MPA | Pharmacy News

by Bruce Chaffee, Pharm.D., FASHP, MSHP IT Committee

The advent of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, spurred the rapid proliferation of electronic health record (EHR) adoption in hospitals. Once EHRs are implemented, hospitals have been incentivized to meet the requirements of a three-phased program which defines the “meaningful use” of health information technology. These phases are designed to improve the safety, quality and efficiency of health care while improving the coordination of care, enhancing population health, reducing health disparities, and better engaging patients and families.

Health care technology implementation is complex and necessitates standardization. Considerable effort is spent by hospitals in determining the proper system configuration to meet their workflows; those which best balance patient safety and clinician efficiency. As with any new technology, process or system, unintended consequences can and do arise. One area where consequences have become acutely tender to prescribers has been alerting within the clinical decision support (CDS) component of computerized prescriber order entry (CPOE) systems. In brief, the collective experience of most prescribers is that excessive alerting occurs leading to alert fatigue, a condition under which prescribers begin to ignore alerts, including those which might prove beneficial.

In response to this challenge, prescribers have tried a number of remedies. Some have asked hospitals to categorically turn off lower severity alerts to reduce the cognitive load imposed by excessive alerting. While this action treats the symptom, it also may result in missed safety warnings and does not address the root cause of the problem, which involves a mixture of pathologies ranging from lower-than-advertised risks, to poorly-timed alerts, to duplicative alerts, among other maladies. Others have formed their own councils to rank or rate the most important drug-drug interactions (DDI), but this process is time consuming, requires ongoing maintenance and may fail to meet standards sufficient for appropriate evidence-based decision making. Finally, some have approached either their EMR or drug database vendor for help, but this typically does not provide additional remedies beyond the ones suggested above. In summary, alerting lacks the required sensitivity and specificity to be effective within the context of clinician workflow.

In 2012, an interdisciplinary council was convened to discuss the problem of alert fatigue and identify potential pathways toward improvement for one aspect of CDS – DDI. The DDI CDS Conference Series, led by Dan Malone, Ph.D., from the University of Arizona, took a three-pronged approach to encapsulating the problems and describing pathways for improvement related to DDI usability, evidence and content. Three groups were formed consisting of 18-24 national and international experts with experience, including one or more of the following domains: clinical practice, academia, health information technology (IT) vendors (EMR and drug database), health care organizations and the Office of the National Coordinator for Health IT. Each participant had significant experience with one or more of the following: DDIs, clinical pharmacology, CDS, informatics, computer interface design and/or establishing health care quality initiatives. These domain groups met regularly, either in-person or via conference call, to define the problems and devise evidence-based and/or consensus-based recommendations for improvement.

The result of this work is represented in two recently released publications and one that has been submitted. Readers are encouraged to obtain and review these in-depth to gain a better appreciation for the work and status of DDI evaluation, content and usability.

  • “Consensus Recommendations for Systematic Evaluation of Drug-drug Interaction Evidence for Clinical Decision Support,” published in Drug Safety in February 2015. The evidence group focused on the following questions:
    • What is the best approach to evaluate DDI evidence?
    • What evidence is required for a DDI to be applicable to an entire class of drugs?
    • How should a structured evaluation process be vetted and validated?

Group discussions centered on defining recommendations for the systematic evaluation of evidence used to document DDIs from the scientific literature, drug product labeling and regulatory documents. 

  • “Recommendations for Selecting Drug-drug Interactions for Clinical Decision Support” has been submitted for publication and should be available to readers soon. The content group addressed four important questions:
    • What process should be used to develop and maintain a standard set of DDIs?
    • What information should be included in a knowledge base of standard DDIs?
    • Can/should a list of contraindicated drug pairs be established?
    • How can DDI alerts be more intelligently filtered?

  • “Recommendations to Improve the Usability of Drug-drug Interaction Clinical Decision Support Alerts,” published online in the Journal of the American Medical Informatics Association in March. The usability group addressed three important questions with respect to DDI:
    • What, how, where and when do we display DDI decision support?
    • Should presentation of DDI decision support vary by clinicians?
    • How should effectiveness of DDI decision support be measured?

Group discussions focused on establishing optimal strategies for presenting DDI clinical decision support alerts to clinicians during patient care activities.

This conference series represents an important, collaborative effort to achieve consensus on best practices surrounding DDI CDS. Clinicians, EHR/EMR vendors and drug database vendors should heed the advice provided in the white paper reports from this series and sources for financial support should be identified to help establish and maintain an expert group tasked with evaluating the content and evidence needed for the appropriate provision of DDI CDS within EHR systems.

References available upon request from MPA office.

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