Eric Pifer

Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan Report of the Joint Clinical Decision Support Workgroup

Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption.

Randomized clinical trial of a customized electronic alert requiring an affirmative response compared to a control group receiving a commercial passive CPOE alert: NSAID—warfarin co-prescribing as a test case

BACKGROUND 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. OBJECTIVE 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). DESIGN 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. MEASUREMENTS Alert adherence was compared between study groups. RESULTS 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). CONCLUSION 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.

Effectiveness of an information technology intervention to improve prophylactic antibacterial use in the postoperative period

BACKGROUND A 2005 report from the Centers for Medicare and Medicaid Services and the Centers for Disease Control Surgical Infection Prevention program indicated that only 41% of prophylactic antibacterials were correctly stopped within 24 h of the end of surgery. Electronic order sets have shown promise as a means of integrating guideline information with electronic order entry systems and facilitating safer, more effective care. OBJECTIVE The aim was to study the effectiveness of a computer-based antibacterial order set on increasing the proportion of patients who have antibacterial wound prophylaxis discontinued in the appropriate time frame. DESIGN The authors conducted a quasi-experimental interrupted time-series analysis over an 8-month study period with the implementation of a computer-based order system designed to prevent excessive duration of surgical prophylaxis antibacterials. MEASUREMENT The primary outcome was the proportion of surgeries with antibacterials discontinued in the appropriate time frame. Additionally, we evaluated the percent of surgeries after implementation of the electronic intervention with chart documentation of infection among surgeries where the prescriber indicated the reason for antibacterial therapy was treatment. RESULTS The computer-based order intervention significantly improved the proportion of surgeries with timely discontinuation of antibacterials from 38.8% to 55.7% (p < 0.001) in the intervention hospital, while the control hospital remained at 56-57% (p = 0.006 for the difference between treated and control hospitals). In surgeries after intervention implementation where a prescriber indicated the reason for antibacterial therapy was treatment, the prevalence of chart documented infection was only 14%. CONCLUSIONS A computer-based electronic order set intervention increased timely discontinuation of postoperative antibacterials.

Computer-Aided Diagnosis †

A providers ability to make correct decisions regarding patient care is predicated on the correct identification of a patients diagnoses. However, the process of developing diagnostic certainty remains a challenging task despite an increasingly sophisticated array of available diagnostic modalities and techniques. Clinicians need support to integrate a broad range of findings from these tools along with a patients symptoms and signs. This chapter discusses the evolution and utility of computer-aided diagnostic decision support systems including recent developments in neural networks, microarray technology, and syndromic surveillance. Keywords: diagnostic decision support; Bayesian analysis; belief networks; decision trees; neural networks; microarray technology; syndromic surveillance