Summary
Background: Electronic health records (EHRs) with clinical decision support (CDS) have shown
to be effective at improving patient safety. Despite this, alerts delivered as part
of CDS are overridden frequently, which is of concern in the critical care population
as this group may have an increased risk of harm. Our organization recently transitioned
from an internally-developed EHR to a commercial system. Data comparing various EHR
systems, especially after transitions between EHRs, are needed to identify areas for
improvement.
Objectives: To compare the two systems and identify areas for potential improvement with the
new commercial system at a single institution.
Methods: Overridden medication-related CDS alerts were included from October to December
of the systems’ respective years (legacy, 2011; commercial, 2015), restricted to three
intensive care units. The two systems were compared with regards to CDS presentation
and override rates for four types of CDS: drug-allergy, drug-drug interaction (DDI),
geriatric and renal alerts. A post hoc analysis to evaluate for adverse drug events
(ADEs) potentially resulting from overridden alerts was performed for ‘contraindicated’
DDIs via chart review.
Results: There was a significant increase in provider exposure to alerts and alert overrides
in the commercial system (commercial: n=5,535; legacy: n=1,030). Rates of overrides
were higher for the allergy and DDI alerts (p<0.001) in the commercial system. Geriatric
and renal alerts were significantly different in incidence and presentation between
the two systems. No ADEs were identified in an analysis of 43 overridden contraindicated
DDI alerts.
Conclusions: The vendor system had much higher rates of both alerts and overrides, although we
did not find evidence of harm in a review of DDIs which were overridden. We propose
recommendations for improving our current system which may be helpful to other similar
institutions; improving both alert presentation and the underlying knowledge base
appear important.
Citation: Wong A, Wright A, Seger DL, Amato MG, Fiskio JM, Bates D. Comparison of
Overridden Medication-related Clinical Decision Support in the Intensive Care Unit
between a Commercial System and a Legacy System. Appl Clin Inform 2017; 8: 866–879
https://doi.org/10.4338/ACI-2017-04-RA-0059
Keywords
Adverse drug event - Clinical decision support - Critical care - Informatics - Patient
safety