Clinical Decision Support Alerts Research Articles

Improving Depression Screening Using CDS and Patient Access to Information Using PHRs

Introduction/aims Depression as a co-morbidity alongside another chronic disease often complicates the patient's ability to adhere to medical treatment. Patients with diabetes are twice as likely to have depression. Inconsistent screening for depression can lead to missed diagnoses and adversely impact the patient's treatment course. The aim of this project was to increase the diabetic population's rate of screening for depression using Clinical Decision Support (CDS) tools and alerts. These tools prompt the clinical care team to use a standardized Patient Health Questionnaire (PHQ)-2 depression screening tool and PHQ-9 for depression symptom level assessment. Further aims included improving the patient's awareness about depression and access to resources regarding diagnosis and treatment. Methods/process/procedures The area of focus for this project includes New York-Presbyterian Hospital's Ambulatory Care Network (ACN), which has adopted the National Committee for Quality Assurance's patient-centered medical home (PCMH) model. Diabetes and depression were identified as two of four conditions to be targeted during the first stage of implementing the PCMH model. A clinical workgroup comprised of primary care and mental health physicians at NewYork-Presbyterian hospital developed a clinical standard of care to identify the conditions, intervals, and frequency in which depression screening and assessment should occur. Structured PHQ-2 and PHQ-9 forms were embedded within appropriate flowsheets and documents in the Electronic Health Record (EHR). The standard of care was used as a roadmap for the technical development of a Medical Logic Module (MLM) or programming code built within the EHR. The MLM triggered CDS alerts that were presented when depression screening process conditions were met. These conditions included: annual PHQ-2 screen; administration of a PHQ-9 with a positive PHQ-2 screen; provider notification for a PHQ-9 score ≥20, or for any patient response other than “not at all” to question #9 (“thoughts that you would be better off dead, or of hurting yourself in some way”). NewYork-Presbyterian Hospital's Personal Health Record (PHR), myNYP.org, was updated to include printable PHQ forms. Resources for treatment and education regarding depression screening, diagnosis, and treatment were also incorporated into myNYP.org. Results A data analytics tool was used to capture the diabetic PCMH population's depression screening rates six months pre-implementation (June 2012) then again six months post-implementation (June 2013). Post-implementation, these data indicated an 8% increase in the number of patients screened for depression using the PHQ-2 (from 16 to 24%) and a 7% increase in the number of patients with a positive PHQ-2 who received a follow-up PHQ-9 assessment within 4 weeks (from 53 to 60%). Discussion/outcomes CDS alerts have the potential to improve the rate of screening for depression. Offering the patient resources for depression in a PHR provides real-time tools that can be beneficial, outside of the hospital setting. There is potential to further automate PHQ data entered by the patient. Lessons learned in this project include challenges with consuming patient-entered data into the EHR. Other considerations include workflow issues and technical alerts for the care providers if patients enter PHQ data that should trigger an immediate response.

Usability evaluation of pharmacogenomics clinical decision support aids and clinical knowledge resources in a computerized provider order entry system: A mixed methods approach

BackgroundPharmacogenomics (PGx) is positioned to have a widespread impact on the practice of medicine, yet physician acceptance is low. The presentation of context-specific PGx information, in the form of clinical decision support (CDS) alerts embedded in a computerized provider order entry (CPOE) system, can aid uptake. Usability evaluations can inform optimal design, which, in turn, can spur adoption. ObjectivesThe study objectives were to: (1) evaluate an early prototype, commercial CPOE system with PGx-CDS alerts in a simulated environment, (2) identify potential improvements to the system user interface, and (3) understand the contexts under which PGx knowledge embedded in an electronic health record is useful to prescribers. MethodsUsing a mixed methods approach, we presented seven cardiologists and three oncologists with five hypothetical clinical case scenarios. Each scenario featured a drug for which a gene encoding drug metabolizing enzyme required consideration of dosage adjustment. We used Morae® to capture comments and on-screen movements as participants prescribed each drug. In addition to PGx-CDS alerts, ‘Infobutton®’ and ‘Evidence’ icons provided participants with clinical knowledge resources to aid decision-making. ResultsNine themes emerged. Five suggested minor improvements to the CPOE user interface; two suggested presenting PGx information through PGx-CDS alerts using an ‘Infobutton’ or ‘Evidence’ icon. The remaining themes were strong recommendations to provide succinct, relevant guidelines and dosing recommendations of phenotypic information from credible and trustworthy sources; any more information was overwhelming. Participants’ median rating of PGx-CDS system usability was 2 on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree). ConclusionsUsability evaluation results suggest that participants considered PGx information important for improving prescribing decisions; and that they would incorporate PGx-CDS when information is presented in relevant and useful ways.

Overrides of medication-related clinical decision support alerts in outpatients

Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue. To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides. We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria. We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies. About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

PG4KDS: A model for the clinical implementation of pre‐emptive pharmacogenetics

Pharmacogenetics is frequently cited as an area for initial focus of the clinical implementation of genomics. Through the PG4KDS protocol, St. Jude Children's Research Hospital pre-emptively genotypes patients for 230 genes using the Affymetrix Drug Metabolizing Enzymes and Transporters (DMET) Plus array supplemented with a CYP2D6 copy number assay. The PG4KDS protocol provides a rational, stepwise process for implementing gene/drug pairs, organizing data, and obtaining consent from patients and families. Through August 2013, 1,559 patients have been enrolled, and four gene tests have been released into the electronic health record (EHR) for clinical implementation: TPMT, CYP2D6, SLCO1B1, and CYP2C19. These genes are coupled to 12 high-risk drugs. Of the 1,016 patients with genotype test results available, 78% of them had at least one high-risk (i.e., actionable) genotype result placed in their EHR. Each diplotype result released to the EHR is coupled with an interpretive consult that is created in a concise, standardized format. To support-gene based prescribing at the point of care, 55 interruptive clinical decision support (CDS) alerts were developed. Patients are informed of their genotyping result and its relevance to their medication use through a letter. Key elements necessary for our successful implementation have included strong institutional support, a knowledgeable clinical laboratory, a process to manage any incidental findings, a strategy to educate clinicians and patients, a process to return results, and extensive use of informatics, especially CDS. Our approach to pre-emptive clinical pharmacogenetics has proven feasible, clinically useful, and scalable.

Improved blood utilization using real‐time clinical decision support

We analyzed blood utilization at Stanford Hospital and Clinics after implementing real-time clinical decision support (CDS) and best practice alerts (BPAs) into physician order entry (POE) for blood transfusions. A clinical effectiveness (CE) team developed consensus with a suggested transfusion threshold of a hemoglobin (Hb) level of 7 g/dL, or 8 g/dL for patients with acute coronary syndromes. The CDS was implemented in July 2010 and consisted of an interruptive BPA at POE, a link to relevant literature, and an "acknowledgment reason" for the blood order. The percentage of blood ordered for patients whose most recent Hb level exceeded 8 g/dL ranged at baseline from 57% to 66%; from the education intervention by the CE team August 2009 to July 2010, the percentage decreased to a range of 52% to 56% (p = 0.01); and after implementation of CDS and BPA, by end of December 2010 the percentage of patients transfused outside the guidelines decreased to 35% (p = 0.02) and has subsequently remained below 30%. For the most recent interval, only 27% (767 of 2890) of transfusions occurred in patients outside guidelines. Comparing 2009 to 2012, despite an increase in annual case mix index from 1.952 to 2.026, total red blood cell (RBC) transfusions decreased by 7186 units, or 24%. The estimated net savings for RBC units (at $225/unit) in purchase costs for 2012 compared to 2009 was $1,616,750. Real-time CDS has significantly improved blood utilization. This system of concurrent review can be used by health care institutions, quality departments, and transfusion services to reduce blood transfusions.

Criteria for assessing high-priority drug-drug interactions for clinical decision support in electronic health records.

BackgroundHigh override rates for drug-drug interaction (DDI) alerts in electronic health records (EHRs) result in the potentially dangerous consequence of providers ignoring clinically significant alerts. Lack of uniformity of criteria for determining the severity or validity of these interactions often results in discrepancies in how these are evaluated. The purpose of this study was to identify a set of criteria for assessing DDIs that should be used for the generation of clinical decision support (CDS) alerts in EHRs.MethodsWe conducted a 20-year systematic literature review of MEDLINE and EMBASE to identify characteristics of high-priority DDIs. These criteria were validated by an expert panel consisting of medication knowledge base vendors, EHR vendors, in-house knowledge base developers from academic medical centers, and both federal and private agencies involved in the regulation of medication use.ResultsForty-four articles met the inclusion criteria for assessing characteristics of high-priority DDIs. The panel considered five criteria to be most important when assessing an interaction- Severity, Probability, Clinical Implications of the interaction, Patient characteristics, and the Evidence supporting the interaction. In addition, the panel identified barriers and considerations for being able to utilize these criteria in medication knowledge bases used by EHRs.ConclusionsA multi-dimensional approach is needed to understanding the importance of an interaction for inclusion in medication knowledge bases for the purpose of CDS alerting. The criteria identified in this study can serve as a first step towards a uniform approach in assessing which interactions are critical and warrant interruption of a provider’s workflow.

The need for collaborative engagement in creating clinical decision-support alerts

Clinical decision support (CDS) encompasses a broad array of technology and approaches, all of which involve the provision and use of clinical information in medical processes. [1][1] Medication-focused CDS is frequently used in the context of inpatient computerized prescriber order entry (CPOE) and

Pharmacy surveillance and low-literacy pharmacist intervention

McCoy et al. 1. McCoy A.B. Cox Z.L. Neal E.B. et al. Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury: a randomized, controlled trial. Appl Clin Inform. 2012; 3: 221-238 Crossref PubMed Scopus (29) Google Scholar concluded that real-time “pharmacy surveillance had no incremental benefit” compared with preexisting clinical decision support (CDS) systems (e.g., computer alerts) in detecting and preventing medication errors. Nearly 400 acute kidney injury patients were studied in a 3-month randomized clinical trial. Adult patients were enrolled who experienced a ±0.5 mg/dL change in serum creatinine over 48 hours. They had an active order for one or more nephrotoxic or renally cleared medications. In addition to CDS alerts and usual care pharmacy services (e.g., rounding with medical and surgical teams), the intervention included real-time monitoring of drug prescribing and kidney function trends by pharmacists using a Web-based surveillance tool. Blinded judges determined that potential or actual adverse drug events (ADEs) occurred for 104 (8.0%) usual care and 99 (7.1%) intervention group patients (P = 0.4). Time until providers modified or discontinued targeted nephrotoxic or renally cleared medications did not differ between usual care and intervention patients (33.4 vs. 30.3 hours, P = 0.3).

The impact of computerised physician order entry with integrated clinical decision support on pharmacist–physician communication in the hospital setting: a systematic review of the literature

ObjectiveTo document the issues and impact that computerised physician order entry (CPOE) with clinical decision support (CDS) can have on pharmacist–physician communication in the hospital setting.HypothesisNovel processes introduced by CPOE...

Impact of Integrating Public Health Clinical Decision Support Alerts Into Electronic Health Records on Testing for Gastrointestinal Illness

Laboratory testing by clinicians is essential to outbreak investigations. Electronic health records may increase testing through clinical decision support that alerts providers about existing outbreaks and facilitates laboratory ordering. The impact on laboratory testing was evaluated for foodborne disease outbreaks between 2006 and 2009. After controlling for standard public health messaging and season, decision support resulted in a significant increase in laboratory testing and may be useful in enhancing public health messaging and provider action.

Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between June 1, 2010 and August 31, 2010 with an acute 0.5 mg/dl change in serum creatinine over 48 hours and a nephrotoxic or renally cleared medication order. Patients randomly assigned to the intervention group received surveillance from a clinical pharmacist using a web-based surveillance tool to monitor drug prescribing and kidney function trends. CDS alerting and standard pharmacy services were active in both study arms. Outcome measures included blinded adjudication of potential adverse drug events (pADEs), adverse drug events (ADEs) and time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications. RESULTS: Potential ADEs or ADEs occurred for 104 (8.0%) of control and 99 (7.1%) of intervention patient-medication pairs (p=0.4). Additionally, the time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications did not differ between control and intervention patients (33.4 hrs vs. 30.3 hrs, p=0.3). CONCLUSIONS: Pharmacy surveillance had no incremental benefit over previously implemented CDS alerts.

A framework for evaluating the appropriateness of clinical decision support alerts and responses

Alerting systems, a type of clinical decision support, are increasingly prevalent in healthcare, yet few studies have concurrently measured the appropriateness of alerts with provider responses to alerts. Recent reports of suboptimal alert system design and implementation highlight the need for better evaluation to inform future designs. The authors present a comprehensive framework for evaluating the clinical appropriateness of synchronous, interruptive medication safety alerts. Through literature review and iterative testing, metrics were developed that describe successes, justifiable overrides, provider non-adherence, and unintended adverse consequences of clinical decision support alerts. The framework was validated by applying it to a medication alerting system for patients with acute kidney injury (AKI). Through expert review, the framework assesses each alert episode for appropriateness of the alert display and the necessity and urgency of a clinical response. Primary outcomes of the framework include the false positive alert rate, alert override rate, provider non-adherence rate, and rate of provider response appropriateness. Application of the framework to evaluate an existing AKI medication alerting system provided a more complete understanding of the process outcomes measured in the AKI medication alerting system. The authors confirmed that previous alerts and provider responses were most often appropriate. The new evaluation model offers a potentially effective method for assessing the clinical appropriateness of synchronous interruptive medication alerts prior to evaluating patient outcomes in a comparative trial. More work can determine the generalizability of the framework for use in other settings and other alert types.

Clinical Decision Support and Malpractice Risk

CLINICAL DECISION SUPPORT (CDS) REFERS TO electronic technology used to enhance clinical decision making. For example, computerized physician order entry with integrated CDS in principle offers an electronic layer of review for ordering prescriptions. An important feature of CDS is automated warnings issued whenever potential drug interactions or other contraindications arise. In practice, however, CDS systems often have been overinclusive in the warnings they generate, to a point at which physician “alert fatigue” may in large part undermine the utility the systems offer. The current generation of CDS systems includes alert parameters for thousands of drug interaction types. Meanwhile, a recent review of empirical studies on computerized physician order entry with integrated CDS observed that physicians override automated warnings a substantial fraction of the time— according to one study, in as many as 19 out of 20 instances. One paradoxical result of overly abundant warnings may be to exacerbate malpractice risk for physicians who either ignore or turn off CDS alerts, even as CDS systems create an audit trail to show that those physicians have done so. Another paradoxical result may be impeded adoption of CDS technologies because of physician and institutional concerns about malpractice risk. These sorts of results could prevent the technologies from achieving their potential benefits in making patients safer and in reducing the risks of medication error. The Office of the National Coordinator for Health Information Technology (ONC) is addressing this problem through its Advancing Clinical Decision Support project. The ONC effort includes a series of tasks designed to promote CDS development and adoption and to overcome barriers to CDS use. One element of the project involved a review of some liability challenges that have impeded CDS; in particular, the development of an optimized clinically meaningful drug-drug interaction list. The use of this list could potentially ameliorate the problem of overinclusive CDS warnings but may create the risk of another set of liability concerns on the part of vendors. Consequently, policy makers may need to untie a liability knot that threatens to strangle CDS. Better understanding of the liability knot, and of strategies available to loosen it, is important for both the policy and the health care communities.

Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use

Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.

Electronic Health Records and Clinical Decision Support Systems

Electronic health records (EHRs) are increasingly used by US outpatient physicians. They could improve clinical care via clinical decision support (CDS) and electronic guideline-based reminders and alerts. Using nationally representative data, we tested the hypothesis that a higher quality of care would be associated with EHRs and CDS. We analyzed physician survey data on 255,402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Based on 20 previously developed quality indicators, we assessed the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable logistic regression. Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults, adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients, adjusted odds ratio, 2.88; 95% confidence interval, 1.69-4.90). There were no other significant quality differences. Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Clinician Acceptance of Computerized Alerts for Public Health Surveillance

Background: With expansion of electronic health records, there is an increasing role for clinical decision support (CDS) alerts, however their acceptability for public health surveillance has not been studied. We surveyed primary care providers (PCPs) and nursing staff at nine clinics in New York City where a pilot respiratory virus surveillance system was implemented. Purpose: Evaluate acceptability of CDS alerts encouraging diagnostic testing for respiratory viruses. Methods: The pilot surveillance system was implemented at nine outpatient clinics in New York City. An evaluation of the first 5 weeks of operation, May 26–June 30, 2009, was performed. Online surveys for PCPs (N=45) and nursing staff (N=47) were developed and sent electronically 5 months after surveillance system implementation. Significance testing was performed using Fisher’s exact test. Results: The survey response rate was 53% (n=24) for PCPs and 55% (n=26) for nursing staff. Nursing staff were significantly more likely to report adherence to CDS alerts than PCPs. PCPs and nursing staff had statistically significant differences in their perceptions of the clinical utility of diagnostic testing. PCPs primarily attributed nonadherence to low clinical utility of diagnostic testing, whereas nursing staff primarily attributed it to lack of PCP orders. Discussion: Low threshold for CDS alert triggers, low sensitivity of diagnostic testing, and prioritization of clinical utility over surveillance objectives contributed to suboptimal adherence among both PCPs and nursing staff to CDS alerts. Conclusion: PCPs and nursing staff perceive and adhere to CDS alerts differently. Future public health surveillance systems should choose user-centered frameworks in designing and implementing CDS alerts, provide training regarding surveillance objectives, consider targeting CDS alerts to the initial encounter between patient and nursing staff, and conduct periodic evaluations of adherence and acceptability.

Electronic Health Record–Based Decision Support to Improve Asthma Care: A Cluster-Randomized Trial

Asthma continues to be 1 of the most common chronic diseases of childhood and affects approximately 6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry. Increases in the number of prescriptions for controller medications, over time, was 6% greater (P = .006) and 3% greater for spirometry (P = .04) in the intervention urban practices. Filing an up-to-date asthma care plan improved 14% (P = .03) and spirometry improved 6% (P = .003) in the suburban practices with the intervention. In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines.

Integrating Incident Reporting into an Electronic Patient Record System

Developments in information technology offer new opportunities to design electronic patient record systems (EPR) which integrate a broad range of functions such as clinical decision support, order entry, or electronic alerts. It has been recently suggested that EPR could support new applications for disease surveillance and patient safety. We describe the integration of a voluntary incident reporting system into an EPR used in operating theatres, to allow the reporting of accidents and preventable complications. We assessed system’s reliability and users’ acceptance. During the 4-years observation period (2002-2006), 48,983 interventional procedures were performed. Clinicians documented 85.1% of procedures on the incident reporting form. Agreement between chart review and electronically reported incidents was 80.6%. The integration of an incident reporting system into an EPR is reliable and well supported by health care professionals.