Unintended Effects of a Computerized Physician Order Entry Nearly Hard-Stop Alert to Prevent a Drug Interaction

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA.
Archives of internal medicine (Impact Factor: 17.33). 09/2010; 170(17):1578-83. DOI: 10.1001/archinternmed.2010.324
Source: PubMed


The effectiveness of computerized physician order entry (CPOE) systems has been modest, largely because clinicians frequently override electronic alerts.
To evaluate the effectiveness of a nearly "hard stop" CPOE prescribing alert intended to reduce concomitant orders for warfarin and trimethoprim-sulfamethoxazole, a randomized clinical trial was conducted at 2 academic medical centers in Philadelphia, Pennsylvania. A total of 1981 clinicians were assigned to either an intervention group receiving a nearly hard stop alert or a control group receiving the standard practice. The study duration was August 9, 2006, through February 13, 2007.
The proportion of desired responses (ie, not reordering the alert-triggering drug within 10 minutes of firing) was 57.2% (111 of 194 hard stop alerts) in the intervention group and 13.5% (20 of 148) in the control group (adjusted odds ratio, 0.12; 95% confidence interval, 0.045-0.33). However, the study was terminated early because of 4 unintended consequences identified among patients in the intervention group: a delay of treatment with trimethoprim-sulfamethoxazole in 2 patients and a delay of treatment with warfarin in another 2 patients.
An electronic hard stop alert as part of an inpatient CPOE system seemed to be extremely effective in changing prescribing. However, this intervention precipitated clinically important treatment delays in 4 patients who needed immediate drug therapy. These results illustrate the importance of formal evaluation and monitoring for unintended consequences of programmatic interventions intended to improve prescribing habits.
clinicaltrials.gov Identifier: NCT00870298.

Download full-text


Available from: Sean Hennessy,
  • Source
    • "Some suggestions include reducing the number of alerts or making them effective by reflecting the nature of the patient condition they are supporting. Other studies suggest the consideration of the context of disease and care, age and function of the end user (e.g., health care professionals) as well as other contextual parameters [25]. Indeed, a number of review articles in health care research note that although there have been enough studies on alarm fatigues, the relevant contextual and situational analysis of alarms is lacking—often leaving the practitioners to ignore or manage the alert related issues internally (see [5] [13] [26]). "

    Health Policy and Technology 08/2015; DOI:10.1016/j.hlpt.2015.08.005
  • Source
    • "Six, the organization must develop the technical and governance infrastructure required to capture, report on, and evaluate the data necessary to measure and monitor both the inner workings of the CDS as well as the effect of the interventions on clinical processes and patient outcomes [31]. Without such careful evaluation, organizations might inadvertently negatively affect the patients' care that they are working to improve [32]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.
    BMC Medical Informatics and Decision Making 02/2011; 11(1):13. DOI:10.1186/1472-6947-11-13 · 1.83 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Studies that have looked at the effectiveness of computerized decision support systems to prevent drug-drug interactions have reported modest results because of low response by the providers to the automated alerts. To evaluate, within an inpatient computerized physician order entry (CPOE) system, the incremental effectiveness of an alert that required a response from the provider, intended as a stronger intervention to prevent concurrent orders of warfarin and non-steroidal anti-inflammatory drugs (NSAIDs). Randomized clinical trial of 1963 clinicians assigned to either an intervention group receiving a customized electronic alert requiring affirmative response or a control group receiving a commercially available passive alert as part of the CPOE. The study duration was 2 August 2006 to 15 December 2007. Alert adherence was compared between study groups. The proportion of desired ordering responses (ie, not reordering the alert-triggering drug after firing) was lower in the intervention group (114/464 (25%) customized alerts issued) than in the control group (154/560 (28%) passive alerts firing). The adjusted OR of inappropriate ordering was 1.22 (95% CI 0.69 to 2.16). A customized CPOE alert that required a provider response had no effect in reducing concomitant prescribing of NSAIDs and warfarin beyond that of the commercially available passive alert received by the control group. New CPOE alerts cannot be assumed to be effective in improving prescribing, and need evaluation.
    Journal of the American Medical Informatics Association 07/2010; 17(4):411-5. DOI:10.1136/jamia.2009.000695 · 3.50 Impact Factor
Show more