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Published on 17.1.2022 in Vol 9 , No 1 (2022) :Jan-Mar
Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/27431, first published January 25, 2021 .
Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences
Monika Knudsen Gullslett 1 ; Trine Strand Bergmo 1
Article Authors Cited by Tweetations (4) Metrics
Monika Knudsen Gullslett, PhD ;
Trine Strand Bergmo, PhD
Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
Monika Knudsen Gullslett, PhD
Norwegian Centre for E-Health Research
University Hospital of North Norway
Tromsø, 9038
Email: monika.knudsen.gullslett@ehealthresearch.no
Background: Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway.
Objective: The objective of this study is to explore GPs' experiences with the challenges and benefits of implementing eMDD in Norway.
Methods: Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data.
Results: The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD ("Be patient"); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD.
Conclusions: There is a variation in different GPs' needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients' total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.
JMIR Hum Factors 2022;9(1):e27431
e-prescribing of multidose drug dispensing (eMDD); pharmacy; start-up; general practitioner (GP); Norway; digital health; digital tools; e-prescriptions; physicians; qualitative study
Digitalization and the use of electronic systems to manage medication are salient elements in developing future health care services that have a current political, clinical, and research focus [1,2]. With a population characterized by an increasing proportion of fragile and older people and people in need of health care, the use of different types of medication is also increasing [3-5]. Changes in population structures have also resulted in a need to change how general practitioners (GPs) and other health personnel perform their tasks and how patients are medicated [6]. This also applies to the handling of medications for people who have several diagnoses (multimorbidity) and who are thus dependent on several types of medication (polypharmacy) [7-9]. In Norway, among other countries, a recent change has been the introduction of e-prescribing of multidose drug dispensing (eMDD) [10-12]. The goal of e-prescription technology is to contribute to a more conscious and safer use of multiple medications by a single individual [13,14]. It is expected that technology, such as the use of eMDD and other solutions, will reduce duplication of medications, contribute to correct dosages, and reduce confusion among providers and patients [12,15].
What Is MDD, and What Is eMDD?
MDD was introduced in the early 2000s to reduce errors and streamline the distribution of medications in municipal health services [6,8]. The main goal of introducing MDD was to reduce incorrect dispensing, save time for health providers, and reduce the disposal of medications [11,16,17]. MDD is intended to replace pill dispensers and is a mechanical system used by central pharmacies to package medications in small unit-of-use bags, with 1 bag for each dosing time. Users receive a strip with many small bags marked with the patient ID, medication information, and time of ingestion. MDD is packaged and delivered every fortnight. Today, more than 90,000 people use MDD in Norway [18]. Of these, 68,400 (76%) receive service from professional caregivers, 18,900 (21%) live in nursing homes, and just under 3600 (4%) receive multidose drugs by private agreement with a pharmacy [1]. GPs prescribe multidose drugs by listing the patient's medications on a prescription card. This medication list is then printed out and mailed or faxed to the pharmacy. Once a GP signs this medication list, it is valid as a prescription for 1 year.
Errors in the e-prescribing of medication as incorrect medication may be a serious problem [8,19]. Several issues, such as training staff, designing routines, and focusing on the environmental aspects of the practice, are important for avoiding such errors [19]. In Norway, safe digital routines are increasingly being designed and implemented to prevent incorrect medications, improve patient quality of life and safety, and contribute to a more efficient workday for practitioners, including GPs [7]. As part of the digitalization of health services, Norwegian health authorities have begun testing eMDD within the e-prescription solution [20]. In this paper, we focus on the challenges and benefits GPs experience when implementing eMDD.
Today, over 90% of prescriptions are sent to the pharmacy as e-prescriptions [21]. Among the medications still prescribed on paper are multidose drugs; in Norway, the goal is to transfer these to the e-prescription system. Toward this end, the Norwegian health authorities have begun testing eMDD within the e-prescribing system. eMDD means that an electronic medication list and e-prescriptions replace the paper list and fax. The GP sends a list of the patient's regular medications to the prescription database, together with e-prescriptions, as the medication list has no prescription function [22]. The prescription database is a central database where prescribing information is shared between all health personnel with prescribing privileges and all pharmacies. In the eMDD system used by the GPs in our study, an electronic MDD message that includes the medication lists was added to the e-prescriptions. The medication list for MDD is called the "medications in use" list (or just the patient's medication list). The patient's medication list shows the patient's regular medications, medications as needed, dietary supplements, and any critical information related to the medications, as well as recently discontinued medications. To be able to submit an MDD notification to the prescription database, the doctor must first register as an MDD-responsible doctor. The medication lists and e-prescriptions are developed in the GP's prescribing module in the medical record system and sent to the prescription database. The pharmacy can access the information and transfer it to the packing machine for dispensing. Prescriptions are displayed in the prescription database 1 month after they have expired. In the e-prescription system, the responsible doctor and the pharmacy electronically communicate regarding any necessary clarifications. The home care staff receives an e-message notification when GPs make changes to patients' medication lists [19]. The target group for eMDD in Norway is currently patients in municipal nursing and care services. There is some variation in the user groups related to age and, among other things, the use of medications.
Going from paper to electronic medication lists also makes medication information available in the prescription database to medical doctors in emergency rooms and hospitals, making medication information more available during care transitions. Moreover, the GP receives a notification from the pharmacy if there are changes in the medication treatment that have not been initiated by the GP [1].
Studies have highlighted a significant decrease in the number of discrepancies between the medication lists at GPs and pharmacies when eMDD is compared with MDD prescribed using paper and fax [22]. In addition, research related to digitalizing prescriptions has found that health professionals experience the solution as a quality improvement [23]. Results from another study focused on the potential to streamline workflow for health care providers and minimize interruptions from, among other things, the use of phone and fax communications. This study also emphasized that technical standards and system design changes, and more targeted training, may be needed to address barriers to e-prescriptions [24].
Context for This Study
The goal of the digital solution being implemented is to provide a safer system based on electronic routines and updated medication lists. As stated, health authorities expect eMDD to reduce incorrect use of drugs, but research in the field is sparse, and studies from other countries cannot be transferred directly to the Norwegian context due to other systems and routines for eMDD [17]; this study also found that health professionals experience the solution as a quality improvement [17]. Discrepancies in the medicine list are also a challenge in transition between institutions, or institutions and homes, in the processes of admission and discharge from the hospital, and electronic tools may be helpful to avoid or minimize medication discrepancies [25].
eMDD was piloted in 24 GP clinics/offices in the southern part of Norway between 2018 and 2020. As part of this pilot, we undertook a study investigating how the GPs experienced the transition from prescribing MDD using paper and fax to eMDD. This paper presents findings from interviews conducted with GPs in different parts of the country based on the research question, What are GPs' experiences with their challenges and benefits regarding the introduction, implementation, and use of eMDD in their practices?
A qualitative, explorative study using in-depth interviews was conducted in GP practice. The study's methodological approach was based in the social sciences, using an abductive strategy that aimed to uncover—and then interpret—knowledge about the social actors in question [26]. Different research strategies are summarized by Peirce [27]: "Deduction proves that something must be; induction shows that something actually is operative; abduction merely suggests that something may be." The abductive strategy works well with the hermeneutic-phenomenological approach we used in the analysis; moreover, the choice of research strategy was integrated into the study's objectives and the research questions under investigation. In this study, the choice of a hermeneutic-phenomenological perspective means that the researchers tried to achieve an in-depth understanding of the study participants' life-world experiences with the topic of the study and to uncover and interpret knowledge about GPs' experiences with implementing eMDD [28,29]. Even if the data gathering and analysis are done with a reflexive and open-minded view, the researcher's hermeneutic position will affect the results based on the theoretical approach and their preconceptions [30,31].
Selection, Sample, and Interviews
The findings in this paper build on this knowledge and focus on the experiences GPs have related to the implementation and use of eMDD. Experiences from the pilot eMDD and whether the system meets expectations were investigated. The Results section emphasizes the GPs' work situation and patient safety—that the patient receives the right medicine at the right time—and the analysis places the eMDD experiences in light of the complexity it is part of and also ensures patient safety and the correct use of medicines for patients who are prescribed medicines through eMDD. All GPs who implemented eMDD between 2018 and 2019 were invited to participate in the study. A total of 24 GP clinics/offices were involved in testing eMDD during this period. We received contact information for these offices from the Directorate for e-Health in Norway. A total of 26 GPs from 10 doctors' offices agreed to participate, of which 3 (11%) agreed to participate in a follow-up interview. A qualitative, explorative study using in-depth interviews was conducted by both authors to investigate how GPs experienced the introduction of eMDD. A third researcher (EJ) conducted interviews together with researcher TSB.
Two focus groups were conducted, with 8 doctors in each interview and 9 individual interviews, 4 of which were telephone interviews. In addition, 1 GP described experiences with eMDD in 2 e-mails. The GPs had between 5 and 20 patients who used MDD. Some GPs were salaried, while others worked on a contractual basis. Some were interviewed after 2-4 months of use and others after 1 and 2 years of eMDD use; 3 GPs were interviewed again after 10 months of use (these were from GP clinic 6 in Table 1). Both women and men participated in the individual and focus group interviews. The interviews lasted from half an hour to three-quarters of an hour, depending on the informants' information and schedules. The interview locations were conducted either in the GPs' offices or digitally via Skype for Business. Skype for Business was a solution to complete the data gathering after the lockdown restrictions that started in March 2020 due to COVID-19. Before each interview, the authors informed the participants about the project, and the GPs provided both written and verbal consent to participate in the study. The interviews were based on a semistructured interview guide, developed to obtain knowledge about issues related to the implementation and use of new technologies (eMDD). All the interviews began with an open question concerning the informant's experiences with eMDD. To ensure that the research question was covered, the interview guide was used as a checklist during the interviews [30]. In addition to the included questions in the guide, topics raised during the interviews were followed up, when appropriate, to obtain in-depth knowledge related to important issues for the GPs. The main topics in the interview guides concerned:
How the doctors experienced using eMDD
How the doctors experienced the start-up phase
What changes occurred in the GPs' organization of clinical work
What the doctors experienced as positive and as negative
What the doctors felt could be improved
Table 1. Information about participants (N=26) and interview details.
GPa clinic number Participants GPs interviewed, n (%) Interviews Setting Researcher
1 County 1 8 (30.8) Focus group f2fb Urban TSB/EJ
2 County 2 1 (3.8) Telephone interview Rural EJ
5 County 2 1 (3.8) E-mail interview Rural EJ
6 County 3 8 (30.8) Focus group f2f Urban TSB/EJ
7 County 3 1 (3.8) Telephone interview Urban MKG
8 County 4 3 (11.5) Individual interview f2f Urban MKG
9 County 4 1 (3.8) Individual interview f2f Urban MKG
10 County 4 1 (3.8) Individual interview f2f Rural MKG
aGP: general practitioner.
bf2f: face-to-face communication/meeting.
The in-depth interviews were digitally recorded and then transcribed verbatim by a professional company. All the transcribed interviews were saved as files in NVivo (QSR International) to systemize the analysis [32]. Both authors were responsible for the interviews and the analysis of the material and also thoroughly discussed this several times during the analysis process. Both authors read all the interviews. To analyze the data, 4 steps of systematic text condensation were followed [30,33]. The authors first read all the interviews, initially to obtain a general impression and then to identify key themes. The authors read the interviews with special attention to the GPs' experiences during the start-up phase. NVivo was used to systematize relevant text [34] and then discussed and agreed on the key themes, categorized the text, and adjusted it, as needed. The categories were developed through an abductive and iterative process based on the topics in the interview guide [26]. The text was then condensed, analyzed, and discussed further, and finally merged into the revealed themes. The key themes are presented in the Results section, augmented by illustrative quotes.
We used a professional agency to translate from Norwegian to English.
The project was approved by the data protection office (DPO) at the University Hospital of North-Norway (UNN; ethical approval no. 02003). The GPs involved in the study received both written and oral information about the study and were guaranteed anonymity before they agreed to voluntary participation. Information was given explaining that they could withdraw from the study at any time. The data are anonymized in the presentations.
GPs' Experiences and Description of Using eMDD
In this section, the GPs' experiences and description of using eMDD are illustrated by presenting the findings, addressing the following research question: How do GPs experience the introduction and use of e-prescribing for MDD? The findings are represented by 4 emergent analytic themes: (1) start-up with eMDD ("Be patient"; (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD.
Start-up With eMDD: "Be Patient"
Prior to the eMDD start-up, a joint introductory meeting was planned and held with each GP's office, with a video conference with pharmacies, the Norwegian Directorate of Health's IT department, and the GPs and technology suppliers. The objective of this meeting was to review how the introduction of eMDD was to be carried out technically and how the lists were to be submitted. The GPs described this meeting as useful, as was the manual sent by the pharmacy with a description of how the MDD patients should initially be registered. Registration was experienced as the most demanding process, and GPs responsible for several MDD patients reported a considerable uptick in work during the registration process. Shortly after the doctors signed up for the system as the responsible MDD GPs, they could start registering patients and medication lists. Several of the GPs emphasized the importance of having patience during the start-up process.
[You must] be patient with it. And be prepared that you may get a lot of messages from the pharmacy in the beginning. In the very stressful everyday life of general medicine, it can seem a bit like an extra stress in the beginning. But eventually, it becomes just part of the job, and then it becomes much easier. You also get a lot back and forth with the home service regarding medication. Be patient at first.
Some GPs also experienced a number of technical problems when they had to register patients. The technology was slow at start-up, and there was a considerable delay between when the information was added and when it was processed into the database. The GPs found it difficult to get started and described it as a slow system. This was revealed as a major obstacle in their everyday work, as it was not possible to do other tasks on the computers while the system was working on storing information. As a result, a number of GPs opted to spend time on this registration process in the evenings and on weekends.
The GPs' overall experience was that the registration took approximately 20-30 minutes per patient or MDD, reconciling the lists that were in different places (ie, at the pharmacy and with the doctor) and registering responsibility for the medication. Here, ensuring the coordination of lists in advance of the start-up proved to be an advantage. Lists from the pharmacy had been sent together with information about how to start with eMDD a few weeks before, which made it easier to complete the registration.
We first got a list from the pharmacies to know who our MDD patients were, and then we started the process of cleaning up medication lists and preparing. It was really like a pre-release, that. So, it was a long time in advance, so we had the opportunity to start working on it. But it still took a long time. However, you must go through each registration to see if it is correct. So, this took time anyway, even though all the work had been done in advance.
According to some GPs, although there were only a few patients per doctor, they still experienced the job of converting to MDD e-prescriptions as an inconvenient but necessary task.
It is a bit of a job but not something that is unmanageable. What we have to think about is how the information should be provided, because since we have a pilot, we had meetings for this where we actually get paid to show up. That will not happen when this is rolled out, broadly.
It was pointed out that the GPs who have the most patients on MDD will have a tremendous workload in the introductory phase but will probably also be the ones who get the most out of it once the system is up and running. One issue related to the introduction of eMDD was the uncertainty regarding the number of resources required to get started. As the GPs already felt overloaded with a considerable number of tasks in their everyday work life, it was a source of concern that there could be additional workload with a new system. To help achieve a smooth introduction, the GPs suggested that the workload associated with the introduction be made visible.
I think it's very good that when you start a project, it's just the beginning of a change that is for the better, and it's good to know what it entails. I would appreciate the project manager being honest and open and saying something about what to expect when we join.
A clear expectation that emerged from the interviews was that eMDD would contribute to a simpler everyday work life for GPs and increase the quality and safety concerning the handling of medication. Several GPs emphasized that the benefit of such a system is safety: multidose drug prescriptions on paper and the use of fax for communication between different parties was described as a low-functional and old-fashioned system. They noted that the use of multidose drugs was often cumbersome and time-consuming and that it could be difficult to keep track of medications. As such, expectations for improvement were high.
So, a multidose is sometimes terrible, like that in paper form with lots of sources of error and lots of nonsense, faxes, and forms and triple lists and all that, so I ended up having to say no to MDD for new patients, because that scheme was low-grade quality. Getting an electronic multidose [system] has been welcome and something we have been waiting for.
The motivation for several of the GPs was that any time spent getting started with the new system was something they would get back later.
The Need for Training
The GPs had different experiences concerning training to use the new system. Some GPs found that a letter from the pharmacy was sufficient for the start-up process, while others would have preferred to have attended courses. Those who were satisfied with the training using eMDD reported that having specific people (ie, at the pharmacy or technology supplier) to contact when they needed help with something was important. It was also easier for the GPs to become acquainted with getting started in doctor's offices where several others were interested in and had familiarized themselves with eMDD.
It was perceived as a problem by the GPs if there was no access to people who could be available as a resource (ie, those with a deeper understanding of the system). If a resource person was not available, this had a negative effect on implementation. Here, tasking someone with the role of a "superuser," who would get to know everything thoroughly and could be available as a resource for others, was recommended. Moreover, several of the GPs expressed that they had received neither the necessary information nor training and wished that someone had come to the office to introduce the project. A day-long conference with information and training with the project leaders was also recommended.
I wish they were clearer on the information about when it was to begin, and preferably, well, there are quite a few of us who are not too good at data (technology use), so to at least consider whether one can collect or create . . .
The GPs pointed out that those who practiced in offices with fewer employees may have greater problems getting acquainted with new systems if they do not have a large patient base to register in the system. The GPs also pointed to training-related challenges as being rooted in a mixture of pedagogical shortcomings and some technical issues that made the initial workload heavier than it should have been. Here, the need for simple, quality training was highlighted—particularly training that could be undertaken during the workday rather than during the doctors' free time. In the interviews, it emerged that the GPs wanted to learn more about the system: for example, what the pharmacy sees on the screen when the doctor sends something and what the hospital doctor can and should do with the medications being taken (ie, the patient's medication list). The GPs emphasized the necessity of adapting training related to their different needs, especially since there was variation in both their interest in and their desire for the digitalization of MDD. With regard to training, video clips and help from colleagues were highlighted as useful.
Interactions, Safety, and Efficiency
One of the most important tasks when first implementing eMDD is to clean up and update the medication lists with the correct information, and all the GPs described this as a tremendous undertaking. They also explained that it was important to approve the lists, be clear on how dosing takes place, and ensure that this is stated clearly; however, they experienced this as challenging when the system did not work properly.
It was a bit chaotic. We thought we had to delete old papers, and for some patients, there were huge lists of old prescriptions saved. But then we found out that it was possible to update without deleting old papers, and that made everything a little easier.
The GPs described this process as quite labor intensive and, for many, surprising. Several related that they had not been mentally prepared for so much work, even though they had been informed well in advance to update the medication lists. One GP explained:
We had been sent what the pharmacy and the home service had on their lists, so it was up to date, and we thought it was mostly a push of a button. I'm not that computer savvy, and it took a lot of time. It was the use of time that was the problem [. . .] So, there was a lot of work then to start the process of getting an overview of all the lists.
Another one shared:
Yes, so the advice is that you must always have an overview of your patients' medications and that you must enter and clean up the medication lists continuously. It must be "up to date."
GPs described having to spend time cleaning up after hospital doctors who had prescribed new medications without deleting the valid prescriptions that were already in place, as the official regulations state that this is the GPs' responsibility. They, therefore, recommended that there must be an implementation period in which time and resources are set aside for training so that everyone understands the importance of doing this.
GPs described both positive and negative experiences related to interaction and safety when using eMDD. For example, the nursing and care e-messages between GPs and the home care staff were experienced as smart and were defined as a "safety valve" concerning communicating changes in the medication lists. The GPs felt this provided a better overview for all actors with regard to determining the correct medication. However, communicating changes in the medication list to the multidose pharmacy was experienced as more uncertain:
I'm not always quite sure if they got it. It has been—or we have to write physically as a message at the bottom, "I have changed so and so." I have actually experienced that they have not done exactly as I have said.
This challenge was explained as being partly due to a lack of knowledge regarding what the technical aspect looks like at the pharmacy (ie, whether it is physically possible for the GP to make a mistake when sending an MDD list to them). The question is whether it goes to a machine and the machine makes all the mistakes or whether it is the case that a person is responsible for what is to be in each small bag.
Several points emerged in the interviews related to weaknesses in the safety of medication use for patients. A problem highlighted by all involved parts in the medication chain was that there was a big safety gap related to the fact that medications prescribed with e-prescriptions can be picked up twice. The GPs pointed to an example: if an electronic prescription is legal for a year, the system is not structured so that it is locked in the multidose drug list. This means that the patient can pick up the medication by themselves, regardless of what is packaged in the MDD. The pharmacy should be able to determine that the prescriptions have all been picked up, but instead, they are packaged in the MDD, and the user will get double medication. To increase safety and overview for all parties, the GPs thus stated that it is important to emphasize a thorough review of medication lists, structured as part of their everyday workday.
The important thing was to have updated medication lists, that we had to make sure that we did not have any magistral prescriptions, or any reminders we had to ourselves, or that there were messages to the home care staff in the medication lists. Because there were some things we did before to make things work, which do not work at all if you have e-multidose. So, it took a while to clean up those lists.
The Working Day With eMDD
The GPs also had different experiences around the use of eMDD in their everyday workday—this seemed related to whether there were clear lines of communication between all involved parties. One frustration noted by many of the GPs was that changes made to the system were not always registered. They would then receive a message from the pharmacy to discontinue and recall the medication list and prescribe again. One GP shared this experience:
Sometimes, I have tried to discontinue medication 5 times and yet it has not worked. Then the message comes back from the pharmacy, and they write smiley faces and try to be nice to us, and say we are sorry, but you actually have to stop again and prescribe again.
One GP suggested a phone-a-friend approach as a solution to this issue.
There are programs on TV that have an option called "phone a friend." And you can at least do that at least once, so I can tell you that you are allowed to call me in the evening, but sitting together and watching it together, I think that might have solved his frustration and your problem, so probably everyone would have saved time.
Many GPs reported that after the initial start-up process, once the system had been in use for a while, it facilitated a better working day. As one stated,
Errors in the lists—they are not there anymore. So now there is a good flow in our workflow, so it is an integral part of our everyday life that we do not think so much about anymore.
Another GP shared his experience:
I am very happy with e-multidose, it is very good. We can reduce the use of paper—as long as it works, it is absolutely fantastic. So, it's just to make it work, but lately it has been very smooth, so there have been no problems in recent weeks, and very few messages from the home nurse and from the pharmacy. When things are established, it rolls smoothly.
Even if it was a challenge during the implementation phase, most of the GPs welcomed the eMDD:
I think no one really knew what they were getting into, so everyone was optimistic and looking forward to finally dropping the fax and stuff.
In the Results section, we presented GPs' experiences with implementing eMDD, focusing on GPs' information and training needs and their experiences with the start-up process, including the coordination of lists, safety and effectiveness, and changes to their working day [23]. There are variations in different health providers' and GPs' needs regarding training and information and considerable variation in competence and motivation related to the use of digital tools [35]. There were also different degrees of understanding concerning the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge [36,37]. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients' total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.
Previous studies have shown that better availability of patients' overall medication increases patient safety and increases collaboration between different health care providers. In addition, access to a patient's medication list and health information enhances safety and saves GPs time [38]. One reason is the faster updating of prescriptions electronically. One of the most positive things about eMDD from the GPs' perspective, compared to the use of paper and fax, is a better overview of lists and that prescribing can be done immediately and increases the chances of the information arriving [22]. As such, to achieve quality implementation, it is important to develop systems that ensure quality information and training provision at start-up; it is equally important to have quality guidelines in place and technology that promotes interaction between all involved parties and ensures safety for patients [39]. To obtain this, it is important to gain a complete and accurate overview of each patient's medication needs. It is essential that the type of medication and dosage be included in the medication list—this, in turn, ensures professional justification and enhances both the quality of services and the patient's quality of life.
As revealed in the Results section, however, there are still several challenges associated with this. Regarding organization and collaboration, the GPs reported a lack of knowledge about what the medication chain looks like for each individual involved—a source of concern as they felt this could affect both safety and effectiveness with regard to medication management. Another challenge was the delay experienced between when information was added to the patients' medication list and when the system reflected the updates. There are several possible solutions to this issue. This could be an opportunity for hospital doctors to discontinue a medication that should be removed from the MDD list. Increased communication and understanding of deadlines between the various actors, and a good support service related to the digital system(s), such as the technology provider, may ensure right medication. Digitalization helps ensure faster and more secure transfer of information when the technology is implemented in an appropriate way [40]. Research has shown that both GPs and employees in the home care service experience MDD as contributing to quality improvement related to patient overview and safety when patients are taking multiple medications [21]. In this study, the primary attitudes toward eMDD among the GPs were positive; they felt it facilitated better patient safety and was efficient and professionally justified. However, they also emphasized that to create and implement a well-functioning eMDD solution, collaboration between all actors is required. The question remains whether the use of eMDD actually contributes to the realization of gains via increased efficiency (ie, through reducing time spent on prescribing and improving interaction and patient safety). The process of getting started with eMDD was labor intensive for the GPs. However, once they spent the time necessary to establish an updated and correct medication list for each MDD patient, it proved a time saver during their everyday workday and contributed to increased patient safety [36]. Nevertheless, there will always be variations within and between municipalities, GPs, and the specialist service; as such, using eMDD on a broader scale in Norway and other countries will necessitate a focus on ensuring that the digital solutions are implemented with quality information, training and structure, and standardized solutions in place as far as possible.
Implications for Practice
There are some important issues to follow up on in the introductory phase and the scaling-up process of introducing eMDD in GPs' offices. Several of the GPs in this study looked forward to the project's start-up, yet many pointed out that it might be difficult to handle the extra tasks. To sum up, good routines are necessary for training all stakeholders, including GPs, pharmacies, municipal health services, technology suppliers, and patients, where appropriate. Making the appointment of a superuser responsible for eMDD, who can follow up when needed, is also of high importance. It was especially pointed out that a specific contact person for both GPs and nurses at pharmacies when complications occur will ease the implementation [21]. The GPs felt that increased contact and collaboration with the pharmacy could have helped simplify the work. Clear placement of responsibility for solving challenges that arise is also needed; this also applies to support for technology challenges. There must be a provision of extra time to register everything correctly when starting eMDD. Having to do the same task repeatedly was time-consuming and was noted as potentially hindering the GPs' ability—and willingness—to implement eMDD as part of their everyday work lives. eMDD seems like a safer and more effective solution when implemented in the organization for all the included parts. Nevertheless, these data may contribute to a greater reflection on—and discussion about—the current, rapid implementation of electronic prescription of medication in the health services and the challenges that may appear.
Limitations/Weaknesses of the Study and Issues for Further Research
The study was performed during the implementation of eMDD and followed up with a few interviews after 3-6 months to explore experiences with the start-up process of eMDD by the GPs. A potential weakness of the study is its reliance on both physical and digital interviews with GPs. As such, the information derived from the interviews may have been different if the interviews had been conducted in person. Another weakness is related to the use of different interview strategies; however, this may also have strengthened the analysis by investigating both individual opinions and opinions reflected in a group of GPs. We further acknowledge the variation of the GPs' experience with eMDD, with some of them being experienced only for 2 months and others for 2 years, as a limitation.
The literature on the topic is growing but still limited, and more research is needed to develop digital prescription of medication to enhance safety for all included parts, especially the users. Awareness of the hindrances revealed both in earlier research and in this study may strengthen the motivation and establish routines including stakeholders and support from both the pharmacies and the technology provider for launching the digital solution eMDD as a working tool for GPs. There is a need for further investigation, including qualitative research, to build solid and evidence-based knowledge that can contribute to developing tailored handling of medication for multidose drug users. Further research should focus on service users' experiences, cocreation between different stakeholders, and how to scale up the use of eMDD, while ensuring that the use of eMDD is appropriate, safe, and available for end users (patient), next of kin, and health service providers (eg, GPs, pharmacists, and nurses).
The authors would like to thank all general practitioners (GPs) who participated in this study and Elin Johnsen for her contribution to the data collection. This study was internally funded by the Norwegian Centre for E-health Research.
Both authors made significant contributions to the manuscript. The study was conceived by MKG and TSB and was drafted in close cooperation. Both MKG and TSB collected data and contributed to the analysis. The researcher EJ also collected data. The manuscript was written by MKG and TSB, and both authors read and approved of the final manuscript.
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eMDD: E-prescribing of multidose drug dispensing
GP: general practitioner
Edited by A Kushniruk; submitted 25.01.21; peer-reviewed by H Kauppinen, H Imeri, H De Loof, E McCourt, G Carot-Sans; comments to author 28.02.21; revised version received 21.05.21; accepted 27.11.21; published 17.01.22
©Monika Knudsen Gullslett, Trine Strand Bergmo. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 17.01.2022.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on https://humanfactors.jmir.org, as well as this copyright and license information must be included.
Gullslett MK, Strand Bergmo T
JMIR Human Factors ISSN 2292-9495


From the Publisher's Desk: It's a marathon, not a sprint
Posted: April 11, 2015 2298
Teresa Wippel
I'm not sure who coined that phrase, but it's one of my favorites, along with "It's not how you start but how you finish," and "You never learn anything in life unless it costs you something."
I thought about my personal marathon as I was sitting at the Edmonds City Council meeting last Tuesday night, watching the council debate several amendments to the Westgate rezoning proposal, trying not to mentally tack on two-and-a-half hours to whatever time the meeting ended.
When the issues are complicated and take a lot of explaining, that's about how long it takes me to write a news story. When it comes to city council meetings, I'm committed to doing that before I go to bed, because I want our readers to have the news ready to read when they wake up each morning. (A tip: If you sign up for our daily newsletter, using the box on the right side of the home page, our daily news digest is delivered directly to you by 4 a.m. each morning via email!)
The marathon analogy is also a suitable metaphor for running any business start-up and especially an online news site. You have to pace yourself, or burnout is inevitable. That's hard to do when you are covering a lively community of nearly 40,000, where more goes on than you'd expect. Don't believe it? Read our coverage of the car thief who barricaded himself in an Edmonds home Thursday — it drew every TV and radio station from Seattle to our Edmonds Kind of Town.
Fortunately, we have a great team of reporters who usually can jump in at a moment's notice, which is what happened Thursday. I was in downtown Edmonds when the event unfolded (ironic, as I actually live less than a mile from where the thief took refuge) but David Pan and Larry Vogel were on the scene quickly, feeding me photos, video and information so that I could update our readers via the website, Twitter and Facebook. When the day was done, I was proud of the work we did. We may not have been the very first on the scene — I am certain that honor belonged to at least one television station helicopter — but we produced a good product for our local audience. It's not how you start, but how you finish…
My other favorite saying comes courtesy of my late father, Maurice "Mose" Wippel, a lifelong resident of Ellensburg, where he owned a grocery store, sold life insurance and even served a term as mayor. Growing up, every time I made a mistake, he would say, You never learn anything in life unless it costs you something. And he wasn't always referring to money either. Mistakes can cost you a lot of things — especially your time.
I keep my dad's advice in mind as I work to grow this news organization into a sustainable long-term venture. I am not afraid to make mistakes as sometimes that is the only way you learn — as my dad would tell me if he were here today. But you keep trying, and you keep learning.
That's why I am so grateful to those readers who have signed up for a voluntary subscription. It helps us pay our reporters, designers and sales people along with our other expenses. I can't thank them enough for their support.
And I hope you'll consider joining them. All of us here appreciate WHATEVER you can give — $5, $10, $15 a month? $100 a year?
I'll leave you with the first of several testimonials from our regular readers, Darrol Haug, about why they value My Edmonds News.
You'll be seeing (and hearing) more of these in the coming weeks. Interested in submitting your own? Email me directly at teresa@myedmondsnews.com.
I'll close with my new favorite saying:
Have you subscribed yet?
Teresa Wippel, Publisher
carol. schillios says:
what a lovely tribute to your father. And I love your phrase about lessons learned. The "cost" is truly more of an investment in our learning!
Michael Plunkett says:
I contributed to My Edmonds News tonight. It is a great sources of news from Edmonds.


Neopia's Fill-in-the-blank News Source Circulation: 183,771,762 Issue: 473 | 10th day of Celebrating, Y12
Ties That Bind: Part Eight
by merlynia
Harwood never liked Sakhmet. On past assignments, he'd had to pass through it once or twice, and he wasn't so keen on returning. The hot weather, sandy scenery, and shouting merchants hadn't left a good impression on him. Now all he saw it as was a city to rest in, and the one place that held the cure to his curse.
Trekking through the dunes of the Desert took most of the day. Crossing into its borders and finding their way through the vast sands hadn't been an easy task. Harwood was feeling steadily worse, making the journey all the harder. Layla did his best to comfort him, but it wasn't of much use. One night of rest in a damp cave hadn't been enough for the Eyrie.
Close to collapsing when they arrived at the city, the first thing Harwood set out to do was find an inn. He remembered the layout of the city enough to find one fairly quickly. Layla still had a bit of money in her reclaimed bag, and some of it was used to buy them both rooms for the night. Harwood immediately went to his room to rest, sleeping for nearly a day before he was able to be woken. A knock at the door was what pulled him from his sleep, telling him it was finally time to get up.
Harwood opened the door to his room to see Layla, awake and chipper, holding a lumpy burlap sack in her arms. He gave her a groggy stare. "Go away."
"Nice to see you up," she said, marching inside. "How are you feeling?"
"Like I should be sleeping."
"Well, you look like dung. Get over here and eat something."
The Eyrie was reluctant, contemplating throwing her out and going back to bed. That was until he remembered just how hungry he actually was. It felt like forever since he'd last eaten.
Harwood sat at the small table that his room provided, running a hand over his face. "You bought food?"
"I got whatever was cheapest, since we're pretty much broke. That doesn't mean this is all completely edible, though." Turning over the sack, she dumped its contents out onto the table, a wide variety of things tumbling out. Most of it dissolved into clumps of sand, but some of the food stayed in one piece. The food that had survived didn't appear to be very appetizing.
Harwood snatched up the first thing he saw and started eating, regardless of what it was. Layla stared at him incredulously. "Harwood, you're eating a grackle bug."
"And it's not even cooked."
He swallowed. "Would you rather have me starve to death?"
"Forget it," she huffed, averting her eyes and taking a bite out of a ripe tchea.
When the Eyrie had satisfied his hunger, he idly gazed out the window. Down on the streets, the bustle of city life rambled below, merchant's cries drifting to his ears. Harwood wished he had as much energy, but was starting to accept that no amount of sleep would ease the curse's effects.
He blinked, bringing himself back to his room. "Where's the sorceress?"
"I've asked around, but no one really knows where she is. She's just here. I'm thinking that she's in a quieter part of the city, since people are wary of magic. She'd be hidden."
Harwood scowled. "I don't have time to scour Sakhmet."
Layla sighed, leaning back in her chair. It was hard to think up a solution when she was in such an unfamiliar place. However, a grin soon made its way over the Gnorbu's face, an answer dawning on her.
"Then I guess we'll just have to find someone who does know where she is."
-x-x-x-
With nothing but Layla's idea to go on, the two found themselves in the heat of the day, wandering through the dark alleyways of Sakhmet with nothing more than a poorly-drawn map. There were a number of passageways that led to the parts of the city that were better left unvisited, and the Eyrie was soon fed up.
"Are you sure this map is right?" he said, turning the parchment over in aggravation.
"How would I know?" she quipped. "I know that Wocky person wasn't an artist, but it can't be that hard to read. Weren't you trained for this kind of stuff?"
Harwood glared at her. "Weren't you told to keep quiet? We're out of options."
"Let's just keep looking, then."
Harwood grunted, exhausted. The last thing he wanted to do go through every corner of the city. The curse was taking its tolls, leeching off of his strength at every given opportunity. It was even too developed for Layla to lessen its effects with spells. Still, if it meant finding the cure, he'd shove through somehow.
The two tried another alleyway, one they had yet to explore. The further they walked down it, the more Harwood was able to sense a strange foreboding. The path was dark and narrow, more so than the others they had gone down before. The shadows seemed to shift and float around them, and there was something in the air that demanded his attention. It was a presence he'd grown to know all too well
"Magic," he muttered, eyes narrowing.
Layla noticed him tense. "You feel it, too? Something must be going on here. A good sorcerer's power shouldn't feel this sinister."
"Then whose magic is it?" Harwood tried to see if anyone was at the end of the path, but it was too dark to make out anything more than a few meters ahead.
"It might still be hers. Think about how much she went through to keep her home hidden. Maybe this is just a spell to ward off people. We have to keep going."
The Eyrie felt compelled to disagree, but she had a point. Cautious, they continued walking through the murk, their footsteps loud in the silence.
The deeper they plunged, the stranger Harwood felt. The abundance of magic in the air made it seem tangible, almost thick as he breathed it in. He tried to make sense of it, but the more he thought about it, the more muddled his mind became. It took longer than he would have guessed possible, but he soon realized that whatever magic this place possessed had an intoxicating effect. The Eyrie only noticed when it was too late, his movements slowed by the spell that infected the air.
"Stop." The defender halted, grabbing Layla's wrist. "This place..."
The Gnorbu trembled, placing a hand to her forehead, unable to think straight. "A trap?"
Harwood turned to meet the new voice as fast as his body would allow. Behind them, walking out from the shadows, was a Wocky. He showed little emotion, but there was an air of satisfaction and amusement about him.
"You," Layla hissed, realizing him to be the author of their faulty map. "What do you want?"
Harwood gave her a fleeting glance, warning her against any foolish outbursts. By the time she'd spoken, reinforcements had appeared, flanking the Wocky's sides. They blocked the only way out; one wrong move and who knew what may happen. The Eyrie doubted he could simply fly out of this one, too dazed to string very coherent thoughts together.
"Very good." The Wocky observed Harwood's stance. "You know when you've been beaten. I admire that. Unfortunately, that doesn't stop you from trying."
Harwood made an effort to ignore the airborne magic, its effects beginning to further dull his senses. He hooked his steely gaze on the man, trying to keep himself composed. "Who are you?"
"Hm." The Wocky chuckled to himself. "You really don't know? Not even a guess? I suppose names can wait. But for now, I'm afraid, you're my temporary hostage."
It was hard for Layla to remember what had happened after that. The Wocky had shown up, said a few words, and then nothing more. The magic in the air seemed to have drugged her, numbing her to all else. She could vaguely recall someone pinning her hands behind her back, but it was all a blurred mass of memories in her head.
The Gnorbu didn't come to her senses till she found herself being tossed into a dank cellar. She winced as she fell hard on the ground, hearing the iron door slam shut behind her. It took effort to string together thoughts, but the magic didn't clog the air so much now. As soon as she was able to realize what had happened, Layla froze, eyes darting to and fro.
Where was she? Where was Harwood? The Eyrie was nowhere to be seen, and by the looks of it, Layla wasn't going anywhere fast. The cellar she'd be thrown into was a dark, small room, and the one exit available was locked tight. The floor was dusted with straw and loose dirt, and the only light she had to see by streamed through a high, barred window. As her eyes grew accustomed to the weak lighting, Layla discovered that she'd overlooked the most vital thing in the room.
There was another detainee in the cellar, a tall, once-elegant desert Kyrii. She looked exhausted and malnourished, but her gilded bangles and plum-colored garments revealed that she was of high status. Her robes seemed much too big for her now, draped limply over her thin, sunken frame.
Upon witnessing Layla's noisy arrival, the Kyrii didn't show much of a reaction. Her blue eyes cracked open, perhaps with some hope, or just bored curiosity. Her features went from blank to confused, staring intently at the one across from her. She began to sit up, but she lacked the strength, her effort fruitless.
"You," she said, her voice raspy. "You're Layla, aren't you?"
"Yes," the Gnorbu replied hesitantly. "Who are you?"
The Kyrii's eyes skirted across the floor. "I am Isis, sorcerer of the Lost Desert. Or, I once was... I doubt I'll be around for much longer."
Layla's eyes widened. "You're Isis? What's going on here? What happened?" She had so many questions that it was hard not to burden the poor Kyrii with more.
"I can't quite remember when it was, but a Krawk showed up at my doorstep, a while ago. I had no idea of his malicious intentions... he possessed greater skill than I, and he forced me to forge a letter to the Earl of Brightvale. He used a horrid, horrid spell... I'm so sorry for pulling you into this."
"Wait, the letter was..." Layla felt her heart sink. She hadn't really been called to an apprenticeship. Not under the great sorceress. The Gnorbu should have realized the peculiarity of the situation, but she had been too blinded with joy to care. As disappointing as it was, Layla knew it didn't matter right now.
"What did the Krawk want, then? Did he want me, or...?"
"No, he had other things in mind, I believe." Isis sighed wearily. "I don't know much. His thugs managed to trap me down here soon afterwards. Now I wait, watching them occupy my house and fill it with vile magic..."
"Don't talk that way. I'm sure there's a way out of this. Did the Krawk say anything else?"
The Kyrii was silent, searching her foggy mind for answers. "There was one thing... something about a defender, if I remember correctly."
Harwood. "We have to get out of here, and fast." Layla stood to her feet, filled with worry and determination. Whatever was going on, Harwood was in danger, and she wouldn't just sit in a cell and hope he made it out alive.
"I know what you're thinking. But there's no way out. When I was of better health, I tried everything I could to get out. It's useless, child."
Layla set her jaw. "There's always a way out. Are you strong enough to use any magic?"
"I'm afraid not. The spell that Krawk subjected me to drained me of my strength long ago. A curse, it was."
Layla turned in surprise. "A curse? What-"
The Gnorbu was abruptly silenced, hearing the jangle of keys near the entrance of the cellar. The iron door swung open, a small group of the Krawk's henchmen coming into view.
"On your feet," one of them sneered. "We wouldn't want our honored guests to miss the main event."
» Ties That Bind: Part One
» Ties That Bind: Part Two
» Ties That Bind: Part Three
» Ties That Bind: Part Four
» Ties That Bind: Part Five
» Ties That Bind: Part Six
» Ties That Bind: Part Seven
» Ties That Bind: Part Nine
» Ties That Bind: Part Ten
Super n00b- Wardrobe wars pt. 1
Sunny is a new player who has had an account before, but her neopets are all total 'n00bs'...
by blackberry2020
A Champion's Guide to the Habitarium
Follow this simple guide, and your Habitarium will be the envy of the neighborhood!
Also by blue_eyed_tiger_j
by element02


How to Understand the Visual Style of 'Homecoming'
Director Sam Esmail's Amazon series draws from the palette of 1970s paranoia cinema, using framing, camera movement, and sound to create an uneasy, modern (and near-future) world all its own
By Adam Nayman Nov 7, 2018, 5:50am EST
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Ringer illustration
The all-around excellence of Amazon's new 10-part thriller Homecoming has been covered already on The Ringer; not since that show about mean rich guys (I think it's called Succession? Can anyone help me with this?) has an original series gotten so many Twitter-verified writers so excited. Fortunately, the hype is justified, at least on a level of pure craft. The Ringer's Alison Herman correctly describes Esmail's aesthetic as "heavily stylized, filled with split screens, overhead shots, and a constant accompaniment in an intricately composed composite of nail-biting scores," to which I would only add—in case there's any ambiguity—that this kind of audiovisual ingenuity is very much a Good Thing. Even in a year when directors like Atlanta's Hiro Murai have already demonstrated serious chops in the TV format—and even without the knowledge that Esmail is trying to find a way to visualize material that began in podcast form—the Mr. Robot helmer's bravura showmanship is worth celebrating. So how about doing it with some of the same detail-oriented focus that the show has itself? I thought you'd never ask.
The first shot of Homecoming's pilot is also the first opportunity for Esmail and his team to play a game of spot the reference. As the camera tracks back from the aquarium in therapist Heidi Bergman's office, Pino Donaggio's satirically overwrought score from Dressed to Kill plays in the background. The obvious in-joke is that Brian De Palma's 1980 thriller hinges on a plot twist involving a psychiatrist with a secret, and the shot's slow, elegant movement copies De Palma's style.
As the camera locks into place and Heidi prepares to deliver the first line of the show, the blinds on either side of her create a frame within a frame whose dimensions mirror the 1:1 aspect ratio used in the flash-forward scenes. Even within the reality of the show's 2018 timeline, Heidi occupies a narrowed position, suggesting a lack of knowledge despite her authoritative position behind her desk. More importantly, the show's visual signature has been established almost subliminally.
On Esmail's television show Mr. Robot—which he has directed every episode of since the beginning of the second season—he uses canted, eccentric angles to accentuate a sense of sci-fi paranoia. Mr. Robot's cinematography is stylized to a fault. In Homecoming, Esmail's visual arsenal is a little more refined, but he still flexes his directorial muscles through the use of recurring motifs. One of the most striking—and beautiful—of these is his use of overhead shots to establish or reconfigure screen space. At least once per episode, the camera takes a hovering, predatory position, turning the locations—a doctor's office, an outdoor fountain, a high-tech rec room—into semi-abstract canvases.
On a thematic level, these top-down compositions indicate that there's always a more observational perspective available than what the characters can see—in effect, the shots align us with the oppressive power structure that serves as the show's unseen villain.
It's also a 1970s paranoid cinema citation: The images evoke the great moment in All the President's Men when Gordon Willis's camera turns the Library of Congress Reading Room into a swirling mandala, reducing its crusading journalist heroes to tiny dots, as it ascends into the ceiling.
Of all the 1970s American classics I detected in Homecoming's DNA, Alan Pakula's fact-based thriller has the most palpable presence, with multiple allusions throughout the series.
David Fincher was also in love with All the President's Men. His 2007 masterpiece Zodiac riffed freely on its fleet, mobile camera movement and David Shire's mournful music cues. Imitation is the sincerest form of flattery, and Homecoming cozies up to Pakula-via-Fincher in a pair of cute homages to Zodiac. The first is an overhead shot of a van being driven by two soldiers who are momentarily on the run from the Homecoming facility (nodding to Fincher's amazing set piece zeroing in on a cab carrying the Zodiac killer). The second is a parody of Zodiac's already-playful vision of a mail cart carrying a mysterious letter into the offices of the San Francisco Chronicle.
Unsolved Mystery
In both cases, Esmail shows imitative reverence for Fincher's master craftsmanship, and yet both shots also work within the narrative and thematic boundaries of his show.
The escape by van introduces the viewer to the desolate, middle-of-nowhere geography surrounding Homecoming's base of operations, while the mail-cart scene visualizes the delivery not of a poison-pen letter by a serial killer but a far-flung medicinal ingredient whose significance (and threat) will become apparent in subsequent episodes.
The split screen was a favored technique of 1970s filmmakers trying to generate suspense without cross-cutting. In the prom sequence of Carrie, De Palma utilized it brilliantly to delineate multiple points of action in a single location.
In Homecoming, the split screen is used primarily to make the phone conversations between Heidi and her off-site boss, Colin, more visually compelling. Not only do we get to see both sides of the dialogue at all times, but the staging plays up the contrast between the two characters. While Heidi is always shown on the job, her boss is placed in a variety of (increasingly humorous) nonprofessional environments—golfing or attending his daughter's birthday party.
The literal and figurative distance between the characters tells us that Colin is smart enough to orchestrate his plan from the sideline while keeping Heidi in the middle of the action. It also keeps them apart in the 2018 scenes, so that when they come together in the flash-forwards, there's novelty in seeing them within the same claustrophobic, compressed frame. In the last frame below, Colin hangs up on Heidi, and the black space to the viewer's left plays up her sense of abandonment and isolation—trapping her in her own narrow frame with nobody to talk to.
Style for its own sake is a double-edged sword. Shots that call attention to their own cleverness or beauty can just as easily be seen as a way to disguise a lack of substance. Homecoming's most sheerly beautiful images are its top-down perspectives on spiral staircases. These images can be taken as nods to similar compositions in the films of Alfred Hitchcock (especially Vertigo, with its numerous ouroboros-like swirls).
It's also a kind of genre trope: From Kiss Me Deadly to The Exorcist, stairs are often sites of danger and intrigue. In Homecoming, Esmail uses the staircases as reminders about the essentially hierarchical nature of the story, which features characters ascending and descending to different levels of power and understanding, sometimes switching positions in the space of a single revelation. In the first frame, Colin is shown moving up a golden staircase to indicate his upward mobility; in the second, the Department of Defense investigator Thomas Carrasco descends with purpose, visualizing his will to get to the bottom of an intractable mystery.
The relationship between Homecoming's characters and their environments is often quite sophisticated, with various layers of meaning inside even simple compositions. In the first shot below, the camera goes inside the fish tank to observe Heidi and returning soldier Walter Cruz watching the fish.
The effect is that it places them behind glass, hinting that they themselves are occupying a kind of lifelike but artificial habitat in Homecoming's offices. The low-angle shot of Carrasco poring through the archives contains nods to the codas of both Citizen Kane and Raiders of the Lost Ark, and their cavernous storage facilities—each piled high with more boxes than any one investigator could unpack in a lifetime. But it also aligns him with a subordinate-close-to-the-ground position.
Between the boxes looming above him and the Geist pamphlet obscuring his face, he is simultaneously surrounded and dwarfed by information, pinned down within an already narrowed frame. In the third shot, a laundromat washing machine's spinning viewfinder provides a subtly cartoonish visualization of the wheels turning in Colin's mind, as he tries to decide how to manipulate the amnesiac Heidi. It's a quietly hilarious image made stronger by Bobby Cannavale's transparent acting.
In the 2018 sequences, the widescreen frame is often used to emphasize the sheer space of certain locations, including Heidi's office, which is designed and lit to give a sense of organized sprawl. During this session with Walter, Esmail gradually collapses the distance between Heidi and her patient by using successively intimate close-ups, not cutting directly out of the master shot but instead mediating the transition. We only gradually register the incredible shift in scale from the initial shot to the screen-filling close-up of Stephan James's face.
Heidi's increasing sense of closeness to Walter—and her guilt at betraying him through her work at Homecoming—becomes encoded in the scene's editing scheme, which uses classical yet strategically heightened film grammar to generate an emotional effect.
Beyond the suspense of its story line, Homecoming contains a secondary form of tension, which is tied to our wondering about when its two timelines and two aspect ratios will catch up with each other. The outcome to this mystery is arguably Homecoming's best-executed moment.
While searching through Homecoming's former offices, Carrasco (occupying the 1:1 aspect ratio, as always) sees Heidi through a window on the other side of the compound. She's also in the 1:1 aspect ratio, and framed even more claustrophobically through the blinds. A few moments later, she's triggered by a suddenly unrepressed memory, and the frame widens to take in her enlarged perspective. (The French Canadian director Xavier Dolan used a similar gimmick in his 2014 Cannes prize winner Mommy, but don't hold this against Homecoming.) After Heidi's moment of clarity, the 1:1 aspect ratio disappears entirely, creating more space within the widescreen frames for each of the film's characters, including Carrasco, who is freed from his visual prison. It also allows all three of the main characters (Heidi, Carrasco, and Colin) to be shown within the same camera set-up.
One of the most enjoyable aspects of Homecoming is its small scale; whatever the larger implications of its story in terms of memory and trauma—and however high the conspiracy will be shown to reach in Season 2—the stakes are refreshingly low and nonapocalyptic. That modesty is tied mostly endearingly to Carrasco, who is not an elite government operative but a midlevel functionary—a "cog"—whose job is to grease the bigger wheels around him.
Shea Whigham's terse, low-key performance has its own kind of no-nonsense joy, but it's the way Esmail films the character that makes him the soul of the show. We see him entering information in an ancient DOS format (despite the near-future setting). The phrase "Complaint Elevated" represents the early culmination of his character arc: He's sent what he knows up the chain of command.
The shot of him sitting back afterward with what could be a sense of satisfaction or futility—we're too far away to know for sure—once again quotes All the President's Men, specifically its final image of Woodward and Bernstein typing away in the Washington Post offices.
It's too early for them—or anybody else—to appreciate the scope of their achievements, but as usual, Pakula's camera placement fills in the bigger picture. Here, the implication is more sinister. Is Carrasco a cog in the machine, or has he been swallowed up by it?


You are here: Home › News › January Newsletter 2017
CERME Croke Park
G4G European Recreational maths Colloquium
Douglas Buchanan's Maths Outside the Textbook
Welcome to the January Newsletter (just about!). Everyone is settled into the new year by now the Maths Week Team had a busy time at The BT Young Scientist and Technology Exhibition where we had a lots of maths activity to engage the visitors. Once again it was an inspiring experience to see all the young people doing such great work in STEM. It was also great to see the huge crowds (>50,000) attend. We shared the Waterford stand which for 15 years has been one of the busiest stands with all other aspects of STEM on display.
We have also been to the European Colloquium on Recreational Maths which just finished to day. You can see more about this below. Eoin Gill and Sheila Donegan of the Maths Week team are also in the middle of an all-Ireland tour giving the Institute of Physics Tyndall Lecture series.
The January blog on www.MathsIreland.ie is also delayed. It will be livehere in the morning.
There was huge response to the offer of 100 free Irish Maths Calendars. In the spirit of Christmas we sent out almost 200 copies. We hope you are all getting great use from them.
Lecturing Job: There is a vacancy for Maths Lecturer at Waterford IT - details here.
1 -5 February 2017
Congress of European Research in Mathematics Education
Over 800 delegates from all over the world are heading for Croke Park for the tenth Congress of the European Society for Research in Mathematics Education that starts tomorrow and runs to 5th February. CERME 10 will promote the development of mathematics education through intellectual communication and cooperation in the context of thematic working groups, plenaries, poster sessions and congenial interactions. It is hosted by the Institute of Education, Dublin City University. Delegates will find an Irish Mathematics Calendar in their packs and other Maths Week info. We will also have a Maths Week stand there. We wish Teresa Dooley and the rest of the local organising committee and all concerned the very best for the week.
The 5th European Colloquium on Recreational Mathematics – Gathering for Gardner Europe – took place in Portugal last weekend. Speakers from around Europe and North America presented various aspects of recreational mathematics covering predictably various games, tricks and puzzles but also art and music and history. Several presenters also talked about the impact of introducing various aspects of recreational mathematics into educational settings.
As educators we have to cover a curriculum and often Recreational Mathematics can be dismissed as trifling or indulgent, but recreational maths can not only help make mathematics more enjoyable to the student but often leads to very deep mathematics. Indeed many important areas of maths have developed from recreational puzzles and games. Martin Gardner (1914 – 2010) was the inspiration for this and is for many involved in recreational maths, not only because he wrote dozens of books on mathematical puzzles and games, but also because he showed how they could be a starting point for some deep explorations in mathematics. (We celebrate Martin Gardner during Maths Week in the Celebration of Mind.) See here for more about Martin. See some of his puzzles here.
The meeting took place in the Museum of Natural History and Sciences in Lisbon which has a special room exhibiting maths games through the ages and a highlight of the meeting was a guided tour of historical games from conference organiser and expert in the history of recreational maths, Prof. Jorge Nuno Silva of University of Lisbon and the Ludus Association dedicated to the promotion of mathematics.
Several visiting presenters to Maths Week Ireland presented and Peter Lynch of UCD, That's Maths and Irish Times gave a talk on the Power tower. This is the function X to the power of X to the power of X to the power of X and so on to infinity. This function will evaluate to 1 for X=1 might be expected to tend towards infinity for X greater than 1. Peter showed the range of values for which the function converges and how this can be used to construct a fascinating fractal structure. Robin Wilson talked about Lewis Carroll's Pillow Puzzles. David Singmaster related 13 mathematical puzzles found in the Annales Stadenses compiled by the Abbot Albert in the 12th Century. Pedro Palhares reviewed Claude-Gaspar Bachet's 1612 book of problems, pleasant and enjoyable.
Several speakers dealt with classes of problems such as inheritance problems and ménage problems. An example of a classical ménage problem is to find how many ways are there to seat a set of couples at a circular table so that no-one sits beside his or her partner. Another form considers a group of people having dinner every evening. What is the minimum number of sittings before everyone gets to sit with everyone else? Jose Paulo Viana presented ways to solve these types of problems, and left us with a classic one. Rev Thomas Penyngton Kirkman posed this is 1850:
Fifteen young ladies in a school walk out three abreast for seven days in succession: it is required to arrange them daily so that no two shall walk twice abreast.
More here on this problem (incl. solution)
The first solution to this problem was published by Arthur Cayley one of the most important mathematicians in history which should be a salutary message to anyone dismissive of recreational maths.
There were several talks concerned with symmetry related to music, art, tiling and quilt-making.
Colin Wright regular visitor to Maths Week gave a talk on the Doodle Theorem which encapsulated the idea that important mathematics may stem readily from recreational mathematics. This was one of several talks on graph theory. This is the area of mathematics concerned with networks and now extremely important but which arose from puzzles and games such as the bridges of Konigsberg and Hamilton's Icosian Game.
Colin was one of the stars of a performance open to the citizens of Lisbon which also featured Circo Matematico and Mentalist Leandro Morgado.
There were several presenters showing how such activities could be used in education and with children with learning difficulties.
It was great to meet up with former visitors to Maths Week and to meet potential future visitors. It was great also to see the energy and creativity in mathematical promotion in Portugal.
We plan to create more resources around the use of recreational mathematics in formal and informal educational settings this year.
Northern Ireland Science Festival
With over 100 events across 25+ venues, the NI Science Festival offers a stimulating and wide range of events focusing on the wonders of science, technology, engineering and mathematics. These events present some of the best scientists from NI and beyond to discuss their work, cutting-edge research and what the future might hold. Click here for more details.
Maths Counts 4th annual national conference for all post primary mathematics teachers. Click here for more details.
4 - 10 March
Engineers Week. Click here for more details.
SciFest @College
The closing date for entries to SciFest@College 2017 is Friday 10 March 2017 except in the case of SciFest@NorthWest in St Mary's College, Derry, where the entry date is Friday 12 May 2017.
The dates for each regional event are available here.
Make sure you keep us updated on your events and activities.
You can find us on Twitter @mathsweek or Facebook.
Douglas Buchanan
Beyond The Text Book
No I have not lost my marbles repeating the heading of my newsletter. In my 36 years of primary school teaching whether it be a class teacher or specialist teaching maths to 7 to 13 year olds we are all grasping for new tools to enhance our teaching. Examples like basic strip film where you project one image then another, projectors in general (slides and film), the spirit duplicator which led to the Gestetner printer (with the wax sheets) and subsequently the photocopier. These tools brought about the worksheet revolution where many made huge amounts of money was made producing inane exercises. Then came the electronic evolution …. enough said on this!
However, when we look at maths teaching on a whole (I know most of my readers are the converted) the dear old textbook is the Bible which is used to inspire pupils in this subject. Has maths teaching really moved forward since you or your parents were at school. Probably not really.
My friend, Andrew Jeffrey, has written a piece on his website- click here about maths teaching and the textbook – an interesting read – click here.
Feeling Dotty
Below are guides to activities to help special awareness, create patterns using dots.
Squares – a very old activity using a network of dots in a square or rectangle and players take turns in joining the dots. When a square has been formed the player receives a point. Click here.
Connecting dots which form a circle – this is a comprehensive guide to this activity which can involve a wide age range of pupils. Click here.
The class maths table
This is the second in my series of setting up a maths table for the pupils' use in their recreational time and wet break times.
· Paper and pencil activities. Layout a series of puzzles for the pupils (change them frequently and only one type of puzzle at a time). The ideal resource website ishttp://krazydad.com. The best ones are Kids Puzzles, Sudoku, Mazes, Kakuro, Inkies (KenKen).
· Memory games. The classic card game (Pelmanism). Click here.
· Packs of cards with card game instructions. Domino cards, Comet. Click here.
The frequent change of activities will keep the table 'fresh' and interesting.
Q: What did the triangle say to the circle?
A: You are pointless!
Puzzle for the month: The Fencing Problems
I wish to fence in a perfectly square field which shall contain just as many acres as there are rails in the required fence. Each hurdle, or portion of fence is seven rails high, and two lengths would extend one pole (sixteen and a half feet) – that is to say, there are fourteen rails to the pole, lineal measure. What is the size of the field?
Do remember this puzzle was taken from a very old book!
Activities galore! Click here.
There are many activities, all practical, to enhance the teaching in the younger year groups – nursery to Year 5. All the items are obtainable at a low cost so it will not affect any budgets. If you are looking for cheap, good quality playing cards do visit the following website: https://www.mxwholesale.co.uk. Ordering about 96 packs will cost less that 50p a pack and I am sure your will be able to sell the excess at a school fair for about 75p
The Fencing solution
28 miles square. There would be 501 760 acres and the same number of rails.
Hope you have an enjoyable term.
See more on Douglas' website http://www.dcbeagle.com/
Feed back or contact Douglas at douglas@dcbeagle.com
To Contact Maths Week with feedback or queries please email mathsweek@wit.ie
Maths Week 2016 schools registration closed. Maths Week 2017 registration will open in August
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