Study: Half of CDS prescription alert overrides are inappropriate

Providers override about half of the alerts they receive when using electronic prescribing systems, according to a new study that also finds only about half of those overrides are medically appropriate.

Researchers reviewed more than 150,000 clinical decision support (CDS) alerts on 2 million outpatient medication orders for the study, published online this week by the Journal of the American Medical Informatics Association (JAMIA).

The most common CDS alerts were duplicate drug (33 percent), patient allergy (17 percent) and drug interactions (16 percent.) Alerts most likely to be overridden, however, were formulary substitutions (85 percent), age-based recommendations (79 percent), renal recommendations (78 percent) and patient allergies (77 percent).

On average, 53 percent of alert overrides were considered appropriate, according to the study abstract. Only 12 percent of renal recommendation alert overrides were deemed appropriate, compared with 92 percent for patient allergies.

The researchers concluded that refining the alerts could improve relevance and reduce alert fatigue.

Alert fatigue and other misuses of EHRs can cause serious problems.

Just this week a report by the Department of Veteran's Affairs' Office of Inspector General found inadequate use--including workarounds and poor documentation of the Memphis VA Medical Center's EHR led to the deaths of at least two patients in its emergency department.

In one case, a nurse had inputted into the EHR the fact that the patient had an allergy to aspirin, but the physician bypassed the EHR and hand-wrote an order for an anti-inflammatory drug that is contraindicated for aspirin. 

A case study published earlier this year in the journal Pediatrics looked at the hospitalization of a 2-year-old boy whose electronic health record indicated an allergy to sulfonamide antibiotics.

Clinical staff overrode more than 100 drug-allergy alerts to provide him alternate medications. But when a new drug allergy alert was added to the EHR, "desensitization" caused by the "deluge of overrides" meant he continued to receive an inappropriate medication, according to the case study. The confusion contributed to a worsening of the child's condition and he later died.

Computerized prescribing alerts were 'too much, too late' in a study that found only 2 percent prompted any action from physicians during patient visits.

A separate study published earlier this year in JAMIA found that an electronic alert late in the complex process of generating a prescription "is likely to be regarded as intrusive and unwelcome, and increases the probability of it being ignored."

During a talk at the Medical Group Management Association conference earlier this year, Derek Kosiorek, a principal with the MGMA's Health Care Consulting Group, recommended "rightsizing" alerts in EHRs as a way to reduce alert fatigue. Being selective about which alerts are activated makes it less likely the alerts will be ignored or overridden, he said.

For more information:
- read the study abstract

EHR workarounds, poor documentation cause deaths at Memphis VA
EHR alert overload complicates treatment, harms patient
Docs rarely 'game' CDS systems to reduce alerts
Newer EHRs with 'refinements' can improve prescription safety
4 ways to optimize your EHR
Emergency department EHRs 'particularly error prone'
E-prescribing alerts often 'too much, too late' for docs

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