Design of Decision Support Interventions for Medication Prescribing

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This is a review for Horsky, J., Phansalkar, S., Desai, A., Bell, D., & Middleton, B. (2013). Design of decision support interventions for medication prescribing. International Journal of Medical Informatics, 82(6), 492–503. doi:10.1016/j.ijmedinf.2013.02.003

Introduction

Horsky et al.’s stated objective in this study is to describe optimal design attributes of clinical decision support (CDS) interventions for medication prescribing, emphasizing perceptual, cognitive and functional characteristics that improve human–computer interaction (HCI) and patient safety.Cite error: Closing </ref> missing for <ref> tag

Designers and developers of health information technology (HIT) need a cohesive, widely accepted and reliable set of industry standards, recommendations and best practices to substantially increase the usability, effectiveness and safety of electronic health records (EHRs) and CDS systems. This report describes design recommendations for CDS interventions that are activated during medication prescribing, such as alerts to drug and allergy interactions, according to Horsky et al. [1]

Background

Horsky et al. performed a background investigation with these findings: There is somewhat scant but increasingly more reported evidence of medical errors, adverse drug events, near misses and other patient safety problems that can be at least in part attributed to failures in human interaction with poorly designed EHR and CDS interfaces. Published reports include descriptions of decreased cognitive performance, medication prescribing errors, unsafe workarounds and poor handling of safety alerts. Existing standards do provide an authoritative source of reference but are difficult to apply by designers without usability training. [1]


Methods

Horsky et al. found from published reports on success, failures and lessons learned during implementation of CDS systems were reviewed and interpreted with regard to HCI and software usability principles. The authors then formulated design recommendations for CDS alerts that would reduce unnecessary workflow interruptions and allow clinicians to make informed decisions quickly, accurately and without extraneous cognitive and interactive effort. [1]

Horsky et al. searched PubMed, Web of Science, PsychInfo, Books @ Ovid and ACM Digital library databases for peer-reviewed articles and trade literature and articles published online by private and public healthcare institutions and usability organizations. The search returned 1544 articles of which Horsky et al. reviewed 421 either in brief (abstract only) or in detail for statements about design, software development or lessons learned from implementation that described positive and negative findings related to specific design characteristics of EHR and decision support systems. [1]

Results

Excessive alerting that tends to distract clinicians rather than provide effective CDS can be reduced by designing only high severity alerts as interruptive dialog boxes and less severe warnings without explicit response requirement, by curating system knowledge bases to suppress warnings with low clinical utility and by integrating contextual patient data into the decision logic. Recommended design principles include parsimonious and consistent use of color and language, minimalist approach to the layout of information and controls, the use of font attributes to convey hierarchy and visual prominence of important data over supporting information, the inclusion of relevant patient data in the context of the alert and allowing clinicians to respond with one or two clicks. [1]

Horsky et al. categorized the research findings with the following headings: reducing excessive alerting, alerts tiered by levels of interaction severity, Interruptive high-severity alerts, non-interruptive alerts for low-severity interactions, filtering of alerts and rule maintenance, alert content, language and typography, visual and perceptual characteristics. [1]

Discussion

Healthcare has been incorporating best practices and proven design principles into IT development at a much slower pace than is necessary to maintain a high level of function and safety for increasingly more complex systems and HIT is therefore often considered as having low reliability, states Horsky et al. Basic HCI standards and guidelines that Horsky et al. review in this report need to be complemented by socio-technical, observational and ethnographic methods to give designers realistic insight into the conditions in which care is provided and the complexities of treating patients with a multitude of comorbid conditions. Safety analyses should not look for a single cause of problems but should consider the system as a whole when looking for ways to make a safer system and avoid unintended consequences of poorly designed HIT. The high rate of drug interaction alerting to even minor possibility of personal discomfort or adverse reaction may in practice counteract the primary objective of CDS to safeguard patients from severe drug injuries.[1]

Conclusion

Horsky et al. highlighted the findings as follows: Alerts should be tiered by severity, have concise text, justification, clear response options, prioritize concurrent alerts, use controlled color sets, consistent terminology, format text to visually associate drug categories, show clinical context data, maintain manageable pick lists, allow multiple entry options and custom order sets.[1]

Reviewer’s Comments

Jonzy’s Comments

Horsky et al. succeeds in its objectives. This article was thorough and informative. The findings of this study should impact all CDS systems in a positive way. I highly recommend reading the entire article. The website link can be found in the references.

References

  1. Cite error: Invalid <ref> tag; no text was provided for refs named Horsky.2C_Phansalkar.2C_Desai.2C_Bell.2C_.26_Middleton.2C_2013