William L. Galanter

A Trial of Automated Decision Support Alerts for Contraindicated Medications Using Computerized Physician Order Entry

BACKGROUND Automated clinical decision support has shown promise in reducing medication errors; however, clinicians often do not comply with alerts. Because renal insufficiency is a common source of medication errors, the authors studied a trial of alerts designed to reduce inpatient administration of medications contraindicated due to renal insufficiency. METHODS A minimum safe creatinine clearance was established for each inpatient formulary medication. Alerts recommending cancellation appeared when a medication order was initiated for a patient whose estimated creatinine clearance was less than the minimum safe creatinine clearance for the medication. Administration of medications in patients with creatinine clearances less than the medications minimum safe clearance were studied for 14 months after, and four months before, alert implementation. In addition, the impact of patient age, gender, degree of renal dysfunction, time of day, and duration of housestaff training on the likelihood of housestaff compliance with the alerts was examined. RESULTS The likelihood of a patient receiving at least one dose of contraindicated drug after the order was initiated decreased from 89% to 47% (p < 0.0001) after alert implementation. Analysis of the alerts seen by housestaff showed that alert compliance was higher in male patients (57% vs. 38%, p = 0.02), increased with the duration of housestaff training (p = 0.04), and increased in patients with worsening renal function (p = 0.007). CONCLUSION Alerts were effective in decreasing the ordering and administration of drugs contraindicated due to renal insufficiency. Compliance with the alerts was higher in male patients, increased with the duration of housestaff training, and increased in patients with more severe renal dysfunction.

Mechanisms, manifestations, and management of digoxin toxicity in the modern era.

Because of the common use of digoxin and because of its narrow therapeutic index, digoxin toxicity has been prevalent historically and, therefore, most clinicians are well aware of the classical dose/concentration-related signs and symptoms of toxicity. Yet, in the modern era the incidence of digoxin toxicity has been declining for a variety of reasons, including a new (lower) therapeutic range, the development of more effective drug therapies for heart failure, and more accurate dosing methods. In addition, digoxin toxicity, once commonly fatal, can now be quickly and effectively treated by the emergency administration of antidigoxin Fab fragments. Indeed, it may be possible to expand the use of Fab fragments to select patients with non-life-threatening digoxin toxicity, in order to save costs and improve patient comfort. Most cases of digoxin toxicity are caused by inappropriately high dosages, which are usually prescribed in the setting of renal dysfunction, while other cases can be attributed to system errors such as multiple prescriptions, poor patient counseling, or errors in transcribing. With modern computerized prescribing systems, such as direct physician order entry and prompts that alert the clinician to the potential for error, it is possible to decrease the incidence of digoxin toxicity even further. A realistic goal is to nearly eradicate once commonplace digoxin toxicity or at least make its occurrence a rare event.

A prescription for improving drug formulary decision making.

Gordon Schiff and colleagues present a new tool and checklist to help formularies make decisions about drug inclusion and to guide rational drug use.

Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance

OBJECTIVE The problem list is a key and required element of the electronic medical record (EMR). Problem lists may contribute substantially to patient safety and quality of care. Physician documentation of the problem list is often lower than desired. Methods are needed to improve accuracy and completeness of the problem list. DESIGN An automated clinical decision support (CDS) intervention was designed utilizing a commercially available EMR with computerized physician order entry (CPOE) and CDS. The system was based on alerts delivered during inpatient medication CPOE that prompted clinicians to add a diagnosis to the problem list. Each alert was studied for a 2-month period after implementation. MEASUREMENTS Measures included alert validity, alert yield, and accuracy of problem list additions. RESULTS At a 450 bed teaching hospital, the number of medication orders which triggered alerts during all 2-month study periods was 1011. For all the alerts, the likelihood of a valid alert (an alert that occurred in patients with one of the predefined diagnoses) was 96+/-1%. The alert yield, defined as occuring when an alert led to addition of a problem to the problem list, was 76+/-2%. Accurate problem list additions, defined as additions of problems when the problem was determined to be present by expert review, was 95+/-1%. CONCLUSION The CDS problem list mechanism was integrated into the process of medication order placement and promoted relatively accurate addition of problems to the EMR problem list.

Promoting More Conservative Prescribing

ALTHOUGH MEDICAL AND PHARMACY CURRICULA and journals are rich with information about drugs and treatment of specific diseases, there is a paucity of education on ways to become effective lifetime prescribers. Two recent reports from the Association of American Medical Colleges (AAMC) lamented the current state of pharmacology teaching and the disturbing extent of pharmaceutical industry influence at all stages of medical education. Given the welldocumented prevalence of medication-related harm and inappropriate prescribing, such educational reform is necessary but not sufficient to ensure that patients are optimally treated. Beyond improved training in pharmacology and minimization of unbalanced industrysponsored education, trainees need guiding principles to inform their thinking about pharmacotherapy to help them become more careful, cautious, evidence-based prescribers. In this Commentary, we offer 25 such principles (BOX), making no claims that they represent the definitive or comprehensive antidote to the many factors contributing to suboptimal prescribing. However, based on our experience educating physicians, pharmacists, and medical students, we believe these lessons are fundamental for teaching clinicians how to develop excellent prescribing skills, yet such fundamentals are absent or underemphasized in current medical and pharmacy education. The AAMC report emphasized expanded teaching about “factors that make each patient unique,” pharmacology and pharmacokinetics, optimal dosing, prescribing regulations, drug interactions and adverse reactions, and use of drug compendia and informational resources. However, prescribers also need to be taught a set of skills and attitudes that will help them approach claims for drugs, especially new drugs, more critically. Although the AAMC document discusses the need for a number of patient monitoring and communication functions embodied in these conservative prescribing principles, without a more cautious and, frankly, more skeptical approach to using drugs, prescribers will lack the will and the skills to resist ubiquitous promotional messages encouraging them to reach for newer and often more expensive medications. Such skepticism needs to be grounded in historical and current lessons that offer reasons for precaution. Lessons from iatrogenic events related to agents such as thalidomide, phen-fen, or rofecoxib (Vioxx); recognition that new medications are tested in limited numbers of patients with few comorbidities, typically for a relatively short time; and disquieting revelations that promotional activities distort what prescribers learn about drugs are lessons worth learning and incorporating into prescribing decision making. Although the attitudes and behaviors recommended in our principles should not be terribly controversial, taken together they represent a departure from current practice. If prescribers routinely heeded these principles, many patients could be spared the risk or expense of needless or harmful drug therapy.

A Trial of Automated Safety Alerts for Inpatient Digoxin Use with Computerized Physician Order Entry

OBJECTIVE Automated clinical decision support (CDS) has shown promise in improving safe medication use. The authors performed a trial of CDS, given both during computerized physician order entry (CPOE) and in response to new laboratory results, comparing the time courses of clinician behaviors related to digoxin use before and after implementation of the alerts. DESIGN Alerts were implemented to notify of the potential risk from low electrolyte concentrations or unknown digoxin or electrolyte concentrations during CPOE. Alerts were also generated in response to newly reported hypokalemia and hypomagnesemia in patients given digoxin. MEASUREMENTS Clinician responses to the alerts for six months were compared with responses to similar situations for six months prior to implementation. RESULTS During CPOE, checking for unknown serum values increased after implementation compared with control at one hour: 19% vs. 6% for digoxin, 57% vs. 9% for potassium, and 40% vs. 12% for magnesium as well as at 24 hours (p < 0.01 for all comparisons). Electrolyte supplementation increased with newly reported hypokalemia and hypomagnesemia after implementation at one hour: 35% vs. 6% and 49% vs. 5% for potassium and magnesium, respectively, as well as at 24 hours (p < 0.01 for all comparisons). During CPOE, supplementation for hypokalemia was not improved, whereas supplementation for hypomagnesemia improved at one hour (p < 0.05). CONCLUSION Overall, the alerts improved the safe use of digoxin. During CPOE, alerts associated with missing levels were effective. For hypokalemia and hypomagnesemia, the alerts given during CPOE were not as effective as those given at the time of newly reported low electrolytes.

Feasibility of implementing a comprehensive warfarin pharmacogenetics service.

To determine the procedural feasibility of a pharmacist‐led interdisciplinary service for providing genotype‐guided warfarin dosing for hospitalized patients newly starting warfarin.

Design and implementation of a privacy preserving electronic health record linkage tool in Chicago

OBJECTIVE To design and implement a tool that creates a secure, privacy preserving linkage of electronic health record (EHR) data across multiple sites in a large metropolitan area in the United States (Chicago, IL), for use in clinical research. METHODS The authors developed and distributed a software application that performs standardized data cleaning, preprocessing, and hashing of patient identifiers to remove all protected health information. The application creates seeded hash code combinations of patient identifiers using a Health Insurance Portability and Accountability Act compliant SHA-512 algorithm that minimizes re-identification risk. The authors subsequently linked individual records using a central honest broker with an algorithm that assigns weights to hash combinations in order to generate high specificity matches. RESULTS The software application successfully linked and de-duplicated 7 million records across 6 institutions, resulting in a cohort of 5 million unique records. Using a manually reconciled set of 11 292 patients as a gold standard, the software achieved a sensitivity of 96% and a specificity of 100%, with a majority of the missed matches accounted for by patients with both a missing social security number and last name change. Using 3 disease examples, it is demonstrated that the software can reduce duplication of patient records across sites by as much as 28%. CONCLUSIONS Software that standardizes the assignment of a unique seeded hash identifier merged through an agreed upon third-party honest broker can enable large-scale secure linkage of EHR data for epidemiologic and public health research. The software algorithm can improve future epidemiologic research by providing more comprehensive data given that patients may make use of multiple healthcare systems.

Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital

PURPOSE The implementation of a mandatory assessment of risk for venous thromboembolism (VTE) in a health systems electronic medical record (EMR) and clinical decision-support (CDS) system was evaluated to measure its effect on the use of pharmacologic prophylaxis and the occurrence of VTE and bleeding events. METHODS A commercially available CDS system was used in designing the automated CDS intervention. During computerized order entry, the system delivered alerts prompting clinician risk assessment and also delivered alerts under circumstances suggesting less-than-optimal prophylaxis. Rates of pharmacologic prophylaxis, clinically diagnosed hospital-acquired VTE, and hospital-acquired bleeding events were measured during one year before and one year after implementation. RESULTS After adjustment for patient age, sex, and high-risk comorbidities, the data showed a postimplementation increase in the percentage of patients who received pharmacologic prophylaxis at some time during their admission from 25.9% to 36.8% (p < 0.001). The rate of VTE for the entire hospital did not change significantly, but a significant reduction among patients on medical units was observed, from 0.55% to 0.33% (p = 0.02). There was no increase in either major or minor bleeding events. CONCLUSION Without increasing the risk of bleeding, a CDS system requiring clinicians to document VTE risk assessment in the EMR promoted improved rates of pharmacologic prophylaxis at any time during an admission and a decreased risk of VTE in general medical patients but not all adult patients.

Economic Analysis of Alvimopan for Prevention and Management of Postoperative Ileus

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small‐ or large‐bowel resection by laparotomy is associated with lower total costs compared with standard care.