The medical profession has been alerted to this problem for almost 2 decades, and yet it persists, which makes a new study of this subject almost tiring to read.
Yep — the subject is alert fatigue in electronic prescribing.
It’s a subject brimming with irony. Electronic prescribing, a standard feature of electronic health record (EHR) systems, is supposed to be safer than the handwritten approach in part because the software warns prescribers about hazards such as drug-drug interactions or patient allergies before they hit the “complete” button. However, physicians complain that they receive too many alerts, and too many insignificant ones at that, and they override most, according to research published as far back as the early 2000s. In the process, they override many alerts they should heed, which becomes a safety issue.
A study published last month in the Journal of the American Medical Informatics Association (JAMIA) reiterates this digital paradox for the umpteenth time. The authors examined a sample of electronic prescribing alerts at Brigham and Women’s Hospital in Boston, Massachusetts, from 2009 to 2012. During that 3-year period, the hospital was using a home-grown EHR system that generated three levels of prescription alerts. Level 1 alerts basically stopped prescribers in their tracks because the risk was so high, and Level 3 alerts were FYIs that didn’t require any action.
The authors confined their study to Level 2 alerts, which interrupted the prescribing process to require clinicians to give a reason why they wanted to override it. These Level 2 alerts were set off by patient allergies, drug-drug interactions, a duplicate drug, nonformulary medicines, and medication substitutions based on age and renal function.
The study found that clinicians overrode 73.3% of the alerts for drug-drug interactions, patient allergies, and duplicate drugs (the authors did not have the total number of alerts for the other Level 2 categories). Most of these overrides were deemed appropriate. However, the override and appropriate-override rates varied considerably by category.
Table. Overriding Concerns
| Alert Type | Override Rate | Appropriate Override Rate | ||
|---|---|---|---|---|
| Patient allergy | 81.9% | 96.5% | ||
| Drug-drug interaction | 68.2% | 62% | ||
| Duplicate drug | 51.9% | 98% | ||
| Source: Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in inpatients. JAMIA 2017. | ||||
The rates of appropriate overrides for the remaining Level 2 alert categories also were all over the map — 82.5% for formulary substitutions, 26.4% for age-based prescribing suggestions, and 2.2% for suggestions based on renal function. Across all Level 2 categories, roughly 60% of alert overrides were warranted, meaning that 40% weren’t.
The study found some threads in the reasons given for overriding alerts. Fifty-seven percent of patient-allergy overrides were justified on the basis of the patient having taken the drug before without experiencing an allergic reaction. With 54% of drug-drug overrides, clinicians said they would monitor the patient to see if an interaction occurred. And with 55.7% of duplicate-drug alerts that were overridden, clinicians said combination therapy was indicated.
“Not Enough Progress,” Says EHR Expert
The authors of the JAMIA study point to at least one fix for alert fatigue based on their findings. They said clinicians were overwhelmingly justified in overriding alerts for duplicate drugs, patient allergies, and formulary substitutions, “suggesting that the numbers of these alerts could be reduced in the inpatient setting to prevent alert fatigue.”
A point person for digital medicine at the American Academy of Family Physicians (AAFP) offers another cure for alert fatigue — incorporate more of a patient’s health information into an EHR’s cogitations on whether to flash a red flag. “We’re not putting alerts into context,” said Steve Waldren, MD, director of the Alliance for eHealth Innovation at the AAFP, in an interview with Medscape Medical News.
Dr Waldren gave an example of how context matters. Normally, directing a patient to take both warfarin and low-dose aspirin is contraindicated, and this combination of anticoagulants understandably triggers a duplicate drug alert. “But when someone has a mechanical heart valve, pairing the two drugs is not an error, but the standard of care,” he said. Ideally, the patient’s EHR would factor in the patient’s mechanical heart valve — it ought to be in the record somewhere — into its prescribing rules and forgo the alert in the first place.
Likewise, it would be nice if the EHR remembered that a physician told it that a patient with a supposed drug allergy doesn’t experience an allergic reaction. “I see a patient every 3 months, and I know that the drug works for him,” Dr Waldren said. “So why are you still asking me about the drug allergy?”
Speaking about AAFP members, Dr Waldren said physicians generally appreciate electronic-prescribing alerts “as long as they don’t block their workflow.” They feel blocked when they have to supply a reason before they can proceed with the prescription, he said.
EHR vendors have taken some steps to alleviate alert fatigue, such as giving clinicians the ability to customize the level of alerts that pop up on the screen, said Dr Waldren, “but I think there’s not been enough progress.”
The study was supported by the Agency for Healthcare Research and Quality, the Swiss National Science Foundation, and the Foundation Saint-Luc (Brussels, Belgium). None of the authors have disclosed any relevant financial relationships except David W. Bates, MD, which are listed in the article.
JAMIA. Published online October 27, 2017. Abstract
Follow Robert Lowes on Twitter @LowesRobert
Tidak ada komentar:
Posting Komentar