Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings:protocol for a systematic review of qualitative studies

Introduction: There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support. Methods and analysis: Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method. Ethics and dissemination: The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

Development of a prescribing indicator for objective quantification of antibiotic usage in secondary care

Objectives: To compare the recognized defined daily dose per 100 bed-days (DDD/100 bed-days) measure with the defined daily dose per finished consultant episode (DDD/FCE) in a group of hospitals with a variety of medicines management strategies. To compare antibiotic usage using the above indicators in hospitals with and without electronic prescribing systems. Methods: Twelve hospitals were used in the study. Nine hospitals were selected and split into three cohorts (three high-scoring, three medium-scoring and three low-scoring) by their 2001 medicines management self-assessment scores (MMAS). An additional cohort of three electronic prescribing hospitals was included for comparison. MMAS were compared to antibiotic management scores (AMS) developed from a questionnaire relating specifically to control of antibiotics. FCEs and occupied bed-days were obtained from published statistics and statistical analyses of the DDD/100 bed-days and DDD/FCE were carried out using SPSS. Results: The DDD/100 bed-days varied from 81.33 to 189.37 whilst the DDD/FCE varied from 2.88 to 7.43. The two indicators showed a high degree of correlation with r = 0.74. MMAS were from 9 to 22 (possible range 0-23) and the AMS from 2 to 13 (possible range 0-22). The two scores showed a high degree of correlation with r = 0.74. No correlation was established between either indicator and either score. Conclusions: The WHO indicator for medicines utilization, DDD/100 bed-days, exhibited the same level of conformity as that exhibited from the use of the DDD/FCE indicating that the DDD/FCE is a useful additional indicator for identifying hospitals which require further study. The MMAS can be assumed to be an accurate guide to antibiotic medicines management controls. No relationship has been found between a high degree of medicines management control and the quantity of antibiotic prescribed. © The British Society for Antimicrobial Chemotherapy; 2004 all rights reserved.

Accessing networked services : a user interface design problem

This research investigates the general user interface problems in using networked services. Some of the problems are: users have to recall machine names and procedures to. invoke networked services; interactions with some of the services are by means of menu-based interfaces which are quite cumbersome to use; inconsistencies exist between the interfaces for different services because they were developed independently. These problems have to be removed so that users can use the services effectively. A prototype system has been developed to help users interact with networked services. This consists of software which gives the user an easy and consistent interface with the various services. The prototype is based on a graphical user interface and it includes the following appJications: Bath Information & Data Services; electronic mail; file editor. The prototype incorporates an online help facility to assist users using the system. The prototype can be divided into two parts: the user interface part that manages interactlon with the user; the communicatIon part that enables the communication with networked services to take place. The implementation is carried out using an object-oriented approach where both the user interface part and communication part are objects. The essential characteristics of object-orientation, - abstraction, encapsulation, inheritance and polymorphism - can all contribute to the better design and implementation of the prototype. The Smalltalk Model-View-Controller (MVC) methodology has been the framework for the construction of the prototype user interface. The purpose of the development was to study the effectiveness of users interaction to networked services. Having completed the prototype, tests users were requested to use the system to evaluate its effectiveness. The evaluation of the prototype is based on observation, i.e. observing the way users use the system and the opinion rating given by the users. Recommendations to improve further the prototype are given based on the results of the evaluation. based on the results of the evah:1ation. . .'. " "', ':::' ,n,<~;'.'

Development and validaton of an indicator to compare antibiotic usage in secondary care in England

The use of antibiotics was investigated in twelve acute hospitals in England. Data was collected electronically and by questionnaire for the financial years 2001/2, 2002/3 and 2003/4. Hospitals were selected on the basis of their Medicines Management Self-Assessment Scores (MMAS) and included a cohort of three hospitals with integrated electronic prescribing systems. The total sample size was 6.65% of English NHS activity for 2001/2 based on Finished Consultant Episode (FCE) numbers. Data collected included all antibiotics dispensed (ATC category J01), hospital activity FCE's and beddays, Medicines Management Self-assessment scores, Antibiotic Medicines Management scores (AMS), Primary Care Trust (PCT) of origin of referral populations, PCT antibiotic prescribing rates, Index of Multiple Deprivation for each PCT. The DDD/FCE (Defined Daily Dose/FCE) was found to correlate with the DDD 100beddays (r = 0.74 pelectronic prescribing cohort was found to be lower, than the sample mean at 3.48 DDD/FCE in 2001/2 and 3.34 DDD/FCE in 2003/4. The MMAS and AMS were found to correlate (r = 0.74 p

Electronic dispersion compensation using full optical-field reconstruction in 10Gbit/s OOK based systems

We investigate the design of electronic dispersion compensation (EDC) using full optical-field reconstruction in 10Gbit/s on-off keyed transmission systems limited by optical signal-to-noise ratio (OSNR). By effectively suppressing the impairment due to low- frequency component amplification in phase reconstruction, properly designing the transmission system configuration to combat fiber nonlinearity, and successfully reducing the vulnerability to thermal noise, a 4.8dB OSNR margin can be achieved for 2160km single-mode fiber transmission without any optical dispersion compensation. We also investigate the performance sensitivity of the scheme to various system parameters, and propose a novel method to greatly enhance the tolerance to differential phase misalignment of the asymmetric Mach-Zehnder interferometer. This numerical study provides important design guidelines which will enable full optical-field EDC to become a cost-effective dispersion compensation solution for future transparent optical networks.

A review of current knowledge on Electronic Vision Enhancement Systems for the visually impaired

Magnification can be provided to assist those with visual impairment to make the best use of remaining vision. Electronic transverse magnification of an object was first conceived for use in low vision in the late 1950s, but has developed slowly and is not extensively prescribed because of its relatively high cost and lack of portability. Electronic devices providing transverse magnification have been termed closed-circuit televisions (CCTVs) because of the direct cable link between the camera imaging system and monitor viewing system, but this description generally refers to surveillance devices and does not indicate the provision of features such as magnification and contrast enhancement. Therefore, the term Electronic Vision Enhancement Systems (EVES) is proposed to better distinguish and describe such devices. This paper reviews current knowledge on EVES for the visually impaired in terms of: classification; hardware and software (development of technology, magnification and field-of-view, contrast and image enhancement); user aspects (users and usage, reading speed and duration, and training); and potential future development of EVES. © 2003 The College of Optometrists.

Benefits of electronic vision enhancement systems (EVES) for the visually impaired

PURPOSE: To examine whether objective performance of near tasks is improved with various electronic vision enhancement systems (EVES) compared with the subject's own optical magnifier. DESIGN: Experimental study, randomized, within-patient design. METHODS: This was a prospective study, conducted in a hospital ophthalmology low-vision clinic. The patient population comprised 70 sequential visually impaired subjects. The magnifying devices examined were: patient's optimum optical magnifier; magnification and field-of-view matched mouse EVES with monitor or head-mounted display (HMD) viewing; and stand EVES with monitor viewing. The tasks performed were: reading speed and acuity; time taken to track from one column of print to the next; follow a route map, and locate a specific feature; and identification of specific information from a medicine label. RESULTS: Mouse EVES with HMD viewing caused lower reading speeds than stand EVES with monitor viewing (F = 38.7, P < .001). Reading with the optical magnifier was slower than with the mouse or stand EVES with monitor viewing at smaller print sizes (P < .05). The column location task was faster with the optical magnifier than with any of the EVES (F = 10.3, P < .001). The map tracking and medicine label identification task was slower with the mouse EVES with HMD viewing than with the other magnifiers (P < .01). Previous EVES experience had no effect on task performance (P > .05), but subjects with previous optical magnifier experience were significantly slower at performing the medicine label identification task with all of the EVES (P < .05). CONCLUSIONS: Although EVES provide objective benefits to the visually impaired in reading speed and acuity, together with some specific near tasks, some can be performed just as fast using optical magnification. © 2003 by Elsevier Inc. All rights reserved.

Organisational learning - a critical systems thinking discipline

Original Paper European Journal of Information Systems (2001) 10, 135–146; doi:10.1057/palgrave.ejis.3000394 Organisational learning—a critical systems thinking discipline P Panagiotidis1,3 and J S Edwards2,4 1Deloitte and Touche, Athens, Greece 2Aston Business School, Aston University, Aston Triangle, Birmingham, B4 7ET, UK Correspondence: Dr J S Edwards, Aston Business School, Aston University, Aston Triangle, Birmingham, B4 7ET, UK. E-mail: j.s.edwards@aston.ac.uk 3Petros Panagiotidis is Manager responsible for the Process and Systems Integrity Services of Deloitte and Touche in Athens, Greece. He has a BSc in Business Administration and an MSc in Management Information Systems from Western International University, Phoenix, Arizona, USA; an MSc in Business Systems Analysis and Design from City University, London, UK; and a PhD degree from Aston University, Birmingham, UK. His doctorate was in Business Systems Analysis and Design. His principal interests now are in the ERP/DSS field, where he serves as project leader and project risk managment leader in the implementation of SAP and JD Edwards/Cognos in various major clients in the telecommunications and manufacturing sectors. In addition, he is responsible for the development and application of knowledge management systems and activity-based costing systems. 4John S Edwards is Senior Lecturer in Operational Research and Systems at Aston Business School, Birmingham, UK. He holds MA and PhD degrees (in mathematics and operational research respectively) from Cambridge University. His principal research interests are in knowledge management and decision support, especially methods and processes for system development. He has written more than 30 research papers on these topics, and two books, Building Knowledge-based Systems and Decision Making with Computers, both published by Pitman. Current research work includes the effect of scale of operations on knowledge management, interfacing expert systems with simulation models, process modelling in law and legal services, and a study of the use of artifical intelligence techniques in management accounting. Top of pageAbstract This paper deals with the application of critical systems thinking in the domain of organisational learning and knowledge management. Its viewpoint is that deep organisational learning only takes place when the business systems' stakeholders reflect on their actions and thus inquire about their purpose(s) in relation to the business system and the other stakeholders they perceive to exist. This is done by reflecting both on the sources of motivation and/or deception that are contained in their purpose, and also on the sources of collective motivation and/or deception that are contained in the business system's purpose. The development of an organisational information system that captures, manages and institutionalises meaningful information—a knowledge management system—cannot be separated from organisational learning practices, since it should be the result of these very practices. Although Senge's five disciplines provide a useful starting-point in looking at organisational learning, we argue for a critical systems approach, instead of an uncritical Systems Dynamics one that concentrates only on the organisational learning practices. We proceed to outline a methodology called Business Systems Purpose Analysis (BSPA) that offers a participatory structure for team and organisational learning, upon which the stakeholders can take legitimate action that is based on the force of the better argument. In addition, the organisational learning process in BSPA leads to the development of an intrinsically motivated information organisational system that allows for the institutionalisation of the learning process itself in the form of an organisational knowledge management system. This could be a specific application, or something as wide-ranging as an Enterprise Resource Planning (ERP) implementation. Examples of the use of BSPA in two ERP implementations are presented.

Adoption of electronic commerce tools in business procurement:enhanced buying center structure and processes

Modern procurement is being shifted from paper-based, people-intensive buying systems toward electronic-based purchase procedures that rely on Internet communications and Web-enhanced buying tools. Develops a typology of e-commerce tools that have come to characterize cutting-edge industrial procurement. E-commerce aspects of purchasing are organized into communication and transaction tools that encompass both internal and external buying activities. Further, a model of the impact of e-commerce on the structure and processes of an organization's buying center is developed. The impact of the changing buying center on procurement outcomes in terms of efficiency and effectiveness is also analyzed. Finally, implications for business-to-business marketers and researchers are discussed.

Knowledge management systems:finding a way with technology

Purpose - To consider the role of technology in knowledge management in organizations, both actual and desired. Design/methodology/approach - Facilitated, computer-supported group workshops were conducted with 78 people from ten different organizations. The objective of each workshop was to review the current state of knowledge management in that organization and develop an action plan for the future. Findings - Only three organizations had adopted a strongly technology-based "solution" to knowledge management problems, and these followed three substantially different routes. There was a clear emphasis on the use of general information technology tools to support knowledge management activities, rather than the use of tools specific to knowledge management. Research limitations/implications - Further research is needed to help organizations make best use of generally available software such as intranets and e-mail for knowledge management. Many issues, especially human, relate to the implementation of any technology. Participation was restricted to organizations that wished to produce an action plan for knowledge management. The findings may therefore represent only "average" organizations, not the very best practice. Practical implications - Each organization must resolve four tensions: Between the quantity and quality of information/knowledge, between centralized and decentralized organization, between head office and organizational knowledge, and between "push" and "pull" processes. Originality/value - Although it is the group rather than an individual that determines what counts as knowledge, hardly any previous studies of knowledge management have collected data in a group context.

Polarisation mode dispersion induced transmission penalties for long-haul high speed optical communication systems

Results of full numerical simulations of a guiding-centre soliton system with randomly birefringent SMF fibre are shown and analysed. It emerges that the soliton system becomes unstable even for small amounts of PMD.

Reliability:its implications in production systems design

Research on production systems design has in recent years tended to concentrate on ‘software’ factors such as organisational aspects, work design, and the planning of the production operations. In contrast, relatively little attention has been paid to maximising the contributions made by fixed assets, particularly machines and equipment. However, as the cost of unproductive machine time has increased, reliability, particularly of machine tools, has become ever more important. Reliability theory and research has traditionally been based in the main on electrical and electronic equipment whereas mechanical devices, especially machine tools, have not received sufficiently objective treatment. A recently completed research project has considered the reliability of machine tools by taking sample surveys of purchasers, maintainers and manufacturers. Breakdown data were also collected from a number of engineering companies and analysed using both manual and computer techniques. Results obtained have provided an indication of those factors most likely to influence reliability and which in turn could lead to improved design and selection of machine tool systems. Statistical analysis of long-term field data has revealed patterns of trends of failure which could help in the design of more meaningful maintenance schemes.

Ultra-long haul optical fibre transmission systems

This thesis examines experimentally options for optical fibre transmission over oceanic distances. Its format follows the chronological evolution of ultra-long haul optical systems, commencing with opto-electronic regenerators as repeaters, progressing to optically amplified NRZ systems and finally solitonic propagation. In each case recirculating loop techniques are deployed to simplify the transmission experiments. Advances in high speed electronics have allowed regenerators operating at 10 Gbit/s to become a practical reality. By augmenting such devices with optical amplifiers it is possible to greatly enhance the repeater spacing. Work detailed in this thesis has culminated in the propagation of 10 Gbit/s data over 400,000 km with a repeater spacing of 160 km. System reliability and robustness are enhanced by the use of a directly modulated DFB laser transmitter and total insensitivity of the system to the signal state of polarisation. Optically amplified ultra-long haul NRZ systems have taken on particular importance with the impending deployment of TAT 12/13 and TPC 5. The performance of these systems is demonstrated to be primarily limited by analogue impairments such as the accumulation of amplifier noise, polarisation effects and optical non-linearities. These degradations may be reduced by the use of appropriate dispersion maps and by scrambling the transmitted state of signal polarisation. A novel high speed optically passive polarisation scrambler is detailed for the first time. At bit rates in excess of 10 Gbit/s it is shown that these systems are severely limited and do not offer the advantages that might be expected over regenerated links. Propagation using solitons as the data bits appears particularly attractive since the dispersive and non-linear effects of the fibre allow distortion free transmission. However, the generation of pure solitons is difficult but must be achieved if the uncontrolled transmission distance is to be maximised. This thesis presents a new technique for the stabilisation of an erbium fibre ring laser that has aUowed propagation of 2.5 Gbit/s solitons to the theoretical limit of ~ 18,000 km. At higher bit rates temporal jitter becomes a significant impairment and to aUow an increase in the aggregate line rate multiplexing in both time and polarisation domains has been proposed. These techniques are shown to be of only limited benefit in practical systems and ultimately some form of soliton transmission control is required. The thesis demonstrates synchronous retiming by amplitude modulation that has allowed 20 Gbit/s data to propagate 125,000 km error free with an amplifier spacing approaching the soliton period. Ultimately the speed of operation of such systems is limited by the electronics used and, thus, a new form of soliton control is demonstrated using all optical techniques to achieve synchronous phase modulation.

Nonlinearity compensation in multi-rate 28 Gbaud WDM systems employing optical and digital techniques under diverse link configurations

Digital back-propagation (DBP) has recently been proposed for the comprehensive compensation of channel nonlinearities in optical communication systems. While DBP is attractive for its flexibility and performance, it poses significant challenges in terms of computational complexity. Alternatively, phase conjugation or spectral inversion has previously been employed to mitigate nonlinear fibre impairments. Though spectral inversion is relatively straightforward to implement in optical or electrical domain, it requires precise positioning and symmetrised link power profile in order to avail the full benefit. In this paper, we directly compare ideal and low-precision single-channel DBP with single-channel spectral-inversion both with and without symmetry correction via dispersive chirping. We demonstrate that for all the dispersion maps studied, spectral inversion approaches the performance of ideal DBP with 40 steps per span and exceeds the performance of electronic dispersion compensation by ~3.5 dB in Q-factor, enabling up to 96% reduction in complexity in terms of required DBP stages, relative to low precision one step per span based DBP. For maps where quasi-phase matching is a significant issue, spectral inversion significantly outperforms ideal DBP by ~3 dB.