Review Paper: Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

[1]  P. Glasziou,et al.  Monitoring in chronic disease: a rational approach , 2005, BMJ : British Medical Journal.

[2]  D. Bates,et al.  Effects of computerized physician order entry on prescribing practices. , 2000, Archives of internal medicine.

[3]  John F Hurdle,et al.  High rates of adverse drug events in a highly computerized hospital. , 2005, Archives of internal medicine.

[4]  J. Teich,et al.  Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients. , 2003, Archives of internal medicine.

[5]  Jonathan M. Teich,et al.  Improving allergy alerting in a computerized physician order entry system , 2000, AMIA.

[6]  Diane L. Seger,et al.  Application of Information Technology: Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care , 2006, J. Am. Medical Informatics Assoc..

[7]  D. Bates,et al.  Guided medication dosing for inpatients with renal insufficiency. , 2001, JAMA.

[8]  D. Bates,et al.  Outpatient prescribing errors and the impact of computerized prescribing , 2005, Journal of General Internal Medicine.

[9]  H Pohl,et al.  Medication prescribing errors in a teaching hospital. , 1990, JAMA.

[10]  D W Bates,et al.  Appropriateness of antiepileptic drug level monitoring. , 1995, JAMA.

[12]  Rainu Kaushal,et al.  Creating an Enterprise-wide Allergy Repository At Partners HealthCare System , 2003, AMIA.

[13]  D. Blumenthal,et al.  A research agenda for bridging the 'quality chasm.'. , 2003, Health affairs.

[14]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[15]  David W. Bates,et al.  Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool , 2003, Int. J. Medical Informatics.

[16]  A. Localio,et al.  Role of computerized physician order entry systems in facilitating medication errors. , 2005, JAMA.

[17]  J. McCulloch,et al.  CHAPTER 7 – Implications for Prevention , 1972 .

[18]  Thomas H. Payne,et al.  Characteristics and override rates of order checks in a practitioner order entry system , 2002, AMIA.

[19]  G J Kuperman,et al.  Patient safety and computerized medication ordering at Brigham and Women's Hospital. , 2001, The Joint Commission journal on quality improvement.

[20]  Gideon Koren,et al.  Large errors in the dosing of medications for children. , 2002, The New England journal of medicine.

[21]  J. Feinglass,et al.  The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. , 2004, Archives of internal medicine.

[22]  D S Stein,et al.  Factors related to errors in medication prescribing. , 1997, JAMA.

[23]  David W. Bates,et al.  Effective drug-allergy checking: methodological and operational issues , 2003, J. Biomed. Informatics.

[24]  H Pohl,et al.  Medication-prescribing errors in a teaching hospital. A 9-year experience. , 1997, Archives of internal medicine.

[25]  N. Laird,et al.  Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention , 1995 .

[26]  Diane L. Seger,et al.  Implementing Renal Impairment and Geriatric Decision Support in Ambulatory e-Prescribing , 2005, AMIA.

[27]  Gina Pugliese,et al.  Reducing Vancomycin Use Utilizing a Computer Guideline , 1999, Infection Control & Hospital Epidemiology.

[28]  Fred Pane,et al.  Pharmacist interventions in electronic drug orders entered by prescribers. , 2004, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[29]  N. Dickey,et al.  Systems analysis of adverse drug events. , 1996, JAMA.

[30]  S. Asch,et al.  Clinical Relevance of Automated Drug Alerts From the Perspective of Medical Providers , 2005, American journal of medical quality : the official journal of the American College of Medical Quality.

[31]  A. Avery,et al.  Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study , 2003, Quality & safety in health care.

[32]  Chike Augustine Igboechi,et al.  Impact of Computerized Prescriber Order Entry on Medication Errors at an Acute Tertiary Care Hospital , 2003 .

[33]  D. Bates,et al.  Improving safety with information technology. , 2003, The New England journal of medicine.

[34]  J. Marc Overhage,et al.  Research Paper: A Randomized Trial of "Corollary Orders" to Prevent Errors of Omission , 1997, J. Am. Medical Informatics Assoc..

[35]  Dean F. Sittig,et al.  How to Design Computerized Alerts to Ensure Safe Prescribing Practices , 2004 .

[36]  T. Clemmer,et al.  A computer-assisted management program for antibiotics and other antiinfective agents. , 1998, The New England journal of medicine.

[37]  J C Russo,et al.  Medication error prevention by clinical pharmacists in two children's hospitals. , 1987, Pediatrics.

[38]  Anthony J Avery,et al.  Incidence and Possible Causes of Prescribing Potentially Hazardous/Contraindicated Drug Combinations in General Practice , 2005, Drug safety.

[39]  M Peters,et al.  Implementation of rules based computerised bedside prescribing and administration: intervention study , 2000, BMJ : British Medical Journal.

[40]  Roger B. Davis,et al.  Physicians' decisions to override computerized drug alerts in primary care. , 2003, Archives of internal medicine.

[41]  Alicia S. Miller.  Pharmacy Issues: Clinical Screenings and Discharge Prescriptions , 2001 .

[42]  R A Miller,et al.  Empirical Derivation of an Electronic Clinically Useful Problem Statement System , 1999, Annals of Internal Medicine.

[43]  Craig Senholzi,et al.  Pharmacist interventions after implementation of computerized prescriber order entry. , 2003, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[44]  D. Bates,et al.  Guided prescription of psychotropic medications for geriatric inpatients. , 2005, Archives of internal medicine.

[45]  S D Small,et al.  Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. , 1995, JAMA.

[46]  David W Bates,et al.  A computer-based intervention for improving the appropriateness of antiepileptic drug level monitoring. , 2003, American journal of clinical pathology.

[47]  David W. Bates,et al.  Systems Analysis of Adverse Drug Events , 2008 .

[48]  Gilad J. Kuperman,et al.  Managing the Alert Process at NewYork-Presbyterian Hospital , 2005, AMIA.

[49]  Nidhi R. Shah,et al.  Adherence to black box warnings for prescription medications in outpatients. , 2006, Archives of internal medicine.

[50]  D W Bates,et al.  Evaluating the appropriateness of digoxin level monitoring. , 1999, Archives of internal medicine.

[51]  D. Bates,et al.  Medication errors and adverse drug events in pediatric inpatients. , 2001, JAMA.

[52]  D. Bates,et al.  Risk factors for adverse drug events among nursing home residents. , 2001, Archives of internal medicine.

[53]  H. Mcdonald,et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. , 2005, JAMA.

[54]  Rainu Kaushal,et al.  To What Extent Do Pediatricians Accept Computer-Based Dosing Suggestions? , 2007, Pediatrics.

[55]  Disciplinary Committee,et al.  Royal Pharmaceutical Society of Great Britain , 2002 .

[56]  Mary Cooper,et al.  Impact of a computerized alert during physician order entry on medication dosing in patients with renal impairment , 2002, AMIA.

[57]  Ervina Resetar,et al.  Customizing a Commercial Rule Base for Detecting Drug-Drug Interactions , 2005, AMIA.

[58]  R Gambino.  Appropriateness of antiepileptic drug level monitoring. , 1996, JAMA.

[59]  M G Amato,et al.  Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. , 1998, Archives of internal medicine.

[60]  G J Kuperman,et al.  A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests. , 1999, The American journal of medicine.

[61]  Gilad J. Kuperman,et al.  Editorial Comments: Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations , 2006, J. Am. Medical Informatics Assoc..

[62]  K. Gleason,et al.  Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. , 2004, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[63]  Joshua Borus,et al.  Adverse drug events in ambulatory care. , 2003, The New England journal of medicine.

[64]  Marc Berg,et al.  Review Paper: Overriding of Drug Safety Alerts in Computerized Physician Order Entry , 2006, J. Am. Medical Informatics Assoc..

[65]  Randolph A. Miller,et al.  The anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt , 2005, J. Biomed. Informatics.

[66]  N. Laird,et al.  Incidence of adverse drug events and potential adverse drug events , 1995 .

[67]  Michael Buck,et al.  Drug-Age Alerting for Outpatient Geriatric Prescriptions: A Joint Study using Interoperable Drug Standards , 2005, AMIA.

[68]  Michael M. Wagner,et al.  Review: Accuracy of Data in Computer-based Patient Records , 1997, J. Am. Medical Informatics Assoc..

[69]  D W Bates,et al.  Preventable medication errors: identifying and eliminating serious drug interactions. , 2001, Journal of the American Pharmacists Association.

[70]  D. Bates,et al.  Systems analysis of adverse drug events. ADE Prevention Study Group. , 1995, JAMA.

[71]  Timothy S Lesar,et al.  Tenfold Medication Dose Prescribing Errors , 2002, The Annals of pharmacotherapy.