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Overrides of Medication Alerts in Ambulatory Care

Overrides of Medication Alerts in Ambulatory Care Isaac et al,1 writing in the February 9, 2009, issue of the Archives, describe an important and disturbing situation in which the promise of electronic prescribing systems to protect patient safety has been only partially realized. We have encountered a similar situation, which encompasses both electronic and paper prescriptions, in a system that generates clinical alerts using pharmacy claims data for prescriptions that have recently been filled. We agree with the authors' point (and the article by Shah et al2 that they cite) that such systems can achieve better physician acceptance if they limit alerts to those with the highest clinical importance, thereby avoiding the initiation of “alert fatigue.” We have also found that adding other sources of information—medical and laboratory claims, test results, feedback from physicians, and self-reported data from patients who are enrolled in disease management or complete health risk assessments—appears to greatly increase the specificity and credibility of clinical alerts, and the number of clinicians who respond by discontinuing the use of potentially dangerous medications.3,4 This enhanced system issued 4.7 million alerts in the year ending June 30, 2008, and used claims incurred later in 2008 to determine the resulting outcomes. As measured by terminations of the offending medications, physician acceptance of alerts warning of potential drug-drug interactions was as high as 92.3% for 143 alerts concerning the danger of toxic effects from the concomitant use of sibutramine and a centrally acting appetite suppressant and 60.6% for 249 alerts warning of the risk of hyperkalemia when eplerenone is combined with certain other drugs. We found similar acceptance when medication alerts were extended to the area of drug-disease interactions. Examples include alerts about the potential for serotonin receptor agonists triggering vasospasm in patients with atherosclerotic disease (585 alerts; 63.9% acceptance) and the danger of valproic acid use by patients with laboratory evidence of significant hepatic dysfunction (59 alerts; 67.8% acceptance). Because the effectiveness of clinical alerts seems to increase in this way as additional data sources are added, we have made the incorporation of other claims and biometric and patient-reported clinical inputs a high priority, and we would strongly urge electronic prescribing systems to adopt a similar strategy. Correspondence: Dr Rosenberg, Outcomes Research Unit, ActiveHealth Management, 1333 Broadway, New York, NY 10018 (srosenberg@activehealth.net). References 1. Isaac TWeissman JSDavis RB et al. Overrides of medication alerts in ambulatory care. Arch Intern Med 2009;169 (3) 305- 311PubMedGoogle ScholarCrossref 2. Shah NRSeger ACSeger DL et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006;13 (1) 5- 11PubMedGoogle ScholarCrossref 3. Rosenberg SNShnaiden TLWegh AAJuster IA Supporting the patient's role in guideline compliance: a controlled study. Am J Manag Care 2008;14 (11) 737- 744PubMedGoogle Scholar 4. Javitt JCRebitzer JBReisman L Information technology and medical missteps: evidence from a randomized trial. J Health Econ 2008;27 (3) 585- 602PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Overrides of Medication Alerts in Ambulatory Care

Abstract

Isaac et al,1 writing in the February 9, 2009, issue of the Archives, describe an important and disturbing situation in which the promise of electronic prescribing systems to protect patient safety has been only partially realized. We have encountered a similar situation, which encompasses both electronic and paper prescriptions, in a system that generates clinical alerts using pharmacy claims data for prescriptions that have recently been filled. We agree with the authors' point (and...
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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2009.224
Publisher site
See Article on Publisher Site

Abstract

Isaac et al,1 writing in the February 9, 2009, issue of the Archives, describe an important and disturbing situation in which the promise of electronic prescribing systems to protect patient safety has been only partially realized. We have encountered a similar situation, which encompasses both electronic and paper prescriptions, in a system that generates clinical alerts using pharmacy claims data for prescriptions that have recently been filled. We agree with the authors' point (and the article by Shah et al2 that they cite) that such systems can achieve better physician acceptance if they limit alerts to those with the highest clinical importance, thereby avoiding the initiation of “alert fatigue.” We have also found that adding other sources of information—medical and laboratory claims, test results, feedback from physicians, and self-reported data from patients who are enrolled in disease management or complete health risk assessments—appears to greatly increase the specificity and credibility of clinical alerts, and the number of clinicians who respond by discontinuing the use of potentially dangerous medications.3,4 This enhanced system issued 4.7 million alerts in the year ending June 30, 2008, and used claims incurred later in 2008 to determine the resulting outcomes. As measured by terminations of the offending medications, physician acceptance of alerts warning of potential drug-drug interactions was as high as 92.3% for 143 alerts concerning the danger of toxic effects from the concomitant use of sibutramine and a centrally acting appetite suppressant and 60.6% for 249 alerts warning of the risk of hyperkalemia when eplerenone is combined with certain other drugs. We found similar acceptance when medication alerts were extended to the area of drug-disease interactions. Examples include alerts about the potential for serotonin receptor agonists triggering vasospasm in patients with atherosclerotic disease (585 alerts; 63.9% acceptance) and the danger of valproic acid use by patients with laboratory evidence of significant hepatic dysfunction (59 alerts; 67.8% acceptance). Because the effectiveness of clinical alerts seems to increase in this way as additional data sources are added, we have made the incorporation of other claims and biometric and patient-reported clinical inputs a high priority, and we would strongly urge electronic prescribing systems to adopt a similar strategy. Correspondence: Dr Rosenberg, Outcomes Research Unit, ActiveHealth Management, 1333 Broadway, New York, NY 10018 (srosenberg@activehealth.net). References 1. Isaac TWeissman JSDavis RB et al. Overrides of medication alerts in ambulatory care. Arch Intern Med 2009;169 (3) 305- 311PubMedGoogle ScholarCrossref 2. Shah NRSeger ACSeger DL et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006;13 (1) 5- 11PubMedGoogle ScholarCrossref 3. Rosenberg SNShnaiden TLWegh AAJuster IA Supporting the patient's role in guideline compliance: a controlled study. Am J Manag Care 2008;14 (11) 737- 744PubMedGoogle Scholar 4. Javitt JCRebitzer JBReisman L Information technology and medical missteps: evidence from a randomized trial. J Health Econ 2008;27 (3) 585- 602PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 27, 2009

Keywords: ambulatory care services

References

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