Abstract
Importance
Expectations of electronic prescribing systems to improve medication safety are generally high but their success -at least partly- depends on appropriate use by its end-users. This thesis focuses on the outpatient setting, because electronic prescribing in the outpatient setting is challenging. Physicians need the skills to correctly register medications in the system, need medication management skills such as the ability to obtain a complete medication history, and need to be aware of new errors. Current training approaches for electronic prescribing are no longer considered sufficient to increase medication safety.
Aim
The aim of this thesis was to improve the training of physicians in electronic prescribing by gaining a thorough understanding of electronic prescribing behavior and the knowledge and skills needed for electronic prescribing, designing a training based on this thorough understanding and based on theory-informed didactical methods, and testing the hypothesis that increasing the effectiveness of training improves medication safety in the outpatient setting of academic hospitals.
Methods
The following study designs were used: systematic literature review, interviews and study of literature and behavioral theories, task-analysis, and a cluster randomized clinical trial. Participants: physicians of internal medicine and related (sub) specialties. Setting: outpatient clinic.
Results
The systematic review of the literature demonstrated that little evidence exists on the optimal strategy to train physicians for the use of electronic health records (EHRs). The available evidence in the literature only suggests a combination of classroom training, computer-based training and feedback. Our theoretical framework describes three main factors influencing physicians’ behavior regarding electronic prescribing: physician’s intention, environment, and knowledge and skills regarding electronic prescribing. The task-analysis elucidated the knowledge and skills needed for electronic prescribing, consisting of both procedural and cognitive skills and knowledge. Using the four components instructional design (4C/ID) model these knowledge and skills were translated into training. The designed training included a small group session and e-Learning.
In a cluster randomized clinical trial, training effectiveness was evaluated. Medication data were collected of 1094 patients treated by 115 physicians in the outpatient settings of two academic hospitals. This revealed a considerable degree of medication discrepancies: a mean of 48% of the registered medications per physician were discrepant with the medications their patients reported, posing a serious risk for patient safety in about 5% of the patients per physician. These percentages did not differ between study groups. The designed training proved effective on the level of participants’ reaction and learning: the training was reasonably appreciated, and physicians in the intervention group had higher test scores compared to the control group.
Conclusion
Interventions aiming to improve electronic prescribing and medication safety are probably most effective when these target both educational and environmental factors. Especially with the proliferation of electronic prescribing systems in a context of increasing complexity of (outpatient) care and an aging population, it is paramount that physicians master appropriate knowledge and skills for electronic prescribing. This thesis shows how the acquisition of knowledge and skills can be achieved by task-analysis based training.
Expectations of electronic prescribing systems to improve medication safety are generally high but their success -at least partly- depends on appropriate use by its end-users. This thesis focuses on the outpatient setting, because electronic prescribing in the outpatient setting is challenging. Physicians need the skills to correctly register medications in the system, need medication management skills such as the ability to obtain a complete medication history, and need to be aware of new errors. Current training approaches for electronic prescribing are no longer considered sufficient to increase medication safety.
Aim
The aim of this thesis was to improve the training of physicians in electronic prescribing by gaining a thorough understanding of electronic prescribing behavior and the knowledge and skills needed for electronic prescribing, designing a training based on this thorough understanding and based on theory-informed didactical methods, and testing the hypothesis that increasing the effectiveness of training improves medication safety in the outpatient setting of academic hospitals.
Methods
The following study designs were used: systematic literature review, interviews and study of literature and behavioral theories, task-analysis, and a cluster randomized clinical trial. Participants: physicians of internal medicine and related (sub) specialties. Setting: outpatient clinic.
Results
The systematic review of the literature demonstrated that little evidence exists on the optimal strategy to train physicians for the use of electronic health records (EHRs). The available evidence in the literature only suggests a combination of classroom training, computer-based training and feedback. Our theoretical framework describes three main factors influencing physicians’ behavior regarding electronic prescribing: physician’s intention, environment, and knowledge and skills regarding electronic prescribing. The task-analysis elucidated the knowledge and skills needed for electronic prescribing, consisting of both procedural and cognitive skills and knowledge. Using the four components instructional design (4C/ID) model these knowledge and skills were translated into training. The designed training included a small group session and e-Learning.
In a cluster randomized clinical trial, training effectiveness was evaluated. Medication data were collected of 1094 patients treated by 115 physicians in the outpatient settings of two academic hospitals. This revealed a considerable degree of medication discrepancies: a mean of 48% of the registered medications per physician were discrepant with the medications their patients reported, posing a serious risk for patient safety in about 5% of the patients per physician. These percentages did not differ between study groups. The designed training proved effective on the level of participants’ reaction and learning: the training was reasonably appreciated, and physicians in the intervention group had higher test scores compared to the control group.
Conclusion
Interventions aiming to improve electronic prescribing and medication safety are probably most effective when these target both educational and environmental factors. Especially with the proliferation of electronic prescribing systems in a context of increasing complexity of (outpatient) care and an aging population, it is paramount that physicians master appropriate knowledge and skills for electronic prescribing. This thesis shows how the acquisition of knowledge and skills can be achieved by task-analysis based training.
| Original language | English |
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| Award date | 22 Dec 2016 |
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| Print ISBNs | 978-94-028-0453-9 |
| Publication status | Published - 22 Dec 2016 |
Keywords
- electronic prescribing
- medication safety
- outpatient
- task-analysis
- training
- e-Learning
- empowerment