Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review

Abstract

Prescribing of potentially inappropriate medications (PIMs) that pose more risk than benefit in older patients is a common occurrence across all healthcare settings. Reducing such prescribing has been challenging despite multiple interventions, including educational campaigns, audits and feedback, geriatrician assessment and formulary restrictions. With the increasing uptake of electronic medical records (EMRs) across hospitals, clinics and residential aged care facilities (RACFs), integrated with computerized physician order entry (CPOE) and e-prescribing, opportunities exist for incorporating clinical decision support systems (CDSS) into EMR at the point of care. This narrative review assessed the process and outcomes of using EMR-enabled CDSS to reduce the prescribing of PIMs. We searched PubMed for relevant articles published up to January 2018 and focused on those that described EMR-enabled CDSS that assisted prescribers to make changes at the time of ordering PIMs in adults. Computerized systems offering only medication reconciliation, dose checks, monitoring for medication errors, or basic formulary information were not included. In addition to outcome measures of medication-related processes and adverse drug events, qualitative data relating to factors that influence effectiveness of EMR-enabled CDSS were also gathered from selected studies. We analysed 20 studies comprising 10 randomized trials and 10 observational studies performed in hospitals ( 8), ambulatory care clinics ( 9) and RACFs ( 3). Studies varied in patient populations (although most involved older patients), type of CDSS, method of linkage with EMR, study designs and outcome measures. However, assuming little publication bias, the totality of evidence favoured EMR-enabled CDSS as being effective in reducing the prescribing of PIMs in hospitals, although results were more mixed for ambulatory care settings and RACFs. While absolute effects in most positive studies were modest, they suggest EMR-enabled CDSS are feasible and acceptable to clinicians, and if certain design features are adhered to, there is potential for even greater impact.

Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice

“…Given the increasing uptake of electronic prescribing and medical records, potential exists for electronic clinical decision support systems (CDSSs) to enhance deprescribing at the point of care. A recent narrative review identified 20 studies investigating the use of CDSSs to reduce inappropriate medication use . While the evidence suggests a benefit of these types of systems, particularly in the hospital setting, there is limited robust work on the development and implementation of such tools.…”

“…A recent narrative review identified 20 studies investigating the use of CDSSs to reduce inappropriate medication use. 36 While the evidence suggests a benefit of these types of systems, particularly in the hospital setting, there is limited robust work on the development and implementation of such tools. Several CDSSs have been specifically developed to enhance and guide deprescribing activities.…”

Real world study for the concordance between IBM Watson for Oncology and clinical practice in advanced non‐small cell lung cancer patients at a lung cancer center in China

“…Icotinib is a primary research drug in China, and studies have shown that it is as effective as the other EGFR‐TKI first‐generation drugs . Compared with cisplatin, nedaplatin, a cisplatin derivative, has fewer toxic effects, higher response rate and longer overall survival, especially in patients with squamous carcinoma . If WFO was able to output these two alternative treatments as “recommended” or “for consideration,” the overall consistency could be elevated from 73.3% to 90.3%.…”

The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care

“…Previously described strategies to address polypharmacy have demonstrated variable efficacy, [12][13][14][15][16] with interventions led by pharmacists having the greatest success. We used the tool to facilitate deprescribing in acute care for the following reasons: polypharmacy is common in this population where the average number of drugs can exceed 10 20 ; hospitalization provides a unique point of contact with the healthcare system and can involve specialists with familiarity in managing polypharmacy; electronic decision support for reducing PIMs has shown promise in the acute care setting 21 ; and finally, there is a unique opportunity to engage patients and/or families in deprescribing because they may be both a "captive audience" and motivated to stop medications that may have contributed to the hospitalization. [17][18][19] In this study (NCT02918058), we tested MedSafer, a Canadian-made electronic decision support tool for deprescribing (www.medsafer.org).…”