Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review
Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review Gilad J. Kuperman, MD, PhD, Anne Bobb, RPh , Thomas Payne, MD, FACP , Anthony J. Avery, MB, CHB, DM , Tejal K. Gandhi, MD, MPH , Gerard Burns, MD, MBA, FACS , David Classen, MD, MS, David W. Bates, MD, MSc J Am Med Inform Assoc. 2007; 14:29-40
This group gives a nice overview of where Clinical Decision Support (CDS) stands now when it combines with Computerized Provider Order Entry (CPOE). The authors go on to describe where the friction occurs between clinicians and the systems, and where research is needed to smooth, improve, and make safe the interaction.
Clinical Decision Support exists at two levels, basic and advanced. Basic CDS usual covers simple drug ordering and the primary drug-drug, drug-allergy, and duplicate drug order checking. Advanced decision support includes functions such as dose adjustment for age, weight and laboratory parameters, and total day or lifetime dose checking for drugs such as chemotherapy drugs. Advanced CDS may also include ‘corollary’ orders for certain drugs or procedures. Advance decision support may also include antibiotic choices for infections, but this borders on linked information.
The authors then explore the problems of CDS as it exists now. Excessive irrelevant alerting “is highly prevalent and a major disruptor of clinicians workflows.” (1) One study looked at “drug allergy alerts based on whether they were ‘definite’ or ‘possible’, [and] found that both groups showed decreasing compliance, from approximately 51% to 27% (definite alerts) and from 46% to 20% (possible alerts)”(2) over time.
Clinicians are trained to think in certain ways. They have their own knowledge and their own way of organizing knowledge. Designers of EHRs do not know how to fit alerts and warnings into the knowledge base and how best to present information from the computer.
One of the most frequent and least useful class of alerts is duplicate drug warnings. These can fire when inpatient drugs are reordered from outpatient drug lists, when a drug taper is ordered, when basal and coverage insulin is ordered, when analgesics are combined and when topical and oral meds are ordered. These sorts of alerts “interrupt clinicians’ workflow and cause frustration when the ‘duplicate’ was already considered. Excessive inappropriate alerting may lead to desensitization to all classes of alerts” (1)
The most useful part of the article is the ‘recommendations for future work”.
Provider organizations should decide how to present different sorts of alerts for highest effectiveness and monitor the affects of the alerts in their systems.
Application vendors must design alerts to be the least interrupting to clinician workflows and vendor tools should allow customization that endure through each new version of the product.
The knowledge base vendors should also allow customization of the database and allow retention across upgrades. Alerts should be “concise and actionable”. The alerts should be linked to the evidence.
National policy makers need to enable sharing of CDS. Now each provider organization has to produce its own, literally reinventing the wheel. Ownership needs to be worked out and a national databank needs to be developed such as by the NIH or the National Library of Medicine.
The authors’ most specific list of recommendations is for the research community, from programmers to behavioral scientists:
To what extent does alerting impact on clinician behavior and patient outcomes? What is the optimal way to present alerts to prescribers? How can clinicians’ sense of satisfaction with alerts and other kinds of decision support be increased, i.e. so clinicians find decision support useful and not annoying? When does “alert fatigue” happen? What is the best way for organizations to share alert knowledge? How can commercial medication knowledge bases be edited to yield clinically valuable knowledge bases? Where there are multiple presentation modes, which mode is most appropriate for any given alert? Which member of the health care team -- for example, physician, nurse, pharmacist, other – is the best recipient of any kind of alert? Should physicians and pharmacists see the same drug-related alerts? (1)
(1) Gilad J. Kuperman, MD, PhD, Anne Bobb, RPh , Thomas Payne, MD, FACP , Anthony J. Avery, MB, CHB, DM , Tejal K. Gandhi, MD, MPH , Gerard Burns, MD, MBA, FACS , David Classen, MD, MS, David W. Bates, MD, MSc . Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review. J Am Med Inform Assoc. 2007; 14:29-40
(2) 11 Abookire SA, Teich JM, Sandige H, Paterno MD, Martin MT, Kuperman GJ, Bates DW. Improving allergy alerting in a computerized physician order entry system. Proc AMIA Symp. 2000; 2-6.
Computerized provider order entry (CPOE) with clinical decision support (CDS) can improve medication safety and reduce medication-related expenditures. To understand the medication-related benefits of CDS within CPOE to improve medication safety, efficiency, and health care quality, the authors reviewed the common categories of medication-related CDS within CPOE. For each category of CDS, the author considered: how does it work? What is the potential benefit? What are the results that document the benefits and/or harms? What are outstanding issues that prevent the benefit of CDS within CPOE? What are future steps that may help the improvement of CDS? For each category of CDS, the authors made recommendations for how the effectiveness of the feature can be optimized and recommendations to healthcare organizations, software vendors, policy makers and researchers for how to advance the delivery of effective medication-related CDS.
The authors divided the CDS categories into two stages:basic and advanced.
The basic CDS includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug– drug interaction checking.
- Drug-Allergy Checking
Potential harm to patients can occur if allergy checking is inadequate—either by missing important alerts or by generating so many unimportant alerts, i.e., over-alerting, that clinicians ignore even important alerts. The authors recommended: allowing clinicians contributing to a common allergy database, requiring a coded allergen and coded reaction for allergy documentation, including evidence-based cross-sensitivity checking, including “reverse allergy checking”, improving specificity of alerts and allergy data quality to avoid over-alerting, analyzing the override reasons, require clinician provide coded override reason and encouraging research that may improve the effectiveness of drug-allergy checking.
- Basic Dosing Guidance for Medications in CPOE
CPOE with CDS can improve medication dosing through offering the clinician a list of patient-appropriate dosing parameters for each specific medication, provision of lists of pre-defined complete order sentences, and reviewing the order (invisible to the user, by algorithm) after obtaining the user’s dosing parameters, and to alert the clinician only when reasonable dosing parameters have been exceeded
- Formulary Decision Support
Recommendations for making optimal use of formulary decision support include considering CDS for medication substitution, Strong P&T support and good communication, screening recommendations with expert clinicians first, including link to information describing institution-specific guidelines for restricted medications, pharmacists’ review on a frequent periodic basis the ignored formulary alerts, and educating the users on Formulary changes, New FDA safety alerts and medication shortages.
- Duplicate Therapy Checking
Recommendations for best duplicate therapy checking practices include customizing duplicate checking to decrease the number of clinically insignificant alerts and firing duplicate alerts selectively
- Drug–Drug Interaction Checking
The limitations of this category are large numbers of clinically insignificant alerts and important messages that are clinically relevant may be buried. Override rates should be monitored to measure the impact of alerts and better user interface may enable better-informed and more appropriate responses.
The 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. Advanced medication-related CDS should only be implemented only after basic CDS is in place.
- Advanced dosing support for renal insufficiency and geriatric patients
Recommendations are determining the most effective way to deliver dosing decision support, developing robust dosing knowledge for the general population as well as special populations (pediatrics, geriatrics, oncology, renal impairment), increasing compliance with dosing suggestions, identifying medications that are most likely to be incorrectly dosed and/or have narrow therapeutic windows, better disseminating dosing knowledge broadly, better reconciling when multiple factors are present that may impact on optimal dose.
- Advanced Guidance for Medication-associated Laboratory Testing
CDS related to medication monitoring could be improved by carrying out reviews and primary research, reviewing and updating monitoring intervals whenever new evidence occurs or when specified inter-review intervals elapse, and improving alerting capabilities to detect when patients are overdue for testing and to notify the patient or clinicians appropriately.
- Advanced Checking of Drug–Disease Interactions and Contraindications
Advanced drug-disease interaction and contraindication alerts can be improved by developing a standardized, comprehensive source of contraindication information, building consensus among healthcare organizations about which contraindications to include in CPOE systems, and developing methods to ensure that all patient “triggering” morbidities for contraindications can be accessed by CPOE systems during ordering sessions.
- Advanced Drug–Pregnancy Alerting
Drug-pregnancy decision support should focus on improved methods and standards for electronic health records to indicate pregnancy or pregnancy related issues and better delineation of when to interrupt the provider with specific alerts.
Recommendation for future work
The authors provided recommendation for future work.
- Recommendations to Healthcare Provider Organizations: Healthcare organizations should actively adopt medication-related CDS safeguards. Each organization should have an appropriate organizational structure and personnel for medication-related CDS implementation and also monitor its effectiveness.
- Recommendations to CPOE Application Vendors: Vendors should be especially attentive to the user interface (UI) for clinical decision support, support the development of more detailed knowledge bases, implement knowledge management tools for their customers’ use, and encourage the research required to improve the quality and breadth of currently available drug information databases.
- Recommendation to Drug Information Knowledge- base Vendors: Drug information knowledge-base vendors should work with CPOE and pharmacy system vendors to implement knowledge management tools. knowledge-base vendors should try to create clinically meaningful, pragmatic knowledge that can be applied at the point of care.
- Recommendations to Policy Makers :policymakers should provide support to create a single national repository of executable medication-related alerting rules.
- Recommendations to Research Community: there are plenty opportunities in the area of clinical decision support research such as the extent of impact of alerting on clinician behavior and patient outcomes, the optimal way to present alerts to prescribers and can clinicians’ sense of satisfaction with alerts etc.
In summary, the complexities of CDS require multiple stakeholders in the healthcare system (government agencies, knowledge-base and application vendors, healthcare providers, pharmacies, researchers and informaticians) will need to collaborate to make medication use as safe and effective.
The authors of this review discussed the common categories of medication-related CDS within CPOE and provided a literature-based summary of the discussions. The selected papers reflected current practice and have direct actionable relevance. The issues they have identified and the recommendations they made would be used as a great reference and guide for the practice and research for medication-related CDS within CPOE.
Kuperman, G. J., Bobb, A., Payne, T. H., Avery, A. J., Gandhi, T. K., Burns, G., ... & Bates, D. W. (2007). Medication-related clinical decision support in computerized provider order entry systems: a review. Journal of the American Medical Informatics Association, 14(1), 29-40.