Clinicians' assessments of electronic medication safety alerts in ambulatory care.

BACKGROUND: While electronic prescribing (e-prescribing) systems with drug interaction and allergy alerts promise to improve medication safety in ambulatory care, clinicians often override these safety features. We undertook a study of respondents' satisfaction with e-prescribing systems, their perceptions of alerts, and their perceptions of behavior changes resulting from alerts. METHODS: Random sample survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system. RESULTS: A total of 184 respondents completed the survey (61%). Respondents indicated that e-prescribing improved the quality of care delivered (78%), prevented medical errors (83%), and enhanced patient satisfaction (71%) and clinician efficiency (75%). In addition, 35% of prescribers said that electronic alerts caused them to modify a potentially dangerous prescription in the last 30 days. They suggested that alerts also led to other changes in clinical care: counseling patients about potential reactions (49% of respondents), looking up information in medical references (44%), and changing the way a patient was monitored (33%). Altogether, 63% of clinicians reported taking action other than discontinuing or modifying an alerted prescription in the previous month in response to alerts. Despite these benefits, fewer than half of respondents were satisfied with drug interaction and allergy alerts (47%). Problems included alerts triggered by discontinued medications (58%), alerts that failed to account for appropriate drug combinations (46%), and excessive volume of alerts (37%). CONCLUSION: Although clinicians were critical of the quality of e-prescribing alerts, alerts may lead to clinically significant modifications in patient management not readily apparent based on "acceptance" rates.

Assessing the value of electronic prescribing in ambulatory care: a focus group study.

INTRODUCTION: Drug allergy and interaction alerts are a core function of most electronic prescribing (e-prescribing) systems. To characterize the value of e-prescribing and medication safety alerts, especially in small and medium-size practices, we undertook a hypothesis-generating focus group study of Massachusetts clinicians. We sought to understand the reasons for adoption and use of e-prescribing, as well as clinicians' complaints about and perceived benefits of drug allergy and interaction alerts. METHODS: We recruited 25 Massachusetts clinicians to participate in three focus groups regarding the use and value of e-prescribing and medication safety alerts. The participants included high-volume (>100 electronic scripts per month) physicians, nurse practitioners, and practice assistants in family practice, internal medicine, pediatrics, and subspecialty practices who used a common commercial e-prescribing system. RESULTS: Most clinicians were in small and medium-size group practices. Participants were, on average, 25 years post-medical school graduation (range 8-36), had used e-prescribing for 2.5 years (range 1.0-5.5), and wrote the majority (89%, range 15-100%) of prescriptions electronically. The participants' decision to adopt e-prescribing was driven largely by financial incentives offered by insurers, and was viewed as a step toward implementation of an electronic medical record. Although participants agreed that the system was easy to learn, few anticipated efficiencies were realized until clinicians configured the device to meet their needs. The participants were ambivalent about whether e-prescribing improved their own or overall office efficiency, and--in the absence of payer incentives--few were willing to pay for the systems out-of-pocket. The most valuable aspects of e-prescribing were the ease of changing doses, renewing prescriptions, ensuring legibility, and transmitting prescriptions to in- and out-of-state pharmacies. Participants were dissatisfied with the unreliability of transmitting prescriptions successfully to the pharmacy, and with their inability to merge duplicate patient entries, to create a comprehensive, allprescriber medication list, to write prescriptions for commonly ordered medications and supplies, and to enter allergy information into the system. Participants were critical of the volume of drug allergy and interaction alerts. Many alerts were of trivial clinical significance or were generated by interactions with out-of-date medications. As a result, many clinicians habitually ignored these alerts. Alerts were most helpful to clinicians who were unfamiliar with a particular drug or patient. Although alerts rarely led the clinicians to abort or alter a prescription, alerts did prompt clinicians to counsel patients about medication side effects, to educate themselves about potential interactions, to check physical examination findings, or to order laboratory tests. Despite problems, few clinicians were willing to forego receiving alerts for fear that they would miss a potentially dangerous drug interaction. CONCLUSION: Electronic prescribing is a potential boon to ambulatory medical practice, although its value may be compromised by inappropriate and irrelevant medication safety alerts and by features of the e-prescribing system that prove burdensome to frontline clinicians. While alerts infrequently result in changed or aborted prescriptions, they may trigger a variety of other provider behaviors that help to ensure safe care.

Overrides of medication alerts in ambulatory care.

BACKGROUND: Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts. METHODS: We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance. RESULTS: A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03). CONCLUSION: Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.