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.
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,
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
Papakonstantinou D., Malamateniou F. and Vassilacopoulos G..
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.
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
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
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
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.
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.
KMIS 2011 - International Conference on Knowledge Management and Information Sharing
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
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)
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.
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
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.
KMIS 2011 - International Conference on Knowledge Management and Information Sharing
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.
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.
Amazon Web Services. 2010. Overview of Amazon Web
Services. Available from URL http://media.amazon
Baron, J. and Schneider, R., 2010. Storage option in the
AWS Cloud. Amazon Web Services. Available from
URL http://media.amazonwebservices.com/AWS_Stor
Bratsas, C., Kapsas, G., Konstantinidis, S., Koutsouridis,
G. and Bamidis, P., 2009. A Semantic Wiki within
Moodle for Greek Medical Education. In CBMS 2009:
The 22nd IEEE International Symposium on
Computer-Based Medical Systems, New Mexico,
Buyya, B., Yeo, C., Venugopal, S., Broberg, J., Brandic,
I., 2009. Cloud computing and emerging IT platforms:
Vision, hype, and reality for delivering computing as
the 5th utility. Future Generation Computer Systems,
25, 599-616.
Devine, E. B., Wilson-Norton, J. L., Lawless, N. M.,
Hansen, R. N., Hollingworth, W., Fisk, A. W.,
Sullivan, S. D., 2008. Implementing an Ambulatory e-
Prescribing System: Strategies Employed and Lessons
Learned to Minimize Unintended Consequences.
Advances in Patient Safety: New Directions and
Alternative Approaches (Vol. 4: Technology and
Medication Safety).
Díaz-Antón, G. and Pérez, M. A., 2006. Towards an
Ontology of LMS, A Conceptual Framework. In
ICEIS 2006 - Proceedings of the Eighth International
Conference on Enterprise Information Systems:
Databases and Information Systems Integration,
Paphos, Cyprus, May 23-27, 2006.
eHealthInitiative, 2006. A clinician’s guide to electronic
prescribing. Available from URL
Fitzgerald, J. and Chalk, D., 2010. CLOUD
TECHNOLOGY: Clear Benefits: The Emerging Role
of Cloud Computing in Healthcare. DELL Services.
Goldman, R.E., Dube C. and Lapane K.L., Beyond the
basics: Refills by electronic prescribing. 2010.
International Journal of Medical Informatics, 79, 507-
Hall, B. (2003). New Technology Definitions. Glossary,
Brandon Hall Research. Available from URL:.
m, Accessed 15.01.2009.
Lapane, K. L., Rosen, R. K. and Dube C., 2010.
Perceptions of e-prescribing efficiencies and
inefficiencies in ambulatory care. International
Journal of Medical Informatics, 80(1), 39-46.
Lenz, R. and Kuhn, K. A., 2004. Towards a continuous
evolution and adaptation of information systems in
healthcare. International Journal of Medical
Informatics, 73(1), 75-89.
Lohr, H. Sadeghi, A.R. and Winandy, M., 2010. Securing
the eHealth Cloud. Proceedings of the 1st ACM
International Health Informatics Symposium, NY,
Makris, A., Papakonstantinou, D., Malamateniou, F. and
Vassilacopoulos, G., 2009. Using Ontology-based
knowledge networks for user training in managing
healthcare processes. International Journal of
Technology Management, 47, Nos 1/2/3, 5-21.
NGA Center for Best Practices, 2009. Accelerating the
adoption of electronic prescribing. Available from
URL http://www.nga.org/Files/pdf/0907EPRESCRIBI
Puustjärvi, J. and Puustjärvi, L., 2006. Improving the
Quality of Medication by Semantic Web
Technologies. Proceedings of the 12th Finnish
Artificial Intelligence Conference (STeP), Helsinki,
Rius, A., Sicilia, M. A. and García-Barriocanal, E., 2008.
An Ontology to Automate Learning Scenarios? An
Approach to its Knowledge Domain. Interdisciplinary
Journal of E-Learning and Learning Objects, 4, 151-
Siemens Medical Solutions USA, 2009. e-Prescribing: The
Path to Physician Adoption of HIT.
Smith, A. D., 2006. Barriers to accepting e-prescribing in
USA. International Journal of Health Care Quality
Assurance. 19(2), 158-180.
Srimathi, H., 2010. Knowledge Representation of LMS
using Ontology, International Journal of Computer
Applications, 6(3), 35-38.
State Alliance Call to Action for NGA. National
Governors Association Website. 2009. Available at
MENT.pdf. Accessed 2/23/2009.
TREND MICRO, 2010. Cloud Computing Security –
Making Virtual Machines Cloud-Ready.
Available from URL: http://emea.trendmicro.com/
Wheeler, S. and Wheeler, D., 2009. Using wikis to
promote quality learning in teacher training. Learning,
Media and Technology. 34(1), 1-10.
Wieringa, R. J., Blanken, H. M., Fokkinga, M. M. and
Grefen, P. W. P. J., 2003. Aligning Application
Architecture to the Business Context. Lecture Notes in
Computer Science, Springer-Verlag, 2681, 209-225.
KMIS 2011 - International Conference on Knowledge Management and Information Sharing