Electronic risk assessment for venous thromboembolism: investigating physicians’ rationale for bypassing clinical decision support recommendations

Abstract

ObjectiveThe underutilisation of venous thromboembolism (VTE) prophylaxis is still a problem in the UK despite the emergence of national guidelines and incentives to increase the number of patients undergoing VTE risk assessments. Our objective was to examine the reasons doctors gave for not prescribing enoxaparin when recommended by an electronic VTE risk assessment alert.DesignWe used a qualitative research design to conduct a thematic analysis of free text entered into an electronic prescribing system.SettingThe study took place in a large University teaching hospital, which has a locally developed electronic prescribing system known as PICS (Prescribing, Information and Communication System).ParticipantsWe extracted prescription data from all inpatient admissions over a 7-month period in 2012 using the audit database of PICS.InterventionThe completion of the VTE risk assessment form introduced into the hospital-wide electronic prescribing and health records system is mandatory. Where doctors do not prescribe VTE prophylaxis when recommended, they are asked to provide a reason for this decision. The free-text field was introduced in May 2012.Primary and secondary outcome measuresFree-text reasons for not prescribing enoxaparin when recommended were thematically coded.ResultsA total of 1136 free-text responses from 259 doctors were collected in the time period and 1206 separate reasons were analysed and coded. 389 reasons (32.3%) for not prescribing enoxaparin were coded as being due to ‘clinical judgment’; in 288 (23.9%) of the responses, doctors were going to reassess the patient or prescribe enoxaparin; and in 245 responses (20.3%), the system was seen to have produced an inappropriate alert.ConclusionsIn order to increase specificity of warnings and avoid users developing alert fatigue, it is essential that an evaluation of user responses and/or end user feedback as to the appropriateness and timing of alerts is obtained.

Effectiveness of clinical decision support in controlling inappropriate red blood cell and platelet transfusions, speciality specific responses and behavioural change

“…Introduction of warnings has an effect on user prescribing in these areas, but this is not sustained. This may be linked to alert fatigue—outside CC and haematology where users do not encounter warnings very often, it is possible that they take more notice of them [ 29 ]. Considering that there is evidence on restricting transfusion in ICU, this is a relevant target for future studies to understand how CDS can create sustained behaviour change in this environment.…”

Computerized Clinical Decision Support: Contributions from 2014

“…However, beyond the quality and the accuracy of medical content, the reliability of a CDSS also depends on the way it is actually used. For instance, Nwulu et al [5] studied physicians' rationale for bypassing CDSS recommendations. In their study, in the domain of venous thromboembolism prophylaxis, alert overriding was measured at 9%, and, in 20% of such cases, CDSS alerts were considered inappropriate.…”

Characterising the impact of pneumonia on outcome in non-small cell lung cancer: identifying preventative strategies

“…The total number of NSCLC patients being treated at QEH within our time frame, both in the inpatient and outpatient setting, were identified through an informatics search for the ICD-10 code C349 and cross referenced for accuracy with the EPR 'prescribing information and communications system' (PICS), a technique which has shown validity in other studies (12). Our study cohort included all patients with known NSCLC who had a UHA to our centre; we retrospectively ascertained clinical and demographic data at admission and during their inpatient stay in this time period.…”