Designing Computerized Provider Order Entry Software in Iran: The Nurses' and Physicians' Viewpoints

A systematic review of data elements of computerized physician order entry (CPOE): mapping the data to FHIR

OBJECTIVE

Medication errors are the third leading cause of death. There are several methods to prevent prescription errors, one of which is to use a Computerized Physician Order Entry system (CPOE). In a CPOE system, necessary data needs to be collected so that making decisions about prescribing medications and treatment plans could be made. Although many CPOE systems have been developed worldwide, studies have yet to identify the necessary data and data elements of CPOE systems. This study aims to identify data elements of CPOE and standardize these data with Fast Healthcare Interoperability Resources (FHIR) to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity.

METHODS

PubMed, Web of Science, Embase, and Scopus databases for studies up to October 2019 were searched. Two reviewers independently assessed original articles to determine eligibility for inclusion in this review. All articles describing data elements of a COPE system were included. Data elements were obtained from the included articles' text, tables, and figures.Classification of the extracted data elements and mapping them to FHIR was done to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity. The final data elements of CPOE were categorized into five main categories of FHIR (foundation, base, clinical, financial, and specialized) and 146 resources, where possible. One of the researchers did mapping and checked and verified by the second researcher. If a data element could not be mapped to any FHIR resources, this data element was considered an extension to the most relevant resource.

RESULTS

We retrieved 5162 articles through database searches. After the full-text assessment, 21 articles were included. In total, 270 data elements were identified and mapped to the FHIR standard. These elements have been reported in 26 FHIR resources of 146 ones (18%). In total, 71 data elements were considered an extension.

CONCLUSIONS

The results of this study showed that the same data elements were not used in the CPOE systems, and the degree of homogeneity of these systems is limited. The mapping of extracted data with data elements used in the FHIR standard shows the extent to which these systems comply with existing standards. Considering the standards in these systems' design helps developers design more coherent systems that can share data with other systems.

Effect of a Developed Nursing Stretch Break Application on Work-Related Musculoskeletal Complications and Fatigue among Nurses: An Interventional Study

Objective

The present study aimed to develop Nursing Stretch Break (NSB) application to relieve work-related musculoskeletal complications and fatigue among hospital nurses.

Methods

This interventional study was conducted among 71 nurses (15 men and 56 women with a mean age of 33.32 ± 6.42) employed in Shiraz governmental hospitals, Southwest Iran, for four months. In this study, NSB was developed; it includes eight main menus for the user, including (1) Registration, (2) Stretches, (3) User panel, (4) Questions from the researcher, (5) About us, (6) Contact us, (7) Reports, and (8) Answers to questions. Data were collected pre and post-intervention via the Persian version of the Nordic Musculoskeletal Questionnaire (P-NMQ), the Persian version of the Multidimensional Assessment of Fatigue (P-MAF) Scale, the Persian version of the Numeric Rating Scale (P-NRS), and the Persian version of the Usefulness, Satisfaction, and Ease of use (P-USE) questionnaire.

Results

NSB application usability testing showed that the mean scores of P-USE subscales were high. The prevalence of work-related musculoskeletal symptoms (WMSs) in the last 7 days in nurses' body parts, except the elbows and knees, was significantly lower after the intervention than before. In addition, the intensity of work-related musculoskeletal pain/discomfort in all body parts, except the knees, was significant relief after the intervention compared to before. The results demonstrated that the difference in the mean score of the total fatigue and its subscales, except "degree of interference with activities of daily living," was significant after the intervention compared to before.

Conclusions

NSB could be a low-cost and feasible ergonomic solution to improve the nurses' musculoskeletal health.

Relationship Between Pharmaceutical Knowledge and Probability of Medication Errors Among Nurses: A Cross-sectional Study in the Northwest of Iran in 2020

Background: Patient safety is a major concern for health care professionals. Medication errors have been considered a major indicator of health care quality. The lack of pharmacological knowledge is a cause of medication error among nurses. Objectives: The purpose of this study was to investigate the relationship between pharmacological knowledge and the probability of medical errors in nurses working in Urmia hospitals in 2020. Methods: This cross-sectional study included 490 nurses randomly selected from among those working in hospitals of Urmia in 2020. The data collection tool was a multiple-choice questionnaire about knowledge and pharmacological skills consisting of 3 sections: demographic information, nurses’ drug knowledge, and the confidence level of response in nurses. To analyze questions and hypotheses via SPSS version 21, the t-test and analysis of variance (ANOVA) were employed. Results: The highest pharmaceutical knowledge scores of nurses were related to methods of administration (2.9 ± 1.01 [72.56%]), and the lowest score was related to drug management (1.05 ± 0.63 [52.84%]). The mean of error probability was very low in 28.81% of nurses, low in 37.66%, high in 11.34%, and very high in 22.85%. Pharmaceutical knowledge had a significant relationship with gender, wards, type of hospital, and number of children (P < 0.05 for all). Conclusions: Since the nurses’ level of pharmaceutical knowledge has an important role in the correct prescription of medicine, we suggest that nurse managers and educational supervisors in the field of nursing use in-service training programs and prepare training booklets and posters to promote nurses’ pharmaceutical knowledge in this field.

Effectiveness of mobile health-based self-management application for posttransplant cares: A systematic review

BACKGROUND AND AIMS

Patients after transplantation need medical management for the rest of their lives, and self-management seems to lead to greater adherence to medical standards, improve early physical changes, and increase patient empowerment. The main objective of this article is to systematic review of the consideration to mobile health applications (m-Health apps) used in transplantation.

METHODS

A systematic search was conducted MEDLINE (through PubMed), Web of Science, Scopus, and Science Direct from inception to November 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was used in this study. Comprehensive research was carried out using a combination of keywords and MeSH terms associated with m-Health, empowerment, self-management, and transplantation. Two independent reviewers screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included posttransplant care and mobile phone-based applications to support self-management and self-care. Also, thesis, book chapters, letters to editors, short briefs, reports, technical reports, book reviews, systematic reviews, or meta-analysis were excluded.

RESULTS

We divided all the reviewed articles into four categories, self-management (medication adherence, adherence to medical regimen, and remote monitoring), evaluation, interaction, and interface; 37.5% of the studies were focused on lung transplantation. In 56.25% of the studies, medication adherence was considered because one of the main reasons for the rejection and graft loss is stated medication nonadherence. Also, 62.5% of the studies demonstrated that the use of m-health improved medication adherence and self-management in transplantation.

CONCLUSIONS

The use of m-Health apps interventions to self-management after transplantation has shown promising feasibility and acceptability, and there is modest evidence to support the efficacy of these interventions. We found that m-Health solutions can help the patient in self-management in many ways after transplantation.

A Systematic Review and Meta-analysis of the Medical Error Rate in Iran: 2005-2019

BACKGROUND AND OBJECTIVES

Medical errors (MEs) are one of the main factors affecting the quality of hospital services and reducing patient safety in health care systems, especially in developing countries. The aim of this study was to determine the rate of ME in Iran.

METHODS

This is a systematic literature review and meta-analysis of extracted data. The databases MEDLINE, EMBASE, Scopus, Cochrane, SID, Magiran, and Medlib were searched in Persian and English, using a combination of medical subject heading terms ("Medical Error" [Mesh] OR "Medication error" [Mesh] OR "Hospital Error" AND ("Iran" [Mesh]) for observational and interventional studies that reported ME rate in Iran from January 1995 to April 2019. We followed the STROBE checklist for the purpose of this review.

RESULTS

The search yielded a total of 435 records, of which 74 articles were included in the systematic review. The rate of MEs in Iran was determined as 0.35%. The rates of errors among physicians and nurses were 31% and 37%, respectively. The error rates during the medication process, including prescription, recording, and administration, were 31%, 27%, and 35%, respectively. Also, incidence of MEs in night shifts was higher than in any other shift (odds ratio [OR] = 38%; 95% confidence interval [CI]: 31%-45%). Moreover, newer nurses were responsible for more errors within hospitals than other nurses (OR = 57%; 95% CI: 41%-80%). The rate of reported error after the Health Transformation Plan was higher than before the Health Transformation Plan (OR = 40%; CI: 33%-49% vs OR = 30%; CI: 25%-35%).

CONCLUSION

This systematic review has demonstrated the high ME rate in Iranian hospitals. Based on the error rate attributed solely to night shifts, more attention to the holistic treatment process is required. Errors can be decreased through a variety of strategies, such as training clinical and support staff regarding safe practices and updating and adapting systems and technologies.

Identification and Prioritization of Clinical Decision Support Functionalities Built Within A Computerized Provider Order Entry System

Background: Clinical decision support (CDS) functionalities in Computerized Provider Order Entry system (CPOE) need to be identified by the institutional healthcare providers in developing countries. In this regard, CDS functionalities should be a priority for the execution in CPOE. Objectives: Thus, our study was done to identify and prioritize the CDS functionalities in CPOE. Methods: A Two-round Modified Delphi process was used. Firstly, a systematic search was conducted in electronic databases from the date of database inception to February 2019 for identifying CDS functionalities integrated into CPOE. Studies were retrieved from databases, including PubMed, Embase, ProQuest, Scopus, Web of Science, Cochrane, Science Direct, ACM digital library, and IEEE Xplore Digital Library. Secondly, the Modified Delphi method was carried out in 2019 to provide contextual priorities regarding CDS functionalities in CPOE in two iterative rounds. A total of 12 experts working in the three Intensive Care Units (ICUs) with more than three years of experience with homegrown CPOE in Shiraz Nemazee Teaching Hospital, including two clinical pharmacists, two health information management faculty member, four cases with critical care fellowship, and four critical care experts participated in the study. The ≥ 66.6% agreement was considered as the consensus level. SPSS software version 24 was used for statistical analysis. Results: Totally, 327 studies, which met eligibility criteria were found. A number of 60 potential CDS functionalities in CPOE were identified from eligible studies. Also, 13 out of 60 CDS functionalities reached high priority consensus after 2 iterative Delphi rounds, including drug-allergy checking (83.3%), basic dosing guidance (75%), single dosing checking (66.7%), duplicate therapy checking (66.7%), drug-pregnancy alerts (75%), time-based alerts (66.7%), alert for deep vein thrombosis prophylaxis (66.7%), alerts for duplicate medication order checking (66.7%), drug-drug interaction checking (75%), intelligent dosing guidance based on the patients’ characteristics (66.7%), renal-drug problems checking (83.3%), drug-disease interaction checking (66.7%), and displaying medication/test cost (75%). Conclusions: Our study identified high-priority CDS functionalities to be considered in the CPOE system from the viewpoint of multidisciplinary experts, especially in Iran. Results of this study may be beneficial to plan, design, and implement CDS functionalities in CPOE in the ICU.

Attitudes of nurses towards clinical information systems: a systematic review and meta-analysis

AIM

This systematic review and meta-analysis evaluates the attitudes of Iranian nurses towards clinical information systems in nursing practice.

BACKGROUND

Nurses are essential in the successful adoption and implementation of clinical information systems.

METHODS

A systematic search was performed in Medline, Embase, Cochrane, CINAHL, Scopus, and Web of Science and Farsi databases, to retrieve relevant studies. The methodological quality of the studies is assessed via the Joanna Briggs Institute's critical appraisal checklist for analytical cross-sectional studies. The random effect model was utilized to analyse the data due to the high heterogeneity in the included studies (n = 17).

RESULTS

Results indicate that clinical information systems impact on at least seven aspects of nursing practice, including documentation, patient safety, quality of treatment, communication, treatment management, nursing tasks and hospital resource management. Results also indicated that one aspect of using clinical information systems in nursing practice is satisfaction with the 'quality and design of clinical information systems', such as ease of use and learning, flexibility and software speed.

CONCLUSION

Clinical information systems can contribute to different aspects of nursing practice. However, their design should improve significantly in order to help nurses perform their professional activities in an efficient and satisfactory manner.

IMPLICATIONS FOR NURSING POLICY

Before the full deployment of clinical information systems, their usability should be tested. In pilot testing, nurses should provide necessary feedback about how well the systems work and improvements needed to meet their professional goals.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.