CancelRx case study: implications for clinic and community pharmacy work systems.

BACKGROUND: Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies. OBJECTIVE: The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation. APPROACH: Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes. KEY RESULTS: CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. CONCLUSIONS: This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis.

BACKGROUND: Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx. METHODS: Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic's electronic health record and discontinued in the pharmacy's dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system's implementation of CancelRx, a novel technology. RESULTS: After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI - 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff. CONCLUSIONS: Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

MOVPE growth of GaP/GaPN core-shell nanowires: N incorporation, morphology and crystal structure.

Dilute nitride III-V nanowires (NWs) possess great potential as building blocks in future optoelectronical and electrochemical devices. Here, we provide evidence for the growth of GaP/GaPN core-shell NWs via metalorganic vapor phase epitaxy, both on GaP(111)B and on GaP/Si(111) hetero-substrates. The NW morphology meets the common needs for use in applications, i.e. they are straight and vertically oriented to the substrate as well as homogeneous in length. Moreover, no parasitical island growth is observed. Nitrogen was found to be incorporated on group V sites as determined from transmission electron microscopy (TEM) and Raman spectroscopy. Together with the incorporation of N, the NWs exhibit strong photoluminescence in the visible range, which we attribute to radiative recombination at N-related deep states. Independently of the N incorporation, a peculiar facet formation was found, with {110} facets at the top and {112} at the bottom of the NWs. TEM reveals that this phenomenon is related to different stacking fault densities within the zinc blende structure, which lead to different effective surface energies for the bottom and the top of the NWs.

Role network measures to assess healthcare team adaptation to complex situations: the case of venous thromboembolism prophylaxis.

Hospitals are complex environments that rely on clinicians working together to provide appropriate care to patients. These clinical teams adapt their interactions to meet changing situational needs. Venous thromboembolism (VTE) prophylaxis is a complex process that occurs throughout a patient's hospitalisation, presenting five stages with different levels of complexity: admission, interruption, re-initiation, initiation, and transfer. The objective of our study is to understand how the VTE prophylaxis team adapts as the complexity in the process changes; we do this by using social network analysis (SNA) measures. We interviewed 45 clinicians representing 9 different cases, creating 43 role networks. The role networks were analysed using SNA measures to understand team changes between low and high complexity stages. When comparing low and high complexity stages, we found two team adaptation mechanisms: (1) relative increase in the number of people, team activities, and interactions within the team, or (2) relative increase in discussion among the team, reflected by an increase in reciprocity.   Practitioner Summary: The reason for this study was to quantify team adaptation to complexity in a process using social network analysis (SNA). The VTE prophylaxis team adapted to complexity by two different mechanisms, by increasing the roles, activities, and interactions among the team or by increasing the two-way communication and discussion throughout the team. We demonstrated the ability for SNA to identify adaptation within a team.

Impact of the Tip-to-Semiconductor Contact in the Electrical Characterization of Nanowires.

Well-defined semiconductor heterostructures are a basic requirement for the development of high-performance optoelectronic devices. In order to achieve the desired properties, a thorough study of the electrical behavior with a suitable spatial resolution is essential. For this, various sophisticated tip-based methods can be employed, such as conductive atomic force microscopy or multitip scanning tunneling microscopy (MT-STM). We demonstrate that in any tip-based measurement method, the tip-to-semiconductor contact is decisive for reliable and precise measurements and in interpreting the properties of the sample. For that, we used our ultrahigh-vacuum-based MT-STM coupled in vacuo to a reactor for the preparation of nanowires (NWs) with metal organic vapor phase epitaxy, and operated our MT-STM as a four-point nanoprober on III-V semiconductor NW heterostructures. We investigated a variety of upright, free-standing NWs with axial as well as coaxial heterostructures on the growth substrates. Our investigation reveals charging currents at the interface between the measuring tip and the semiconductor via native insulating oxide layers, which act as a metal-insulator-semiconductor capacitor with charging and discharging conditions in the operating voltage range. We analyze in detail the observed I-V characteristics and propose a strategy to achieve an optimized tip-to-semiconductor junction, which includes the influence of the native oxide layer on the overall electrical measurements. Our advanced experimental procedure enables a direct relation between the tip-to-NW junction and the electronic properties of as-grown (co)axial NWs providing precise guidance for all future tip-based investigations.

CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems.

Background: The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. Objective: The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations. Approach: Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis. Key Results: CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. Conclusions: This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Impact of a problem-oriented view on clinical data retrieval.

OBJECTIVE: The electronic health record (EHR) data deluge makes data retrieval more difficult, escalating cognitive load and exacerbating clinician burnout. New auto-summarization techniques are needed. The study goal was to determine if problem-oriented view (POV) auto-summaries improve data retrieval workflows. We hypothesized that POV users would perform tasks faster, make fewer errors, be more satisfied with EHR use, and experience less cognitive load as compared with users of the standard view (SV). METHODS: Simple data retrieval tasks were performed in an EHR simulation environment. A randomized block design was used. In the control group (SV), subjects retrieved lab results and medications by navigating to corresponding sections of the electronic record. In the intervention group (POV), subjects clicked on the name of the problem and immediately saw lab results and medications relevant to that problem. RESULTS: With POV, mean completion time was faster (173 seconds for POV vs 205 seconds for SV; P < .0001), the error rate was lower (3.4% for POV vs 7.7% for SV; P = .0010), user satisfaction was greater (System Usability Scale score 58.5 for POV vs 41.3 for SV; P < .0001), and cognitive task load was less (NASA Task Load Index score 0.72 for POV vs 0.99 for SV; P < .0001). DISCUSSION: The study demonstrates that using a problem-based auto-summary has a positive impact on 4 aspects of EHR data retrieval, including cognitive load. CONCLUSION: EHRs have brought on a data deluge, with increased cognitive load and physician burnout. To mitigate these increases, further development and implementation of auto-summarization functionality and the requisite knowledge base are needed.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

OBJECTIVE: Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software. MATERIALS AND METHODS: CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time. RESULTS: There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software. CONCLUSION: CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care.

MRSA Septicemia With Septic Arthritis and Prostatic, Intraretinal, Periapical, and Lung Abscesses.

INTRODUCTION: Methicillin-resistant staphylococcus aureus (MRSA) bacteremia is a life-threatening illness and a major global health care problem. It can cause metastatic and complicated infections. CASE PRESENTATION: A 58-year-old man with uncontrolled type 2 diabetes mellitus presented with altered mental status after a fall. He was found to have a hip fracture, diabetic ketoacidosis, and MRSA bacteremia. This was complicated by septic knee arthritis, prostatic abscess, intraretinal abscess, periapical abscesses, and pulmonary abscesses. He was treated with intravenous vancomycin and oral linezolid and eventually recovered. DISCUSSION: Severe metastatic MRSA infection was likely due, in part, to the patient's uncontrolled diabetes, as he has no underlying immunodeficiency and was HIV negative. Prostatic abscesses are a relatively rare occurrence that typically develop in immunocompromised patients. CONCLUSION: This case is an interesting confluence of sequelae of MRSA bacteremia and reinforces the necessity for clinicians to be diligent when evaluating a patient with a suspected prostatic abscess.

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

OBJECTIVE: In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway. MATERIALS AND METHODS: We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS). RESULTS: Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx. CONCLUSIONS: This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety.

Charge transport in GaAs nanowires: interplay between conductivity through the interior and surface conductivity.

The charge transport through GaAs nanowires, partially p-doped and partially intrinsic, is analyzed by four-point resistance profiling along freestanding nanowires using a multip-STM. The charge transport channel in the undoped segment is assigned to the surface conductivity, while the interior of the nanowire is the conductance channel in the p-doped segment. The convoluted interplay between conduction through the interior of the nanowire and surface state conduction is studied in detail. Measurements of the I-V curves along the nanowires provide the experimental basis for the proposed charge transport model for the transition of the conduction from the interior to the surface of the nanowire. A voltage drop along the surface state conduction channel leads to an upward shift of the band edges at the surface. This results, for higher applied voltages, in the removal of the depletion layer and an opening of a conductance channel between the interior of the nanowire and the surface states.

The Design of PE Dx, a CDS to Support Pulmonary Embolism Diagnosis in the ED.

Designing and implementing clinical decision support (CDS) in health care has been challenging. Attempts have been made to design and implement CDS to support clinical procedures, but many of these CDSs have met user resistance. One possible explanation for the lack of acceptability can be the poor design of the CDS. In this study, we describe the design of PE Dx, a CDS built to support the diagnosis of pulmonary embolism (PE) in the emergency department (ED) using human factors methods.

Impact of N Incorporation on VLS Growth of GaP(N) Nanowires Utilizing UDMH.

III-V nanowires (NWs) possess great potential for use in future semiconductor technology. Alloying with dilute amounts of nitrogen provides further flexibility in tuning their material properties. In this study, we report on successful in situ nitrogen incorporation into GaP(N) NWs during growth via the Au-catalyzed vapor-liquid-solid (VLS) mechanism. The impact of the nitrogen precursur unsymmetrical dimethyl hydrazine (UDMH) on morphology was found to be overall beneficial as it strongly reduces tapering. Analysis of the crystal structure of NWs with and without N reveals zinc blende structure with an intermediate amount of stacking faults (SF). Interestingly, N incorporation leads to segments completely free of SFs, which are related to dislocations transverse to the growth direction.

Impact of Rotational Twin Boundaries and Lattice Mismatch on III-V Nanowire Growth.

Pseudomorphic planar III-V transition layers greatly facilitate the epitaxial integration of vapor-liquid-solid grown III-V nanowires (NW) on Si(111) substrates. Heteroepitaxial (111) layer growth, however, is commonly accompanied by the formation of rotational twins. We find that rotational twin boundaries (RTBs), which intersect the surface of GaP/Si(111) heterosubstrates, generally cause horizontal NW growth and may even suppress NW growth entirely. Away from RTBs, the NW growth direction switches from horizontal to vertical in the case of homoepitaxial GaP NWs, whereas heteroepitaxial GaAs NWs continue growing horizontally. To understand this rich phenomenology, we develop a model based on classical nucleation theory. Independent of the occurrence of RTBs and specific transition layers, our model can generally explain the prevalent observation of horizontal III-V NW growth in lattice mismatched systems and the high crystal quality of horizontal nanowires.

Comparative analysis on resistance profiling along tapered semiconductor nanowires: multi-tip technique versus transmission line method.

The detection of doping dependent values like contact- and path resistances along nanowires (NWs) still proves to be rather challenging compared to planar structures. Unfortunately, the usually used and well established TLM (transmission line measurement) setup exhibits some drawbacks. Complex preliminary preparation steps and the necessity of ohmic contacts limit the investigation to certain semiconductor materials. The simultaneous determination of contact- and path resistances with an unknown distribution makes an analysis on complex structures like tapered nanowires very challenging. Our approach is the utilization of a multi-tip scanning tunneling microscope (MT-STM) as a four point prober, which allows the investigation of freestanding nanowires with an increased spatial resolution. Here, the used measurement setup allows a local separation of current injection and potential measurement and thus a highly precise determination of path resistances. Tapered p-doped GaAs-NWs were used to compare both techniques. Whereas the evaluation of the axial doping profile by MT-STM was rather simple, correction factors had to be introduced for the TLM measurement to calculate the specific resistances and transfer length. By comparing the results of both methods for the very same NW-sample, the precision and accuracy of MT-STM measurements was demonstrated. We found an agreement, which allows the conclusion that both methods exhibit advantages; however the MT-STM was determined as the more precise setup, which enables additional characterization capabilities, such as surface, temperature or light dependent measurements.

Time-Resolved In Situ Spectroscopy During Formation of the GaP/Si(100) Heterointerface.

Though III-V/Si(100) heterointerfaces are essential for future epitaxial high-performance devices, their atomic structure is an open historical question. Benchmarking of transient optical in situ spectroscopy during chemical vapor deposition to chemical analysis by X-ray photoelectron spectroscopy enables us to distinguish between formation of surfaces and of the heterointerface. A terrace-related optical anisotropy signal evolves during pulsed GaP nucleation on single-domain Si(100) surfaces. This dielectric anisotropy agrees well with the one calculated for buried GaP/Si(100) interfaces from differently thick GaP epilayers. X-ray photoelectron spectroscopy reveals a chemically shifted contribution of the P and Si emission lines, which quantitatively corresponds to one monolayer and establishes simultaneously with the nucleation-related optical in situ signal. We attribute that contribution to the existence of Si-P bonds at the buried heterointerface. During further pulsing and annealing in phosphorus ambient, dielectric anisotropies known from atomically well-ordered GaP(100) surfaces superimpose the nucleation-related optical in situ spectra.

Formation of GaP/Si(100) Heterointerfaces in the Presence of Inherent Reactor Residuals.

Adequate silicon preparation is a prerequisite for defect-free III-V growth on Si. We transfer the silicon processing from clean to GaP containing metalorganic vapor phase epitaxy reactors, where we monitor the entire process in situ with reflection anisotropy spectroscopy and analyze the chemical composition of the surface with X-ray photoelectron spectroscopy. Beyond a certain submonolayer threshold value of (Ga,P) residuals found on the Si(100) surface, GaP grows with an inverted majority sublattice. Analogously to III-V growth on two-domain substrates, the coexistence of Si-Ga and Si-P interfacial bonds at terraces of the same type causes antiphase disorder in GaP epilayers.