While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.

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.

The computer-based monitor identified fewer ADEs than did chart review but many more ADEs than did stimulated voluntary report. The overlap among the ADEs identified using different methods was small, suggesting that the incidence of ADEs may be higher than previously reported and that different detection methods capture different events. The computer-based monitoring system represents an efficient approach for measuring ADE frequency and gauging the effectiveness of ADE prevention programs.

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Background: Computerized order entry systems have the potential to prevent errors, to improve quality of care, and to reduce costs by providing feedback and suggestions to the physician as each order is entered. This study assesses the impact of an inpatient computerized physician order entry system on prescribing practices.

A b s t r a c t Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians. Computerized prescribing applications that embed clinical decision support systems (CDSS) within computerized provider order entry reduce medication error rates both by structuring prescriptions and by checking them for potential problems such as drug interactions, allergies, and other issues.1-9 If a potential problem is found, the CDSS can provide clinicians with real-time alerts, allowing the clinician to make appropriate changes before the prescription is finalized.While computerized prescribing applications are commercially available (either as stand-alone applications or as part of an electronic medical record), these systems may not be as effective for improving safety if clinicians override clinically important alerts. When the threshold for alerting is set too low, clinicians are inundated with alerts of low clinical significance, leading to high override rates and the potential to override even important alerts. [10][11][12] In one inpatient study, Payne et al. 10 found an 88% override rate for drug interaction alerts, and a 69% override rate for drug-allergy alerts. Similarly, Weingart et al 11 found ambulatory physicians overrode 91% of drug-allergy alerts, and 89% of high-severity drug-drug interaction alerts.

Several analyses have detected substantial quality problems throughout the health care system. Information technology has consistently been identified as an important component of any approach for improvement. Computerized physician order entry (CPOE) is a promising technology that allows physicians to enter orders into a computer instead of handwriting them. Because CPOE fundamentally changes the ordering process, it can substantially decrease the overuse, underuse, and misuse of health care services. Studies have documented that CPOE can decrease costs, shorten length of stay, decrease medical errors, and improve compliance with several types of guidelines. The costs of CPOE are substantial both in terms of technology and organizational process analysis and redesign, system implementation, and user training and support. Computerized physician order entry is a relatively new technology, and there is no consensus on the best approaches to many of the challenges it presents. This technology can yield many significant benefits and is an important platform for future changes to the health care system. Organizational leaders must advocate for CPOE as a critical tool in improving health care quality.