Medication alerts within EHRs can save lives, but as many clinicians are quick to point out, these alerts can also prove to be a major headache. The alerts sometimes note potential adverse effects that even first year medical students would know. While there's no perfect system, we can do better.
Given that between 33% and 96% of medical alerts are ignored, there's little doubt that providers need help in this regard. A good place to start is with a core set of critically important drug/drug interactions (DDIs) that everyone in your healthcare system needs to watch.
With that in mind, researcher Shobba Phansalkar, from Brigham and Women's Hospital in Boston, along with colleagues from Harvard, Rand Corp., and UCLA, did an exhaustive review of medication databases to compile a must-have list of severe DDIs. They came up with 15 essential interactions that all your clinicians should probably have access to in a clinical decision support system (CDSS). The list, published in the latest issue of Journal of Medical Informatics Association, was derived from Partners Healthcare System Medication database; commercial databases, including Micromedex, First Data Bank, and Drugs.com; and from academic research papers written by experts in the field.
Once you have a core list in place, the next logical step is to expand it with less critical but useful alerts, and then decide how to alert physicians to the entire data set. Typically a CDSS prioritizes medical alerts into three tiers. The most serious, life threatening DDIs, are set up as a hard stops in the system. As Phansalkar explains in the JAMIA paper, that requires the med order be cancelled or that one of the two interacting drugs be discontinued. In tier two, clinicians would have to give a reason for overriding an alert for a moderately serious DDI. Tier 3 is reserved for non-interruptive yet useful alerts.
Deciding where to place a medical alert in a three-tier system is only one of the related issues. IT managers and clinical leaders have to join forces to decide which type of clinician needs to see which alerts. It doesn't make sense for a physician to see an alert that's only relevant for a pharmacist, for instance. In other words, we need role-specific drug alerts.
That point was driven home in a study published in April issue of International Journal of Medical Informatics. V.A. and Regenstrief healthcare researchers observed 30 physicians, nurse practitioners, and pharmacists entering and processing a total of 320 outpatient prescription orders. They found that prescribing clinicians often were confused about why the EHR delivered alerts and determined that the electronic warnings tended to be oriented more toward pharmacists than those who write prescriptions.
The researchers also found that prescribers spent too much time retrieving data in response to an alert, suggesting that EHR systems should automatically deliver relevant information from patient records, such as test results and documentation about adverse reactions to certain medications. "Prescribers wanted more patient-specific alerts, and were particularly appreciative of alerts triggered by a patient's laboratory values," said the article.
Because the medication alert system at Regenstrief is home grown and more readily customizable, it allows alerts to be tweaked based on lab data from individual patients. In a recent interview published in American Medical News, Jon D. Duke, MD, assistant professor at the Indiana University School of Medicine, talks about Regenstrief's Context-Aware Drug-to-Drug Interaction (CADDI) alert system, which is capable of such specificity. "... if there’s an interaction between a medication like an ACE inhibitor and a potassium supplement, which is a common interaction associated with hyperkalemia, the system goes and checks the [patient’s] last potassium level and is able to then increase or decrease the intensity of the alert based on whether there was any abnormal baseline levels."
It's likely clinicians will keep complaining about alert fatigue for some time to come. But as medical informatics specialists get better at designing medication databases, we'll eventually find the right balance between patient safety and clinician convenience.
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