Have you ever looked at the paper prescription your doctor hands you and wondered how anyone could make out those chicken scratches? Although pharmacists seem to have developed an amazing ability to read even the worst doctor handwriting, serious mistakes still occur if they misinterpret a letter or number. Prescriptions written and transmitted electronically, called “e-prescribing,” promise to prevent these mistakes as well as provide increased convenience for the patient. However, a recent study is suggesting that one of the safeguards built into the system may backfire with dire consequences.
In a recent study, researchers found that physicians override more than three-quarters of drug interaction alerts provided by e-prescribing software. These alerts are decision support tools for physicians in order to avoid errors related to drug interaction and/or allergic reactions, together called adverse drug events or ADEs.
ADEs are a major focus of the Obama administration in eradicating human error and in turn increasing overall health care system efficiency. A reduction in adverse effects increases the quality of patient care while reducing health care costs through the elimination of unnecessary medical care (fixin’ you up after an ADE injury).
The scientific literature reports that one-quarter of patients experience an ADE episode and one-third of those are preventable. Yikes. In this recent study, a tri-state approach yielded similar findings to traditionally smaller studies—physicians override alerts frequently. Physicians, on average, received an alert for almost 7 percent of their prescriptions (over 3 million records were sampled)—of those, they accepted only 9.2 percent of drug interaction alerts and 23 percent of allergy alerts. There is no specialty that overrides more than another though the majority of the sample was primary care physicians. Should we be concerned? Well, yes and no.
Luddite Distrust or Decision Support Overkill?
Why are physicians overriding alerts at such high rates? Researchers are not clear about why physicians override the alerts but they suggest that 1) generally, the alerts are inadequate; 2) physicians discriminate based on the type of drugs a patient is taking (heart issues are weighed more seriously than less potentially emergent conditions); 3) unless addressed, physicians will develop “alert fatigue” and continue to be dismissive of alerts to the detriment of patient health.
So, maybe docs don’t trust technology to guide them in their decision-making and are uncomfortable using an electronic format? The study found that, on average, physicians had over a year’s worth of experience using an e-prescribing system. It appears that Luddite tendencies are not to blame for physicians overriding habits but rather an annoyance with many alerts that do not mirror the clinician’s knowledge base. According to users, the e-prescribing alerts are like a hyperactive child that asks you ten times to eat candy when you said “no” the first time. The complaint is that by alerting doctors numerous times and hyping up potential threats (not discriminating enough regarding what is a high alert interaction versus a more moderate ADE) threatens the utility of the entire system. The problem is a lack of congruency between clinical decision support and physician’s experience and practice style.
Matching Physician Insight with Electronic Ease
Clinical decision support regarding ADEs must be an important part of patient care. The system, however, is clearly imperfect. Physicians maintain that the clinical decision support around prescribing is inadequate. Researchers argue that software companies and their partners should take into account clinician insight and alert override practices. In short, software systems should alter alerts based on the acceptance and override rates by clinicians themselves.
While this appears to be good advice, there also needs to be attention paid to the patient outcome. How did the patient fare when there was a drug prescription override? Is the physician prudent in overriding an ADE alert? These are important questions yet to be addressed by researchers and software companies engaged in clinical decision support.
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Tags: Doctors, E-Prescribing Systems, E-Prescription, electronic prescription Software, Electronic Prescription USA, Hospital
Posted May 13, 2009 by admin under E-Prescription, Electronic Prescription
