EMBEDDING ON-LINE TRAINING IN AN

E-PRESCRIBING SERVICE

D. Papakonstantinou, F. Malamateniou and G. Vassilacopoulos

Department of Digital Systems, University of Piraeus, 80, Karaoli & Dimitriou Str.,185 34, Piraeus, Greece

Keywords: Healthcare information services, ePrescribing, User training, LMS.

Abstract: As the number of prescriptions rising nationally each year, Electronic Prescribing (ePrescribing) has been

described as the solution to improved patient safety and reduced medication costs. Web-based technology

should be fully embraced in the pharmacy industry as an aid to improve not only effectiveness and

efficiency but also quality of health services, by reducing the number of errors that may be incurred with

hand-written prescriptions. Healthcare information systems are facing the challenge of attempting to satisfy

the needs of both novice and expert users, focusing on a high likelihood of physician adoption of

ePrescribing. An ePrescribing service that premises a reusable, flexible, agile and adaptable training content

with the objective to enable healthcare professionals instil their knowledge and expertise in the ePrescribing

process, it may conduct to ePrescribing adoption. To this end, an online training embedded within the

ePrescribing service could be used as it offers an intuitive, clear, how-to instruction on performing each

action that the system provides to the user. In this paper the training content is provided as a system

embedded within the ePrescribing service, using a learning management system (LMS) and to this end, the

online training system acts as a collective online memory containing training material, contributing to the

adoption of the ePrescribing service.

1 INTRODUCTION

Healthcare has registered unsatisfactory

performance in both costs and quality over many

years. The drive in healthcare to reduce cost and

improve quality requires enhanced cooperation and

collaboration among disparate healthcare units.

Hence, considerable attention has been paid on

developing healthcare information systems that

support intra- and inter-organizational healthcare

processes, focusing on reducing (or eliminating)

medical errors, containing costs and improving

quality of care (Makris et al, 2009); (Wieringa et al,

2003).

Healthcare providers face the challenge to

incorporate technology solutions as part of their cost

containment strategy. Thus, ePrescribing has been

described as an opportunity to improve the quality of

health services, while reducing medication and

adverse drug events (Lapane, 2010; Siemens

Medical Solutions USA, 2009, Devine et al, 2008).

Moreover, an evolving focus on ePrescribing, may

present the best opportunity to successfully

introduce acceptable, valuable technology into the

broader physician community. Success in this

manageable area could open the door to broader

adoption of e-Health services (Siemens Medical

Solutions USA, 2009); (Devine et al, 2008).

It is estimated that thousands of deaths occur

each year worldwide due to medication errors. These

errors are predominately due to hand-writing

illegibility, wrong dosing, missed drug-drug or drug-

allergy reactions (Lapane, 2010; Siemens Medical

Solutions USA, 2009, Devine et al, 2008).

The execution and management of value-added

ePrescribing processes requires extensive and

continuing education of healthcare professionals,

mainly prescribing physicians and pharmacists, in

order to gain user acceptance, as healthcare

professionals acceptance is often the pivotal factor

determining the success or failure of a healthcare

information system. Properly designed user training

material should enable users understand process-

oriented healthcare delivery, visualize the cross-

organizational ePrescribing process, assimilate the

logic underlying existing processes and identify

areas where redesigning existing processes is

required in order to adapt to today’s dynamic

180

Papakonstantinou D., Malamateniou F. and Vassilacopoulos G..

EMBEDDING ON-LINE TRAINING IN AN E-PRESCRIBING SERVICE.

DOI: 10.5220/0003656401800186

In Proceedings of the International Conference on Knowledge Management and Information Sharing (KMIS-2011), pages 180-186

ISBN: 978-989-8425-81-2

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

healthcare environment (Lenz and Kuhn, 2004);

(Makris et al, 2009); (Wieringa et al, 2003). The

knowledge that these intra- and inter-organizational

ePrescribing processes contain (e.g., flow of

activities, resources involved, physical location) and

the data content must be made explicit through

training so that healthcare professionals understand

the requirements of the environment. For example,

contextual constraints may dictate that ambulatory

care physicians should not sent prescriptions directly

to pharmacies but the pharmacy choice is left to

patients. This paper focuses on the objective of

empowering users interaction, being particularly

concerned with designing and developing relevant

training material for healthcare professionals,

regarding ePrescribing procedures.

Along these lines, the ePrescribing service

adoption is a two-level process that firstly should

provide a user-friendly environment to foster active

user participation and secondly should grant online

training content, at the point of care, on an as-

needed, just-in-time basis.

In particular, to enable users understand

ePrescribing concepts, so that may instil their

knowledge and expertise in the definition and

execution of ePrescribing processes while paying

due regard to culture, we propose an online training

system into an ePrescribing service. The online

training content should offer a task-oriented, clear,

how-to instruction on performing each action that

the ePrescribing service provides to the user. Thus,

the knowledge provided by the ePrescribing service

will have great potential to reduce and facilitate

healthcare professionals work, provided that they

typically want to execute their work, devoting

limited attention to learning new systems.

To this end, this paper is concerned with the

development of an online training system that is

embedded within an ePrescribing service with the

objective to assist healthcare professionals (e.g.

physicians and pharmacists) in understanding the

ePrescribing processes and their roles in it and

possible drug interactions and also in using the

ePrescribing service within the context, framed by

the current legislation and medical advances.

2 BACKGROUND

ePrescribing enables healthcare providers to

electronically generate and submit prescriptions to a

pharmacist. ePrescribing has the potential to

empower both prescribers and pharmacists to deliver

higher quality care and improve workflow

efficiencies. An ePrescribing service allows

providers to evaluate a patient’s medication history,

allergies, possible drug interactions and drug

coverage information. Pharmacies can also

communicate with physicians through ePrescribing

services to clarify prescription orders and process

renewal requests (Goldman et al, 2010); (Lapane et

al, 2010); (NGA Center for Best Practices, 2009);

(Devine et al, 2008).

ePrescribing is a promising approach as

healthcare costs augmentation and poor quality

impact are major concerns. Evidence today suggests

that the use of ePrescribing can result in (Lapane,

2010); (Siemens Medical Solutions USA, 2009);

(Devine et al, 2008):

 reduction in healthcare and legal costs and also in

fraud through drug pricing information

 improved patient safety, decreasing the risk of

medication errors, reducing oral miscommunications

regarding prescriptions and providing warning and

alert systems at the point of prescribing (drug-drug

interactions, drug-allergy interactions, drug

appropriateness etc)

 complete patient medication history

 improved coordination of care through real-time

communications between doctors, pharmacies and

patients

 healthcare professional work efficiency

 administrative efficiencies (Lapane et al, 2010;

NGA Center for Best Practices, 2009).

However, regional interconnectivity to ensure

prompt transfer of patient information has become a

critical issue as the patients increasingly travel

across countries. Hence, besides the obvious

advantages of reducing medication errors and saving

upon time and money, ePrescribing is building path

for a global healthcare structure and this is an issue

to which this approach should give considerable

attention.

Healthcare systems have been slower to adopt

ePrescribing standards (Siemens Medical Solutions

USA, 2009. Differences in adoption are not only

seen between countries, but also between primary

and secondary care to a large extend. ePrescribing in

primary and secondary care are very different in

terms of its application, being more successful in

primary care, due to the standardization of products

and coherent user group (eHealthInitiative, 2006).

ePrescribing is expected to have a steady

penetration in the coming years with the

encouragement from physicians and pharmacies to

adopt the technology and also with the appropriate

acts from governments (Smith, 2006; State Alliance

EMBEDDING ON-LINE TRAINING IN AN E-PRESCRIBING SERVICE

181

Call to Action for NGA, 2009). All these efforts

would set this technology to find its acceptance for a

broader use in the global healthcare. With

contributing factors such as increased mobility,

changing lifestyles and the increasing ageing

population worldwide, the market for ePrescribing is

expected to grow (Smith, 2006). It should be

mentioned that ePrescribing must be understood in

the context of the whole medicines use process.

Beyond central stakeholders (e.g. doctors, nurses

and pharmacists) are many other healthcare

professionals who are potential users of ePrescribing

if and when they need to review a patient’s

medication, like staff of insurance agencies and

hospital staff (Lohr et al, 2010; Trend Micro, 2010).

The motivation of individual healthcare

professionals to use ePrescribing is a critical issue.

Healthcare professionals beyond using ePrescribing

service need to understand the overall vision of a

more robust medicines use practice and the change

that accompanies an ePrescribing implementation.

To this end they should be motivated by a user-

friendly and task-oriented ePrescribing service that

helps them accomplish their own tasks. Training can

be considered as part of a solution to the persistent

problem of ePrescribing service adoption. The aim

of training is to get staff up to speed with basic

ePrescribing functions, so they can perform their

tasks effectively, quickly and with minor effort.

Training can also build up confidence, reveal

concerns and pick up important bugs or problems

within a system (eHealthInitiative, 2006).

How can we enforce healthcare professionals to

be open to change and adopt ePrescribing service?

Training may be an answer to these questions, as it

could be used to convince healthcare staff that

ePrescribing is a focal point of the health

information technology (HIT) industry, which will

contribute to improve the safety, quality and

efficiency of patient care. Unfortunately, no much

focus has been given on prescriber training.

Nevertheless, for a successful ePrescribing

implementation to occur, healthcare professionals

will need to focus on necessary decisions and

changes, meaning that they should allocate extra

time for training. Also, all healthcare stakeholders

should collaborate to encourage widespread

adoption and optimal use of standards-based

ePrescribing through collaborative development and

delivery of education resources, training, and

support (eHealthInitiative, 2006).

Several efforts have been made, as concerns the

adoption and use of ePrescribing services. Blue

Cross Blue Shield of Massachusetts (BCBSMA) has

developed a pay-for-performance program for

participating primary care providers in training.

Also, Blue Cross Blue Shield of Tennessee and West

Virginia Bureau for Medical Services

(WVeSCRIPT) (http://www.wvescript.com) provide

training materials to healthcare professionals.

Furthermore, the U.S Department of Health and

Human Resources and Centers for Medicare and

Medicaid Services (CMS; https://www.cms.gov)

provide to healthcare professionals educating

resources, in the context of E-prescribing Incentive

Program. As concerns Europe, the England NHS

Foundation Trust Electronic Prescribing On-line

Training Web Site (http://ep-training.co.uk/) provide

training through course categories (e.g. for

pharmacists, anaesthetists, doctors, nurses). All

training materials described are part of a support

process, focusing on educating healthcare

professionals to use the ePrescribing service.

However, a training material embedded in the

ePrescribing service may be a motivation for

adopting and efficiently using the system, as this

type of training requires less effort and time and also

it serves healthcare professionals need for a task-

oriented training content, thus what they need, when

they need it. An online training is always available,

providing quick access to contents and full search

functionality, by making information easy to find.

Figure 1 shows the adoption process of the

ePrescribing service, as it is described in this

approach. The development of an online training as

a training material, into the boundaries of the

ePrescribing service can be a remarkable incentive

for healthcare professionals to adopt ePrescribing

concepts and ensure consequently the high quality of

healthcare provided.

3 MOTIVATING SCENARIO

Recent years have seen considerable attention on

designing new healthcare processes or redesigning

existing ones according to current requirements

(Lenz and Kuhn, 2004); (Makris et al, 2009);

(Wheeler and Wheeler, 2009). In particular,

ePrescribing processes are required to be designed

through active user participation so that users’

knowledge and expertise is incorporated into their

definitions. In turn, this facilitates a user awareness

activity on ePrescribing process management

concepts which calls for a suitable and adaptable

training content to be made available to users

anytime and from anywhere.

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Figure 1: The ePrescribing process adoption.

To illustrate the main principles of the training

approach proposed, consider an ePrescribing service.

The benefits accrued from the implementation of an

ePrescribing service are manifold: for example, the

service puts eligibility, insurances and formulary

information at the physician’s fingertips at the time

of prescribing. This enables physicians to select

medications that are on formulary and are covered

by the patient’s drug insurance. It also informs

physicians of lower cost alternatives such as generic

drugs. In addition, physicians can access a timely

and clinically sound view of a patient’s medication

history at the point of care, decreasing the risk of

preventable medication errors (Bratsas et al, 2009).

This scenario shows an example implementation

of an ePrescribing service that involves physicians,

pharmacists, patients and the insurance

organizations:

 The physician diagnoses a patient using the

computer or a PDA.

 The physician uses his/her computer or PDA to

access an ePrescribing application which is

interfaced to an EMR (Electronic Medical Record)

system.

 The physician reads the summary record of his/her

current patient and selects one or more drugs from

the Insurance Organization’s formulary based on

information regarding eligibility status and ID

numbers of the medication list covered.

 Upon selection of one or more drugs by the

physician, the ePrescribing service can check for

appropriate dosing, therapeutic duplication, drug-

drug and also drug-allergy interactions, and

formulary status.

 The ePrescribing service alerts the physician if the

prescription needs to be changed, so he selects an

alternative medication.

 In case of a clear prescription, the prescription is

stored, as pending, in the medication profile area of

the insurance organization’s designated data center.

 A pharmacist connects to the insurance

organization’s cloud infrastructure, selects the

patient’s prescription and executes it.

 The pharmacist dispenses the medication with

minimal time spent on verifying the formulary status

of the medication.

 The pharmacist counsels the patient.

 The patient or a delegated person thereof collects

the prescribed drugs from a pharmacy of his/her

choice (Puustjärvi and Puustjärvi, 2006).

The system structure regarding the ePrescription for

a patient is represented at the class diagram of figure

2 that conducts to the corresponding ontology. The

ontology may include for example the following

information (Puustjärvi and Puustjärvi, 2006):

 ePrescription is prescribed by a physician and it is

targeted at a patient.

 An ePrescription of a patient may precede other

ePrescription of the patient.

 Each ePrescription includes a drug.

 Each drug has a price, and it may have one or more

substitutable drugs.

 Each drug corresponds to a medicinal product.

 Each drug belongs to a product group.

 Each electronic patient record (EPR) is associated

with a patient and it is written by a physician.

The benefits of using the ontology are:

 To obtain formal specifications of learning

scenarios oriented to their automation

 To catalogue learning scenarios

 To validate the behavior of new scenarios

 To personalize learning scenarios

 To monitor the behavior of the learning scenarios

within a Learning Management System (LMS) (Rius

et al, 2008).

Design or redesign of the ePrescribing process

model can be performed by manipulating already

defined objects, providing flexibility, agility and

reusability of the training material designed.

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183

4 AN ONLINE TRAINING

WITHIN AN EPRESCRIBING

SERVICE

Healthcare professionals should be adequately

motivated to change their behaviour and to accept

new technological efforts in the healthcare domain,

as ePrescribing, being aware of their superiority.

Nevertheless, these conditions require that

healthcare professionals should have a clear picture

of the new technological effort, opportunities to

practice it with a sequence of appropriate materials

and also continuing reinforcement of it.

The need for providing training material for

ePrescribing process management concepts requires

a training environment so that users not only acquire

knowledge about the training/learning objects but

also learn the relations between them.

LMS as a program that manages the

administration of complete on-line education

provides authoring, sequencing, and aggregation

tools that structure the content to facilitate the

learning process. An LMS integrates educational

resources, the learners and support tools (Díaz-

Antón and Pérez, 2006), (Rius et al, 2008).

The LCMS is one of the sub components in LMS

which promotes a complete integration of eLearning

system. While a LMS is used to deliver, manage,

and track content over the Internet or a connected

network, a LCMS is used to author and edit the

content (Díaz-Antón and Pérez, 2006).

A LCMS is an environment where developers

can create, store, reuse, manage, and deliver learning

content from a central object repository, usually a

database. LCMSs generally work with content that is

based on a learning object model (Srimathi, 2010).

These systems usually have good search capabilities,

allowing developers to quickly find the text or media

needed to build training content. Learning content

management systems often strive to achieve a

separation of content – which is often tagged in

XML – from presentation (Hall, 2003).

Ontologies can also enhance the management,

distribution and retrieval of the learning material

within a LMS and therefore play a relevant role in

eLearning procedure.The objective of a LMS and a

LCMS is different: the primary objective of a LMS

is to manage learners, keeping track of their progress

and performance across all types of training

activities (Hall, 2003; Srimathi, 2010). On the other

hand, the main focus of LCMSs is on achieving

personalized learning on demand (LOD) to drive

performance in an organization by delivering

content to learners to solve business problems (Díaz-

Antón and Pérez, 2006).

The prototype learning system consists of an

LMS system called Docebo LMS (www.docebo.org)

which is an open - source LMS and LCMS that

offers several capabilities:

 It provides a “multi-model didactic” approach that

can be configured for different environments that

use didactic modes.

 It makes extremely easy to construct the didactic

content of lessons.

 Trainers are free to reuse files that they already

have.

 It has a comprehensive user management system

that lets an administrator manage user in groups or

in hierarchical fashion.

 It provides web 2.0 features, such as wiki, forum

and chat, allowing for collaborative knowledge.

The training content implemented includes Docebo

LMS and behaves as an online training, embedded

into the ePrescribing service, accessible from the

authorized users that can access also the

ePrescribing service. The ePrescribing service is

hosted onto the Amazon cloud infrastructure, which

is a flexible, scalable and low-cost and secure cloud

computing platform. The architecture of the

approach proposed is represented in figure 3.

Figure 2: The class diagram of the ePrescribing process.

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5 RESULTS

The approach proposed in this paper is concerned

with capturing the knowledge existing in

ePrescribing processes and in structuring this

knowledge through a LMS that operates as an online

training, developed into the boundaries of an

ePrescribing service. Thus, the training content

enables users to search through the LMS for learning

objects/ontology constructs, understand their

meaning and usage with the help of the supportive

text and media and navigate to associated constructs.

In this way, an in-depth understanding of each

healthcare process of the ePrescribing procedure is

ensured. From the trainee’s point of view, the main

advantages of the proposed model are knowledge or

conceptual navigation and knowledge dissemination

and ease of use without further education and

training through the ePrescribing service, simply by

pressing the online training button into the

ePrescribing service.

The cloud solution to host the training content of

the ePrescribing service has significant advantages

to healthcare organizations such as cost saving,

accelerated time to delivery, offloaded maintenance

and management to the cloud, elastic resources,

redundancy and scalability. More importantly, due

to the information sharing capability, healthcare

professionals can share standardized and best

practice medical protocols thus improving the

quality of care provided.

6 CONCLUDING REMARKS

Healthcare is an increasingly collaborative enterprise

involving a variety of activities (administrative,

paramedical, nursing and medical) that are

interconnected into healthcare processes in a

manifold manner and are performed within and

outside healthcare organizations.

This paper takes the stance that implementing an

ePrescribing service may contribute to cost

containment, quality improvement and rapid

adoption from healthcare professionals that is

necessary and that to facilitate adoption there is a

need for an effective training aid embedded into the

ePrescribing service. Thus, a prototype approach to

providing and structuring training content in

ePrescribing processes is proposed.

The approach is based on a LMS embedded on

the ePrescribing service, behaving as an online

training system. The ePrescribing service should be

available anytime and from anywhere to authorized

users and to this end it is hosted on a cloud

environment. Thus, the main concept of this paper is

a process to implement a successful ePrescribing

system that will be adopted from healthcare

professionals. To this end, after implementing the

ePrescribing service, it defines a general ontology,

refines the general ontology by adding all learning

objects/ontology constructs required, implements the

LMS infrastructure into the system and store the

ePrescribing service in a virtual private cloud.

Figure 3: The architecture of the online training of the ePrescribing service.

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185

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