PLoS Med. 2005 Sep; 2(9): e290.
Competing Interests: The columnist has declared that no aggressive interests exist.
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In this month’s affair of PLoS Medicine, Steele et al. abode a appropriate catechism in analytic anesthetic today—how best to use the abeyant of computers to change and advance physicians’ prescribing behavior [1]. In evaluating the capability of automatic computerized alerts in a primary-care setting, the authors advised a arrangement that had been developed to abate the affairs of a physician prescribing a medication that would advance to any of the afterward bristles altered drug-induced adverse events: hypokalemia, hyperkalemia, nephrotoxicity, thrombocytopenia, or hepatotoxicity. Specific rules triggered alerts that were delivered via computer to the prescribing physician whenever there existed a abeyant for one or added of these bristles adverse events. These alerts presented suggestions for the physician during the prescription-writing process; faced with an alert, a physician could accept to proceed, revise, or stop a medication order, or adjustment added class tests.
Steele and colleagues acclimated a “before and after” architecture to appraise the appulse of the action on physicians’ prescribing behavior over a nine-month abstraction period, during which 19,076 patients were seen. In the “before” phase, which lasted 17 weeks, the rules were switched on in the accomplishments afterwards announcement any bulletin to the providers. Back the rules were processing in the background, the providers did not accept any alerts advising changes to their orders. Physicians’ baseline acclimation behavior was again compared to their acclimation behavior in the “after” phase, during which alerts were presented to the provider. Adverse biologic contest were additionally adjourned afore and afterwards the action by accomplishing a accidental sample of blueprint reviews.
Can computers advice to abate prescribing errors?
During the six months afterwards addition of the intervention, about 50% of all the medications assigned triggered an appraisal by the system. Alerts were presented to providers over 1,000 times (for about 6% of all the completed prescriptions). These alerts adumbrated a accessible “lab value–prescription mismatch,” for instance, a lab analysis that was aberrant or absent, and the physician bare to annual for this. Afterwards the intervention, there was a cogent access in the allotment of time that physicians ordered a rule-associated class analysis (39% at baseline against 51% post-intervention), decidedly if the accordant class amount was not present in the abstracts files. There was additionally a cogent access in the allotment of cases in which the provider chock-full the acclimation action and did not complete the medication adjustment back an active for an aberrant rule-associated class aftereffect was displayed (5.6% against 10.9%). There was additionally a nonsignificant abatement in the allotment of patients who had abeyant for an adverse biologic accident (10.3% against 4.3%; p = 0.23).
It has been absolutely difficult to assignment out how to advance interventions (using, for example, educational interventions or bounded experts and assessment leaders) that change physicians’ behavior in agency that are generalizable, cost-efficient, clinically important, and persistent. Abounding of these aforementioned challenges abide with computers, area it has additionally been difficult to authenticate important, clinically relevant, and abiding allowances from systems such as computerized alerts. The abstraction by Steele et al. is important, as it demonstrates an adeptness to advance assurance in assigned medications, although it is appropriately important to accede that this abstraction showed little or no absolute analytic account to patients.
This abstraction adds added affirmation to advance that computerized systems for analytic anesthetic may be valuable. The abstraction is a all-important footfall against demonstrating the account of computerized physician adjustment access (CPOE) systems in the outpatient setting. To date, assessments of CPOE systems in the outpatient ambience accept been depressingly rare, with best studies of CPOE systems accepting been performed on patients in hospitals or in emergency departments. Back these analytic locations accept had to accord with added complicated situations and added alarmingly ill patients, it is not hasty that the aboriginal attempts by hospitals to automate their analytic advice systems concentrated on such settings. There is now abundant affirmation assuming the account of altered types of CPOE systems for ailing patients [2], but abominably there is little affirmation for its capability in the outpatient setting, area best prescriptions are written.
Studies of CPOE systems amid alarmingly ill ailing patients are not generalizable to the outpatient setting: not alone do the types of prescriptions alter (typically articulate for outpatients, while generally intravenous or intramuscular for inpatients), but the accommodating issues alter as well. CPOE systems in the outpatient ambience accept to be geared mostly against chronically ill patients with assorted needs centered on abiding management, admitting inpatient systems accept to action for issues of astute affliction in alarmingly ill ailing patients. Hence, CPOE-based improvements in one ambience cannot be affected to extend to the other, back the altitude they accord with and the types of demands on the systems are so different.
Although Steele and colleagues’ abstraction showed a favorable aftereffect for the use of computerized active systems, there were some limitations. Although there was an access in class tests ordered back antecedent analysis ethics were either aberrant or absent, the abstraction was not powered—as the authors themselves note—to authenticate a abridgement in adverse biologic events. Use of agent outcomes (such as changes in lab acclimation behavior) is a well-accepted convenance in studies area adverse outcomes are actual attenuate and area such surrogates are affiliated to the accident of adverse outcomes. Nevertheless, afore some clinics or convenance groups adjudge to advance in big-ticket systems that will appulse the circadian activities of abounding health-care providers, added studies of CPOE systems demonstrating not alone a change in physician behavior but a absolute abridgement in adverse contest will acceptable be needed.
Also, because this abstraction was not a randomized analytic trial, it is all-important to accede added affidavit for the findings. In any “before and after” abstraction such as this one, improvements in prescribing patterns over time may occur, behindhand of whether or not the action was effective. External factors (such as statewide initiatives to advance decree practices) or centralized factors (such as added absorption by alone dispensary physicians to the botheration of drug–lab interactions) may advance to the erroneous ascertainment that the action was able when, in fact, improvements were a aftereffect of these added influences.
Assessments of CPOE systems in the outpatient ambience accept been depressingly rare.
A randomized analytic balloon would accept abhorred the problems of trends over time and, if done correctly, could accept bargain contagion by added factors. However, such trials are generally diffuse and expensive. In comparison, abounding additions to CPOE systems are incremental, and absorption in any accurate change is generally time-limited. Additionally, in abounding situations, CPOE systems are accomplished by clinic-affiliated affection advance departments, which accede abundant factors back chief to acquirement or advance such systems. In these cases, there may be little action to abstraction alone aspects of such a system, abundant beneath undertake a cher randomized trial. Hence, for abounding changes, it will acceptable not be achievable to appraise anniversary one by way of randomized analytic trials.
Regardless of their limitations, empiric studies such as the one by Steele et al. that analyze nonrandomized physicians’ behavior afore interventions to behavior afterwards interventions, and that depend abundantly on agent outcomes, accommodate able affirmation on the capability of computerized systems to abate medication errors and advance accommodating safety. Similar studies will acceptable abide to be an important agency acclimated to appraise abounding approaching developments in CPOE technology.
Citation: Davis RL (2005) Computerized physician adjustment access systems: The advancing of age for outpatient medicine. PLoS Med 2(9): e290.
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