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Appl Clin Inform 2011; 02(01): 50-62
DOI: 10.4338/ACI-2010-04-RA-0026
Research Article
Schattauer GmbH

Towards Meaningful Medication-Related Clinical Decision Support: Recommendations for an Initial Implementation

S. Phansalkar
1   Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
2   Partners HealthCare System, Wellesley, MA
,
A. Wright
1   Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
2   Partners HealthCare System, Wellesley, MA
,
G.J. Kuperman
3   New York-Presbyterian Hospital, New York, NY
,
A.J. Vaida
4   Institute for Safe Medication Practices, Huntingdon Valley, PA
,
A.M. Bobb
5   Northwestern Memorial Hospital, Chicago, IL
,
R.A. Jenders
6   National Library of Medicine, US National Institutes of Health, Bethesda, USA
10   Georgetown University. Washington, DC
,
T.H. Payne
7   Biomedical and Health Informatics, and UW Medicine Information Technology Services, University of Washington, Seattle, WA
,
J. Halamka
8   Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, MA
,
M. Bloomrosen
9   The American Medical Informatics Association, Bethesda, MD
,
D.W. Bates
1   Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
2   Partners HealthCare System, Wellesley, MA
› Author Affiliations
Further Information

Publication History

received: 28 April 2010

accepted: 24 January 2011

Publication Date:
16 December 2017 (online)

Also available at
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Summary

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that health-care organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

Keywords

Clinical decision support - decision support systems - CDS - medication alerting - drug-drug interactions - therapeutic duplication - medical informatics
 

  • References

  • 1 Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care 1994; 996. PMid:7950101 PMCid:2247898.
    PubMedGoogle Scholar
  • 2 Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM. et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Jama 1998; 280 (15) 1311-1316. PMid:10428004 PMCid:61372.
    CrossrefPubMedGoogle Scholar
  • 3 Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N. et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6 (04) 313-321. PMid:15802474 PMCid:1174880.
    CrossrefPubMedGoogle Scholar
  • 4 Teich JM, Osheroff JA, Pifer EA, Sittig DF, Jenders RA. Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup. J Am Med Inform Assoc 2005; 12 (04) 365-376. doi:10.1197/jamia. M1822 PMid:17068355 PMCid:2215064.
    CrossrefPubMedGoogle Scholar
  • 5 Kuperman GJ, Bobb A, Payne TH, Avery AJ, Gandhi TK, Burns G. et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 2007; 14 (01) 29-40. doi:10.1197/jamia. M2170 PMid:11025783.
    CrossrefPubMedGoogle Scholar
  • 6 Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000; 160 (18) 2741-2747. doi:10.1001/archinte.160.18.2741 PMid:9292842 PMCid:61254.
    CrossrefPubMedGoogle Scholar
  • 7 Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of "corollary orders" to prevent errors of omission. J Am Med Inform Assoc 1997; 4 (05) 364-375. PMid:16622160 PMCid:1513681.
    CrossrefPubMedGoogle Scholar
  • 8 Kuperman GJ, Reichley RM, Bailey TC. Using commercial knowledge bases for clinical decision support: opportunities, hurdles, and recommendations. J Am Med Inform Assoc 2006; 13 (04) 369-371. doi:10.1197/jamia. M2055 PMid:16221941 PMCid:1380196.
    CrossrefPubMedGoogle Scholar
  • 9 Shah NR, Seger AC, Seger DL, Fiskio JM, Kuperman GJ, Blumenfeld B. et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13 (01) 5-11. doi:10.1197/jamia. M1868 PMid:14638563.
    CrossrefPubMedGoogle Scholar
  • 10 Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163 (21) 2625-2631. doi:10.1001/archinte.163.21.2625 PMid:12463894 PMCid:2244252.
    CrossrefPubMedGoogle Scholar
  • 11 Drug interaction. (n.d.).. Mosby’s Dental Dictionary. Retrieved October 23, from Answers.com Web site: < http://www.answers.com/topic/drug-interaction >.
    PubMedGoogle Scholar
  • 12 Payne TH, Nichol WP, Hoey P, Savarino J. Characteristics and override rates of order checks in a practitioner order entry system. Proc AMIA Symp 2002: 602-606. PMid:18579840 PMCid:2528033.
    PubMedGoogle Scholar
  • 13 Lin CP, Payne TH, Nichol WP, Hoey PJ, Anderson CL, Gennari JH. Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs’ Computerized Patient Record System. J Am Med Inform Assoc 2008; 15 (05) 620-626. doi:10.1197/jamia. M2453 PMid:18952941 PMCid:2605599.
    CrossrefPubMedGoogle Scholar
  • 14 Paterno MD, Maviglia SM, Gorman PN, Seger DL, Yoshida E, Seger AC. et al. Tiering drug-drug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc 2009; 16 (01) 40-46. doi:10.1197/jamia. M2808 PMid:18436915 PMCid:2442265.
    CrossrefPubMedGoogle Scholar
  • 15 van der Sijs H, Aarts J, van Gelder T, Berg M, Vulto A. Turning off frequently overridden drug alerts: limited opportunities for doing it safely. J Am Med Inform Assoc 2008; 15 (04) 439-448. doi:10.1197/jamia. M2311 PMid:17213487 PMCid:2213467.
    CrossrefPubMedGoogle Scholar
  • 16 Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inform Assoc 2007; 14 (02) 141-145. doi:10.1197/jamia. M2334 PMid:15905481 PMCid:1174885.
    CrossrefPubMedGoogle Scholar
  • 17 Miller RA, Gardner RM, Johnson KB, Hripcsak G. Clinical decision support and electronic prescribing systems: a time for responsible thought and action. J Am Med Inform Assoc 2005; 12 (04) 403-409. doi:10.1197/jamia. M1830 PMid:19033481.
    CrossrefPubMedGoogle Scholar
  • 18 van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of Drug Safety Alerts in Computerized Physician Order Entry. J Am Med Inform Assoc 2006; 13 (02) 138-147.
    CrossrefPubMedGoogle Scholar
  • 19 Wong CM, Ko Y, Chan A. Clinically significant drug-drug interactions between oral anticancer agents and nonanticancer agents: profiling and comparison of two drug compendia. Ann Pharmacother 2008; 42 (12) 1737-1748. doi:10.1345/aph.1L255 PMid:16329715.
    CrossrefPubMedGoogle Scholar
  • 20 van Roon EN, Flikweert S, le Comte M, Langendijk PN, Kwee-Zuiderwijk WJ, Smits P. et al. Clinical relevance of drug-drug interactions: a structured assessment procedure. Drug Saf 2005; 28 (12) 1131-1139. doi:10.2165/00002018-200528120-00007 PMid:19745260.
    CrossrefPubMedGoogle Scholar
  • 21 Middleton B. The clinical decision support consortium. Stud Health Technol Inform 2009; 150: 26-30. PMid:19786683.
    PubMedGoogle Scholar
  • 22 Weingart SN, Simchowitz B, Shiman L, Brouillard D, Cyrulik A, Davis RB. et al. Clinicians’ assessments of electronic medication safety alerts in ambulatory care. Arch Intern Med 2009; 169 (17) 1627-1632. doi:10.1001/archinternmed.2009.300 PMid:9609492 PMCid:61296.
    PubMedGoogle Scholar
  • 23 Hazard Alert! Action needed to avert fatal errors from concomitant use of heparin products. Institute for Safe Medication Practices (ISMP) Medication Safety Alert [serial on the Internet]. February 21, 2001; 6(4).
    PubMedGoogle Scholar
  • 24 Zielstorff RD. Online practice guidelines: issues, obstacles, and future prospects. J Am Med Inform Assoc 1998; 5 (03) 227-236. PMid:8130503 PMCid:2248539.
    CrossrefPubMedGoogle Scholar
  • 25 Pryor TA, Hripcsak G. Sharing MLM‘s: an experiment between Columbia-Presbyterian and LDS Hospital. Proc Annu Symp Comput Appl Med Care 1993: 399-403. PMid:15298998 PMCid:524628.
    PubMedGoogle Scholar
  • 26 Hsieh TC, Kuperman GJ, Jaggi T, Hojnowski-Diaz P, Fiskio J, Williams DH. et al. Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc 2004; 11 (06) 482-491. doi:10.1197/jamia. M1556 PMid:15802481 PMCid:1174882.
    CrossrefPubMedGoogle Scholar
  • 27 Reichley RM, Seaton TL, Resetar E, Micek ST, Scott KL, Fraser VJ. et al. Implementing a commercial rule base as a medication order safety net. J Am Med Inform Assoc 2005; 12 (04) 383-389. doi:10.1197/jamia. M1783 PMid:16779381 PMCid:1560631.
    CrossrefPubMedGoogle Scholar
  • 28 Resetar E, Reichley RM, Noirot LA, Dunagan WC, Bailey TC. Customizing a commercial rule base for detecting drug-drug interactions. AMIA Annu Symp Proc 2005; 1094. PMid:9794308.
    PubMedGoogle Scholar