Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use

Application of the Failure Mode and Effects Analysis (FMEA) to identify vulnerabilities and opportunities for improvement prior to implementing a computerized prescription order entry (CPOE) system in a university hospital oncology clinic

INTRODUCTION

Prior to implementing a new computerized prescription order entry (CPOE) application, the potential risks associated with this system were assessed and compared to those of paper-based prescriptions. The goal of this study is to identify the vulnerabilities of the CPOE process in order to adapt its design and prevent these potential risks.

METHODS AND MATERIALS

Failure mode and effects analysis (FMEA) was used as a prospective risk-management technique to evaluate the chemotherapy medication process in a university hospital oncology clinic. A multidisciplinary team assessed the process and compared the critical steps of a newly developed CPOE application versus paper-based prescriptions. The potential severity, occurrence and detectability were assessed prior to the implementation of the CPOE application in the clinical setting.

RESULTS

The FMEA led to the identification of 24 process steps that could theoretically be vulnerable, therefore called failure modes. These failure modes were grouped into four categories of potential risk factors: prescription writing, patient scheduling, treatment dispensing and patient follow-up. Criticality scores were calculated and compared for both strategies. Three failure modes were prioritized and led to modification of the CPOE design. Overall, the CPOE pathway showed a potential risk reduction of 51% compared to paper-based prescriptions.

CONCLUSION

FMEA was found to be a useful approach to identify potential risks in the chemotherapy medication process using either CPOE or paper-based prescriptions. The e-prescription mode was estimated to result in less risk than the traditional paper mode.

Usage and Usability of a National e-Library for Chemotherapy Regimens: Mixed Methods Study

Background

Accurate information about chemotherapy drugs and regimens is needed to reduce chemotherapy errors. A national e-library, as a common knowledge source with standardized chemotherapy nomenclature and content, was developed. Since the information in the library is both complex and extensive, it is central that the users can use the resource as intended.

Objective

The aim of this study was to evaluate the usage and usability of an extensive e-library for chemotherapy regimens developed to reduce medication errors, support the health care staff in their work, and increase patient safety.

Methods

To obtain a comprehensive evaluation, a mixed methods study was performed for a broad view of the usage, including a compilation of subjective views of the users (web survey, spontaneous user feedback, and qualitative interviews), analysis of statistics from the website, and an expert evaluation of the usability of the webpage.

Results

Statistics from the website show an average of just over 2500 visits and 870 unique visitors per month. Most visits took place Mondays to Fridays, but there were 5-10 visits per day on weekends. The web survey, with 292 answers, shows that the visitors were mainly physicians and nurses. Almost 80% (224/292) of respondents searched for regimens and 90% (264/292) found what they were looking for and were satisfied with their visit. The expert evaluation shows that the e-library follows many existing design principles, thus providing some useful improvement suggestions. A total of 86 emails were received in 2020 with user feedback, most of which were from nurses. The main part (78%, 67/86) contained a question, and the rest had discovered errors mainly in some regimen. The interviews reveal that most hospitals use a computerized physician order entry system, and they use the e-library in various ways, import XML files, transfer information, or use it as a reference. One hospital without a system uses the administration schedules from the library.

Conclusions

The user evaluation indicates that the e-library is used in the intended manner and that the users can interact without problems. Users have different needs depending on their profession and their workplace, and these can be supported. The combination of methods applied ensures that the design and content comply with the users’ needs and serves as feedback for continuous design and learning. With a broad national usage, the e-library can become a source for organizational and national learning and a source for continuous improvement of cancer care in Sweden.

Exploring the Intersection Between Health Professionals' Learning and eHealth Data: Protocol for a Comprehensive Research Program in Practice Analytics in Health Care

Background

There is an increasing amount of electronic data sitting within the health system. These data have untapped potential to improve clinical practice if extracted efficiently and harnessed to change the behavior of health professionals. Furthermore, there is an increasing expectation from the government and peak bodies that both individual health professionals and health care organizations will use electronic data for a range of applications, including improving health service delivery and informing clinical practice and professional accreditation.

Objective

The aim of this research program is to make eHealth data captured within tertiary health care organizations more actionable to health professionals for use in practice reflection, professional development, and other quality improvement activities.

Methods

A multidisciplinary approach was used to connect academic experts from core disciplines of health and medicine, education and learning sciences, and engineering and information communication technology with government and health service partners to identify key problems preventing the health care industry from using electronic data to support health professional learning. This multidisciplinary approach was used to design a large-scale research program to solve the problem of making eHealth data more accessible to health professionals for practice reflection. The program will be delivered over 5 years by doctoral candidates undertaking research projects with discrete aims that run in parallel to achieving this program’s objectives.

Results

The process used to develop the research program identified 7 doctoral research projects to answer the program objectives, split across 3 streams.

Conclusions

This research program has the potential to successfully unpack electronic data siloed within clinical sites and enable health professionals to use them to reflect on their practice and deliver informed and improved care. The program will contribute to current practices by fostering stronger connections between industry and academia, interlinking doctoral research projects to solve complex problems, and creating new knowledge for clinical sites on how data can be used to understand and improve performance. Furthermore, the program aims to affect policy by developing insights on how professional development programs may be strengthened to enhance their alignment with clinical practice. The key contributions of this paper include the introduction of a new conceptualized research program, Practice Analytics in Health care, by describing the foundational academic disciplines that the program is formed of and presenting scientific methods for its design and development.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27984

What Oncologists Want: Identifying Challenges and Preferences on Diagnosis Data Entry to Reduce EHR-Induced Burden and Improve Clinical Data Quality

PURPOSE

Accurate recording of diagnosis (DX) data in electronic health records (EHRs) is important for clinical practice and learning health care. Previous studies show statistically stable patterns of data entry in EHRs that contribute to inaccurate DX, likely because of a lack of data entry support. We conducted qualitative research to characterize the preferences of oncological care providers on cancer DX data entry in EHRs during clinical practice.

METHODS

We conducted semistructured interviews and focus groups to uncover common themes on DX data entry preferences and barriers to accurate DX recording. Then, we developed a survey questionnaire sent to a cohort of oncologists to verify the generalizability of our initial findings. We constrained our participants to a single specialty and institution to ensure similar clinical backgrounds and clinical experience with a single EHR system.

RESULTS

A total of 12 neuro-oncologists and thoracic oncologists were involved in the interviews and focus groups. The survey developed from these two initial thrusts was distributed to 19 participants yielding a 94.7% survey response rate. Clinicians reported similar user interface experiences, barriers, and dissatisfaction with current DX entry systems including repetitive entry operations, difficulty in finding specific DX options, time-consuming interactions, and the need for workarounds to maintain efficiency. The survey revealed inefficient DX search interfaces and challenging entry processes as core barriers.

CONCLUSION

Oncologists seem to be divided between specific DX data entry and time efficiency because of current interfaces and feel hindered by the burdensome and repetitive nature of EHR data entry. Oncologists' top concern for adopting data entry support interventions is ensuring that it provides significant time-saving benefits and increasing workflow efficiency. Future interventions should account for time efficiency, beyond ensuring data entry effectiveness.

Progress in the study of D-α-tocopherol polyethylene glycol 1000 succinate (TPGS) reversing multidrug resistance

Currently, multidrug resistance (MDR) is one of the major reasons for failure in clinical cancer chemotherapy. Overexpression of the ATP binding cassette (ABC) transporter P-glycoprotein (P-gp), which significantly increases the efflux of anticancer drugs from tumor cells, enhances MDR. In the past few decades, four generations of P-gp inhibitors have appeared. However, they are limited in clinical application due to their severe toxic side effects. As a P-gp inhibitor and carrier for loading chemotherapy agents, TPGS has received increasing attention due to its advantages and unique properties of reversing MDR. TPGS is an amphipathic agent that increases the solubility of most chemotherapy drugs and decreases severe side effects. In addition, TPGS is an excellent carrier with P-gp-inhibiting ability. In this review, we summarize the latest articles on TPGS-based nanodelivery systems to prevent MDR.

Categorization of Medication Safety Errors in Ambulatory Electronic Health Records

Preventable medication errors continue to affect the quality and consistency in the delivery of care. While numerous studies on medication safety have been performed in the inpatient setting, a review of ambulatory patient safety by the American Medical Association found that medication safety errors were the most frequent safety problems in the outpatient arena. The leading cause of ambulatory safety problems, adverse drug events (ADEs), are common, with estimates of more than 2 million ADEs each year in the ambulatory Medicare population alone, and these events are frequently preventable. We conducted an environmental scan that allowed us to create our own categorization schema of medication safety errors in electronic healthcare records (EHRs) found in the outpatient setting and observed which of these were additionally supported in the literature. This study combines data from the California Hospital Patient Safety Organization (CHPSO), with several key articles in the area of medication errors in the EHR era. Method: To best utilize the various EHR ambulatory medication events submitted into CHPSO’s database, we chose to create a framework to bucket the near misses or adverse events (AEs) submitted to the database. This newly created categorization scheme was based on our own drafted categorization labels of events, after a high-level review, and from two leading articles on physician order entry. Additionally, we conducted a literature review of computerized provider order entry (CPOE) medication errors in the ambulatory setting. Within the newly created categorization scheme, we organized the articles based on issues addressed so we could see areas that were supported by the literature and what still needed to be researched. Results: We initially screened the CHPSO database for ambulatory safety events and found 25,417 events. Based on those events, an initial review was completed, and 19,242 events were found in the “Medication or Other Substance” and “Other” categories, in which the EHR appeared to have been a potential contributing factor. This review identified a subset of 2,236 events that were then reviewed. One hundred events were randomly selected for further review to identify common categories. The most common categories in which errors occurred were orders in order sets and plans (n=12) and orders crossing or not crossing encounters (n=12), incorrect order placed on correct patient (n=10), orders missing (n=8), standing orders (n=8), manual data entry errors (n=6), and future orders (n=6). Conclusion: There were several common themes seen in this analysis of ambulatory medication safety errors related to the EHR. Common among them were incorrect orders consisting of examples such as dose errors or ordering the wrong medication. The manual data entry errors consisted of height or weight being entered incorrectly or entering the wrong diagnostic codes. Lastly, different sources of medication safety information demonstrate a diversity of errors in ambulatory medication safety. This confirms the importance of considering more than one source when attempting to comprehensively describe ambulatory medication safety errors.

Evolving Best Practice for Take-Home Cancer Drugs

PURPOSE

Take-home cancer drugs (THCDs) have become a standard treatment of many cancers. Robust guidelines have been developed for intravenous chemotherapy drugs, but few exist for THCDs with a focus on decentralized models. Hence, Ontario Health (Cancer Care Ontario) established the Oncology Pharmacy Task Force (OPTF) to develop consensus-based recommendations on best practices for THCDs to ensure that patients receive safe, consistent, high-quality care in the community once they leave the cancer center/practice with a prescription.

METHODS

The OPTF included 34 members with comprehensive representation. Guidance from leading authorities was extracted through literature review, thematically analyzed, and synthesized to develop 29 recommendations. The consensus process (> 70% agreement) included a three-step modified Delphi method followed by an extensive review process.

RESULTS

Sixteen recommendations were developed: training and education for providers (2), drug access (1), prescribing (4), patient and family/caregiver education (3), communication (1), dispensing (3), monitoring for patient adherence and adverse effects (1), and incident reporting (1).

CONCLUSION

Through a rigorous methodology, the OPTF derived a robust set of recommendations similar to the ASCO/Oncology Nursing Society and ASCO/National Community Oncology Dispensing Association guidelines, further validating and strengthening the applicability across multiple jurisdictions, including those with decentralized models. Unique aspects in a decentralized model include the need for two pharmacy professionals, with one doing cognitive verification of the script and the other dispensing the medication; moreover, they optimize interprofessional communication between community providers and the cancer center/practice health care team.

Implementation of Computerized Physician Order Entry for Chemotherapy: A Latin American Experience

PURPOSE

We describe the implementation process of a computerized physician order entry (CPOE) for outpatient chemotherapy at a Latin American hospital, with the intent of providing other institutions with general guidance and insight through our experience.

METHODS

In 2012, under the direction of the Department of Medicine of the Instituto Nacional de Enfermedades Neoplásicas, a multidisciplinary team composed of oncologists, nurses, pharmacists, and informatics engineers was formed to develop software for a CPOE for chemotherapy within a preexistent homegrown electronic medical record system in various phases. This included mapping and redesigning processes in an entirely electronic format, integrating the needs of the user for the development of electronic order sets, developing a checkpoint and a warning system to minimize prescription errors, and finally, training all the staff in implementation of the system.

RESULTS

A CPOE for outpatient chemotherapy was successfully implemented in 2016. We have successfully standardized 266 chemotherapy orders, including for both solid tumors and hematologic malignancies, on the basis of appropriate guidelines. The software is linked to laboratory results and allows entry of important details for the patient's safety, such as anthropometric information for an automatic dose calculation and ranges for safe prescription. In addition, it is linked to the nursing plan sheets. Finally, it is possible to assess and continuously monitor the complex process of chemotherapy prescription.

CONCLUSION

This is the first report of implementation of a CPOE for chemotherapy in our region. The system was designed by a multidisciplinary team with its own resources. Our experience demonstrates the feasibility of computerizing the chemotherapy prescription process, constituting a tangible example for other institutions with potential impact on patient care.

A virtual centralized cytotoxic preparation unit simulation to evaluate the pharmacy staff knowledge

BACKGROUND

The risk of medication errors related to drug preparation unit cannot be totally avoided because of human interference. The aim of this study is to investigate the background and knowledge of the pharmacy staff by replicating the cytotoxic preparation unit with potential errors.

METHODS

A 10-m² room was provided to duplicate the centralized chemotherapy unit with three areas reproducing virtually the equipment preparation bench, the isolator, and the dispensing bench. The 14 situations selected by experts were integrated to each corresponded area. For each participant, a form was given and answers were analyzed by two independent experts. Statistical processing data were performed using GraphPad Prism® software.

RESULTS

A total of 19 professionals participated in error simulation workshop over a one-month period. The overall rate of correct responses was 58 ± 19%. In five situations, correct responses rate was lower than 50%: wrong drug batch related to the preparation sheet (40%), inappropriate sterilizing conditions (15%), the time on the preparation sheet provides an expired expiry date for melphalan preparation (45%), a maximum drug dose exceeded (25%), the dispensing form not corresponds to the preparation sheet and final product label (30%). The rate of correct responses was 45 ± 25% for professionals not specifically dedicated to chemotherapy preparation. The overall satisfaction workshop rate was 8.7 ± 1.0 out of 10.

CONCLUSION

This study showed the importance of training programs to sensitize personal staff to the risks of chemotherapy preparation and prevent errors.

Improving the Safety and Quality of Systemic Treatment Regimens in Computerized Prescriber Order Entry Systems

PURPOSE

Systemic treatment (ST) computerized prescriber order entry (CPOE) and preprinted orders (PPO) are proven to reduce errors. There is no known guidance in oncology to facilitate high-quality, accurate regimen development and review; hence, this was identified as a system-wide gap. This provincial initiative aimed to improve the quality of oncology regimens through a comprehensive review of systemic treatment (ST) regimens and the development of standards.

METHODS

A system-wide analysis of all active regimens (both CPOE and PPO) to ensure they were built as intended was conducted in 2015. Thirty-five hospitals (on behalf of 75 treatment facilities) were asked to report any unintentional discrepancies and details of the maintenance review process. Discrepancies were compiled, categorized, and analyzed for potential to cause harm. In addition, a multidisciplinary expert working group was formed to create best practice recommendations.

RESULTS

The review yielded a 94% response rate and took a total of 18 months to complete (70% completed within 9 months). The average number of regimens reviewed was 336 (range, 15 to 700; n = 9). Unintentional discrepancies were reported by nine hospitals (27%). A total of 369 discrepancies were reported (average, 55 per hospital), and 28 were deemed to have a moderate potential for harm. Only two hospitals (6%) had an established maintenance process; now, all have standard processes for review. Consensus-based recommendations for ST-CPOE and PPO regimen development and maintenance were developed.

CONCLUSION

The review identified unintentional discrepancies and, because of the potential for patient harm, corrective action has been taken. Identified discrepancies have been amended, and standard regimen development and maintenance review processes are now implemented system-wide to improve the quality and safety of systemic treatment delivery.

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

This study aimed to identify the functional requirements of computerized provider order entry software and design this software in Iran. This study was conducted using review documentation, interview, and focus group discussions in Shiraz University of Medical Sciences, as the medical pole in Iran, in 2013-2015. The study sample consisted of physicians (n = 12) and nurses (n = 2) in the largest hospital in the southern part of Iran and information technology experts (n = 5) in Shiraz University of Medical Sciences. Functional requirements of the computerized provider order entry system were examined in three phases. Finally, the functional requirements were distributed in four levels, and accordingly, the computerized provider order entry software was designed. The software had seven main dimensions: (1) data entry, (2) drug interaction management system, (3) warning system, (4) treatment services, (5) ability to write in software, (6) reporting from all sections of the software, and (7) technical capabilities of the software. The nurses and physicians emphasized quick access to the computerized provider order entry software, order prescription section, and applicability of the software. The software had some items that had not been mentioned in other studies. Ultimately, the software was designed by a company specializing in hospital information systems in Iran. This study was the first specific investigation of computerized provider order entry software design in Iran. Based on the results, it is suggested that this software be implemented in hospitals.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics

BACKGROUND

One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers' confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications.

OBJECTIVE

This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting.

METHODS

A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period.

RESULTS

We found that a small but not dismissible percentage of orders issued by hospitalists-up to 4.18 percent (95 percent confidence interval, 3.84-4.56 percent) per month-were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed.

CONCLUSION

Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution.

Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study

BACKGROUND

Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care.

METHODS

We used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014.

RESULTS

The top three problems were incomplete reconciliation of medication during patient 'hand-overs', inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities. The highest ranked suggestions received the strongest agreement among the clinicians, i.e. the highest AEA score.

CONCLUSIONS

Clinicians identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions. PRIORITIZE is a new, convenient, systematic, and replicable method, and merits further exploration with a view to becoming a part of a routine preventative patient safety monitoring mechanism.

A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre-post implementation

The purpose was to study users' attitudes towards an electronic medical record (EMR) closely integrated into the clinicians' cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real-time support to the coordination of shared care processes involving all the care personnel. Mixed method pre-post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users' attitudes towards the EMR (response rate of 71%) measured after the go-live were positive ranging from 3.42 to 3.95 on a 5-point scale. Besides, the content analysis of 33 pre-post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users' expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey

BACKGROUND

Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience.

MATERIALS AND METHODS

This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data.

RESULTS

Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%).

CONCLUSIONS

Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Chemotherapy e-prescribing: opportunities and challenges

Chemotherapy drugs are characterized by low therapeutic indices and significant toxicities at clinically prescribed doses, raising serious issues of drug safety. The safety of the chemotherapy medication use process is further challenged by regimen complexity and need to tailor treatment to patient status. Errors that occur during chemotherapy prescribing are associated with serious and life-threatening outcomes. Computerized provider order entry (CPOE) systems were shown to reduce overall medication errors in ambulatory and inpatient settings. The adoption of chemotherapy CPOE is lagging due to financial cost and cultural and technological challenges. Institutions that adopted infusional or oral chemotherapy electronic prescribing modified existing CPOE systems to allow chemotherapy prescribing, implemented chemotherapy-specific CPOE systems, or developed home-grown chemotherapy electronic prescribing programs. Implementation of chemotherapy electronic prescribing was associated with a significant reduction in the risk of prescribing errors, most significantly dose calculation and adjustment errors. In certain cases, implementation of chemotherapy CPOE was shown to improve the chemotherapy use process. The implementation of chemotherapy CPOE may increase the risk of new types of errors, especially if processes are not redesigned and adapted to CPOE. Organizations aiming to implement chemotherapy CPOE should pursue a multidisciplinary approach engaging all stakeholders to guide system selection and implementation. Following implementation, organizations should develop and use a risk assessment process to identify and evaluate unanticipated consequences and CPOE-generated errors. The results of these analyses should serve to further enhance the chemotherapy electronic prescribing process and improve the quality and safety of cancer care.

Integrating mHealth in Oncology: Experience in the Province of Trento

BACKGROUND

The potential benefits of the introduction of electronic and mobile health (mHealth) information technologies, to support the safe delivery of intravenous chemotherapy or oral anticancer therapies, could be exponential in the context of a highly integrated computerized system.

OBJECTIVE

Here we describe a safe therapy mobile (STM) system for the safe delivery of intravenous chemotherapy, and a home monitoring system for monitoring and managing toxicity and improving adherence in patients receiving oral anticancer therapies at home.

METHODS

The STM system is fully integrated with the electronic oncological patient record. After the prescription of chemotherapy, specific barcodes are automatically associated with the patient and each drug, and a bedside barcode reader checks the patient, nurse, infusion bag, and drug sequence in order to trace the entire administration process, which is then entered in the patient's record. The usability and acceptability of the system was investigated by means of a modified questionnaire administered to nurses. The home monitoring system consists of a mobile phone or tablet diary app, which allows patients to record their state of health, the medications taken, their side effects, and a Web dashboard that allows health professionals to check the patient data and monitor toxicity and treatment adherence. A built-in rule-based alarm module notifies health care professionals of critical conditions. Initially developed for chronic patients, the system has been subsequently customized in order to monitor home treatments with capecitabine or sunitinib in cancer patients (Onco-TreC).

RESULTS

The STM system never failed to match the patient/nurse/drug sequence association correctly, and proved to be accurate and reliable in tracing and recording the entire administration process. The questionnaires revealed that the users were generally satisfied and had a positive perception of the system's usefulness and ease of use, and the quality of their working lives. The pilot studies with the home monitoring system with 43 chronic patients have shown that the approach is reliable and useful for clinicians and patients, but it is also necessary to pay attention to the expectations that mHealth solutions may raise in users. The Onco-TreC version has been successfully laboratory tested, and is now ready for validation.

CONCLUSIONS

The STM and Onco-TreC systems are fully integrated with our complex and composite information system, which guarantees privacy, security, interoperability, and real-time communications between patients and health professionals. They need to be validated in order to confirm their positive contribution to the safer administration of anticancer drugs.

Health information technology in oncology practice: a literature review

The adoption and implementation of information technology are dramatically remodeling healthcare services all over the world, resulting in an unstoppable and sometimes overwhelming process. After the introduction of the main elements of electronic health records and a description of what every cancer-care professional should be familiar with, we present a narrative review focusing on the current use of computerized clinical information and decision systems in oncology practice. Following a detailed analysis of the many coveted goals that oncologists have reached while embracing informatics progress, the authors suggest how to overcome the main obstacles for a complete physicians' engagement and for a full information technology adoption, and try to forecast what the future holds.