Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

Abstract

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.

Reducing PSA-Based Prostate Cancer Screening in Men Aged 75 Years and Older with the Use of Highly Specific Computerized Clinical Decision Support

“…We believe that the combination of a highly specifiable pop-up architecture such as ours and the electronic availability of a wide range of structured clinical data (including inpatient and outpatient diagnosis and procedure codes, laboratory, pharmacy, demographics, and problem list data) allowed our alert to be more targeted than most previously reported CCDS tools, which may have contributed to its success. 28,29,[31][32][33] Formal development of the alert language through focus groups and solicited feedback may have further improved its performance.…”

Transitioning Between Electronic Health Records: Effects on Ambulatory Prescribing Safety

“…However, the value of CDS is often limited by providers' lack of alert acceptance. Multiple studies have shown that providers frequently override alerts because they are perceived as irrelevant [39][40][41][42] . The inability of EHR systems to effectively present information for CDS purposes may contribute to the mixed safety benefits observed in studies 1,[7][8][9][10]12,13 .…”

“Stealth” Alerts to Improve Warfarin Monitoring When Initiating Interacting Medications

“…First, we were concerned that busy primary care clinicians would have "'alert fatigue," 3,17 and might not respond to the new co-prescription safety alerts, having already just seen the standard drug-drug interaction alert in each case. Others have proposed more parsimonious alerting (e.g., fewer triggers in a given system 18 ) or tailoring alerts to the specific characteristics of individual patients. 4,19 Our strategy was to direct these alerts to the AMS managers, rather than to the ordering clinicians.…”