Does the Doctor Really Know Best?

The following rather horrifying article appeared recently in the American Journal of Managed Care.

Reasons Provided by Prescribers When Overriding Drug-Drug Interaction Alerts

Amy J. Grizzle, PharmD; Maysaa H. Mahmood, MS; Yu Ko, MS; John E. Murphy, PharmD; Edward P. Armstrong, PharmD; Grant H. Skrepnek, PhD; William N. Jones, MS; Gregory P. Schepers, PharmD; W. Paul Nichol, MD; Antoun Houranieh, PhD; Donna C. Dare, PharmD; Christopher T. Hoey, PharmD; and Daniel C. Malone, PhD

Objectives: To investigate prescribers’ rationales for overriding drug–drug interaction (DDI) alerts and to determine whether these reasons were helpful to pharmacists as a part of prescription order verification.

Study Design: An observational retrospective database analysis was conducted using override reasons derived from a computerized system at 6 Veterans Affairs medical centers.

Methods: Data on DDI alerts (for interactions designated as “critical” and “significant”) were obtained from ambulatory care pharmacy records from July 1, 2003, to June 30, 2004. Prescribers’ reasons for overriding alerts were organized into 14 categories and were then rated as clinically useful or not to the pharmacist in the assessment of potential patient harm.

Results: Of 291 890 overrides identified, 72% were for critical DDIs. Across the Veterans Affairs medical centers, only 20% of the override reasons for critical DDI alerts were rated as clinically useful for order verification. Despite a mandatory override reason for critical DDI alerts, 53% of the responses were “no reason provided.” The top response categories for critical and significant DDI alerts were “no reason provided,” “patient has been taking combination,” and “patient being monitored.”

Conclusions: When given the opportunity to provide a reason for overriding a DDI alert, prescribers rarely enter clinical justifications that are useful to order verification pharmacists. This brings into question how computerized physician order entry systems should be designed.

(Am J Manag Care. 2007;13:573-580)

The full text for the article is available for no cost at the following URL.

http://www.ajmc.com/Article.cfm?Menu=1&ID=4380

This is really a very important article as it shows that the human factors are the ones that may be the most important in getting the anticipated benefits from clinical decision support. If the systems do not provide a compelling reason for an alert to be taken seriously virtually all of the time then it seems the human and knowledge engineering of the systems under evaluation must be very suspect.

While the focus of the paper is to see how usefully physicians explain their decisions to override alerts in the eyes of the dispensing pharmacist that there were 292,000 alerts generated and then overridden, by just six hospitals in a calendar year, which works out at 130 overridden alerts per hospital per day, seems – on the face of it – to be quite high. It is not clear just what the common range of alerts were for and this would have added greatly to interpreting the paper.

That said it seems to me that careful consideration needs to be focused on the balance between ‘alert fatigue’ and patient safety. This study suggests that the VA system in 2003/4 had not got the balance quite right.

The suggestions made towards the end of the paper all deserve careful consideration.

Given the results of this study, it is clear that additional attention is needed to provide solutions that will improve the prescriber’s ability to communicate with the pharmacist and to ensure optimal patient outcomes with every medication prescribed. The following is a list of suggestions for improving patient outcomes related to exposure to DDIs:

1. A feedback mechanism should be incorporated into the DDI alert process. Reducing the frequency of clinically irrelevant alerts increases the importance of the remaining alerts. How prescribers and pharmacists respond to these alerts is then increasingly important. Override reasons (or, most important, the lack of response) need to be reviewed and an educational process used to modify practices that compromise patient safety.

2. The patient’s medication history should be incorporated into the DDI alerts. For each patient, systems should recognize responses to previous alerts and prescriber responses. This information could be presented to prescribers at the end of the order entry process.

3. Once an acceptable override reason is provided for a particular patient, repeat alert messages on refills are eliminated.

4. Drop-down menus could be used to more clearly and efficiently communicate override reasons.

5. Mandatory override reason responses could be expanded to include more than the most severe DDIs (in this case, requiring override reasons for significant and critical interactions).

6. Alternative management strategies should be available to prescribers when DDI alerts are first issued. This would provide opportunities for timely decisions to make changes in medication selection.

7. When guidelines require patient monitoring, automatic generation of reminders for laboratory tests and office visits should occur.

I commend this paper to all those interested in clinical decision support as very useful food for thought.

David.