Kuperman GJ et al. 2007 "Medication-related clinical decision support in computerized provider order entry systems: a review."
Reference
Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 2007;14(1):29-40.
Abstract
"While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers."
Objective
"To outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed."
Size
unknown
Type of Health IT
Decision support system
Type of Health IT Functions
"We divided the CDS categories into two stages - basic and advanced... In basic CDS, we included drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-disease contraindication checking, and drug-pregnancy checking."
Workflow-Related Findings
"Excessive drug-allergy alerting in clinically irrelevant circumstances is highly prevalent and a major disruptor of clinicians' workflows."
"In one study, physicians accepted less than 20% of drug-allergy alerts. Another study showed that almost all overrides of alerts were clinically appropriate and that overrides rarely caused serious adverse outcomes. A major reason for over-alerting is that drug prescribing knowledge bases often include drug-allergy rules that are of questionable clinical value."
"Drug-allergy checking is inconsistent across CPOE applications and major shortcomings plague many drug-allergy checking features. For example, some applications do not require structured, coded entry of allergens and allergic reactions. Drug-allergy checking then becomes close to impossible.... Also, many applications do not distinguish between a drug allergy and a drug sensitivity, depriving the physician of important information when faced with difficult, limited therapeutic options."
"Providing constrained lists of dosing options both delivers dosing guidance and improves user acceptance of the system by enhancing workflow."
"Three studies evaluating reasons for pharmacist interventions after CPOE implementations identified increases in duplicate therapy events--presumed to occur after prescribers ignored duplicate therapy alerts."
"Clinicians do not consider most serious drug-drug interaction messages as meritorious of a change in behavior, and perhaps deservedly so. In one study, adverse consequences almost never occurred even when the highest level drug-drug interactions were overridden. However, some clinically relevant drug-drug interactions will occur and such important messages may be buried in a sea of unimportant messages."
"The ability to customize commercial systems' alerts is very crude because vendor-supplied software allows limited flexibility for modifications, for example, by selecting from only a few predetermined, broad severity levels."
"Another limitation of drug interaction alerting is faulty warning design. Screens or pop-up windows may fail to clearly convey the intended message, and confuse the clinician. Alerts should present the names of the interacting drugs, a brief (one-line) description of the interaction, optional links to more detailed information, and a menu for potentially appropriate actions in response to the alert."
"Even in CPOE with basic dosing CDS (standard default lists for medication doses and frequencies) researchers found a 55% decrease in serious dosing errors and a decrease from 2.1% to 0.6% of doses exceeding the recommended maximum dose."
Study Design
Other
Study Participants
Based on discussions during a CPOE conference held in June 2005, the authors "selected papers that reflect exemplary current practice and have direct actionable relevance to system designers working to implement these features in today's technical environment. We also identified papers that illustrate the limitations of today's technology and can help point the way forward for future developments in the field." The number of papers selected is not discussed.