Utilization of computerized clinical decision support for potentially inappropriate medications

Abstract

Background: Electronic medical record (EMR) alerts may inform point of care decisions, including the decision to prescribe potentially inappropriate medications (PIM) identified in the Beers criteria. EMR alerts may not be considered relevant or informative in the clinician context, leading to a phenomenon colloquially known as "alert fatigue." Objective: To assess the frequency of clinical interaction with EMR alerts and associated deprescribing behaviors in ambulatory settings. Methods: This is a retrospective observational study in two ambulatory clinics (the Kaye Edmonton Clinic Senior's Clinic and the Lynnwood Family Practice Clinic) in Edmonton over an observational period of 30 months. Statistical analysis was done using descriptive statistics, chi-square and regression analysis. Results: The reminder performance for interactions with the alert was 17.2% across the two clinics. The Number Needed to Remind (NNR) or mean number of alerts shown on clinician screens prior to a single interaction of any kind with the alert was 5.8. When actions were defined as a deprescribing (ie discontinuation) event that was related to the alert and that particular interaction in the EMR, the reminder performance was 1.2%, for an NNR of 82.8. Conclusion: The configuration of alerts in the EMR was not associated with a clinically detectable increase in the uptake of the Beers criteria for high hazard medications.

Keywords: Beers Criteria; alert fatigue; best practice advisory; deprescribing; e-prescribing; polypharmacy; prescribing.

Figure 1

Legend: Patient visits, alert presentations, interaction rates and discontinuation rates over the 30-month study period. (A) Volume of patient care visits at two clinics, primary care (black bars) and a geriatrics clinic (grey bars). Each bar represents a month of data. (B) Volume of alert presentations in the two clinics. (C) Percent of alert presentations with any interaction (reminder performance) in primary care practice clinics (squares), geriatrics clinic reminder performance (circles). (D) Percent of alert presentations associated with a possible deprescribing event in primary care clinic (squares), or geriatrics clinic (circles).