Development and evaluation of a computerised clinical decision support system for switching drugs at the interface between primary and tertiary care

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Abstract

Background

Upon admission to a hospital patients’ medications are frequently switched to alternative drugs compiled in so called hospital drug formularies. This substitution process is a laborious and error-prone task which should be supported by sophisticated electronic tools. We developed a computerised decision support system and evaluated benefit and potential harm associated with its use.

Methods

Based on a multi-step algorithm we identified drug classes suitable for exchange, defined conversion factors for therapeutic interchange, built a web-based decision support system, and implemented it into the computerised physician order entry of a large university hospital. For evaluation we compared medications manually switched by clinical pharmacists with the results of automated switching by the newly developed computer system and optimised the system in an iterative process. Thereafter the final system was tested in an independent set of prescriptions.

Results

After iterative optimisation of the logical framework the tool was able to switch drugs to pharmaceutical equivalents and alternatives; in addition, it contained 21 different drug classes for therapeutic substitution. In this final version it switched 91.6% of 202 documented medication consultations (containing 1,333 drugs) automatically, leaving 8.4% for manual processing by clinical professionals. No incorrect drug switches were found.

Conclusion

A large majority (>90%) of drug switches performed at the interface between primary and tertiary care can be handled automatically using electronic decision support systems, indicating that medication errors and workload of healthcare professionals can be considerably reduced.

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Most cited references 23

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Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

David Bates (1998)

Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. Large tertiary care hospital. For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. Nonintercepted serious medication errors. Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.

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Medication-related clinical decision support in computerized provider order entry systems: a review.

Gilad Kuperman, Anne M Bobb, Thomas H Payne … (2015)

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

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Effect of medication dosing frequency on adherence in chronic diseases.

Sameer Saini, Philip Schoenfeld, Kellee Kaulback … (2009)

To systematically review available data on the effect of daily medication dosing frequency on medication adherence in chronic disease states, as assessed by precise medication event monitoring systems (MEMS). Systematic review of relevant literature published between January 1986 and August 2007. Four electronic databases were searched to identify appropriate studies. Study selection criteria included prospective study design, patient population with quiescent chronic disease, medication intervention prescribed to each treatment arm for at least 6 weeks, and the use of MEMS to measure adherence. Data were extracted on the chronic disease being treated, the frequency of medication dosing, and the proportion of days with correct number of doses. Twenty studies met the selection criteria. All studies reported higher adherence rates in patients using less frequently dosed medications, and these differences were statistically significant (P <.05) in 75% (15 of 20) of studies. For 5 of 6 studies comparing once-daily versus thrice-daily dosing, patients receiving once-daily dosing had 22% to 41% more adherent days compared with patients receiving thrice-daily dosing. For studies comparing once-daily versus twice-daily dosing, patients receiving once-daily dosing had 2% to 44% more adherent days compared with patients receiving twice-daily dosing, with most studies clustering around 13% to 26%. Patients are more compliant with once-daily compared with twice-daily or thrice-daily treatment regimens.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Med Inform Decis Mak

Journal ID (iso-abbrev): BMC Med Inform Decis Mak

Title: BMC Medical Informatics and Decision Making

Publisher: BioMed Central

ISSN (Electronic): 1472-6947

Publication date Collection: 2012

Publication date (Electronic): 27 November 2012

Volume: 12

Page: 137

Affiliations

[1 ]Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

[2 ]Hospital Pharmacy, University of Heidelberg, Heidelberg, Germany

Article

Publisher ID: 1472-6947-12-137

DOI: 10.1186/1472-6947-12-137

PMC ID: 3518241

PubMed ID: 23185973

SO-VID: 0691fbc4-1d18-4654-b2d5-2f54016299cb

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Development and evaluation of a computerised clinical decision support system for switching drugs at the interface between primary and tertiary care

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Abstract

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Methods

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Conclusion

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Most cited references 23

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

Medication-related clinical decision support in computerized provider order entry systems: a review.

Effect of medication dosing frequency on adherence in chronic diseases.

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