Publications by authors named "Jos Aarts"

45 Publications

Optimization and Validation of a Classification Algorithm for Assessment of Physical Activity in Hospitalized Patients.

Sensors (Basel) 2021 Feb 27;21(5). Epub 2021 Feb 27.

Department of Physical Therapy, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands.

Low amounts of physical activity (PA) and prolonged periods of sedentary activity are common in hospitalized patients. Objective PA monitoring is needed to prevent the negative effects of inactivity, but a suitable algorithm is lacking. The aim of this study is to optimize and validate a classification algorithm that discriminates between sedentary, standing, and dynamic activities, and records postural transitions in hospitalized patients under free-living conditions. Optimization and validation in comparison to video analysis were performed in orthopedic and acutely hospitalized elderly patients with an accelerometer worn on the upper leg. Data segmentation window size (WS), amount of PA threshold (PA Th) and sensor orientation threshold (SO Th) were optimized in 25 patients, validation was performed in another 25. Sensitivity, specificity, accuracy, and (absolute) percentage error were used to assess the algorithm's performance. Optimization resulted in the best performance with parameter settings: WS 4 s, PA Th 4.3 counts per second, SO Th 0.8 g. Validation showed that all activities were classified within acceptable limits (>80% sensitivity, specificity and accuracy, ±10% error), except for the classification of standing activity. As patients need to increase their PA and interrupt sedentary behavior, the algorithm is suitable for classifying PA in hospitalized patients.
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http://dx.doi.org/10.3390/s21051652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7956397PMC
February 2021

The potential of real-time analytics to improve care for mechanically ventilated patients in the intensive care unit: an early economic evaluation.

Cost Eff Resour Alloc 2020 Dec 11;18(1):57. Epub 2020 Dec 11.

Erasmus School of Health Policy & Management (ESHPM), Erasmus University, Burgemeester Oudlaan 50, P.O. Box 1738, 3062 PA, Rotterdam, The Netherlands.

Background: Mechanical ventilation services are an important driver of the high costs of intensive care. An optimal interaction between a patient and a ventilator is therefore paramount. Suboptimal interaction is present when patients repeatedly demand, but do not receive, breathing support from a mechanical ventilator (> 30 times in 3 min), also known as an ineffective effort event (IEEV). IEEVs are associated with increased hospital mortality prolonged intensive care stay, and prolonged time on ventilation and thus development of real-time analytics that identify IEEVs is essential. To assist decision-making about further development we estimate the potential cost-effectiveness of real-time analytics that identify ineffective effort events.

Methods: We developed a cost-effectiveness model combining a decision tree and Markov model for long-term outcomes with data on current care from a Greek hospital and literature. A lifetime horizon and a healthcare payer perspective were used. Uncertainty about the results was assessed using sensitivity and scenario analyses to examine the impact of varying parameters like the intensive care costs per day and the effectiveness of treatment of IEEVs.

Results: Use of the analytics could lead to reduced mortality (3% absolute reduction), increased quality adjusted life years (0.21 per patient) and cost-savings (€264 per patient) compared to current care. Moreover, cost-savings for hospitals and health improvements can be incurred even if the treatment's effectiveness is reduced from 30 to 10%. The estimated savings increase to €1,155 per patient in countries where costs of an intensive care day are high (e.g. the Netherlands). There is considerable headroom for development and the analytics generate savings when the price of the analytics per bed per year is below €7,307. Furthermore, even when the treatment's effectiveness is 10%, the probability that the analytics are cost-effective exceeds 90%.

Conclusions: Implementing real-time analytics to identify ineffective effort events can lead to health and financial benefits. Therefore, it will be worthwhile to continue assessment of the effectiveness of the analytics in clinical practice and validate our findings. Eventually, their adoption in settings where costs of an intensive care day are high and ineffective efforts are frequent could yield a high return on investment.
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http://dx.doi.org/10.1186/s12962-020-00254-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729701PMC
December 2020

The Validation of a Pocket Worn Activity Tracker for Step Count and Physical Behavior in Older Adults during Simulated Activities of Daily Living.

Gerontol Geriatr Med 2020 Jan-Dec;6:2333721420951732. Epub 2020 Sep 30.

Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Zuyd University of Applied Sciences, Heerlen, Netherlands.

Purpose: The purpose of this study was to validate optimized algorithm parameter settings for step count and physical behavior for a pocket worn activity tracker in older adults during ADL. Secondly, for a more relevant interpretation of the results, the performance of the optimized algorithm was compared to three reference applications.

Methods: In a cross-sectional validation study, 20 older adults performed an activity protocol based on ADL with MOX versus MOX, activPAL, and Fitbit. The protocol was video recorded and analyzed for step count and dynamic, standing, and sedentary time. Validity was assessed by percentage error (PE), absolute percentage error (APE), Bland-Altman plots and correlation coefficients.

Results: For step count, the optimized algorithm had a mean APE of 9.3% and a correlation coefficient of 0.88. The mean APE values of dynamic, standing, and sedentary time were 15.9%, 19.9%, and 9.6%, respectively. The correlation coefficients were 0.55, 0.91, and 0.92, respectively. Three reference applications showed higher errors and lower correlations for all outcome variables.

Conclusion: This study showed that the optimized algorithm parameter settings can more validly estimate step count and physical behavior in older adults wearing an activity tracker in the trouser pocket during ADL compared to reference applications.
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http://dx.doi.org/10.1177/2333721420951732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545746PMC
September 2020

Economic evaluations of big data analytics for clinical decision-making: a scoping review.

J Am Med Inform Assoc 2020 07;27(9):1466-1475

Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.

Objective: Much has been invested in big data analytics to improve health and reduce costs. However, it is unknown whether these investments have achieved the desired goals. We performed a scoping review to determine the health and economic impact of big data analytics for clinical decision-making.

Materials And Methods: We searched Medline, Embase, Web of Science and the National Health Services Economic Evaluations Database for relevant articles. We included peer-reviewed papers that report the health economic impact of analytics that assist clinical decision-making. We extracted the economic methods and estimated impact and also assessed the quality of the methods used. In addition, we estimated how many studies assessed "big data analytics" based on a broad definition of this term.

Results: The search yielded 12 133 papers but only 71 studies fulfilled all eligibility criteria. Only a few papers were full economic evaluations; many were performed during development. Papers frequently reported savings for healthcare payers but only 20% also included costs of analytics. Twenty studies examined "big data analytics" and only 7 reported both cost-savings and better outcomes.

Discussion: The promised potential of big data is not yet reflected in the literature, partly since only a few full and properly performed economic evaluations have been published. This and the lack of a clear definition of "big data" limit policy makers and healthcare professionals from determining which big data initiatives are worth implementing.
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http://dx.doi.org/10.1093/jamia/ocaa102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526472PMC
July 2020

Optimization and Validation of an Adjustable Activity Classification Algorithm for Assessment of Physical Behavior in Elderly.

Sensors (Basel) 2019 Dec 4;19(24). Epub 2019 Dec 4.

Department of Nutrition and Movement Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.

Due to a lack of transparency in both algorithm and validation methodology, it is difficult for researchers and clinicians to select the appropriate tracker for their application. The aim of this work is to transparently present an adjustable physical activity classification algorithm that discriminates between dynamic, standing, and sedentary behavior. By means of easily adjustable parameters, the algorithm performance can be optimized for applications using different target populations and locations for tracker wear. Concerning an elderly target population with a tracker worn on the upper leg, the algorithm is optimized and validated under simulated free-living conditions. The fixed activity protocol (FAP) is performed by 20 participants; the simulated free-living protocol (SFP) involves another 20. Data segmentation window size and amount of physical activity threshold are optimized. The sensor orientation threshold does not vary. The validation of the algorithm is performed on 10 participants who perform the FAP and on 10 participants who perform the SFP. Percentage error (PE) and absolute percentage error (APE) are used to assess the algorithm performance. Standing and sedentary behavior are classified within acceptable limits (±10% error) both under fixed and simulated free-living conditions. Dynamic behavior is within acceptable limits under fixed conditions but has some limitations under simulated free-living conditions. We propose that this approach should be adopted by developers of activity trackers to facilitate the activity tracker selection process for researchers and clinicians. Furthermore, we are convinced that the adjustable algorithm potentially could contribute to the fast realization of new applications.
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http://dx.doi.org/10.3390/s19245344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961012PMC
December 2019

Monitoring Parkinson's disease symptoms during daily life: a feasibility study.

NPJ Parkinsons Dis 2019 30;5:21. Epub 2019 Sep 30.

4Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.

Parkinson's disease symptoms are most often charted using the MDS-UPDRS. Limitations of this approach include the subjective character of the assessments and a discrepant performance in the clinic compared to the home situation. Continuous monitoring using wearable devices is believed to eventually replace this golden standard, but measurements often lack a parallel ground truth or are only tested in lab settings. To overcome these limitations, this study explores the feasibility of a newly developed Parkinson's disease monitoring system, which aims to measure Parkinson's disease symptoms during daily life by combining wearable sensors with an experience sampling method application. Twenty patients with idiopathic Parkinson's disease participated in this study. During a period of two consecutive weeks, participants had to wear three wearable sensors and had to complete questionnaires at seven semi-random moments per day on their mobile phone. Wearable sensors collected objective movement data, and the questionnaires containing questions about amongst others Parkinson's disease symptoms served as parallel ground truth. Results showed that participants wore the wearable sensors during 94% of the instructed timeframe and even beyond. Furthermore, questionnaire completion rates were high (79,1%) and participants evaluated the monitoring system positively. A preliminary analysis showed that sensor data could reliably predict subjectively reported OFF moments. These results show that our Parkinson's disease monitoring system is a feasible method to use in a diverse Parkinson's disease population for at least a period of two weeks. For longer use, the monitoring system may be too intense and wearing comfort needs to be optimized.
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http://dx.doi.org/10.1038/s41531-019-0093-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768992PMC
September 2019

Samantha Adams Festschrift: Coming of Age-Samantha Adam's Career at Erasmus University Rotterdam.

Authors:
Jos Aarts

Appl Clin Inform 2018 07 3;9(3):493-495. Epub 2018 Jul 3.

Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1055/s-0038-1656523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029931PMC
July 2018

Clinical reasoning in the context of active decision support during medication prescribing.

Int J Med Inform 2017 01 23;97:1-11. Epub 2016 Sep 23.

Division of General Internal Medicine and Primary Care, Brigham &Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.

Objective: Describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. Insights could be used to inform the design of decision-support interventions.

Methods: Thirty-two clinicians working with five EHRs in two countries completed sets of six medication orders each and responded to high- and low-severity drug-drug interaction alerts while verbalizing their thoughts in a standard think-aloud protocol. Tasks were recorded and analyzed to describe reasoning patterns about patient-risk assessment and strategies to avoid or mitigate it.

Results: We observed a total of 171 prescribing decisions. Clinicians actively sought to reduce risk when responding to high-severity alerts, mostly by monitoring patients and making dose adjustments (52 alerts, 40%). In contrast, they routinely left prescriptions unchanged after low-severity alerts when they felt confident that patients would tolerate the drug combination and that treatment benefits outweighed the risks (30 alerts, 71%). Clinicians used similar reasoning patterns regardless of the EHR used and differences in alert design.

Discussion: Clinicians conceptualized risk as a complex set of interdependent tradeoffs specific to individual patients and had a tendency not to follow advice they considered of low clinical value. Omission of patient-specific data, which was not shown in alerts or included in trigger logic, may have contributed to the constancy of reasoning and to similarities in risk-control strategies we observed despite significant differences in interface design and system function.

Conclusion: Declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher. Clinicians believed that the risk indicated in drug-drug interaction alerts needs to be interpreted as one factor in the broader context of care, specific to a patient.
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http://dx.doi.org/10.1016/j.ijmedinf.2016.09.004DOI Listing
January 2017

A sociotechnical perspective of health information technology.

Authors:
Jos Aarts

Int J Med Inform 2013 Dec 26;82(12):1133-5. Epub 2013 Oct 26.

Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands. Electronic address:

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http://dx.doi.org/10.1016/j.ijmedinf.2013.10.007DOI Listing
December 2013

On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop.

BMC Med Inform Decis Mak 2013 Oct 1;13:111. Epub 2013 Oct 1.

University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB UK.

Background: Clinical decision support (CDS) for electronic prescribing systems (computerized physician order entry) should help prescribers in the safe and rational use of medicines. However, the best ways to alert users to unsafe or irrational prescribing are uncertain. Specifically, CDS systems may generate too many alerts, producing unwelcome distractions for prescribers, or too few alerts running the risk of overlooking possible harms. Obtaining the right balance of alerting to adequately improve patient safety should be a priority.

Methods: A workshop funded through the European Regional Development Fund was convened by the University Hospitals Birmingham NHS Foundation Trust to assess current knowledge on alerts in CDS and to reach a consensus on a future research agenda on this topic. Leading European researchers in CDS and alerts in electronic prescribing systems were invited to the workshop.

Results: We identified important knowledge gaps and suggest research priorities including (1) the need to determine the optimal sensitivity and specificity of alerts; (2) whether adaptation to the environment or characteristics of the user may improve alerts; and (3) whether modifying the timing and number of alerts will lead to improvements. We have also discussed the challenges and benefits of using naturalistic or experimental studies in the evaluation of alerts and suggested appropriate outcome measures.

Conclusions: We have identified critical problems in CDS, which should help to guide priorities in research to evaluate alerts. It is hoped that this will spark the next generation of novel research from which practical steps can be taken to implement changes to CDS systems that will ultimately reduce alert fatigue and improve the design of future systems.
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http://dx.doi.org/10.1186/1472-6947-13-111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3850158PMC
October 2013

Context sensitive health informatics: concepts, methods and tools.

Stud Health Technol Inform 2013 ;194:1-7

Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada.

Context is a key consideration when designing and evaluating health information technology (HIT) and cannot be overstated. Unintended consequences are common post HIT implementation and even well designed technology may not achieve desired outcomes because of contextual issues. While context should be considered in the design and evaluation of health information systems (HISs) there is a shortcoming of empirical research on contextual aspects of HIT. This conference integrates the sociotechnical and Human-Centered-Design (HCD) approaches and showcases current research on context sensitive health informatics. The papers and presentations outlines theories and models for studying contextual issues and insights on how we can better design HIT to accommodate different healthcare contexts.
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May 2014

Patient-centered care requires a patient-oriented workflow model.

J Am Med Inform Assoc 2013 Jun 28;20(e1):e14-6. Epub 2013 Mar 28.

Industrial Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts 01609, USA.

Effective design of health information technology (HIT) for patient-centered care requires consideration of workflow from the patient's perspective, termed 'patient-oriented workflow.' This approach organizes the building blocks of work around the patients who are moving through the care system. Patient-oriented workflow complements the more familiar clinician-oriented workflow approaches, and offers several advantages, including the ability to capture simultaneous, cooperative work, which is essential in care delivery. Patient-oriented workflow models can also provide an understanding of healthcare work taking place in various formal and informal health settings in an integrated manner. We present two cases demonstrating the potential value of patient-oriented workflow models. Significant theoretical, methodological, and practical challenges must be met to ensure adoption of patient-oriented workflow models. Patient-oriented workflow models define meaningful system boundaries and can lead to HIT implementations that are more consistent with cooperative work and its emergent features.
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http://dx.doi.org/10.1136/amiajnl-2013-001633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715352PMC
June 2013

The social act of electronic medication prescribing.

Authors:
Jos Aarts

Stud Health Technol Inform 2013 ;183:327-31

Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.

Prescribing medication is embedded in social norms and cultures. In modern Western health care professionals and policy makers have attempted to rationalize medicine by addressing cost-effectiveness of diagnostic and therapeutic treatments and the development of guidelines and protocols based on the outcomes of clinical studies. These notions of cost-effectiveness and evidence-based medicine have also been embedded in technology such as electronic prescribing systems. Such constraining systems may clash with the reality of clinical practice, where formal boundaries of responsibility and authorization are often blurred. Such systems may therefore even impede patient care. Medication is seen as the essence of medical practice. Prescribing is a social act. In a hospital medications may be aimed at treating a patient for a specific condition, in primary care the professional often meets the patient with her or his social and cultural notions of a health problem. The author argues that the design and implementation of electronic prescribing systems should address the social and cultural context of prescribing. Especially in primary care, where health problems are often ill defined and evidence-based medicine guidelines do not always work as intended, studies need to take into account the sociotechnical character of electronic prescribing systems.
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July 2013

A comparative review of patient safety initiatives for national health information technology.

Int J Med Inform 2013 May 21;82(5):e139-48. Epub 2012 Dec 21.

Centre for Health Informatics, Australian Institute of Health Innovation, The University of New South Wales, Sydney, Australia.

Objective: To collect and critically review patient safety initiatives for health information technology (HIT).

Method: Publicly promulgated set of advisories, recommendations, guidelines, or standards potentially addressing safe system design, build, implementation or use were identified by searching the websites of regional and national agencies and programmes in a non-exhaustive set of exemplar countries including England, Denmark, the Netherlands, the USA, Canada and Australia. Initiatives were categorised by type and software systems covered.

Results: We found 27 patient safety initiatives for HIT predominantly dealing with software systems for health professionals. Three initiatives addressed consumer systems. Seven of the initiatives specifically dealt with software for diagnosis and treatment, which are regulated as medical devices in England, Denmark and Canada. Four initiatives dealt with blood bank and image management software which is regulated in the USA. Of the 16 initiatives directed at unregulated software, 11 were aimed at increasing standardisation using guidelines and standards for safe system design, build, implementation and use. Three initiatives for unregulated software were aimed at certification in the USA, Canada and Australia. Safety is addressed alongside interoperability in the Australian certification programme but it is not explicitly addressed in the US and Canadian programmes, though conformance with specific functionality, interoperability, security and privacy requirements may lead to safer systems. England appears to have the most comprehensive safety management programme for unregulated software, incorporating safety assurance at a local healthcare organisation level based on standards for risk management and user interface design, with national incident monitoring and a response function.

Conclusions: There are significant gaps in the safety initiatives for HIT systems. Current initiatives are largely focussed on software. With the exception of diagnostic, prognostic, monitoring and treatment software, which are subject to medical device regulations in some countries, the safety of the most common types of HIT systems such as EHRs and CPOE without decision support is not being explicitly addressed in most nations. Appropriate mechanisms for safety assurance are required for the full range of HIT systems for health professionals and consumers including all software and hardware throughout the system lifecycle. In addition to greater standardisation and oversight to ensure safe system design and build, appropriate implementation and use of HIT is critical to ensure patient safety.
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http://dx.doi.org/10.1016/j.ijmedinf.2012.11.014DOI Listing
May 2013

The dangerous decade.

J Am Med Inform Assoc 2012 Jan-Feb;19(1):2-5. Epub 2011 Nov 24.

Centre for Health Informatics, University of New South Wales, Sydney, New South Wales, Australia.

Over the next 10 years, more information and communication technology (ICT) will be deployed in the health system than in its entire previous history. Systems will be larger in scope, more complex, and move from regional to national and supranational scale. Yet we are at roughly the same place the aviation industry was in the 1950s with respect to system safety. Even if ICT harm rates do not increase, increased ICT use will increase the absolute number of ICT related harms. Factors that could diminish ICT harm include adoption of common standards, technology maturity, better system development, testing, implementation and end user training. Factors that will increase harm rates include complexity and heterogeneity of systems and their interfaces, rapid implementation and poor training of users. Mitigating these harms will not be easy, as organizational inertia is likely to generate a hysteresis-like lag, where the paths to increase and decrease harm are not identical.
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http://dx.doi.org/10.1136/amiajnl-2011-000674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3240771PMC
March 2012

Reporting qualitative research in health informatics: REQ-HI recommendations.

Stud Health Technol Inform 2011 ;169:877-81

Department of Medical Informatics, Urmia University of Medical Science, Iran.

To develop a set of recommendations for authors of qualitative studies in the field of health informatics, we conducted an extensive literature search and also manually checked major journals in the field of biomedical informatics and qualitative research looking for papers, checklists, and guidelines pertaining to assessing and reporting of qualitative studies. We synthesized the found criteria to develop an initial set of reporting recommendations that are particularly relevant to qualitative studies of health information technology systems. This paper presents a preliminary version of these recommendations. We are planning to refine and revise this version using comments and suggestions of experts in evaluation of health informatics applications and publish a detailed set of recommendations.
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December 2011

What makes an information system more preferable for clinicians? a qualitative comparison of two systems.

Stud Health Technol Inform 2011 ;169:392-6

Department of Medical Informatics, Urmia University of Medical Science, Urmia, Iran.

Two different information systems with respect to their ability to afford clinicians' needs in the chemotherapy medication process were implemented in a large Dutch academic hospital. A commercially available Computerized Physician Order Entry (CPOE) system was not appreciated because clinicians believed that it could not support complex chemotherapy process. Later, a home-grown IT system with the capability of prescribing chemotherapy medications based on standard care protocols was appreciated and fully used by clinicians. We evaluated both systems from their users' perspective to find the sources of clinicians' preference and to trace them back to their Systems Development Life Cycle (SDLC).
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December 2011

The shift in workarounds upon implementation of computerized physician order entry.

Stud Health Technol Inform 2011 ;169:290-4

Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.

Workarounds are working processes deviating from formal rules or intended work methods to smooth workflow and circumvent problems without eliminating them. Former research focused on workarounds in the medication use process after implementation of computerized physician order entry (CPOE). This study on 2 wards of a general hospital shows that workarounds exist in both paper-based and electronic prescribing systems. After CPOE implementation workarounds present in the paper-based system had disappeared or remained existent, and new ones had emerged.
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December 2011

The future of electronic prescribing.

Authors:
Jos Aarts

Stud Health Technol Inform 2011 ;166:13-7

Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands.

Implementing electronic prescribing in health care has been a slow process. Health authorities are now requiring mandatory electronic prescribing because of patient safety concerns. Electronic prescribing is not yet a mature technology, and may therefore pose a risk if especially organizational conditions are not taken into account. The paper offers some thoughts on the future of electronic prescribing in practice. It is especially important to extend electronic prescribing to the continuum of care in order avoid that medication safety falls in the cracks of fragmented health care organizations.
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August 2011

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

Int J Med Inform 2011 Jul 8;80(7):490-506. Epub 2011 May 8.

Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.

Objective: To evaluate the problems experienced after implementing a computerized physician order entry (CPOE) system, their possible root causes, and the responses of providers in order to incorporate the system into daily workflow.

Methods: A qualitative study in the medication-use process after implementation of a CPOE system in an academic hospital in The Netherlands. Data included 21 interviews with clinical end-users, paper-based and system-generated documents used daily in the process, and educational materials used to train users.

Findings: The problems in the medication-use process included cognitive overload on physicians and nurses, unmet information needs, miscommunication of orders and ideas, problematic coordination of interrelated tasks between co-working professionals, a potentially faulty administration phase, and suboptimal monitoring of the medication plans. These problems were mainly rooted in the lack of mobile computer devices, the uneasy integration of coexisting electronic and paper-based systems, suboptimal usability of the system, and certain organizational factors with regard to procuring drugs affecting the technology use. Various types of workarounds were used to address the difficulties, including phone calls, taking multiple paper notes, issuing paper-based and verbal orders, double-checking, using other patients' procured drugs or another department's drug supply, and modifying and annotating the printed orders.

Conclusion: This study shows how providers are actively involved in working around the interruptions in workflow by bypassing the technology or adapting the work processes. Although certain workarounds help to maintain smooth workflow and/or to ensure patient safety, others may burden providers by necessitating extra time and effort and/or endangering patient safety. It is important that workarounds having a negative nature are recognized and discussed in order to find solutions to mitigate their effects.
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http://dx.doi.org/10.1016/j.ijmedinf.2011.03.009DOI Listing
July 2011

Does electronic clinical microbiology results reporting influence medical decision making: a pre- and post-interview study of medical specialists.

BMC Med Inform Decis Mak 2011 Mar 30;11:19. Epub 2011 Mar 30.

Laboratory of Clinical Microbiology and Infectious Diseases, Isala klinieken, Stilobadstraat 3, 8021 AB Zwolle, The Netherlands.

Background: Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant preliminary results at any moment during the diagnostic process, mostly by telephone. Telephone reporting is error prone, however. Electronic reporting of culture results instead of reporting on paper may shorten the turnaround time and may ensure correct communication of results. The purpose of this study was to assess the impact of the implementation of electronic reporting of final microbiology results on medical decision making.

Methods: In a pre- and post-interview study using a semi-structured design we asked medical specialists in our hospital about their use and appreciation of clinical microbiology results reporting before and after the implementation of an electronic reporting system.

Results: Electronic reporting was highly appreciated by all interviewed clinicians. Major advantages were reduction of hardcopy handling and the possibility to review results in relation to other patient data. Use and meaning of microbiology reports differ significantly between medical specialties. Most clinicians need preliminary results for therapy decisions quickly. Therefore, after the implementation of electronic reporting, telephone consultation between clinician and microbiologist remained the key means of communication.

Conclusions: Overall, electronic reporting increased the workflow efficiency of the medical specialists, but did not have an impact on their decision-making.
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http://dx.doi.org/10.1186/1472-6947-11-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073869PMC
March 2011

Clinical observational gait analysis to evaluate improvement of balance during gait with vibrotactile biofeedback.

Physiother Res Int 2012 Mar 5;17(1):4-11. Epub 2011 Jan 5.

Department of Biomedical Engineering, University Hospital Maastricht, Maastricht, the Netherlands.

Background And Purpose: This study explores the effect of vibrotactile biofeedback on gait in 20 patients with bilateral vestibular areflexia using observational gait analysis to score individual balance.

Methods: A tilt sensor mounted on the head or trunk is used to detect head or body tilt and activates, via a microprocessor, 12 equally distributed vibrators placed around the waist. Two positions of the tilt sensor were evaluated besides no biofeedback in three different gait velocity tasks (slow/fast tandem gait, normal gait on foam) resulting in nine different randomized conditions. Biofeedback activated versus inactivated was compared. Twenty patients (10 males, 10 females, age 39-77 years) with a bilateral vestibular areflexia or severe bilateral vestibular hyporeflexia, severe balance problems and frequent falls participated in this study.

Results: Significant improvements in balance during gait were shown in our patients using biofeedback and sensor on the trunk. Only two patients showed a significant individual gait improvement with the biofeedback system, but in the majority of our patients, it increased confidence and a feeling of balance.

Conclusion: This study indicates the feasibility of vibrotactile biofeedback for vestibular rehabilitation and to improve balance during gait.
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http://dx.doi.org/10.1002/pri.504DOI Listing
March 2012

From safe systems to patient safety.

Stud Health Technol Inform 2010 ;157:1-3

Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands.

In this introduction we summarize the contributions to the Fourth International Conference Information Technology in Health Care: Socio-technical Approaches. We argue that putting to use information systems in health care is a difficult and winding road. Systems may even compromise instead of improving patient safety. Designing and implementing systems requires a thorough understanding of the context in which technology is being used. But this understanding should also lead to better design and implementation methods. Therefore this conference wishes to address the challenges of safe systems and patient safety, ten years after the publication of the landmark reports on human error and quality of health care by the Institute of Medicine.
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September 2010

Understanding handling of drug safety alerts: a simulation study.

Int J Med Inform 2010 May 19;79(5):361-9. Epub 2010 Feb 19.

Department of Hospital Pharmacy, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands.

Purpose: To study correctness of drug safety alert handling and error type in a computerized physician order entry (CPOE) system in a simulated work environment.

Methods: Disguised observation study of 18 physicians (12 from internal medicine and 6 from surgery) entering 35 orders of predefined patient cases with 13 different drug safety alerts in a CPOE. Structured interviews about how the generated drug safety alerts were handled in the simulation test and resemblance of the test to the normal work environment. Handling and reasons for this were scored for correctness and error type.

Results: Thirty percent of alerts were handled incorrectly, because the action itself and/or the reason for the handling were incorrect. Sixty-three percent of the errors were categorized as rule based and residents in surgery used incorrect justifications twice as often as residents in internal medicine. They often referred to monitoring of incorrect substances or parameters. One alert presented as a second alert in one screen was unconsciously overridden several times. One quarter of residents showed signs of alert fatigue.

Conclusion: Although alerts were mainly handled correctly, underlying rules and reasoning were often incorrect, thereby threatening patient safety. This study gave an insight into the factors playing a role in incorrect drug safety alert handling that should be studied in more detail. The results suggest that better training, improved concise alert texts, and increased specificity might help. Furthermore, the safety of the predefined override reason 'will monitor' and double alert presentation in one screen is questioned.
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http://dx.doi.org/10.1016/j.ijmedinf.2010.01.008DOI Listing
May 2010

Functionality test for drug safety alerting in computerized physician order entry systems.

Int J Med Inform 2010 Apr 9;79(4):243-51. Epub 2010 Feb 9.

Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands.

Purpose: To evaluate the functionality of drug safety alerting in hospital computerized physician order entry (CPOE) systems by a newly developed comprehensive test.

Methods: Comparative evaluation of drug safety alerting quality in 6 different CPOEs used in Dutch hospitals, by means of 29 test items for sensitivity and 19 for specificity in offices of CPOE system vendors. Sensitivity and specificity were calculated for the complete test, and for the categories "within-order checks", "patient-specific checks", and "checks related to laboratory data and new patient conditions". Qualitative interviews with 16 hospital pharmacists evaluating missing functionality and corresponding pharmacy checks.

Results: Sensitivity ranged from 0.38 to 0.79 and specificity from 0.11 to 0.84. The systems achieved the same ranking for sensitivity as for specificity. Within-order checks and patient-specific checks were present in all systems; alert generation or suppression due to laboratory data and new patient conditions was largely absent. Hospital pharmacists unanimously rated checks on contra-indications (absent in 2 CPOEs) and dose regimens less than once a day (absent in 4 CPOEs) as important. Pharmacists' opinions were more divergent for other test items. A variety of pharmacy checks were used, and clinical rules developed, to address missing functionality.

Conclusions: Our test revealed widely varying functionality and appeared to be highly discriminative. Basic clinical decision support was partly absent in two CPOEs. Hospital pharmacists did not rate all test items as important and tried to accommodate the lacking functionality by performing additional checks and developing clinical rules.
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http://dx.doi.org/10.1016/j.ijmedinf.2010.01.005DOI Listing
April 2010

CPOE in Non-Surgical Versus Surgical Specialties: A Qualitative Comparison of Clinical Contexts in the Medication Process.

Open Med Inform J 2010 Sep 15;4:206-13. Epub 2010 Sep 15.

Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.

Background: Computerized provider order entry (CPOE) systems are implemented in various clinical contexts of a hospital. To identify the role of the clinical context in CPOE use, we compared the impact of a CPOE system on the medication process in both non-surgical and surgical specialties.

Methods: We conducted a qualitative study of surgical and non-surgical specialties in a 1237-bed, academic hospital in the Netherlands. We interviewed the clinical end users of a computerized medication order entry system in both specialty types and analyzed the interview transcripts to elicit qualitative differences between the clinical contexts, clinicians' attitudes, and specialty-specific requirements.

Results: Our study showed that the differences in clinical contexts between non-surgical and surgical specialties resulted in a disparity between clinicians' requirements when using CPOE. Non-surgical specialties had a greater medication workload, greater and more diverse information needs to be supported in a timely manner by the system, and thus more intensive interaction with the CPOE system. In turn these factors collectively influenced the perceived impact of the CPOE system on the clinicians' practice. The non-surgical clinicians expressed less positive attitudes compared to the surgical clinicians, who perceived their interaction with the system to be less intensive and less problematic.

Conclusion: Our study shows that clinicians' different attitudes towards the system and the perceived impact of the system were largely grounded in the clinical context of the units. The study suggests that not merely the CPOE system, the technology itself, influences the perceptions of its users and workflow-related outcomes. The interplay between technology and clinical context of the implementation environment also matters. System design and redesigning efforts should take account of different units' specific requirements in their particular clinical contexts.
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http://dx.doi.org/10.2174/1874431101004010206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096890PMC
September 2010

Salient and placebo vibrotactile feedback are equally effective in reducing sway in bilateral vestibular loss patients.

Gait Posture 2010 Feb 18;31(2):213-7. Epub 2009 Nov 18.

Department of Biomedical Engineering, University Hospital Maastricht, The Netherlands.

This study explores the effect of vibrotactile biofeedback on body sway in stance in patients with severe bilateral vestibular losses in a placebo-controlled study. A tilt sensor mounted on the head or trunk is used to detect head or body tilt and activates via a microprocessor 12 small vibrators that are placed around the waist with a mutual distance of 30 degrees. Two positions of the tilt sensor (head and trunk) and three types of biofeedback (normal, full and random) were evaluated, besides no biofeedback. Body sway during stance was assessed in 10 patients with bilateral vestibular areflexia and performance was scored in the seven different conditions. Inter-individual and test-retest variability without biofeedback was assessed in 10 additional patients with bilateral vestibular areflexia. In six patients no significant change in body swaypath was observed using biofeedback. In four patients body swaypath decreased significantly using biofeedback and sensor on the head in all three activation modes, whereas with sensor on the trunk only one patient showed a significant improvement in swaypath in all three activation modes. The patients rated the functionality of the AVBF system and its effect on balance on average 6.5 on a scale from 0 to 10. Thus, body sway improved in 4 out of 10 patients using biofeedback, but the improvement with true biofeedback was only observed in those subjects where an improvement was present in placebo mode as well. The improvement was, at least partially, caused by other effects than biofeedback, like training, increased self-confidence or alertness.
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http://dx.doi.org/10.1016/j.gaitpost.2009.10.008DOI Listing
February 2010

CPOE, alerts and workflow: taking stock of ten years research at Erasmus MC.

Stud Health Technol Inform 2009 ;148:165-9

Institute of Health Policy and Management, Erasmus MC, Rotterdam, The Netherlands.

Ten years ago research of the impact of health information technology (HIT) on medical work practices started at Erasmus MC. The research is characterized by practice driven field research. From the beginning computerized physician order entry systems (CPOE) were a major topic. Research questions were how implementation of CPOE could be understood, how physicians were responding to reminders and alerts and how CPOE impacted professional workflow and collaboration. Studies of CPOE implementation aimed to understand why the adoption rate is so low and riddled with difficulties. Studies of reminders and alerts addressed the problem of alert fatigue. Finally, studies of workflow explored how CPOE influenced clinical workflow and how simplistic and linear models underlying CPOE may lead to poor designed systems and even compromise patient safety. Findings include the need for a shared understanding of medical challenges when implementing CPOE, conceptual models to understand alert fatigue and medical workflow and the impossibility of agreeing which alerts to suppress hospital-wide. The underlying research principle is the sociotechnical approach, which stipulates that technology, people and organizations should be studied from a single theoretical framework. This paper summarizes the results of ten years of research.
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January 2010
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