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

Technical change and work organisation

This thesis is an exploration of the social and political processes involved in the introduction of new technology to the shopfloor. Through a series of case studies of applications of microelectronics to batch manufacture, it attempts to uncover the ways in which the values and interests of managers, engineers, workers and others profoundly influence the choice and use of technology, and thus the work organisation which emerges. Previous analyses have tended to treat new technology as if it had "impacts" on work organisation - especially skills - which are inevitable in particular technical and economic circumstances. It is in opposition to this view that technical change is here treated as a matter for social choice and political negotiation, the various interested parties to the change being shown to attempt to incorporate their own interests into the technical and social organisation of work. Section one provides the relevant background to the case studies by summarising and criticising previous theoretical and empirical work in the area. The inadequacies of this work for our concerns are drawn out, and the need for detailed studies of the political aspects of technical change is justified. The case studies are presented in section two as a set of "episodes" of innovation, and section three analyses the empirical findings. The innovations are compared and contrasted in order to illustrate the social and political dynamics involved in the various stages of the innovation process. Finally some comments are made on policy issues for which the research has important implications.

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.

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.

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.

Dispersion aspects of periodically amplified soliton transmission systems

This thesis presents improvements to optical transmission systems through the use of optical solitons as a digital transmission format, both theoretically and experimentally. An introduction to the main concepts and impairments of optical fibre on pulse transmission is included before introducing the concept of solitons in optically amplified communications and the problems of soliton system design. The theoretical work studies two fibre dispersion profiling schemes and a soliton launch improvement. The first provides superior pulse transmission by optimally tailoring the fibre dispersion to better follow the power, and hence nonlinearity, decay and thus allow soliton transmission for longer amplifier spacings and shorter pulse widths than normally possible. The second profiling scheme examines the use of dispersion compensating fibre in the context of soliton transmission over existing, standard fibre systems. The limits for solitons in uncompensated standard fibre are assessed, before the potential benefits of dispersion compensating fibre included as part of each amplifier are shown. The third theoretical investigation provides a simple improvement to the propagation of solitons in a highly perturbed system. By introducing a section of fibre of the correct length prior to the first system amplifier span, the soliton shape can be better coupled into the system thus providing an improved "average soliton" propagation model. The experimental work covers two areas. An important issue for soliton systems is pulse sources. Three potential lasers are studied, two ring laser configurations and one semiconductor device with external pulse shaping. The second area studies soliton transmission using a recalculating loop, reviewing the advantages and draw-backs of such an experiment in system testing and design. One particular example of employing the recirculating loop is also examined, using a novel method of pulse shape stabilisation over long distances with low jitter. The future for nonlinear optical communications is considered with the thesis conclusions.

Aspects of the design and control of manufacturing systems subject to demand uncertainty

The recent explosive growth in advanced manufacturing technology (AMT) and continued development of sophisticated information technologies (IT) is expected to have a profound effect on the way we design and operate manufacturing businesses. Furthermore, the escalating capital requirements associated with these developments have significantly increased the level of risk associated with initial design, ongoing development and operation. This dissertation has examined the integration of two key sub-elements of the Computer Integrated Manufacturing (CIM) system, namely the manufacturing facility and the production control system. This research has concentrated on the interactions between production control (MRP) and an AMT based production facility. The disappointing performance of such systems has been discussed in the context of a number of potential technological and performance incompatibilities between these two elements. It was argued that the design and selection of operating policies for both is the key to successful integration. Furthermore, policy decisions are shown to play an important role in matching the performance of the total system to the demands of the marketplace. It is demonstrated that a holistic approach to policy design must be adopted if successful integration is to be achieved. It is shown that the complexity of the issues resulting from such an approach required the formulation of a structured design methodology. Such a methodology was subsequently developed and discussed. This combined a first principles approach to the behaviour of system elements with the specification of a detailed holistic model for use in the policy design environment. The methodology aimed to make full use of the `low inertia' characteristics of AMT, whilst adopting a JIT configuration of MRP and re-coupling the total system to the market demands. This dissertation discussed the application of the methodology to an industrial case study and the subsequent design of operational policies. Consequently a novel approach to production control resulted. A central feature of which was a move toward reduced manual intervention in the MRP processing and scheduling logic with increased human involvement and motivation in the management of work-flow on the shopfloor. Experimental results indicated that significant performance advantages would result from the adoption of the recommended policy set.

Aspects of the design and operation of production control systems in manufacturing industry

Computerised production control developments have concentrated on Manufacturing Resources Planning (MRP II) systems. The literature suggests however, that despite the massive investment in hardware, software and management education, successful implementation of such systems in manufacturing industries has proved difficult. This thesis reviews the development of production planning and control systems, in particular, investigates the causes of failures in implementing MRP/MRP II systems in industrial environments and argues that the centralised and top-down planning structure, as well as the routine operational methodology of such systems, is inherently prone to failure. The thesis reviews the control benefits of cellular manufacturing systems but concludes that in more dynamic manufacturing environments, techniques such as Kanban are inappropriate. The basic shortcomings of MRP II systems are highlighted and a new enhanced operational methodology based on distributed planning and control principles is introduced. Distributed Manufacturing Resources Planning (DMRP), was developed as a capacity sensitive production planning and control solution for cellular manufacturing environments. The system utilises cell based, independently operated MRP II systems, integrated into a plant-wide control system through a Local Area Network. The potential benefits of adopting the system in industrial environments is discussed and the results of computer simulation experiments to compare the performance of the DMRP system against the conventional MRP II systems presented. DMRP methodology is shown to offer significant potential advantages which include ease of implementation, cost effectiveness, capacity sensitivity, shorter manufacturing lead times, lower working in progress levels and improved customer service.

Dissipative nonlinear structures in optical fiber systems II : self-similar parabolic pulses in active fibers

In this second talk on dissipative structures in fiber applications, we overview theoretical aspects of the generation, evolution and characterization of self-similar parabolic-shaped pulses in fiber amplifier media. In particular, we present a perturbation analysis that describes the structural changes induced by third-order fiber dispersion on the parabolic pulse solution of the nonlinear Schrödinger equation with gain. Promising applications of parabolic pulses in optical signal post-processing and regeneration in communication systems are also discussed.

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.

Dissipative nonlinear structures in optical fiber systems II:self-similar parabolic pulses in active fibers

In this second talk on dissipative structures in fiber applications, we overview theoretical aspects of the generation, evolution and characterization of self-similar parabolic-shaped pulses in fiber amplifier media. In particular, we present a perturbation analysis that describes the structural changes induced by third-order fiber dispersion on the parabolic pulse solution of the nonlinear Schrödinger equation with gain. Promising applications of parabolic pulses in optical signal post-processing and regeneration in communication systems are also discussed.

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.