No abstract

This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.

Objective-The Dietary Intake Monitoring Application (DIMA) is an electronic dietary selfmonitor developed for use on a personal digital assistant (PDA). This paper describes how computer, information, numerical, and visual literacy were considered in development of DIMA.Methods-An iterative, participatory design approach was used. Forty individuals receiving hemodialysis at an urban inner-city facility, primarily middle-aged and African American, were recruited.Results-Computer literacy was considered by assessing abilities to complete traditional/ nontraditional PDA tasks. Information literacy was enhanced by including a Universal-ProductCode (UPC) scanner, picture icons for food with no UPC code, voice recorder, and culturally sensitive food icons. Numerical literacy was enhanced by designing DIMA to compute real-time totals that allowed individuals to see their consumption relative to their dietary prescription. Visual literacy was considered by designing the graphical interface to convey intake data over a

No abstract

Computerized medication alerts (e.g., drug-drug interactions, drug-allergy interactions), which are intended to protect patient safety, need to match the mental models of medication prescribers in order to aid medication ordering. To maximally protect patient safety, the programmer mental model, system image, and prescriber mental model should work seamlessly together to fully support prescriber decision-making. In this study, we examined prescribing processes in the context of routine patient care to understand how the design of medication alerts can be enhanced for prescribers. We shadowed prescribers, including physicians, pharmacists, and nurse practitioners, across five outpatient primary care clinics at a large Veterans Affairs Medical Center (VAMC). In addition, prescribers were opportunistically interviewed as they ordered mediations via a computerized order entry system and resolved any subsequent medication alerts. This investigation is one of the few to examine medication alerts by directly observing prescribers during patient care. Altogether, 191 medication alerts occurred across 63.5 total hrs of observation, 19 prescribers, and 86 patients during routine patient care tasks. Results reveal problematic system images and mismatches between programmer and prescriber mental models. Findings can help inform medication alert redesigns, which may promote safer, more effective prescribing practices.

No abstract

While the potential benefits of computerized provider order entry (CPOE) are well recognized, little is known about how prescribers have integrated electronic medication ordering into other aspects of patient care. As part of a larger investigation of computerized medication alerts, we observed and opportunistically interviewed 20 primary care prescribers at a major Veterans Affairs Medical Center (VAMC). Participants were recruited from each of the VAMC's 5 primary care clinics and included physicians, nurse practitioners, and clinical pharmacists. Prescribers were observed as they ordered mediations via the CPOE system during routine patient care. In total, observations included 91 routine patient encounters across 66.5 hrs of observation. This paper provides illustrative case examples of how prescribers have integrated CPOE into medication decision-making processes and other patient care tasks. Results demonstrate that CPOE workflow varies widely among prescribers. In addition, results indicate that there are trade-offs associated with using CPOE with the patient in the exam room versus outside of the exam room. Findings may have implications for provider-patient relationships, workflow efficiency, and medication safety, and may ultimately enhance the effectiveness of CPOE in primary care.

We appreciate the discussion about our article, "Reducing Prescribing Errors through Creatinine Clearance Alert Redesign." 1 We are pleased to respond.We agree with Gaffo's et al's comments indicating that dosing allopurinol requires numerous considerations, and that medical evidence and consideration of patient-specific factors are paramount for medical decisions. The alerts in our study 1 provided information but not specific recommendations; nor was any dosing algorithm developed as part of this research. Our study team defined correct and incorrect actions for allopurinol by incorporating information available from Micromedex, 2 whose information about renal dosing is confirmed by a May 2015 package insert for allopurinol as provided by Accord Healthcare (Durham, NC). 3 We fully acknowledge that clinical guidelines, latest medical evidence, and standards of practice sometimes conflict, and that the definition of an error might thus change according to which guideline or standard is chosen.We acknowledge that any implementation of alerts in real clinical practiceejust as with all clinical decision supportewould require deliberation and periodic updates, to ensure appropriateness and consistency with the most current guidelines, evidence, and standards of practice. Our study does not assert any specific clinical guideline as much as it tests the effect of an innovative alert display. Our redesigned display provided easier access to laboratory results 1,4 and added information about the risk associated with continued use of the medicationehepatotoxicity in the case of allopurinol 1,3 eto facilitate clinical decision-making. Although providers can review and monitor uric acid levels and hepatic function, in our simulation, no provider reviewed these laboratory tests prior to acting on the alert information. Regardless of how the reader currently defines erroneous prescribing of allopurinol, our study demonstrated that a redesigned alert display leads to a significant change in practice. With our patient scenario, this change was consistent with evidence and information that would be readily available to a primary care provider. The capabilities of our design can be used to improve prescribing and safety.We welcome the opportunity to discuss our study further. This discussion underscores the importance of interdisciplinary input about alert systems and illustrates the challenges associated with developing effective clinical decision support.