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The objective of this review is to describe the implementation of human factors principles for the design of alerts in clinical information systems. First, we conduct a review of alarm systems to identify human factors principles that are employed in the design and implementation of alerts. Second, we review the medical informatics literature to provide examples of the implementation of human factors principles in current clinical information systems using alerts to provide medication decision support. Last, we suggest actionable recommendations for delivering effective clinical decision support using alerts. A review of studies from the medical informatics literature suggests that many basic human factors principles are not followed, possibly contributing to the lack of acceptance of alerts in clinical information systems. We evaluate the limitations of current alerting philosophies and provide recommendations for improving acceptance of alerts by incorporating human factors principles in their design.
Computerized clinical decision support (CDS) systems have been defined as 'computer programs that provide expert support for health professionals making clinical decisions'.1 One type of CDS is the generation of alerts that warn healthcare staff about potential errors, enabling them to make better therapeutic decisions. Many types of clinical alerts are currently incorporated as part of complex CDS systems. Medication-related alerting forms a large part of the CDS in most clinical information systems. Examples of medication alerts in clinical information systems include an alert generated when two interacting drugs are prescribed together or a warning when the maximum dose for a drug is exceeded. Several mechanisms of providing medication-related decision support are available in a care provider order entry (CPOE) system but the specific types of alerts discussed here are visual alerts that may or may not be interactive in nature.
Medication-related alerting used in conjunction with a CPOE system has the ability to prevent dangerous adverse events and serves as an important decision support aid.2–5 However, clinicians often override the recommendations provided in alerts, even clinically significant ones.6–10 In particular, generation of an excessive number of alerts results in 'alert fatigue' and highlights the importance of reducing the utilization of this mechanism for providing CDS.7 11 The goal should be to reduce the number of alerts that are not useful to the clinician. A clinician may choose to override an alert because the data used to drive the alert may be incorrect or not current. However, it is also possible that a clinician might override a potentially useful alert due to alert fatigue. Our goal in this study is to discuss how the latter can be minimized by designing alerts that incorporate important human factors principles into alert design.
In a previous review, Kuperman et al12 described the state of the art in medication-related decision support and also outlined recommendations for optimizing the effectiveness of medication-related alerting. Recommendations focused on: (1) bridging our gaps in understanding the impact of such alerting on clinician behavior; (2) optimizing alert presentation; and (3) considering the underlying reasons for alert fatigue.12 An understanding of how to successfully prompt clinicians at the point of care is a complex problem, one that requires consideration of a combination of issues: technological, clinical, and sociotechnical. The technological and clinical aspects have received the most attention, while the sociotechnical aspect of alerting, which is related to the human aspect of the interaction between users and technology, has been relatively neglected.
Medical informatics is a multidisciplinary field that has, in the past, drawn from evidence in other domains.13–18 In this paper, we begin by summarizing a wealth of research from the human factors literature focusing on computer-based alerting systems from a range of industry contexts. Our aim is primarily to delineate the effects of alert design and implementation parameters on task performance and alert acceptability. We then review the literature on computer-based alerting systems in health care, focusing on medication-related alerting. We conclude by providing actionable recommendations that need further consideration for the successful development and deployment of medication-related alerting in clinical information systems.
We conducted a literature review to identify human factors principles that have been used in alerting systems. In this review, we also identified studies that described how these principles have been employed in the realm of clinical information systems. Two researchers (EH, JE) evaluated the literature from the last 20 years (January 1987 to December 2007) in the following databases: Web of Knowledge, PsychLit, Medline, PsychINFO and Google Scholar. The search terms used were selected to identify, first, all articles related to the design and implementation of alerts, and second, for computerized systems in health care. Search terms included: alarm, warning, alert design, handling, learning, compliance, use and medication-related alerting. These words were then combined with keywords used to describe computerized decision support systems such as electronic prescribing, e-prescribing, reminder systems, decision support systems, and drug alerts and prompts. Studies that appeared relevant were reviewed by two researchers (JE and EH). Furthermore, the bibliographies of extracted articles were reviewed to identify any relevant studies that were not identified through this search strategy. Reviewers examined studies to extract information regarding the design and implementation of the alerting system. In particular, in defining the underlying inclusion criteria for our review, we wanted to extract information surrounding the consideration of human factors principles in the design of the alerts themselves and on the way these alerts were implemented.
Our intent was not to conduct an exhaustive systematic review but instead to provide a literature-based discussion of how human factors principles have been implemented in clinical information systems, especially those related to medication ordering. We selected papers that reflected exemplary current implementations of medication-related alerting and used these to identify the shortcomings of current implementations and suggest actionable recommendations for future alert design and implementations.
Alerting systems are implemented as safety mechanisms in a wide variety of industries.19–24 The basic principles guiding the successful use of alerting systems are consistent across domains. These principles emerge from the discipline of human factors engineering, which applies knowledge about human capabilities and limitations to the design of products, processes, systems, and work environments. The application of these principles across domains improves ease of use and user satisfaction, while reducing potential errors and user fatigue.
An alerting system should be used when it is beneficial to indicate to a user that a particular action exceeds task safety thresholds and may undermine task accuracy, completion or safety. Alerting systems are implemented with the aim of improving task performance, for which careful consideration must be given to the design and implementation of the alerting system itself. While a well-designed alerting system will act as a decision aid and improve task performance, a poorly designed one may become an irritation or distraction to the user and can impede performance. Therefore, successful adoption requires careful consideration of not only the knowledge driving the alerting system but also the human factors principles in alert implementation.
We describe general guidance based on human factors principles that can be employed in the design and implementation of alerting systems. A majority of the alerts related to medication–decision support focus on safety, for example, drug–drug interaction alerts, therapeutic duplication alerts, etc. The guidelines discussed below are also applicable to other types of alerts available in clinical information systems, such as, blood product alerts or alerts related to the absence of allergy information, etc. Alerts in clinical information systems are largely visually displayed, hence the focus of this review is on the design and implementation of visually displayed computerized alerts in clinical information systems. While auditory alerts have been implemented in some clinical information systems, they are not discussed in this review.
The logic that underpins the determination of an event as unsafe is termed 'alarm philosophy'. A well-documented alarm philosophy is necessary to guide decision-making and ensure consistency in alerting. Documentation of alarm philosophy should include a catalog of unsafe events, an indication of the level of priority (based on the severity of the consequences) of an alert, a description of the logic underpinning the classification of an event as unsafe, and a description of the specific alerts indicating each unsafe event.
We discuss below important considerations that should be kept in mind when developing the alarm philosophy of an alerting system. First, the underlying philosophy should seek to minimize the overall number of alerts in the system and the frequency with which they activate. This can be achieved by ensuring that only safety-critical events are classified as unsafe and requiring an alert. This, in turn, would require an explicit definition of what is meant by a safety-critical event since this can vary based on the judgment of the user. Another important consideration is to assess what corrective actions are going to be required by an alert and how the alert is acknowledged and canceled. It is desirable that the users' response to an alert is the appropriate corrective action rather than an acknowledgment, that is alerts should cancel and reset in response to the appropriate corrective action rather than requiring an acknowledgment from the operator followed by the corrective action. Furthermore, the corrective actions should be easy to perform, facilitating the user's compliance with the alert.
Consideration of false alarms is equally as important as the proper ergonomic design of alerts. A false alarm occurs when an alert activates but there is no need for the user to be aware of the event being signaled or to take corrective action. False alarms may be present either because the alerts in a system are too sensitively calibrated, that is they activate before a meaningful safety threshold is exceeded, or because alerts have been matched to events that are basically safe rather than unsafe. Another reason false alarms exist is because the data driving the alert may be incorrect or out of date.
False alarms increase workload and may even cause distraction and lower performance. There is evidence suggesting that people will decrease their response as the false alarm rate increases,25 26 and these might not necessarily be the most clinically significant alerts. Recommendations to curb false alarm rates include moving from 'boundary based' alarm strategies (whereby an alarm sounds when a given parameter exceeds pre-set limits) to intelligent alarm monitoring systems that monitor several parameters simultaneously and use fuzzy logic-based algorithms to initiate an alert.
The most important consideration with regard to the implementation of a visual alert is the likelihood that it will be seen by the user. In order to be reliably detected, visual alerts must be placed within an operator's visual field. The normal viewing angle is 15 degrees below the horizontal line of sight. However, this may be unnecessarily restrictive and the viewing angle can be anywhere from 0 to 50 degrees below the horizontal line of sight.27 Once the viewing angle is established, the visual field can be defined. The visual field is usually defined vertically as 25% above and 30% below the normal viewing angle. Sanders28 defined three areas in the visual field. In the stationary field (30 degrees horizontal from the normal viewing angle), targets can be detected without movement; in the eye field (30–80 degrees horizontal from the viewing angle), targets can be detected with eye movements; and in the head field (80–180 degrees horizontal from the normal viewing angle), targets can be detected with head movements. Variability in screen design, dimensions and the frequent use of additional monitors make it difficult to generalize the exact visual field of the user. However, these general guidelines may be useful in assessing what portions of the screen the user is most likely to focus on.
Visual alerts should be located in the visual field in order of importance, so that the highest priority alerts are located in the stationary field, with lower priority alerts in the eye field and head field. Besides being detected, it must also be clear what situation a visual alert is indicating. The proximity compatibility principle of Wickens and Carswell29 suggests that in order to make clear what situation is being indicated by a visual alert, alerts should be grouped meaningfully and should be located in close proximity to the controls and displays relevant to the situation being indicated.
Besides being detected, a visual alert must also be legible and visible, ie, bright enough for the user to perceive when it is presented on the screen. There are various factors that need to be considered to improve legibility and visibility. Target size, luminance, background contrast, and lettering characteristics are important considerations, but are context specific and relative to the expected viewing distance and potential exposure time. As a generalization, the size of the target should be increased as viewing distance increases or contrast decreases. Heglin30 reports that a visual target should be twice as bright as the background against which it must be detected. Practical consideration must also be given to position alerts in order to avoid glare and reflection, as both will also reduce visibility.
For text, the same factors determine visibility, but here the size of the letters and the ratios between letter height and width and the stroke width also determine legibility. Letter heights should normally be larger when reading from a visual display unit. A mixture of upper and lower case lettering is easier to read than upper case only31; and dark text on a light background is easier to read than light text on a dark background.32
Visual alerts should be prioritized, and prioritization goes hand in hand with hazard matching as a warning implementation strategy. In visual warning research, 'hazard matching' is used to describe the process of matching the appearance of the warning to the level of hazard implied by the situation that it indicates.33 For visual warnings, priority is normally indicated by color. Colors such as red and orange increase the hazard, as well as the priority, associated with a visual alert when compared with colors such as green, blue and white.34 Colorblind users must be considered when utilizing color to indicate the priority level of an alert.
In addition to color the use of a signal word is particularly relevant to text-based alerts. Providing additional information, signal words can enhance the user's ability to distinguish between alerts. Signal words are the header terms often found at the top of warning labels, terms such as 'danger', 'warning', and 'caution'. A wealth of research has indicated that these signal words exist on a continuum of perceived hazard, with 'deadly', 'danger', and 'lethal' rated as implying more hazard than words such as 'warning' and 'caution', that in turn imply more hazard than words such as 'note' and 'attention'.34–39 It should be noted that although many standardization bodies recommend the use of the terms 'danger', followed by 'warning' and then 'caution' to denote decreasing levels of hazard, in fact most research suggests that the terms 'warning' and 'caution' are synonymous in terms of the level of hazard they imply. Riley et al40 have indicated that it may be possible to prioritize visual alerts by shape, with angular and unstable shapes (ie, an inverted triangle) indicating higher levels of priority than regular shapes (ie, a circle). In this text, the use of the terms 'low priority' and 'high priority' alerts refers to how the principle of prioritization was adopted for a specific alert.
Besides indicating priority level, color can be used in other ways to code visual alerts and make them less confusable. For example, visual alerts can also be color-coded by the type of unsafe event or category of risk, by response required, or by their function. The number of colors used to code in an environment should be kept to a minimum (fewer than 10) as incorrect color identifications increase with the absolute number of colors used.41 Furthermore, color affects the legibility of text-based alerts, with blue and green resulting in the poorest performance and red and yellow resulting in the best.42 This is important when considering general screen context, where a low contrast between the target and background screen may result in a textual alert not being easily detected.
Color-coding is one means of making visual alerts more distinct from one another. Another means of reducing potential confusability between visual alerts is to minimize the number of visual features that they share with each other. The fewer features that alerts share, the more distinctive they appear. Sanders and McCormick43 have shown that as the ratio of the number of shared features between alerts increases, so does the potential confusion. Color, shape, and size are the variables commonly manipulated to make visual alerts distinct from one another, although these manipulations must take into account any coding for prioritization.
Visual alerts can contain textual information with specific details about the unsafe event. When text is being used in visual alerts, the first issue to resolve is what information should be provided by the text. Research on the information components of textual visual alerts has mainly focused on the context of warning labels.44 Recommendations have been made that a warning label should, if possible, have four information components: a signal word to indicate the priority of the alerts (ie, 'note', 'warning', or 'danger'), a statement of the nature of the hazard, an instruction statement (telling the user how to avoid the danger), and a consequence statement (telling the user what might happen if the instruction information is ignored). Research in this area has also suggested that when space considerations make it impossible to include all four information components, instruction and hazard statements are the most important to include.
Several other features of wording have been shown to influence the effectiveness or perceived effectiveness of visual alerts. While much of this research has been conducted in the context of warning labels, some general principles might be important in the context of general alert design. Features that increase the effectiveness of visual alerts include using explicit rather than non-explicit terms (eg, smoking causes lung cancer vs smoking is damaging to health) leads to higher ratings of risk seriousness.45 46 In addition, it has been shown that the effectiveness of labels can be increased by the use of definitive rather than probabilistic statements,46 47 and by including personal pronouns, ie, 'You must (…)', in the wording.47 Previous research indicates that, for clarity, the order of words should reflect the order of required actions (ie, 'turn off engine before opening emergency exit' rather than 'to open emergency exit first turn off engine'), that affirmative and active sentences are used, and that instructions are standardized and validated for clarity and understandability with the intended user population.43 While these findings may not be completely generalizable to alerting in dynamic computer screens, some of the basic principles are useful in the determination of the text accompanying computerized visual alerts.
Habituation refers to a reduction in the behavioral or physiological response to a stimulus that occurs with repeated exposure to that stimulus, if the stimulus does not have consequences for the recipient. If we think of an alert as a stimulus, then it is apparent that habituation has important implications for the design and implementation of alerts.
Habituation predicts that repeated exposure to an alert that does not require a meaningful response will result in a decrease, and eventual elimination of, responding to the alert. The phenomenon of habituation highlights the necessity to reduce false alarm rates in alerting systems. For example, when an alert activates erroneously and then requires no response, the likelihood of a future response to it will be reduced. Indeed, habituation probably explains the reduction in responses to alerts with a high false alarm rate that have been observed.26 The existence of habituation also underscores the importance of an alarm philosophy that does not over-warn. Habituation may also imply that if the alerts that a user is exposed to all look or sound the same, then they will be perceived as the being the same stimulus and that habituation to them is more likely. Current research is limited in its understanding of how varying the appearance or sound of alerts, by priority or risk category, will likely help them to be perceived as different stimuli, reducing the likelihood of habituation.
The belief and understanding that individuals have about a particular topic is called their 'mental model'.48 When people interact with technology, they form mental models of the objects with which they interact. Users' mental models of the task are likely to be derived from a variety of sources and contain inaccuracies or missing information. Given that mental models will be part of what drives subsequent behavior, it is essential that alerting systems adequately support users' mental models and correct them as appropriate. In order to achieve this, systems designers must elucidate the mental models that users already have of a given task.49–52 This will allow systems to support users' assessment of the risks and processes associated with performing the tasks. Systems can be designed to reflect users' mental models by allowing users to express how they conceptualize a system to work.
Research into the design of visual displays distinguishes between different types of tasks being performed by the operator and the different displays that should be designed to support those tasks. Carswell et al53 describe the 'proximity compatibility principle', whereby tasks can be conceptualized as being either high or low in proximity. A high proximity task requires the integration of information from different sources, dimensions, or categories for successful task completion, whereas a low proximity task requires information from different sources, dimensions or categories to be judged independently from each other.
The proximity compatibility principle suggests that high proximity tasks should be supported by high proximity displays and that low proximity tasks should be supported by low proximity displays. A high proximity display is achieved by ensuring that the components that are important for task decision-making are represented in the display in a perceptually similar manner. This can be achieved by presenting them as an integrated object and by presenting them close together spatially or temporally. For example, Robinson et al54 found that a rectangle showing one task component as length and another task component as height was an advantageous way of displaying multidimensional data in a simulated flight task. While research such as this supports the use of high proximity displays to support high proximity tasks, it also makes the point that a high proximity display may result in poorer performance if the task is low proximity, ie, one that requires task components to be judged independently. The application of this principle is relevant in health care, where it has been shown that anesthesiologists' cognitive demand in interacting with a cardiovascular visualization system could be reduced by placing relevant pieces of information close together.55
A number of relevant studies across domains have utilized these human factors principles to be able to improve the decision-making processes of the user. Computer-based alerts, irrespective of the domain for which they are constructed, need to consider the design principles discussed above. In the next section, we describe a literature review we conducted to understand how these principles have been employed in clinical information systems that utilized alerts for providing medication decision support.
Development of a sound alarm philosophy and careful consideration of human factors principles form the underpinnings of effective alarm management. Despite their significance these factors have received less importance in the design of alerts in clinical information systems. We provide a literature-based discussion of how human factors principles have been implemented in clinical information systems. We have considered these human factors principles and have the following recommendations for future alert design.
Anton et al56 described a computerized prescribing system used in the inpatient renal unit of a teaching hospital, where the alerting messages given to the provider were based on seven levels of urgency. An activity dimension was subsumed into the system, whereby depending on the level of urgency, the user was required to execute one or more different actions. Several limitations, both in terms of the nature as well as the structure, existed in the alarm philosophy. First, a single urgency metric was calculated regardless of the type of risk. Second, the logic for the calculation of this metric was not always apparent to the user. Third, the alerting system itself transgressed basic human factors principles. For example, the system described a category of alerts called 'red information'. However, despite the use of the word 'red', the information itself was low priority, and no action was required. Fourth, missing data were categorized as a high priority alert by default, even though, in practice, missing data could be high or low priority. In addition to these limitations, some of the inferences drawn from the study were not based on empirical evidence. The authors inferred that providers with more experience using this system produced fewer alerts, and the decrease in alerts was interpreted as an improvement. Finally, there was no indication of how the alerting system was calibrated in terms of the relative severity of specific prescribing decisions. If the entire system was calibrated conservatively, then presumably acceptable but risky prescribing decisions would decrease as the propensity of the users to generate fewer alerts increased.
In another study, Kilbridge et al57 evaluated inpatient CPOE systems at six medical centers in the USA. One hospital used a CPOE system that was developed in-house, while the remaining hospitals used commercial vendors. These systems were designed to provide alerts for 12 categories of prescribing errors, of which at least 50% were serious prescribing errors. The categories used in this system were: therapeutic duplication, single and cumulative dose events, allergies and cross allergies, contraindicated route of administration, drug–drug and drug–food interactions, four categories of contraindication (patient diagnosis, age/weight, dose-related laboratory studies and dose-related laboratory radiology studies), corollary, and cost of care and nuisance (adverse events with low consequence) alerts. A grading system was developed for these categories, the details of which were not reported in the paper.
Two studies described potentially problematic categories for which electronic prescribing systems should provide alerts. Luo58 described nine categories of events which need to be signaled. These were medication withdrawal, missing data, drug–drug interaction, drug interactions with medications already being taken by the patient, rearranging of priorities by the family practitioner because of the system itself, knowledge gaps by the user, over-confidence in the efficacy of the system on the part of the user, data overload, and problems with the system. The study did not suggest that these situations should form part of the alert philosophy, but simply listed these as possible sources of problems. According to Goundry-Smith59 medication alerts should be provided for the following categories: allergy checking; drug interactions; duplicate therapy/drug doubling; cautions/contraindications; dose checking; formulary/prescribing status; and monitoring warnings.
Taylor and Tamblyn60 identified eight alert categories used by the Medical Office of the Twenty First Century (MOXXI–III) CDS system. In this intervention, CDS was provided to 30 outpatient primary care physicians through a personal digital assistant. The alert categories identified were age-related contraindications, allergies, adverse health contraindications, dosing errors, therapeutic duplication, known patient intolerance, medical interaction, and possible toxicity effects. All of these eight categories were directly related to the drugs themselves. The study showed that different categories of alerts were subject to higher or lower rates dismissal. Users disregard age alerts the least, while ignoring dosing errors and intolerance the most. Alternatively, users demonstrated greater compliance with interaction and adverse health contraindications categories.
van Mil et al61 illustrated 10 care activity codes assigned by community pharmacists to computer-generated alerts. These categories were: interaction; contraindication; allergy; drug duplication; unclear prescription; questionable strength; dosage different from a previous prescription; drug dispensed for the first time; incorrect patient data; and unusual quantity. Most of the categories corresponded to the alerts issued by the electronic system used in outpatient pharmacies.
Alert philosophies might be based on the most common causes of prescribing error. In a study that examined inpatient orders, Bobb et al62 identified the most common types of errors in prescribing: dose; frequency; nomenclature; drug allergy; incorrect medication; omission; duplication; route; and drug interactions. The authors also described a set of provider-related issues which may cause error, such as lack of knowledge of the patient, lack of specific medical knowledge, and mental slips. This study pointed to a general quandary in alert design: how to limit the scope of alert philosophy. For example, should the scope be limited to the patient and his/her drugs or should the scope be expanded to anticipate gaps in the provider's knowledge or compensate for a system's lack of information. Ideally, all of these issues should be considered when the alert philosophy is developed.
Nightingale et al8 described the impact on prescribing behavior of a rule-based CPOE system implemented in an inpatient renal unit. Although the details of the alerting system were not described, the alerts were produced in response to a range of the usual prescribing issues, such as drug–drug interactions, allergies, etc, as well as in response to non-prescribing activities, such as password-related alerts. The data also showed that low priority alerts were much more prevalent than alerts for high priority events. An example of a low priority event would be warning a nurse when he/she attempts to prematurely administer a drug, whereas a high priority alert would fire upon ordering penicillin for a patient who has a known penicillin allergy. When developing an alert philosophy, one must carefully consider the threshold of the alert. Previous studies have demonstrated that systems tend to have a low alerting threshold, resulting in physicians receiving a large number of clinically insignificant alerts. In studying an outpatient CPOE system in hospital-based clinics and community-based practices, Weingart et al10found that physicians justifiably overrode 91% of allergy alerts. Similar to the study by Nightingale et al,8 Weingart et al10 showed that high priority alerts were much less prevalent than lower priority alerts; however, providers overrode nearly 90% of high severity alerts.
In a study describing their experience with the development of the WizOrder system, an inpatient CPOE system developed and implemented at Vanderbilt Medical Center, Miller et al63 described their alerting philosophy with respect to the timing of alerts. The type of alert determined the timing of its appearance in the workflow during CPOE. Rather than firing a drug–drug interaction or allergy alert after a physician has completed a medication order, an alert is fired as soon as the physician first indicates the name of the new medication to be prescribed, enhancing alerting efficiency. On the other hand, following an order for a blood thinner such as heparin, an alert could remind the clinician to order a partial thromboplastin time at the end of the order entry session. Holding such an alert until order completion facilitates a smooth workflow and promotes physician autonomy. Such delayed warnings or 'exit checks' give clinicians the opportunity to correct errors spontaneously and prevents overreliance on the clinical information system to make decisions. In addition, the WizOrder system prevents excessive alerting by generating general non-clinical alerts (ie, alerts advising users of new CPOE features) once and then spontaneously removing the user from the new users list.63 Miller et al63 also described the use of effective placement or 'geographical consistency' whereby the same types of clinical information are displayed in the same areas of the screen in order to draw attention to important warnings.
In general, the studies reviewed showed that there was a lack of uniformity in the logic for generating alerts. This was exemplified by a comparison done by Fernando et al,64 who evaluated four alerting systems and found large discrepancies in alert firing criteria. The study evaluated the safety features of four commonly used primary care CPOE systems in the UK. The discrepancies in alerting arose because of differences in the underlying knowledge bases used in these CPOE systems.
The UK National Health Service Common User Interface Project effectively outlined the general design principles for alerting.65 The study employed alerts for six categories: drug information; drug warning; drug critical; information; warning confirmation; and system critical. Only three of these categories (drug information, drug warning, and drug critical) were related to prescribing—the other three categories of alerts were informational. Informational alerts were used to inform the user that referral details had been sent, while warning confirmation alerts presented the user with information about his or her actions in relation to the system. System critical alerts informed the user of important system features. There are two issues that need consideration in this alerting schema. First, the three system alerts are very similar in design to drug-related alerts, potentially resulting in confusion. Also, this schema entails presentation of three different types of alerts (for allergy, drug–drug interactions, and drug contraindications), each with three levels of priority. This requires the alert to provide information about the category of risk being warned about, as well as the priority of the alert within that category. In this case, we recommend that system warnings be easily distinguishable from drug warnings.
Horsky et al66 described a cognitive walk-though of a provider order entry system for heparin dosing, drawing attention to a number of deficits in the timing and manner of alert presentation. For example, delayed presentation of administrative guidelines decreased their usefulness, and the graphical representation of data was not well conceptualized. Also, a key piece of information, such as the calculated dose for a patient, was embedded in general text about the administration of heparin. This study highlighted the importance of the principles of proximity and prioritization by elucidating the effectiveness of appropriately timing information presentation and of distinguishing urgent information.
A review by van der Sijs et al7 in 2006 considered a number of papers which have looked at the efficacy of alerts. In this study, they found that physicians overrode alerts between 49% and 96% of the time, although the override rates for interactions and contraindications were lower (35% and 43%). Low-level alerts were overridden more often than high-level alerts. The most significant finding, however, was the lack of a systematic standardizing of alerts. This suggests a problem, both in terms of alert philosophy and the design and presentation of the alerts themselves. Van der Sijs et al7 point to a number of reasons for a high rate of alert override, all of which are well known in the alarms literature and have been indicated at various points in this report. The most significant contributor to a high override rate was high signal-to-noise ratios, ie, presenting too many low priority alerts. In addition, textual information lacked brevity. Reasons for a high override rate also included the lack of knowledge about the importance of the alert, suggesting that alerts had not been categorized by urgency and coded by color, size, and use of signal words. The authors describe an effective alerting system to be one that is tailored to either or both the user and the patient, has appropriately prioritized alerts which are designed in a way that can be easily understood by the user.
The content of medication alerts has been well studied within the domain of informatics. Nonetheless, very few studies have focused their attention on how these alerts should be communicated to the end-user. Following this review, we developed a set of actionable recommendations for future alerting systems, summarized in box 1. In the next section, we discuss the implementation of some recommendations and the consequent impact on the use of these clinical systems.
The medical informatics literature suggests that while there is general agreement about the major drug issues for which clinicians should be alerted, there is little agreement on how these alerts should be generated. In addition, studies evaluating the occurrence of alerts suggest that alerts for low severity events are much more prevalent than those for high severity events, and that users override the vast majority of low severity alerts. Few studies have examined the reason for frequently overriding low severity alerts, but it is most likely due to a conservatively calibrated system. Overly conservative calibrations would trigger an excessive amount of non-severe alerts that the user might consider insignificant. Over time, these excessive and clinically insignificant alerts could encourage users to lose faith in the reliability of the system, increasing the frequency of non-severe alert overrides. An alert philosophy which encourages low priority alerts will lead to many more alerts than one that signals for only high priority problems, since the prevalence of the latter is usually much lower. Given that low priority alerts are generally overridden, an important consideration is whether or not they should be included at all, or assigned to an 'information only' category. More research is needed to determine the effectiveness and possibility of causing harm when low priority alerts are not generated in a clinical information system. On the one hand, the removal of these alerts could focus the provider's attention on high priority alerts, while on the other, removing them completely may result in unintended harm in situations where these alerts were meaningful to the provider and the patient in context.
The design features outlined in the UK Common User Interface Project provide a valuable representation of employing human factors principles in alerting. In this project, drug alerts were prioritized into three levels based on severity. The study recommended the following design features: using green, yellow and red to indicate the three levels; presenting the lowest priority information in the periphery of the visual field, but the second and first priority information in the centre of the screen so as to be in the centre of the viewer's visual field; the appropriate use of urgent signal words ('information', 'warning', and 'stop') to differentiate between levels of priority. Finally, alert messages were designed to consist of four components: a signal word; the hazard itself; instructions; and consequences. The standardization of alerts along a common design framework and the use of human factors principles allow the system to alerts users effectively.
Alerts are meant to serve as a safety net for providers, but one key problem with current alarm philosophies is the large numbers of alerts, many of which disrupt workflow and are ignored. Robezieks67 highlights the advantages of providing only high priority alerts in order to minimize interruption of workflow. That study also highlights the frustration caused by interrupting alerts which are not relevant to the specific prescribing. Over-alerting as well as lack of tailoring of the system to the specific requirements of the user, or the specific details relevant to the patient being prescribed for, will not only frustrate the user but will lead to the impression that of the system generates an excessive amount of false alerts, which will in turn degrade the integrity of the system. In addition, prescribing medications is an inherently complex task that requires taking into account the physiological condition of the patient along with characteristics of age, disease severity, etc, all of which might not be accounted for in the alert logic. Future alarm philosophies might take into consideration this complexity by assigning a 'risk level' rather than a simplistic 'true/false' for alerting clinicians.
In general, during alert design, alarm philosophies should consider the characteristics of specificity, information content, sensitivity, workflow, and safe and efficient handling. Alerts should be of clinical significance, denote urgency, and they should be accurate. These recommendations closely follow human factors principles about warning presentation. The studies reviewed determined their alert philosophies in a wide variety of ways. While some complied with basic design recommendations, others were not specific in informing the users about the underlying logic and the consequences of their actions. Designing an alert philosophy should undertake both tasks of outlining the nature as well as the structure of the alerts. Focusing on only one of these characteristics can undermine the effectiveness of alerts.
In this review, we limited our discussion to studies that implemented medication-related visual alerts as this is the most common alert modality used in clinical information systems. Several factors, beyond the human factors principles discussed here, need consideration in alert design. The modality of the alert, medium of presenting the alert, design of accompanying alerts, and the setting in which the clinical information system is implemented all play an important role and require further examination. Future work should explore how alert modality (visual or auditory) would impact acceptance among users because each category has its strengths and weaknesses. While we limited our review to medication alerting, the human factors principles discussed here are applicable to the design of alerts for other types of orders, such as laboratory results, radiology, etc. Also, the design of these non-medication alerts would consequently impact the design of medication alerts. Further exploration is needed to understand how a medium or a combination of mediums for presenting these alerts, ie, pagers, personal digital assistants, phones or other mobile and stationary devices or a combination of audio/visual modalities, may influence alert design. Determination of the optimal modality and medium would depend upon the specific setting in which the clinical information system would be used. Visual alerts may be most appropriate in a setting which is noisy or when noise is particularly undesirable. Also, user response to an alert would be determined by whether other forms of automated decision support are in place. Further research is needed to determine whether specific healthcare settings are better suited to visual, auditory or a combination of modalities, and how alert design can be tailored to suit the needs of the environment in which the clinical information system is implemented.
A number of studies suggest that computerized alerts and prompts can improve prescribing and medication error rates when carefully managed.68–70 However, these alerts are not a panacea, and many implementations may actually be delivering little or no benefit if active management is not undertaken. This is of particular concern with alerts in CPOE systems that employ commercial drug frameworks to generate alert logic. In these systems users have little or no ability to manipulate alert priorities and content.
Studies thus far have focused mainly on understanding the override rates of alerts as a measure of the efficacy of the alert.7 10 71–73 Override rates are accessible and represent a valuable process measure. It will be helpful to assess the relationships between alerts and outcomes.
This review highlights how key human factors principles, such as learnability and confusability, placement, and visibility, etc, have not been adequately considered, implemented or described in the design of alerts in clinical information systems. Despite the usefulness of these human factors principles in other domains, their utility in clinical information systems has not been directly and comprehensively evaluated. While general design principles may be common, their impact on the complex domain of patient care needs further evaluation. Further research is also needed to examine how alert design changes can help or harm the provider's decision-making abilities.
The complex nature of clinical information systems requires careful consideration of human factors principles for future alert design and implementation. A deeper understanding of these design principles in the clinical context might reveal unique characteristics of clinical information systems that cannot be fulfilled by existing knowledge of these principles and might lead to the development of new human factors principles that are specific to the domain of medical informatics.
Despite the wealth of literature and experience available on alert design and implementation, we found that there were major deficiencies in many clinical systems, suggesting that current best practices are not being routinely implemented. Issues relating to what alerts are delivered, and how they are delivered are both extremely important. Addressing these issues requires additional research and stronger consensus by subject matter experts on the criteria that justify alert generation. Additional evidence supporting the 'how' of delivering alerts should be obtained to better inform design and implementation of future clinical alerting systems. Better use of human factors principles in the design of CDS systems demands more attention from the medical informatics community and from health information technology developers.
Funding: This study was sponsored by an NHS grant (principal investigator DWB) and presented in part at the 'Improving Patient Safety' conference organized by the Ergonomics Society in Cambridge, UK, in July 2008.
Contributors: The authors would like to acknowledge the contribution of Ms. Marianne Zachariah who carefully proof-read many versions of this draft and helped with the revisions.
Provenance and peer review: Not commissioned; externally peer reviewed.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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How the Chelsea players rated
9 - Petr Cech Commanded his area with authority and composure, made several outstanding saves and stopped Robben's extra-time penalty even before his shoot-out heroics.
7 - José Bosingwa Abandoned his defensive position with worrying frequency, but settled down as the match progressed and was able to exert some control over Ribéry.
8 - Gary Cahill So outstanding that Chelsea barely missed John Terry, winning headers, making crucial blocks and interceptions that would have made his captain proud.
8 - David Luiz An incredible performance given that he should not have played because of a hamstring injury, making last-ditch challenges and scoring the best penalty.
8 - Ashley Cole Given problems by Robben, but held his own and made several vital blocks. His goalline…

subset: commoncrawl


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I will be in St. Paul for 3 days at the beginning of July. I am on a somewhat tight budget as I just finished grad school, but I'd like to eat as much awesome Twin Cities food as possible while I'm there. I tried searching the board, but since this board covers the entire midwest and the current chowhound search function is difficult, I figured I would just ask.
I'm visiting from Boston and would especially like to eat things I can't get here or that are better there. If there are any regional specialties, I'd love to hear about them. I love Vietnamese, Japanese (esp. hamachi kama and vegetable sushi), pizza (not cracker crust but most other pizza if it's good), duck, and really good bread and baked goods. I tend to not like foods involving lots of cheese or cream, and I love most vegetables.
I'm really excited to finally visit the Twin Cities (I lived in Wisconsin for 5 years without ever going) and check out the awesome food there. Thanks in advance for any suggestions!


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Interwork Technologies is an execution-focused organization. In other words, we pay attention to detail. Our Partners, both Resellers & Vendors, do business with us because it's easy and we keep it simple. From offering flexible credit terms to working on a Saturday morning at quarter-end to close a deal, we go the extra mile and work really hard to earn the business.
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Kitty Rhoades says her experience is a big asset in legislature
Kitty Rhoades said that re-electing her to the 30th District Assembly seat will ensure voters of having an experienced representative with a history of getting things done.
"I've taken on big challenges that are beneficial to our district, but required bi-partisan support," Rhoades said. "I've built those relationships."
Rhoades, who was first elected in 1999, serves on numerous Assembly committees and is co-chair of the Joint (Assembly and Senate) Committee on Finance -- considered among the most powerful in the state structure.
Rhoades gave her thoughts on several questions during a recent interview:
"We need to get the state to live within its checkbook," Rhoades said. "People's incomes are down -- we can't have tax increases when the economy is in a slump. The bottom line is decreased spending."
She said the state can get involved in assisting the economy by keeping jobs in the state and attracting new jobs.
"That will be my mission in the next session -- control spending, keep jobs and attract new jobs," Rhoades said.
"That is the number one issue when we go door to door," Rhoades said. "But keep in mind that people want reform -- not government-run health care."
She said she will work for a simpler system.
"People want affordable premiums and they want to be able to take health care with them (from job to job)," Rhoades said. "They also want a system that is easier to understand -- they don't want government to run it."
She said she has accomplished a number of things related to health care, including work on a package known as IRIS (Include, Respect, I Self-Direct).
The Medical Assistance program benefits the elderly, adults with physical disabilities and adults with developmental disabilities.
Rhoades said the same model could be used in other areas of health care.
Rhoades said the cap came after rapid increases in home values.
"Before the cap, people saw huge increases in property taxes and nothing else had really changed." Rhoades said. "The cap was an effort to keep taxes in line with the ability to pay."
She noted that there is a safety valve.
"Municipalities can use the referendum process to go over the cap.
"The problem is not that we are taxing too little -- it's that we are spending too much.
"The cost of everything is going up. This is not the time to increase taxes on people or businesses -- more business taxes will force them to go elsewhere."
On the other hand, she said tax incentives can be a good tool to get businesses to come to Wisconsin and create jobs. She has been on the battlefront to add those sorts of programs to the state arsenal. The programs include the Innovation Tax Credits, Technology Development Zone Program, Angel Investment Expansion, Capital Gains Reinvestment and Education Tax Credits -- all designed to assist, attract and keep businesses in Wisconsin.
"If we were to remove the 3.8 percent caps (Qualified Economic Offer -- known as QEO), it would have a direct impact on property tax," Rhoades said. "As far as funding education, nearly 50 cents of every dollar the state collects goes into education."
Like municipal budgets, the QEO can be raised via referendum.
Regarding the state aid dilemma facing smaller districts, or districts with decreasing enrollment, Rhoades said, "No matter what formula you have, it will always be tied to the number of students.
"We have helped districts with declining enrollments by extending aid, etc. No one has proposed a different system that is affordable.
"Everyone is willing to look at new ideas -- so far, nothing has been brought forward. In 10 years, no Democrat has introduced a bill to get rid of the QEO."
Rhoades said there are some funding problems, one of which involves the funding of Milwaukee area schools.
"We're spending $80 million a year in Milwaukee for all the wrong reasons -- it's known as the Chapter 220 funding program."
"Government preserves and protects our natural resources," Rhoades said. "In efforts to protect the ground water, I authored the 'pharmaceutical recycling program' currently being implemented in many counties including Pierce County.
Traditionally many people have flushed unused prescriptions and medicines down the toilet in efforts to keep them from misuse. Although well-intended, many of the drugs are now showing up in groundwater.
"For the past couple of years, I have chaired a national task force that addresses this same issue," Rhoades said. "We also provided funding for invasive species grants. With boat launches here in the district, we know how serious this issue has become."
Rhoades said everyone is concerned with the price of gas, and she helped provide funding for renewable energy grants to help find a better, long-term solution to energy issues.
"In Wisconsin we have developed a significant stewardship program, which preserves pristine land for future generations," Rhoades said. "Most recently, we have encouraged the DNR to purchase the development rights of owners wishing to sell, but keep the land in private ownership.
"Experience and a track record of getting things done," Rhoades said. "I've taken on big challenges that are beneficial to our district, but required bi-partisan support. I've built those relationships."
In addition, she believes she has played a major role in getting western Wisconsin recognized in Madison.
"I've been able to get the voices of western Wisconsin heard in the Legislature -- we're able to get things done because people are finding out where we are."
She also said she has built strong bi-partisan relationships in Madison.
"I have a long-term understanding of history and where we want to go," Rhoades said.
Rhoades said the next session will have priorities focused on budget, economic development and jobs.
"Fortunately, this district is in the best position to recover quickly from a slow economy," Rhoades said. "We're close to the Twin Cities and we have colleges and universities which will give us a boost."
Among other things, she said she will focus on increasing the number of jobs and keeping college graduates in the area.
She also would like to reform the Department of Commerce and Forward Wisconsin. She said the Department of Commerce is being unfair in the distribution of funds and that Forward Wisconsin needs to work on recruiting business to western Wisconsin.


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Targeting the poor and smallholder farmers: empirical evidence from Malawi
This paper develops low cost, reasonably accurate, and simple models for improving the targeting efficiency of development policies in Malawi. Using a stepwise logistic regression (weighted) along with other techniques applied in credit scoring, the research identifies a set of easily observable and verifiable indicators for correctly predicting whether a household is poor or not, based on the 2004-05 Malawi Integrated Household Survey data. The predictive power of the models is assessed using out-of-sample validation tests and receiver operating characteristic curves, whereas the model's robustness is evaluated by bootstrap simulation methods. Finally, sensitivity analyses are performed using the international and extreme poverty lines. The models developed have proven their validity in an independent sample derived from the same population. Findings suggest that the rural model calibrated to the national poverty line correctly predicts the status of about 69% of poor households when applied to an independent subset of surveyed households, whereas the urban model correctly identifies 64% of poor households. Increasing the poverty line improves the model's targeting performances, while reducing the poverty line does the opposite. In terms of robustness, the rural model yields a more robust result with a prediction margin ±10% points compared to the urban model. While the best indicator sets can potentially yield a sizable impact on poverty if used in combination with a direct transfer program, some non-poor households would also be targeted as the result of model's leakage. One major feature of the models is that household score can be easily and quickly computed in the field. Overall, the models developed can be potential policy tools for Malawi.
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References listed on IDEAS
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- Ahmed, Akhter U. & Rashid, Shahidur & Sharma, Manohar & Zohir, Sajjad, 2004. "Food aid distribution in Bangladesh," FCND briefs 173, International Food Policy Research Institute (IFPRI).
- Jonah B. Gelbach & Lant H. Pritchett, 2000. "Indicator targeting in a political economy: Leakier can be better," Journal of Economic Policy Reform, Taylor & Francis Journals, vol. 4(2), pages 113-145.
- Wodon, Quentin T., 1997. "Targeting the poor using ROC curves," World Development, Elsevier, vol. 25(12), pages 2083-2092, December.
- Ricker-Gilbert, Jacob & Jayne, Thomas S., 2009. "Do Fertilizer Subsidies Affect the Demand for Commercial Fertilizer? An Example from Malawi," 2009 Conference, August 16-22, 2009, Beijing, China 51606, International Association of Agricultural Economists.
- Grootaert, Christiaan & Braithwaite, Jeanine, 1998. "Poverty correlates and indicator-based targeting in Eastern Europe and the Former Soviet Union," Policy Research Working Paper Series 1942, The World Bank.
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Jun 2nd, 2002 #1----
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A date with the desi http://www.jang.com.pk/thenews
By Asha'ar Rehman
Two organisations recently joined hands to come up with a Punjabi calendar -- as part of a campaign which aims at protecting our heritage
There have been occasions when the desi calendar date given on one Urdu daily has not tallied with the date carried on the masthead of another Urdu daily. This could well be yet another example to prove that the task of promoting all that is indigenous has been left to the English-language newspapers -- newspapers which do not carry the desi-calendar dates.
They include in their columns stories about weather, about how a particular month has been hotter, cooler or wetter than what has been the 'norm' over the years. If you are lucky, there may be some clues thrown around that while it may be a freak year according to the Georgian faithful, the nature 'perhaps' is in perfect harmony with the time and place according to our own calendar as our forefathers saw it. But on the whole, while in the villages the old jantari may still have some say in deciding issues crucial to life, all the average overloaded urban-dweller seems to be interested in is counting the days till the next weekend materialises.
The desi calendar is vital since everything we do and are a part of revolves around it. "Just to give you an example, it determines the time of sowing and harvesting of crops," says Amjad Saleem Minhas, convener of Punjab Naujawan Mahaz. His organisation has recently collaborated with the America-based Punjabi Council in taking out a desi calendar for the year 2059. The calendar has been illustrated by Sabir Nazar "in the colours of the Earth", and carries verses from the collection of famous sufi poets on each page.
Minhas recalls that the Youth Front had decided to publish a desi calendar a decade ago, but despite promises that it will be a permanent feature, the project had to be shelved after publication of only one calendar. This time round, however, he says that the people behind the idea are keen to ensure that there is no let up and the calendar is published regularly. With each copy of the calendar priced at Rs 100, they are expecting that they will make just enough money through these sales to keep the project going.
The people behind the calendar have been active in politics. They have been part of movements, and one constant running through their activism has been protecting our heritage in the face of a modern-day clamouring for change just for the sake of it.
Along with Amjad Saleem Minhas and Haroon, who is the convening secretary of the Punjab Naujawaan Mahaz, the group includes people from various professions all committed to one common ideal. The Punjabi Council comprises names such as Irfan Malik, a former leader of the Democratic Students Federation, and Chaudhry Nazir, who, with a background of activism in Pakistan, is now a member of the Green Party in the United States.
The two organisations have shared the cost -- Rs 57,000 -- of producing the calendar. Valuable help has been provided by Maqsood Saqib, the editor of Pancham, a respected Punjabi journal from Lahore, by well-known Punjabi writer Iftikhar Qaiser who was assigned the job of determining the accuracy of the dates and of course by artist Sabir Nazar who has illustrated the calendar and laid it out with assistance from Ashfaq Ahmed.
"We had to follow an accurate jantari on which to base our calendar on," Amjad Minhas says as he details the process of producing the calendar. "We came across quite a number jantaris, many of which were just the reprints of jantaris available in India. They had one thing in common; contrary to what the poets who have in their verses mentioned Chetra as the first month of the desi calendar, these jantaris all begin the year with the month of Waisaakh. Thus we have also begun our calendar with Waisaakh. But generally these jantaris were published for monetary gains and lacked the accuracy of dates which we were looking for. Finally we decided to follow the Mufeed-i-Alam Jantari."
The exercise has led to a need being felt about coming out with a standard jantari. Not only this, Minhas says the people behind the calendar are now thinking about compiling a Punjabi dictionary for children -- a task which he adds should have been taken up by a university.
"We are striving to create a Punjabi syllabus in two years time. We are working in association with likeminded people in other towns of Punjab and are looking forward to establish small groups all over the province for promotion of the Punjabi language.
"It is much more than a linguistic issue for us. It is part of a greater whole that concerns the people directly," Amjad Minhas explains, saying that the calendar, fulfilling a need as it has, is only the beginning.
How can a man die better than facing fearful odds for the ashes of his fathers and the Temple of his Gods?
Jun 2nd, 2002 #2
Good, the logic goes that as more Punjabis realize the importance of their own language and culture, the more they will let other people breathe.
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Becker 'minimum salaries' far below actual wages
Thinking of running for county office? The Becker County Board set minimum salaries Tuesday for elected department heads.
The salaries are far below what those department heads are actually paid, but if a new person is elected, they can negotiate for a higher salary with the county board -- based on their qualifications for the job, said County Administrator Brian Berg.
The minimum salary for the new auditor-treasurer position was set at $45,000.
Auditor Keith Brekken earns $63,795. Treasurer Ryan Tangen earns $61,697.
The minimum salary for county attorney was set at $48,000. County Attorney Joe Evans earns $107,877. His salary is tied to a percentage of what a district judge makes.
The minimum salary for sheriff was set at $48,000. Sheriff Tim Gordon earns $73,526.
The board set the minimum salary for county recorder at $38,000 per year. County Recorder Darlene Maneval earns $53,560.
All the positions are up for election this November.
Commissioners Bob Bristlin and Harry Salminen are also up for re-election. Both said Tuesday they'd like to wait a few weeks before announcing whether they will seek re-election.
Filing opens July 5 and closes July 18. All positions are four-year terms.
The positions of county surveyor and county coroner are also up for election, but they are not full-time positions and no minimum salary was required to be set, Berg said.
Berg, who earns $94,484 a year, said the board was supposed to have set the minimum salaries in January, because it is an election year, but the issue didn't come up until the board acted March 28 to combine the offices of auditor and treasurer, and a salary needed to be established.
He said he simply took the minimum salaries established four years ago and rounded them up to even numbers.
For instance, the minimum sheriff's salary was $47,653 four years ago and he rounded it up to $48,000 this year.
State law sets minimum salaries at $7,500 per year for the offices of auditor, treasurer, recorder and sheriff, and $7,000 for county attorney, according to a memo to the board from Evans, who had been asked to research the matter.
"The action taken by the board is simply to establish the minimum to be paid for the position," Evans wrote. "This does not mean that the individual elected will be paid the minimum."
The board opted to set the minimum salaries higher than state statute in order to ensure a living wage, but also to have lots of negotiating room if a person is elected that commissioners consider unqualified or only partly qualified for the office.
Brekken, who has announced his retirement effective the end of this year, said there is a risk that setting the minimum salaries so low could discourage challengers from running for office. It could give an unfair advantage to the incumbents, he said.
Berg said incumbents, in theory, will also have to negotiate their salaries up from the minimum if they are re-elected. But in practice, he added, commissioners are not going to cut the pay of department heads that are doing their jobs well.
Berg said it would not be fair to give a newcomer right out of college, for example, the same pay as what a seasoned predecessor made after years on the job.
Brekken said he would have preferred to see the board set the minimum salary 25 percent under what the elected department heads are now earning, with built-in step increases so that in four years a newcomer would be making what his or her predecessor makes now.
That's how it was done when he was first elected auditor, and it worked well, he said.
By way of comparison, here are what other some other Becker County department head positions pay: the highway engineer and human services director both earn $75,920; the environmental officer earns $75,170; the assessor makes $74,420; the housing and economic development director earns $50,421; the natural resources management director, personnel director and zoning administrator each earn $54,540; and the veterans service officer earns $51,708.
Commissioners earn $19,979, plus per diem.


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My wife and I took our two teenage granddaughters to the spa, and we all had a great time. It's very clean, and the staff is efficient and friendly. The complex is huge, with at least 8 big conventional swimming pools. The spa part is...More
Getting you more information on this room
Getting you more information on this room
"1st floor you have your patio area near the pool area but you can hear people outside very easily. 2nd floor..."
"Choose a room away from the waterslide. Lots of happy noisy kids during the day."


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Portable Audio
Party all the time? This portable speaker boasts 50 hours on a single charge
Despite market saturation, portable Bluetooth speakers are still a big deal. Chalk it up to advancements in design, features, style, or a combination of those, but consumers are still snapping up what manufacturers are producing. There's no such thing as too much choice when it comes to accessorizing to one's personal tastes.
Marshall announces Kilburn, their first-ever portable speaker
Marshall Headphones creates some seriously amazing audio products, from their recent Major II headphone to the mighty Woburn speaker. Despite all their classy, retro goodness, they've been missing one type of speaker for quite some time. All that ends now.
TechnologyTell Review: 808 Audio Performer BT headphones
At CES, what interested me most about the 808 Audio Performer BT headphones was their ear cup design. It's different, and it felt pretty good for a quick fit. As a value-oriented entry into the headphone market, these headphones deserve a deeper listen. Design & Connectivity Compared to the abundance of headphones out there that more »
NEOH smart 3D headphones now available for pre-order
If you're an avid gamer, or one who likes to enjoy movies in the quiet comfort of headphones, then 3D Sound Labs has what can be your best unbirthday present ever. Ever. The company has just opened up pre-orders for their NEOH smart 3D headphones on Kickstarter, with deliveries anticipated to commence this summer.
TechnologyTell Review: High Resolution Technologies dSp
While attending CES 2015, I made a point to visit as many audio-related booths as I could. While floating through the upper floors in the Venetian, I happened to pop into the suite for High Resolution Technologies. Why? Because they were playing some fun music loud enough to lure me in (unlike almost half of the other suites on those three floors).
Get your fancy elegance on with Braven's latest LUX speaker
2015 is definitely starting to look like the year set for colors and styles. If you read the second half of my 2015 CES wrap-up, you'd know that when it comes to personal audio, black is outsold by color options. Now, black will always have a place in my heart and on my tech, but it's nice to own other gear with some lively pop.
Theatre Box wireless 3D speaker now available for purchase
Holophonic sound has been around for some time, but only recently harnessed in a small, portable form. The Theatre Box completed its Kickstarter funding goal only a few months ago, and is now available for new customer orders.
CES 2015 Wrap-Up: Trends and expectations (part 2)
Without a doubt, this is going to be a year of the drones. CES 2015 had an area dedicated to drones, and the enthusiasm was neither lacking nor diluted.
Kube Bluetooth speaker cooler keeps you lubricated and entertained
The next time you're drinking with your buds, why not bring the noise and the booze in the same package? That's what Kube, a new product we spotted at CES, proposes.
UE MEGABOOM takes top slot for all things mega at CES 2015
When it comes to products that are mega, there are some pretty badass options out there. First, you've got yourself Mega Man. Then there's also the Nerf N-Strike Mega Centurion. Heck, even the kiddies have Mega Bloks. So when you're Ultimate Ears and want to juice up one of your best-ever inventions, you go mega.
TechnologyTell Review: House of Marley Liberate BT speaker
The Liberate BT is smaller than expected, but it doesn't take away from how cool it looks and feels. There's something about naked fabric, wood, and metal.
TechnologyTell Review: Woojer wearable "woofer"
One of my favorite, most awesome things to feel is the vibrations that come from deep, resonating bass. The bigger the better. Even your standard floor-standing subwoofer is good enough to thunder out sound with that kind of power. You just need the right placement and volume, of course.


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Two men were seriously injured after their car veered off the road and crashed into tree Friday morning in Carlsbad, police said.
Police responded to the single-vehicle crash at the intersection of Tamarack Avenue and La Portalada Drive about 9:50 a.m.
One of the passengers was thrown out of the Cobra sports car and the driver was trapped inside until Carlsbad firefighters freed him from the wreckage. The driver was then flown to Scripps Hospital in La Jolla by medical helicopter and the passenger was taken to the same hospital by ambulance, officials said.
The condition of the two men is unknown and their names have not been released. The cause of the crash is under investigation.


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Mayor Rob Ford continued to seize the spotlight on the ice storm recovery file, accusing his councillor counterparts of "grandstanding" over the weather calamity that has produced a unified front from GTA mayors seeking financial assistance.
A special Friday council meeting recessed for the Sabbath and will reconvene on Monday, despite objections from the mayor that politicians should come in on Saturday to finish talking about the storm's impact and how to pay for the damage.
Bureaucrats estimate it will cost $106-million to recover. With the addition of the July flood, Toronto's extreme weather tab last year hit $171-million, and it only has $30-million in reserves.
At the request of Mississauga Mayor Hazel McCallion, mayors and regional chairs from across the GTA will convene this Friday in Mississauga to discuss a "co-ordinated response" during extreme weather events and "consistent messaging." Mayor Ford plans to attend.
Mississauga is among a handful of municipalities that have already asked the provincial government to declare the December ice storm a "disaster area," so as to access provincial disaster relief funding.
[np_storybar title="What is the Ontario Disaster Relief Assistance Program?" link=""]
It is a provincial program, established in the 1960s, designed to help municipalities, individuals, farmers and small businesses get back on their feet after a natural disaster. It is geared towards smaller, typically rural municipalities that do not have the kind of financial capacity to address an emergency. The program doesn't have a specific amount of money assigned to it, rather the government draws on reserves to fulfill requests. Once a municipality is deemed eligible it is declared a "disaster area." "In determining whether a disaster has occurred, the minister will consider both the cause of the damages, the extent of the damages relative to the financial resources of the city and its ability to cope and fully recover," city officials stated. The tornado that demolished a chunk of Goderich, Ont., received disaster relief funding. In the case of Toronto, a provincial official speaking on background said that the July storm will be taken into account if the city seeks to have the ice storm declared a disaster, but there wouldn't be funding through the program for the flood.
Natalie Alcoba
City manager Joe Pennachetti and Deputy Mayor Norm Kelly say Toronto should do the same. Both officials want the three orders of government to share the cost of both storms equally, so that Ottawa and Queen's Park would pitch in $114-million combined, and the city the remaining $57-million.
The city already asked the province about funding for the July storm, and was turned down.
Mayor Ford questioned the point of asking again, and will put forward a competing proposal at council for $60-million, roughly two-thirds of the municipality's ice storm share. (Toronto Hydro customers will foot the remaining $13-million.)
"I think realistically, we can get $60-million. We're asking for a third, which is fair. We've got thirty mil in the game, that's a lot of money," he said.
At the special meeting, councillors grilled city and hydro officials about the winter wallop that plunged thousands of people into darkness, toppled hydro wires and left a mangled mess of trees. The storm also knocked 19 fire stations and 10 EMS stations off the grid at one point, forcing some on back-up generators. Hydro said that within four days, 225,000 of the initial 300,000 customers had power back.
Still, councillors had pointed questions for the utility, with Paula Fletcher wondering why Toronto Hydro had called some customers to tell them they had power when in fact they did not. Hydro CEO Anthony Haines blamed it on "false positives" in their system. He also conceded that the meter system the utility uses to measure power has a "fundamental shortfall" which is that it tended to not read about 1% of its 700,000 customers, resulting in a level of error.
Councillors also hammered again at the mayor's decision not to declare a state of emergency during the height of the crisis, a move that some allege had to do with him not wanting to relinquish control to the deputy mayor, who has assumed many of Mr. Ford's powers. City staff said that while they had first considered making the declaration, they backed off when they learned that it was not necessary to secure provincial assistance. The city manager said that requests for disaster relief do not rely on an emergency declaration.
Mayor Ford, who was admonished by a councillor for discussing his football pool during the meeting, later questioned councillors' work ethic during the storm.
"This is no more than grandstanding, and they should have been here when we were here. Myself, Denzil Minnan-Wong was here. I wonder where the councillors were? Don't they read what's in front of them?"
Councillor Mike Del Grande said the mayor may have been the person front and centre, but he and his office were busy working the phones and getting an earful from constituents who couldn't reach anyone else.
"I don't know about this grandstanding," said Mr. Del Grande. "I guess a number of people could accuse him of the same thing."
National Post
• Email: email@example.com | Twitter: nataliealcoba


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No sooner was the election over than the administration began the finger-pointing at the UN secretary general, Kofi Annan, who had called the invasion of Iraq "illegal". News was leaked that his son had been a consultant to a company involved with the UN oil-for-food programme, though Annan said he knew nothing about it. The outgoing US ambassador to the UN, John Danforth, was sent out to declare that Annan's resignation was a live issue.
The relevant facts about the oil for food programme were pushed to one side. James Dobbins, the former US ambassador to Afghanistan, wrote in the Washington Post: "First, no American funds were stolen. Second, no UN funds were stolen. Third, the oil-for-food programme achieved its two objectives: providing food to the Iraqi people and preventing Saddam Hussein from rebuilding his military threat to the region."
Then the Post published a story that the US was wire-tapping Mohamed ElBaradei, director general of the UN's International Atomic Energy Agency, in an operation to discover that he was secretly aiding Iran in hiding its nuclear weapons programme. In fact, ElBaradei was working with the Europeans in negotiating a resolution with the Iranians. It was this diplomacy that neoconservatives were seeking to discredit. Compliance with internationally monitored nuclear development of Iran isn't the objective of the neocons; they want regime change, Iraqredux.
The techniques of the permanent campaign, especially negative attacks, recently applied in the re-election contest, are being transferred seamlessly and shamelessly to international relations.
In part, the slash-and-smear campaign against Annan and ElBaradei is the Bush administration's effort to subjugate international civil servants and organisations to its central command. But this episode also reflects the rolling coup of the neocons as they struggle for power, position and policy in a second Bush term.
In the wake of catastrophe in Iraq, they are trying to foster a new conflict with Iran. Even Karl Rove, Bush's political strategist, plays in this arena, with his very own Iran adviser - Michael Ledeen, a sleazy operator on the fringes who was involved in the Iran-contra scandal in which even Oliver North suspected him of skimming money.
At the least, the attacks on the UN serve as a political distraction from Iraq, where 178 US soldiers have been killed since the election. But frontline troops have not been distracted from the reality of carnage. On December 8, they asked secretary of defence Donald Rumsfeld about the failure to provide sufficient armour.
Rumsfeld said: "You go to war with the army you have. They're not the army you might want or wish to have at a later time." He said the soldiers, who were rigging their armour, might be killed anyway. "It's interesting... you can have all the armour in the world on a tank and a tank can be blown up."
Never before has a defence secretary been rebuked by the troops; never has a defence secretary insulted them. Two Republican mavericks, senators John McCain and Chuck Hagel, called for his resignation, but they were whistling in the dark. Rumsfeld's disasters are Bush's. They are of such monumental dimensions that to lose him is to admit failure: he cannot be thrown overboard.
On Wednesday Bush gave honours for failure, with his bestowal of the presidential medal of freedom on Tommy Franks, the former CentCom commander, who allowed Osama bin Laden to escape at Tora Bora; on George Tenet, former CIA director, who jumped on the bandwagon for the Iraq war, informing Bush that the WMD claims were "a slam dunk"; and on L Paul Bremer, former chief of the Coalition Provisional Authority, who disbanded the Iraqi army, among other blunders. Failure will be celebrated as success in the second term.
The farcical unravelling of the nomination of former New York City police commissioner Bernard Kerik as secretary of homeland security further illuminated the administration's methods. The fact that Kerik neglected to pay taxes on a nanny who was an illegal immigrant was a convenient alibi. Beyond his extramarital affairs, secret marriage and love nests, he appears also to be married to the mob - on the take from the Gambino crime family. Yet Bush had been attracted to Kerik's Rambo-like aggression; the White House vetting process seems to be as credulous as the Mickey Mouse Club; and the impulse to cover up instant.
The fall guy is former New York mayor Rudy Giuliani, Kerik's patron. Inadvertently, Giuliani's tainting eliminates him as a moderate Republican pretender to the throne. If only Kerik's foibles had passed beneath the radar, he might have been honoured for any calamity. Thus the risks and rewards in Bush's imperial capital.
Sidney Blumenthal, a former senior adviser to President Clinton, is Washington bureau chief of salon.com


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BacktoBetter FAQs
There is important information on this page that may be difficult to read on a small screen device. You may wish to switch to a larger display.
If you're looking into buying a Solutions policy for your company you will probably have heard us refer to our BacktoBetter musculoskeletal (MSK) rehabilitation service. We often get asked similar questions about the service so we have included the most common questions on this page. Have a look though, and if you still have any other questions we're always happy to talk over the phone, you can call us on 0800 158 5182 quoting reference SME-NAT. Calls to and from Aviva may be monitored and/or recorded.
What are musculoskeletal (MSK) conditions?
MSK conditions are any conditions relating to back, neck, muscle or joint pain, commonly referred to as orthopaedic conditions.
What is BacktoBetter?
BacktoBetter is our market-leading musculoskeletal (MSK) rehabilitation service.
BacktoBetter provides end-to-end case management for your employees, regardless of the treatment path their condition requires – our expert BacktoBetter clinicians will assess the employee and coordinate the appropriate clinical pathway that they need.
BacktoBetter is included as standard on all Solutions policies, as part of core cover, as we believe it is the most clinically appropriate way to manage MSK claims. It also supports your business by managing claims spend responsibly.
For more information read our BacktoBetter flyer (PDF 3,056KB).
How does BacktoBetter work?
BacktoBetter introduces high quality clinical decision-making throughout your employees' claims. Using BacktoBetter means that employees don't need to see their GP, they just need to call us and they'll be connected with one of our BacktoBetter expert clinicians. This makes sure that only appropriate and effective interventions are approved, which means a better outcome for your employees, a well-managed claims spend for you and a positive impact on absence levels.
So if an employee experiences back, neck, muscle or joint pain, the BacktoBetter service is their first point of contact – there is no need for them to see a GP first.
We will then organise for the employee to receive a telephone based clinical assessment with our rehabilitation partner at a time which is convenient for them (we always aim to have this take place within 2 hours of them contacting us to ensure the benefit of early intervention).
From this call, the employee will begin the most appropriate course of treatment for their condition – this could be self-managed exercises (given to them over the telephone and backed up by online support), physiotherapy treatment or referral to a specialist for further investigations and/or treatment.
All of our physiotherapists and rehabilitation experts have a wealth of experience – meaning employees are being supported by someone who really understands their condition.
The Chartered Society of Physiotherapy (CSP) supports this approach to managing MSK conditions.
What are the benefits of BacktoBetter for your employees?
BacktoBetter is a service that can help employees recover better, faster. No matter how complex the problem, the individual will receive on-going clinical support to help meet treatment goals and get better quicker. Early intervention is key in treating MSK conditions, which is why employees will find it a much easier process, enabling them to get treatment as quickly as possible.
- No need to see a GP
- No excess for the employee to pay for physiotherapy treatment (if one applies)
- No impact on physiotherapy if any of the selected out-patient limits are chosen
- Choice of over 1,500 clinics throughout the UK
- A shorter claims journey for employees
- Provides easy access to clinical expertise and a tailored treatment plan specific to their individual condition
- Delivers end-to-end case management, whatever the course of treatment.
What are the benefits of BacktoBetter for your business?
BacktoBetter offers rapid access to a qualified clinician who can help employees deal with musculoskeletal pain.
- A service that complements your wellbeing strategy, offering preventative advice early on, as well as treatment
- There's no need to see a GP. It is quicker and easier for employees to access treatment
- Employees get the right treatment at the right time, which can lead to a faster recovery, reducing workplace absence
- Getting employees back to work quickly is especially important for small businesses, as having key staff off work for any period of time can have a significant effect on your business
- It's an end-to-end service that delivers best practice rehabilitation no matter how complicated the problem is
- It can help lower future insurance costs, as the cost per MSK claim is reduced on average by 15% when managed through BacktoBetter, and can be as much as 30%, compared to unmanaged MSK claims. This is partly down to the fact that only 20% to 30% of MSK claims require further investigations by a specialist through BacktoBetter, compared with 60% of unmanaged MSK claims
- And it encourages happier, healthier employees.


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2017 Hurricane Recovery: Get information about disaster assistance, or find out how you can help.LEARN MORE
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NJ 13367 - SBA Closing Several Disaster Centers in New Jersey
ATLANTA –The U. S. Small Business Administration (SBA) announced today that several Disaster Centers in New Jersey will cease operations due to a steady decrease in activity. The SBA is also encouraging Hurricane Sandy survivors to visit one of the Centers before they close, and reminding them the deadline to return applications for physical damage is May 1, 2013.
Center locations and scheduled closing dates are indicated below:
Atlantic County
Margate Municipal Building
9001 Winchester Avenue
Margate City, NJ 08402
Hours: 9 a.m. – 4 p.m., Mon. – Fri.
Closing: Thur., May 2 at close of business
Cape May County
Cape May County Chamber of Commerce
13 Crest Haven Road
Cape May Courthouse, NJ 08210
Hours: 8:30 a.m. - 4:30 p.m., Mon. - Fri.
Closing: Tue., April 30 at close of business
Monmouth County
Belmar Municipal Building
601 Main Street
Belmar, NJ 07719
Hours: 9 a.m. – 6 p.m., Mon. – Fri.; 10 a.m. – 2 p.m., Sat.
Closing: Wed., May 1 at close of business
Monmouth County
Brookdale Community College
Bankier Library Room 247
765 Newman Springs Road
Lincroft, NJ 07738
Hours: 9 a.m. – 5 p.m., Mon. – Fri.
Closing: Wed., May 1 at close of business
Ocean County
South Ocean County Chamber of Commerce
West Bay Avenue
Manahawkin, NJ 08050
Hours: 9 a.m. – 6 p.m., Mon – Fri., 10 a.m. – 2 p.m., Sat.
Closing: Wed., May 1 at close of business
Union County
Business One Stop Service – The Incubator
320 Park Avenue
Plainfield, NJ 07060
Hours: 9 a.m. – 5 p.m., Mon. – Fri.
Closing: Wed., May 1 at close of business
Survivors may also apply online using the Electronic Loan Application (ELA) via SBA's secure website at https://disasterloan.sba.gov/ela.
Disaster loan information and application forms may be obtained by calling the SBA's Customer Service Center at 800-659-2955 (800-877-8339 for the deaf and hard-of-hearing) or by sending an email to firstname.lastname@example.com. Loan applications can be downloaded from www.sba.gov. Completed applications should be mailed to: U.S. Small Business Administration, Processing and Disbursement Center, 14925 Kingsport Road, Fort Worth, TX 76155.
The filing deadline to return applications for physical damage is now May 1, 2013. The deadline to return economic injury applications is July 31, 2013.
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Internet Address:
Release Number:
Release Date:
Friday, April 26, 2013 - 4:00am
Michael Lampton
Related State:
New Jersey
Field Operations Center: