Difference between revisions of "Optimizing the acceptance of medication-based alerts by physicians during CPOE implementation in a community hospital."

Revision as of 20:06, 6 April 2015

Article review on Optimizing the acceptance of medication-based alerts by physicians during CPOE implementation in a community hospital. ^[1]

Abstract

The article reported that a community hospital with no mandate for system use faces challenges in implanting a CPOE with CDS such as medication base alert. The article added, CDSs are important in benefit realization; however, clinicians may perceive those support systems as deterrent on the clinical workflow. Therefore, to achieve maximum acceptance and successful deployment, the authors monitored “frequency of alert presentation, frequency of “positive response to the alert and physician satisfaction with each of those interactions”. In a response to monitoring the system, implementers had to change different aspects of the alert system so that the system can be adopted smoothly.

Introduction

The article was written as Memorial Health Service System implemented inpatient focused EHR across the organization. Here the goal was to improve patient safety and quality of care through the adoption of CPOE. In the previous system the article described, “medication orders were entered into a legacy order entry system, then printed in the pharmacy and reentered into a disparate pharmacy system.” This process created a great concern to providers considering the amount of error that can be introduced as information transferred from one system to another manually. Besides doctors and nurses didn’t have any medication based alert, pharmacists had only drug- drug interaction alert. The allergy alert was presented for the pharmacist only if that information was reentered manually to the pharmacy system. On the other hand, the new system consists of a variety of medication-based alerts to physician. Meanwhile, the implantation required a thoughtful approach to increase system’s acceptability and usability by physicians in addition to involving them actively throughout the process.

Strategic Decision

Physician steering committee strategic decision

• During the implementation the committee decided to deploy a limited number of alerts so that system acceptability increases while alert fatigue decreased.
• Increase the number and category of alerts as the system become familiar to users.
• Use of the same alert for physicians, pharmacist and other intermediate providers.

The above strategy was to achieve a process that leads to reconsideration or deletion of medication orders at least 25-30% of the time. In an attempt to tackle the target physician steering and medication management team agreed to deploy drug alerts which are easy to understand and have greater impact on a large number of problematic orders, while holding on a more complicated alerts. Further, the steering committee continued fine-tuning medication orders by removing some alerts that are deemed to be inappropriate or inefficient.

Data Extraction and Analysis

According to the article data extraction and analysis included, collecting relevant data such as: “ frequency of alert presentation, action taken on alert presentation, and CPOE utilization statistics.” Those information were analyzed and presented in a form of chart for better understanding of system utilization.

Result

The first six month after deployment of the system, there were high frequency of alert presentation and actions such as removal and reconsideration of medication order ranging form 32.7% to 66%. Besides based on information form system monitoring, adjustment was made on the number, category and display of alerts. However, despite best effort, dose alert response continued to be low, which lead to further adjustment of dosage range for over 1000 drug records. This slightly improved number of alert responses with regard to dosing. Even so over all alert presentation frequency decreased, frequency of order modification continued to grow in acceptable range. On the other hand, frequency of alert display had been source of physician frustration. To tackle this challenge filtering became stringent to focus only on high-risk interactions. As a result of this continuous monitoring and adjustment of alerts, the implementer were successful in managing steady rate of CPOE adoption despite the insertion of new alert categories and other drug interaction notification.

On going challenges and concerns

Some of the on going concerns the authors reported and continued to work on are the following:

• Duplicate drug alerts
• Dose range alerts
• Pregnancy related alerts and
• Drug-drug interaction alert.

Conclusion

The article concluded “ Achieving and maintain an excellent rate of physician adoption of CPOE while implementing real-time medication order-base alert is a significant but not insurmountable challenge.” However, through continuous monitoring and subsequent adjustment on medication order alert, it was possible to attain a decent amount of success rate in adopting CPOE system by physicians. Finally the article noted that such monitoring and changes should continue perhaps for indefinite time in the post-go-live period considering possibilities of having new problems and challenges along the way.

Comments

To attain adequate level of success in CPOE adoption, it is mandatory to maintain continuous monitoring and adjustment of CDS within the system based on feedbacks from monitoring phase.

References

1. ↑ http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC2655789/