How to fine-tune CDS alerts for controlled substances to reduce intrusion

Medical Alert

Clinical decision support alerts in the electronic health record for controlled substances can be tweaked to maximize clinical utility without being overly intrusive, according to a new study in BMC Medical Informatics and Decision Making.

The country is in the middle of an opioid epidemic, but often clinicians considering prescribing a narcotic are not aware of patient interactions with other prescribers in different care settings. Yet when clinicians receive too many CDS alerts, the tools may be ignored, FierceHealthIT has previously reported.

The researchers, from Carolinas Health Care System, created a CDS built into the EHR to address opioid and benzodiazepine use.

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They identified five objective risk factors for misuse, abuse and diversion of the drugs that would trigger the alert: current open narcotic prescriptions; prior visits to an urgent care center (UCC) or emergency department (ED) with onsite treatment with narcotics; 30-day prescription narcotic history; history of overuse; and history of positive drug or alcohol screens within the EHR. 

The researchers then used the data collected to conduct two “silent” tests to revise the triggers and their timing. For instance, they changed the trigger threshold from three ED/UCC visits to two. They also modified the timing of the alert so that it would fire not at the immediate opening of the EHR, but as soon as possible after a narcotic might be prescribed.

They found that the modified alert became triggered for patients at high risk, but only in a small percentage of patient encounters, so it should not be intrusive.

“[I]t is important that EMR alerts are tested and tuned sufficiently to ensure a smooth rollout and that buy-in and support from all stakeholders is obtained early in the process. The utilization of the silent phases was a useful step that is translatable to other EMR systems,” the researchers concluded.