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Automated alerts found lacking
3/7/2012
 
Traditional clinical-decision support systems issue too-broad warnings for clinicians to take them seriously or don’t keep up with patients’ clinical status, argues a recent essay in Patient Safety & Quality Healthcare.

The author cites a simple example to make the point. A patient acquires pneumonia, the physician prescribes the antibiotic ceftriaxone, and the system issues a warning that the patient is allergic to the medication. The physician switches to another antibiotic.

So far so good, but that is not the whole story. The clinical decision support system failed to alert the physician that because of the patient’s unusual clinical status, the second prescribed antibiotic would be ineffective.

Decision-support tools are improving patient care but suffer from several weaknesses. “Clinicians are discovering that there are two notable limitations to its use for medication management: 1) lack of data rich enough to deliver informed alerts to clinicians and 2) the inability to monitor patient activity after an initial order is made,” the author notes.

A common problem is too-broad warnings. A 2009 study conducted by researchers at Dana-Farber Cancer Institute and Beth Israel Deaconess Medical Center found that 90% of drug interaction alerts were overridden, along with 77% of the drug allergy alerts.

“The vast majority of the alerts were for a potential interaction with a drug a patient was already taking. In these cases, the CDS alerting system did not recognize that the patient was already tolerating the medication in question without any notable adverse effects related to the interaction,” the article reports.

It notes physicians who have been working with patients over time often understand the nuances of their care better than the alerts provided by current clinical-decision support applications. “Alerts often are based on general population knowledge rather than contextual information that is relevant to a particular patient. Physicians frequently complain that CDS is simply not able to provide the types of alerts that can really make a difference in care because the systems aren’t intuitive enough to compile relevant information in a meaningful way,” the author writes.

To address these issues, many hospitals are deploying advanced surveillance technology. “This technology enables the aggregation of richer data covering the overall scope of care and ultimately rendering an alert that is more relevant to the patient’s true condition,” he adds.

For instance, using surveillance technology, a specific clinical rule was written to identify patients experiencing a real change in serum potassium and alert clinicians for follow-up, rather than sending an alert out across the board for any combination of the three medications. The rule addressed patients whose lab results fell within specific parameters of the combination of potassium, ACE/ARB and K sparing diuretics,” the author says.

“It also alerted pharmacists of patients whose serum potassium increased by a particular percentage or rose above a defined level. The rule could be further refined to consider the patient’s renal function, another risk factor for the development of hyperkalemia,” he adds.