Doctors prefer alerts over look-ups to prevent drug interactions

While drug-safety experts warn of the problem of 'alert fatigue' when designing computerised alert systems to identify drug-drug interactions (DDIs) in hospitals, prescribing doctors actually prefer alerts to alternative tools like look-ups, Australian research has found.

Researchers from the University of NSW undertook a series of semi-structured interviews with both pharmacological experts and prescribers at one hospital in Sydney to determine their opinions on computerised strategies to assist in the identification and prevention of DDIs.

They found that while the experts were concerned that the known issue of alert fatigue would prove a problem for prescribers, doctors themselves lacked confidence in their ability to identify DDIs and would in fact prefer computerised alerts to alternative strategies that asked them to remember to check for potential DDIs when prescribing.

The researchers conclude that while a large number of problems related to DDI alert implementations have been reported, doctors still appear to be receptive to the idea of computerised alerts and that by ensuring they are involved in DDI strategy design, it could result in greater use and satisfaction with the chosen strategy.

As the researchers write, DDIs are a preventable cause of medication errors in community and hospital settings and account for up to four per cent of hospital admissions. The most common adverse effects are low blood pressure, bleeding or kidney damage.

As both doctors and pharmacists are often unable to recognise potential DDIs, technology has been used to help identify and prevent them, predominantly through integrating automated alerts into electronic prescribing systems. While there is not a great deal of evidence showing that DDI alerts demonstrate actual reductions in errors, there is a lot of research showing that too many alerts can overload or fatigue users.

Alternatives such as computerised DDI checking programs, in which prescribers enter the names of medications into a program to check combinations for potential DDIs, are often considered to try to avoid this problem.

This particular study was conducted at St Vincent's Hospital in Sydney, which uses CSC's MedChart electronic medications management system. As the researchers write, when MedChart was implemented a decision was made not to incorporate DDI alerts into the system because it was felt that having a large number would lead to prescribers being over-alerted and the alerts being ignored.

“The aim of this study was to determine the opinions of both experts and users on computerised strategies available to target DDIs,” the researchers write.

“Given the complexity of the emerging field of health informatics, the focus is now shifting towards consulting users to develop more effective and efficient systems.

“Users’ views are important because users have a unique ability to pick up problems and suggest ideas for improvement that system developers sometimes overlook.”

Machines that go 'ping'

In phase one of the study, the researchers interviewed clinical pharmacologists and pharmacists with expertise in the area of medication safety, and then in phase two, a mix of junior medical officers and staff specialists working in a variety of specialties.

Phase one participants were asked for their opinion on what would be an effective strategy to reduce DDIs in hospital and many mentioned an alert system. However, as the researchers write, they all felt strongly about a number of problems that could arise following DDI alert implementation.

“The main concern was that having too many alerts would be disruptive and lead to ‘alert fatigue’. Participants also discussed the potential long-term effects of implementing DDI alerts. Experts felt that having an alert system in place might lead to prescribers beginning to over-rely on the system to detect DDIs, resulting in fewer prescribers remembering DDIs on their own.”

As one participant mentioned, if you have an alert system people tend to rely on it, “...and they forget that if it doesn’t go “bing” in front of them, then it doesn’t mean that there’s no interaction, it just means that that particular database doesn’t think there’s an interaction.”

These participants suggested that an alternative strategy could be to use a reference look-up tool that allows doctors to do a DDI check of all a patient's medications with one click when prescribing.

Doctors, however, were not so keen on this idea. While they all said they gave some level of thought to DDIs while prescribing, it usually depended on the specific drug or the condition of the patient.

When asked which strategy they would prefer to assist them to prevent DDIs – an alert system or a reference look-up tool – the majority said they preferred an alert system.

“The main advantage of an alert system was reported to be the fact that alerts occurred independently of a conscious decision by a prescriber to check an interaction,” they write.

“Participants also felt that prescribers’ ability to recognise DDIs was compromised when they were busy or time-constrained, so a look-up tool would not be used.”

The researchers say the results were unexpected, as their previous research at the same hospital had shown that alerts currently operational in MedChart were not seen as helpful in guiding prescribing decisions and were largely ignored by prescribers on ward rounds.

“A major barrier to the success of [look-up reference] software programs in healthcare is prescribers not using them and one of the most significant independent predictors of improved clinical outcomes with clinical decision support (CDS) is the automatic provision of decision support, instead of the requirement for users to seek out the advice on their own,” they write.

“Our findings are consistent with those of a recent survey study that showed that prescribers working in an intensive care unit preferred to receive pop-up alerts than be presented with the same information on request.

“If a look-up tool is implemented at our study hospital, there is a real and significant risk that prescribers will not consult the source as often as they need to, particularly because they are not aware of many potentially harmful medication combinations.”

They conclude that by ensuring users are aware of the limitations of alert systems and involving them in DDI strategy design, there could be greater use and satisfaction with the adopted strategy.

Identifying effective computerized strategies to prevent drug-drug interactions in hospital: A user-centered approach is published in the International Journal of Medical Informatics.

Posted in Australian eHealth

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