., Results: We introduced two new subactivities into UP: business rule specification and business rule instantiation activity. The pharmacist made an effective contribution to five of the eight BRDF design activities. Validation of the two new subactivities was effected in the context of drug dosage adaption to the patients' clinical and biological contexts. Pilot experiment shows that business rules modeled with BRDF and implemented as an alert system triggered an alert for 5824 of the 71,413 prescriptions considered (8.16%)., Conclusion: A business rule design framework approach meets one of the strategic objectives for decision support design by taking into account three important criteria posing a particular challenge to system designers: 1) business processes, 2) knowledge modeling of the context of application, and 3) the agility of the various design steps.

Objectives: The primary aim of this study was to assess the antecedents of health information technology (HIT) innovativeness in public hospitals. To do so, we built upon our own previous work to relate the level of HIT innovativeness to organizational capacity characteristics., Methods: We conducted a survey of chief information officers (CIOs) in public hospitals in the two largest Canadian provinces to identify the level of HIT innovativeness in these settings and test nine research hypotheses derived from the proposed research model., Results: A total of 106 completed questionnaires were received, which represents a response rate of 52%. Our findings indicate strong support for the research model. Seven out of nine hypotheses were supported indicating a significant relationship between HIT innovativeness and structural, financial, leadership, and knowledge sharing capacity characteristics. Results also reveal a moderate level of HIT innovativeness in the surveyed hospitals, with more emphasis on administrative systems and their integration than on clinical systems and emerging technologies., Conclusions: This study demonstrates that organizational characteristics are related to HIT innovativeness; this relationship holds irrespective of the public or private nature of hospitals.

Objectives: To examine the impact of design aspects of computerized physician order entry (CPOE) systems for medication ordering on usability, physicians' workflow and on medication orders., Methods: We systematically searched PubMed, EMBASE and Ovid MEDLINE for articles published from 1986 to 2007. We also evaluated reference lists of reviews and relevant articles captured by our search strategy, and the web-based inventory of evaluation studies in medical informatics 1982-2005. Data about design aspects were extracted from the relevant articles. Identified design aspects were categorized in groups derived from principles for computer screen and dialogue design and user guidance from the International Standard Organization, and if CPOE-specific, from the collected data., Results: A total of 19 papers met our inclusion criteria. Sixteen studies used qualitative evaluation methods and the rest both qualitative and quantitative. In total 42 CPOE design aspects were identified and categorized in seven groups: 1) documentation and data entry components, 2) alerting, 3) visual clues and icons, 4) drop-down lists and menus, 5) safeguards, 6) screen displays, and 7) auxiliary functions., Conclusions: Beside the range of functionalities provided by a CPOE system, their subtle design is important to increase physicians' adoption and to reduce medication errors. This requires continuous evaluations to investigate whether interfaces of CPOE systems follow normal flow of actions in the ordering process and if they are cognitively easy to understand and use for physicians. This paper provides general recommendations for CPOE (re)design based on the characteristics of CPOE design aspects found.

Objectives: To assess the effects of a CPOE system on inter-professional workflow in the medication process., Methods: Twenty-three semi-structured interviews with physicians, nurses, and pharmacists were conducted in a Dutch academic hospital. In addition, the handwritten and system-generated documents used daily were collected for analysis. Data was analyzed on the basis of three conceptual themes in the inter-professional workflow: division of tasks, flow of information, and task coordination., Results: The CPOE system reorganized the existing work procedures, affecting the workflow among the three professional groups both advantageously and disadvantageously. The system resulted in the reassignment of tasks and reallocation of areas of expertise in the medication process. Moreover, patients' medication-related information became fragmented in both the paper records and in the electronic records, as well as in different professional domains. The system provided limited support for professional groups to coordinate their tasks temporally. It also made it difficult to build mutual intelligibility upon new changes in the medication plan. To integrate tasks, the professional groups had to bypass the system or add new steps and extra coordinative tasks., Conclusion: We identified several workflow integration issues after the implementation of a CPOE system. Our insights into these issues can help ensure that the system design or redesign properly integrates all tasks, information, and areas of expertise of professional groups into those of the physicians.

Objectives: Because information of contraindication and careful indication of medication is vast, there have been numerous cases of prescribing medication inappropriately. Our goal is to have a clinical decision support system (CDSS) combined with a computerized physician order entry (CPOE) to aid physicians in prescribing medication appropriately. In this study we developed an alert system for evaluating renal function and checking doses of medication according to the patient's renal function. In addition, we developed functions of extracting target problems from the raw data and verifying if contraindicated medication has being prescribed., Methods: This system scrutinizes data handled in the CPOE system. It picks up the data needed to ascertain problems and the data of medication entered from the order entry system. First we made an alert system for renal dysfunction. Creatinine clearance (Ccr) of a patient was calculated by the estimate equation of Cockcroft and Gault. If a patient data fulfills the condition of impaired renal function, the alert message is sent to the database. The alert system also checks the dosage of each medication according to a patient's renal function. When the dosage is over-prescribed, an alert is sent. Next, we made an alert system targeting contraindication for liver diseases, renal diseases and diabetes mellitus. The criteria of these problems were set in the knowledge base. If a patient's data meets the criteria, that fact is stored in the problem database. The system also keeps a prescription check master and checks whether the patient has a problem which is a contraindication of the prescribed medication. If a problem exists, an alert is sent to the alert message database. The alert-presenting module is a web system. After accepting patients' ID indicated by a user, the system searches the alerts concerning the patients from the database and constructs pages presenting the alert message., Results: We compared the period during which the contraindicated medication was prescribed before and after the alert system was put into operation. Of the patients with renal dysfunction who were prescribed the contraindicated medication, 24% had their medication discontinued before the alert system was put into operation. In contrast, the rate significantly increased to 54% after the alert system began to function., Conclusion: We developed an alert system for inappropriate prescriptions for each patient's clinical condition. The alerts generated by this system were effective for discontinuing contraindicated medication.

Objectives: Few studies have measured the long-term effects of computerised provider order entry systems on pathology test turnaround time. Further, a recent study has raised the possibility that such systems, which require significant work practice change, may be associated with an increase in mortality rates. Our study answered two questions in relation to system introduction in a major Australian teaching hospital: i) are improvements in turnaround times achieved in the first 12 months after system introduction sustained 24 months post-implementation; and ii) do mortality rates change following the introduction of an order entry system?, Methods: Turnaround time and mortality rates 5 months before and 12 and 24 months after implementation of a computerised order entry system were measured. Turnaround time was defined as the time from receipt of a specimen and order in a laboratory to availability of a result., Results: Improvements in turnaround time achieved in the first 12 months were sustained with a further significant 12.6% reduction at 24 months post-implementation, with no change in average number of tests per patient. The mortality rate significantly increased in the year following system introduction but returned to the pre-system rate in the second year of system use. Review of the excess deaths demonstrated these were most likely attributable to a coincidental influenza outbreak and not to system introduction., Conclusions: The computerised provider order entry system produced sustained and continuing improvements in laboratory efficiency over a two-year period. Associations between increased mortality rates and system introduction should be investigated carefully to ascertain any likely association.

Objective: To measure doctors' and nurses' perceptions of organisational culture and relate this to their attitudes to, and satisfaction with, a hospital-wide mandatory computerised provider order entry (CPOE) system in order to illuminate cultural compositions in CPOE use., Methods: A cross-sectional survey design was employed. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. Clinicians from the hospital had used the CPOE system since 1991 to order and view clinical laboratory and radiology tests electronically for all patients. The OCI provides a measure of culture in terms of three general styles which distinguish between: constructive; passive/defensive, and aggressive/defensive cultures. The cluster which best describes the overall culture is the one that has the highest percentile score when the percentile scores of the four cultural norms included in the cluster are averaged. The user satisfaction survey asked questions relating to satisfaction with, and attitudes to, the system., Results: We found identifiable sub-cultures based on professional divisions where doctors perceived an aggressive-defensive culture (mean percentile score = 43.8) while nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors., Conclusion: The manifestation of sub-cultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation. Identification and management of the cultural characteristics of different groups of health professionals may facilitate the successful implementation and use of clinical information systems.

Objectives: This paper illustrates a high speed clinical data retrieving system, from 10 years of data of operating hospital information system for the purposes of research, evidence creation, patient safety, etc., even incorporating time sequence of causal relations., Methods: Total of 73,709,298 records of 10 years at Hamamatsu University Hospital (as of June 2008) are sent from HIS to retrieval system in HL7 v2.5 format. Hierarchical variable length database is used to install them., Results: A search for "listing patients who were prescribed Pravastatin (Mevalotin and generic drugs, any titer)" took 1.92 seconds. "Pravastatin (any) prescribed and recorded AST >150 within two weeks" took 112.22 seconds. Searching conditions can be set to be more complex, connected by Boolean operator and/or. This system called D*D is in operation at Hamamatsu University Hospital since August 2002. It is used for 48,518 times (monthly average of 703 searches). Neither searching, nor background export of data from HIS caused delay of routine operating CPOE., Conclusions: Search database outside of routine operating CPOE, with daily export of order data in HL7 v2.5 format, is proved to provide excellent search environment without causing trouble. Hierarchical representation gives high-speed search response, especially with time sequence of events.

Objectives: To compare the outcome of the implementation of computerized physician order entry (CPOE) systems in two Dutch hospitals., Methods: Qualitative research methods, including interviews in both hospitals, observations of system in use, observations of staff meetings and document analysis were used to understand the implementation of CPOE. The transcribed texts and implementation documents were analyzed for relevant concepts. The transcripts and field notes were analyzed using a heuristic success and failure model with medical work as the primary focus., Results: Occasions that determined the outcome of the implementation were classified according to factors that may influence the success or failure of implementing systems., Conclusions: The themes and patterns that emerged from the data helped validate the concept of medical work as the primary focus of our analysis model; in addition the concept of a support base necessary to accept changes in medical work that result from introducing CPOE may help to understand the different implementation outcomes.