Antonia Hordern

The Effect of Computerized Provider Order Entry Systems on Clinical Care and Work Processes in Emergency Departments: A Systematic Review of the Quantitative Literature

STUDY OBJECTIVE We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). METHODS We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. RESULTS We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). CONCLUSION There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care.

Consumer e-health: an overview of research evidence and implications for future policy.

Consumer e-health is rapidly becoming a fundamental component of healthcare. However, to date only provisional steps have been taken to increase our understanding of how consumers engage with e-health. This study, an interpretive review, assessed the evidence about consumer use of e-health and identified five categories that encompass consumer e-health: (i) peer-to-peer online support groups; (ii) self-management/self-monitoring applications; (iii) decision aids; (iv) the personal health record; and (v) Internet use. Our findings reveal that e-health offers consumers many possibilities and potential benefits, although there appears to be apprehension concerning the efficacy of some interventions and barriers relating to the trustworthiness of Internet-acquired information. It is imperative that policy initiatives address these issues to ensure that consumer e-health services can be effectively, efficiently, and safely accessed.

The impact of clinical leadership on health information technology adoption: systematic review.

PURPOSE To conduct a systematic review to examine evidence of associations between clinical leadership and successful information technology (IT) adoption in healthcare organisations. METHODS We searched Medline, Embase, Cinahl, and Business Source Premier for articles published between January 2000 to May 2013 with keywords and subject terms related to: (1) the setting--healthcare provider organisations; (2) the technology--health information technology; (3) the process--adoption; and (4) the intervention--leadership. We identified 3121 unique citations, of which 32 met our criteria and were included in the review. Data extracted from the included studies were assessed in light of two frameworks: Bassellier et al.s IT competence framework; and Avgar et al.s health IT adoption framework. RESULTS The results demonstrate important associations between the attributes of clinical leaders and IT adoption. Clinical leaders who have technical informatics skills and prior experience with IT project management are likely to develop a vision that comprises a long-term commitment to the use of IT. Leaders who possess such a vision believe in the value of IT, are motivated to adopt it, and can maintain confidence and stability through the adversities that IT adoptions often entail. This leads to proactive leadership behaviours and partnerships with IT professionals that are associated with successful organisational and clinical outcomes. CONCLUSIONS This review provides evidence that clinical leaders can positively contribute to successful IT adoption in healthcare organisations. Clinical leaders who aim for improvements in the processes and quality of care should cultivate the necessary IT competencies, establish mutual partnerships with IT professionals, and execute proactive IT behaviours to achieve successful IT adoption.

The characteristics of a cohort who tamper with prescribed and diverted opioid medications

AIMS To describe the methods and baseline characteristics of a cohort of people who tamper with pharmaceutical opioids, formed to examine changes in opioid use following introduction of Reformulated OxyContin®. METHODS Participants were 606 people from three Australian jurisdictions who reported past month injecting, snorting, chewing or smoking of a pharmaceutical opioid and had engaged in these practices at least monthly in the past 6 months. Baseline interviews were conducted prior to introduction of Reformulated OxyContin® in April 2014. Patterns of opioid use and cohort characteristics were examined according to whether participants were prescribed opioid medications, or exclusively used diverted medication. RESULTS The cohort reported high levels of moderate/severe depression (61%), moderate/severe anxiety (43%), post-traumatic stress disorder (42%), chronic pain or disability (past 6 months, 54%) and pain (past month, 47%). Lifetime use of oxycodone, morphine, opioid substitution medications and codeine were common. Three-quarters (77%) reported ICD-10 lifetime pharmaceutical opioid dependence and 40% current heroin dependence. Thirteen percent reported past year overdose, and 70% reported at least one past month opioid injection-related injury or disease. The cohort displayed complex clinical profiles, but participants currently receiving opioid substitution therapy who were also prescribed other opioids particularly reported a wide range of risk behaviors, despite their health service engagement. CONCLUSIONS Findings highlight the heterogeneity in the patterns and clinical correlates of opioid use among people who tamper with pharmaceutical opioids. Targeted health interventions are essential to reduce the associated harms.

Methods and predictors of tampering with a tamper-resistant controlled-release oxycodone formulation

BACKGROUND In April 2014, a tamper-resistant controlled-release oxycodone formulation was introduced into the Australian market. This study aimed to identify the level and methods of tampering with reformulated oxycodone, demographic and clinical characteristics of those who reported tampering with reformulated oxycodone, and perceived attractiveness of original and reformulated oxycodone for misuse (via tampering). METHODS A prospective cohort of 522 people who regularly tampered with pharmaceutical opioids and had tampered with the original oxycodone product in their lifetime completed two interviews before (January-March 2014: Wave 1) and after (May-August 2014: Wave 2) introduction of reformulated oxycodone. RESULTS Four-fifths (81%) had tampered with the original oxycodone formulation in the month prior to Wave 1; use and attempted tampering with reformulated oxycodone amongst the sample was comparatively low at Wave 2 (29% and 19%, respectively). Reformulated oxycodone was primarily swallowed (15%), with low levels of recent successful injection (6%), chewing (2%), drinking/dissolving (1%), and smoking (<1%). Participants who tampered with original and reformulated oxycodone were socio-demographically and clinically similar to those who had only tampered with the original formulation, except the former were more likely to report prescribed oxycodone use and stealing pharmaceutical opioid, and less likely to report moderate/severe anxiety. There was significant diversity in the methods for tampering, with attempts predominantly prompted by self-experimentation (rather than informed by word-of-mouth or the internet). Participants rated reformulated oxycodone as more difficult to prepare and inject and less pleasant to use compared to the original formulation. CONCLUSION Current findings suggest that the introduction of the tamper-resistant product has been successful at reducing, although not necessarily eliminating, tampering with the controlled-release oxycodone formulation, with lower attractiveness for misuse. Appropriate, effective treatment options must be available with increasing availability of abuse-deterrent products, given the reduction of oxycodone tampering and use amongst a group with high rates of pharmaceutical opioid dependence.

Jurisdictional differences in opioid use, other licit and illicit drug use, and harms associated with substance use among people who tamper with pharmaceutical opioids

INTRODUCTION AND AIMS The harms associated with non-medical use of pharmaceutical opioid analgesics are well established; however, less is known about the characteristics and drug-use patterns of the growing and hidden populations of people using pharmaceutical opioids illicitly, including the frequency of pharmaceutical opioid injection. This paper aimed to undertake a detailed examination of jurisdictional differences in patterns of opioid use among a cohort of people who regularly tamper with pharmaceutical opioids in Australia. DESIGN AND METHODS Data were drawn from the National Opioid Medications Abuse Deterrence study. The cohort was recruited from New South Wales (NSW; n = 303), South Australia (SA; n = 150) and Tasmania (TAS; n = 153) to participate in face-to-face structured interviews collecting data on use of pharmaceutical opioids, benzodiazepines, other sedative drugs and illicit substances, as well as the harms associated with substance use. RESULTS TAS participants reported greater use and injection of certain pharmaceutical opioids (particularly morphine and methadone tablets), and limited heroin use, with lower rates of engagement in opioid substitution treatment, compared with NSW participants. NSW participants were more socially disadvantaged and more likely to report risky injecting behaviours and injecting-related injuries and diseases compared with SA and TAS participants. SA participants reported greater rates of pain conditions, greater use of pain-based services, as well as broader use of pharmaceutical opioids in regards to forms and route of administration, compared with NSW participants. DISCUSSION AND CONCLUSIONS Distinct jurisdictional profiles were evident for people who tamper with pharmaceutical opioids, potentially reflecting jurisdictional differences in prescribing regulatory mechanisms and addiction treatment models.

Comprehensive medical assessments for monitoring and improving the health of residents in aged care facilities: existing comprehensive medical assessments coverage and trial of a new service model.

Aim:  To measure comprehensive medical assessment (CMA) completions among aged care residents in Australia; and to report the outcomes of a CMA service trial.

What do radiology incident reports reveal about in-hospital communication processes and the use of health information technology?

BACKGROUND There has been recent rapid growth in the use of medical imaging leading to concerns about an increase in unnecessary investigations, patient exposure to radiation, and incorrect diagnoses. Incident reporting systems provide a portal for staff to catalogue adverse events which occur within a hospital or department. Analysing incident reports can reveal trends and provide guidance for quality improvement efforts. METHODS Classification of medical imaging related-incidents from a major teaching hospital in Sydney, Australia using WHO International Classification for Patient Safety (ICPS) taxonomy. All incidents with radiology identified as incident location (n=219) were extracted. Incidents were from January 2005 to October 2011. Two researchers independently cleaned the data set. One researcher then applied the ICPS to free text incident reports. RESULTS 216 unique incidents were extracted. 15 incidents were unable to be classified using the ICPS. 8 incidents were classified twice, resulting in 209 coded incidents. Communication breakdown was a contributing factor in 49% (103/209) of incidents reported. 147 of the 209 incidents were associated with activities associated with data collection, storage or retrieval of electronic information. Health information technology (HIT) systems were mentioned explicitly in 10% of incidents, indicating some contribution to the error. CONCLUSIONS Communication breakdown and HIT systems are contributors to error, and should be addressed. HIT systems need to be monitored and flaws addressed to ensure quality care.

Effective notification of important non‐urgent radiology results: A qualitative study of challenges and potential solutions

We report on the implementation of a Radiology Notification System (RNS), set up by the medical imaging department of a major Sydney teaching hospital in March 2010. This study aimed to investigate the views of the medical imaging department staff about: (i) the results follow‐up problem encountered by the medical imaging department prior to the implementation of the RNS; (ii) what changes occurred following implementation of the RNS; and (iii) suggestions for improving the RNS.

Response to Catherine Pettiford

References Cebul, R.D., Love, T.E., Jain, A.K. and Hebert, C.J. (2011). Electronic health records and quality of diabetes care. New England Journal of Medicine 365: 825-833. Cripps, H., Standing, C. and Prijatelj, V. (2011). The implementation of electronic health records: a two country comparison. 24th Bled eConference eFuture: Creating solutions for the individual, organisations and society. Bled, Slovenia. Department of Health and Ageing. (2011). Concept of operations: relating to the introduction of a personally controlled electronic health record (PCEHR) system. eHealth Division, Australian Department of Health and Ageing, Canberra. Iezzoni, L.I. (1997). How much are we willing to pay for information about quality of care. Annals of Internal Medicine 126: 391-393. Pearce, C. and Haikerwal, M.C. (2010). E-health in Australia: time to plunge into the 21st century. Medical Journal of Australia 193: 397-398.