Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients

Development of machine-learning models using pharmacy inquiry database for predicting dose-related inquiries in a tertiary teaching hospital

BACKGROUND

Drug-related problems (DRPs) are a significant concern in healthcare. Pharmacists play a vital role in detecting and resolving DRPs to improve patient safety. A pharmacy inquiry program was established in a tertiary teaching hospital to document inquiries about physicians' orders, aimed at preventing potential DRPs or providing medication information during order reviews.

OBJECTIVE

We aimed to develop machine-learning models using a pharmacy inquiry database to predict dose-related inquiries based on prescriptions and patient information.

METHODS

This retrospective study analyzed 20,393 pharmacy inquiries collected between January 2018 and February 2023. Data included prescription information (drug ingredient, dose, unit, and frequency), patient characteristics (age, sex, weight, and department), and renal function. The inquiries were categorized into two classes: dose-related inquiries (e.g., wrong dose and inappropriate regimen) and non-dose-related inquiries (e.g., inappropriate drug form and administration route). Six machine-learning models were developed: logistic regression, support vector classifier, decision tree, random forest, extreme gradient boosting, and categorical boosting. To evaluate the performance of the models, the area under the receiver operating characteristic curve and the accuracy were compared.

RESULTS

The CatBoost model achieved the highest performance (sensitivity: 0.92; accuracy: 0.79). The SHapley Additive exPlanations values highlighted the importance of features in the model predictions, drug ingredients, units, and renal function, in that order. Notably, lower renal function positively contributed to the prediction of dose-related inquiries. Additionally, the subsequent feature importance among drug ingredients showed that drugs such as acetylsalicylic acid, famotidine, metformin, and spironolactone strongly influenced the prediction of dose-related inquiries.

CONCLUSION

Machine-learning models that use pharmacy inquiry data can effectively predict dose-related inquiries. Further external validation and refinement of the models are required for broader applications in healthcare settings. These findings provide valuable guidance for healthcare professionals and highlight the potential of machine learning in pharmacists' decision-making.

Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice

OBJECTIVE

Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations.

MATERIALS AND METHODS

A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist.

RESULTS

Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups.

DISCUSSION AND CONCLUSION

Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.

Implementation costs of hospital-based computerised decision support systems: a systematic review

BACKGROUND

The importance of accurately costing implementation strategies is increasingly recognised within the field of implementation science. However, there is a lack of methodological guidance for costing implementation, particularly within digital health settings. This study reports on a systematic review of costing analyses conducted alongside implementation of hospital-based computerised decision support systems.

METHODS

PubMed, Embase, Scopus and CINAHL databases were searched between January 2010 and August 2021. Two reviewers independently screened and selected original research studies that were conducted in a hospital setting, examined the implementation of a computerised decision support systems and reported implementation costs. The Expert Recommendations for Implementing Change Framework was used to identify and categorise implementation strategies into clusters. A previously published costing framework was applied to describe the methods used to measure and value implementation costs. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

Titles and abstracts of 1836 articles were screened, with nine articles eligible for inclusion in the review. Implementation costs were most frequently reported under the 'evaluative and iterative strategies' cluster, followed by 'provide interactive assistance'. Labour was the largest implementation-related cost in the included papers, irrespective of implementation strategy. Other reported costs included consumables, durable assets and physical space, which was mostly associated with stakeholder training. The methods used to cost implementation were often unclear. There was variation across studies in the overall quality of reporting.

CONCLUSIONS

A relatively small number of papers have described computerised decision support systems implementation costs, and the methods used to measure and value these costs were not well reported. Priorities for future research should include establishing consistent terminology and appropriate methods for estimating and reporting on implementation costs.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (ID: CRD42021272948).

Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions

Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.

The Impact of Clinical Pharmacy Services in a Tertiary Care Center Specialized in Pediatric Hemato-Oncology

Clinical pharmacy services (CPS) have shown beneficial effects on several outcome measures in hospital patients, including the reduction of drug-related problems (DRP) and of therapy costs. Less is known about the impact of CPS in pediatric haemato-oncology, even though this patient population is highly susceptible to DRP. CPS were implemented in a tertiary care children’s hospital specialized in hemato-oncology and hematopoietic stem cell transplantation. The main outcome measures were type and number of DRP, type and number of pharmaceutical interventions (PI), their acceptance rate, and their clinical significance and economic benefit. During 6 months and 32 ward rounds, 275 DRP were identified and addressed by PI. The acceptance of PI was high (73.4%), and up to 80% of PI were rated as very significant or significant by independent external raters. The estimated therapy cost reductions were substantial, approaching at least EUR 54,600 for avoided follow-up costs. Conclusion: CPS improve medication safety in pediatric hemato-oncology and may reduce therapy costs.

Cost-effectiveness of check of medication appropriateness: methodological approach

Background Adverse drug events following inappropriate prescribing in the hospital cause a substantial and avoidable medical and economic burden to hospitals, payers and patients alike. A clinical rule-based, pharmacist-led medication-review service, the 'Check of Medication Appropriateness' (CMA) was implemented in the University Hospitals Leuven. The CMA is shown to be effective in reducing potentially inappropriate prescriptions. Aim This study investigated whether this centralised clinical pharmacy service is cost-effective. Method We performed a cost-effectiveness analysis of three clinical rules of the CMA, targeting adverse drug events at three levels of severity: A) persistent opioid-induced constipation, B) ketorolac-induced gastrointestinal bleeding and C) drug-induced Torsade de Pointes. A decision tree was developed for each clinical rule. Both intervention costs as well as total costs associated with the occurrence of an adverse drug event were considered. The outcomes were reported in the form of an incremental cost-effectiveness ratio, expressed as an incremental cost per adverse drug event avoided. Results Applying clinical rules to avoid persistent opioid-induced constipation and ketorolac-induced gastrointestinal bleeding were cost-saving. Implementation of a medication check to avoid drug-induced Torsade de Pointes costed €8,846 per Torsade de Pointes avoided. Conclusion Our study provides strong indications that the CMA is worth its investment for clinical rules targeting (very) common adverse drug events, that can be avoided with limited expenses. Further research is required to assess the full CMA. The proposed model may be useful to perform cost-effectiveness analyses of other centralised clinical pharmacy services targeting inappropriate prescribing, at the level of individual adverse drug events.

Costs and Cost-Effectiveness of User-Testing of Health Professionals' Guidelines to Reduce the Frequency of Intravenous Medicines Administration Errors by Nurses in the United Kingdom: A Probabilistic Model Based on Voriconazole Administration

AIM

In the UK, injectable medicines are often prepared and administered by nurses following the Injectable Medicines Guide (IMG). Our earlier study confirmed a higher frequency of correct administration with user-tested versus standard IMG guidelines. This current study aimed to model the cost-effectiveness of user-testing.

METHODS

The costs and cost-effectiveness of user-testing were explored by modifying an existing probabilistic decision-analytic model. The adapted model considered administration of intravenous voriconazole to hospital inpatients by nurses. It included 11 error types, their probability of detection and level of harm. Model inputs (including costs) were derived from our previous study and other published data. Monte Carlo simulation using 20,000 samples (sufficient for convergence) was performed with a 5-year time horizon from the perspective of the 121 NHS trusts and health boards that use the IMG. Sensitivity analyses were undertaken for the risk of a medication error and other sources of uncertainty.

RESULTS

The net monetary benefit at £20,000/quality-adjusted life year was £3,190,064 (95% credible interval (CrI): -346,709 to 8,480,665), favouring user-testing with a 96% chance of cost-effectiveness. Incremental cost-savings were £240,943 (95% CrI 43,527-491,576), also favouring user-tested guidelines with a 99% chance of cost-saving. The total user testing cost was £6317 (95% CrI 6012-6627). These findings were robust to assumptions about a range of input parameters, but greater uncertainty was seen with a lower medication error risk.

CONCLUSIONS

User-testing of injectable medicines guidelines is a low-cost intervention that is highly likely to be cost-effective, especially for high-risk medicines.

A Method for Detecting Adverse Drug Events through the Chronological Relationship Between the Medication Period and the Presence of Adverse Reactions from Electronic Medical Record Systems: Observational Study

BACKGROUND

Medicines may cause various adverse reactions. An enormous amount of money and effort are spent investigating adverse drug events (ADEs) in clinical trials and post-marketing surveillance. Real-world data from multiple electronic medical records (EMRs) can make it easy to understand the ADEs that occur in actual patients.

OBJECTIVE

In this study, we generated a patient medication history database from physician orders recorded in EMRs, which allowed the period of medication to be clearly identified.

METHODS

We developed a method for detecting ADEs based on the chronological relationship between the presence of an adverse event and the medication period. To verify our method, we detected ADEs with alanine aminotransferase (ALT) elevation in patients receiving aspirin, clopidogrel and ticlopidine. The accuracy of the detection was evaluated with a chart review and by comparison with the Roussel Uclaf Causality Assessment Method (RUCAM), which is a standard method for detecting drug induced liver injury.

RESULTS

The calculated rates of ADE with ALT elevation in patients receiving aspirin, clopidogrel and ticlopidine were 3.33% (868 of 26,059 patients), 3.70% (188 of 5,076 patients) and 5.69% (226 of 3,974 patients), respectively, which were in line with the rates of previous reports. We reviewed the medical records of the patients in whom ADEs were detected. Our method accurately predicted ADEs in 90% (27 of 30patients) treated with aspirin, 100% (9 of 9 patients) treated with clopidogrel and 100% (4 of 4 patients) treated with ticlopidine. Only 3 ADEs that were detected by the RUCAM were not detected by our method.

CONCLUSIONS

These findings demonstrate that the present method is effective for detecting ADEs based on EMR data.

CLINICALTRIAL

Supporting deprescribing in hospitalised patients: formative usability testing of a computerised decision support tool

Background

Despite growing evidence that deprescribing can improve clinical outcomes, quality of life and reduce the likelihood of adverse drug events, the practice is not widespread, particularly in hospital settings. Clinical risk assessment tools, like the Drug Burden Index (DBI), can help prioritise patients for medication review and prioritise medications to deprescribe, but are not integrated within routine care. The aim of this study was to conduct formative usability testing of a computerised decision support (CDS) tool, based on DBI, to identify modifications required to the tool prior to trialling in practice.

Methods

Our CDS tool comprised a DBI MPage in the electronic medical record (clinical workspace) that facilitated review of a patient’s DBI and medication list, access to deprescribing resources, and the ability to deprescribe. Two rounds of scenario-based formative usability testing with think-aloud protocol were used. Seventeen end-users participated in the testing, including junior and senior doctors, and pharmacists.

Results

Participants expressed positive views about the DBI CDS tool but testing revealed a number of clear areas for improvement. These primarily related to terminology used (i.e. what is a DBI and how is it calculated?), and consistency of functionality and display. A key finding was that users wanted the CDS tool to look and function in a similar way to other decision support tools in the electronic medical record. Modifications were made to the CDS tool in response to user feedback.

Conclusion

Usability testing proved extremely useful for identifying components of our CDS tool that were confusing, difficult to locate or to understand. We recommend usability testing be adopted prior to implementation of any digital health intervention. We hope our revised CDS tool equips clinicians with the knowledge and confidence to consider discontinuation of inappropriate medications in routine care of hospitalised patients. In the next phase of our project, we plan to pilot test the tool in practice to evaluate its uptake and effectiveness in supporting deprescribing in routine hospital care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01484-z.

National and Institutional Trends in Adverse Events Over Time: A Systematic Review and Meta-analysis of Longitudinal Retrospective Patient Record Review Studies

OBJECTIVE

This study aimed to determine if the implementation of large-scale patient safety initiatives have been successful in reducing overall and preventable adverse event rates in hospital inpatients.

DESIGN

The design used in this study was systematic review and meta-analysis.

DATA RESOURCES

We followed our published protocol (PROSPERO [CRD42019140058]) and searched the following databases: PubMed, CINAHL, PsycINFO, Cochrane Library, and Embase from inception to February 2020. The reference lists of eligible studies were also searched.

ELIGIBILITY

All longitudinal retrospective record review studies that examined adverse event rates before and after the introduction of patient safety initiatives in hospital inpatients were included.

DATA EXTRACTION

Data extraction, quality, and risk of bias assessment were carried out by 2 independent reviewers. Information on study design, setting, demographics, interventions, and safety outcome measures was extracted.

RESULTS

A total of 3894 articles were screened, and 7 articles met the eligibility criteria for our systematic review with 5 of these providing sufficient information for inclusion in the meta-analysis. The degree of heterogeneity was high among studies. The meta-analysis demonstrated a minimal risk reduction in overall adverse event rates of 0.017 (95% confidence interval, 0.002-0.032) when the lower-quality studies were excluded, with one adverse event being prevented for every 59 hospital admissions.

CONCLUSIONS

These findings are significant when the large numbers of admissions to a hospital every year are considered. Given the low numbers of large-scale implementation studies, there is a need for more research on the effectiveness of patient safety initiatives to further assess the impact of such initiatives on adverse events.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review

Purpose

Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs.

Methods

A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the ‘meta’ package in R. The systematic review was registered with PROSPERO CRD42018104220.

Results

The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08–0.44) favouring CPOE (I² = 99%).

Conclusion

The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03099-9.

Limiting the number of open charts does not impact wrong patient order entry in the emergency department

OBJECTIVE

We sought to examine the impact of limiting the number of open active charts on wrong patient order entry events among 13 emergency departments (EDs) in a large integrated health system.

METHODS

A retrospective chart review of all orders placed between September 2017 and September 2019 was conducted. The rate of retract and reorder events was analyzed with no overlap in both the period pre- and post-intervention period. Secondary analysis of error rate by clinician type, clinician patient load, and time of day was performed.

RESULTS

The order retraction rate was not improved pre- and post-intervention. Retraction rates varied by clinician type with residents retracting more often than physicians (odds ratio [OR] = 1.443 [1.349, 1.545]). Advanced practice providers also showed a slightly higher rate than physicians (OR = 1.114 [1.071, 1.160]). Pharmacists showed very low rates compared to physicians (OR = 0.191 [0.048, 0.764]). Time of day and staffing ratios appear to be a factor with wrong patient order entry rates slightly lower during the night (1900-0700) than the day (OR 0.958 [0.923, 0.995]), and increasing slightly with every additional patient per provider (OR 1.019 [1.005, 1.032]). The Academic Medical Center had more retractions that the other EDs. OR for the various ED types compared to the Academic Medical Center included Community (OR 0.908 [0.859, 0.959]), Teaching Hospitals (OR 0.850 [0.802, 0.900]), and Freestanding (OR 0.932 [0.864, 1.006]).

CONCLUSIONS

Limiting the number of open active charts from 4 to 2 did not significantly reduce the incidence of wrong patient order entry. Further investigation into other factors contributing to order entry errors is warranted.

Economic impact of clinical decision support interventions based on electronic health records

Background

Unnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR).

Methods

We searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools.

Results and discussion

Twenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems.

Conclusion

Current research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.

Cost-consequence analysis of self-administration of medication during hospitalization: a pragmatic randomized controlled trial in a Danish hospital setting

Objectives:

The objective of this study was to evaluate the costs and consequences of introducing "self-administration of medication" (SAM) during hospitalization as compared with nurse-led dispensing and administration of medication.

Methods:

This pragmatic randomized controlled trial was performed in a Danish Cardiology Unit. Patients ⩾18 years old capable of self-administering medication were eligible. In the intervention group, patients self-administered their medication. In the control group, medication was dispensed and administered by nurses. The implementation of SAM was used to evaluate the cost–consequences. The micro-costing analysis used the hospital perspective and a short-term incremental costing approach. The costs for medication, materials, and nursing time were included. Consequences included the dispensing error proportion, patients’ perceptions regarding medication, satisfaction, and deviations in the medication list at follow-up. In addition, the number of readmissions and general practitioner (GP) contacts within 30 days after discharge was included.

Results:

The total cost (TC) per patient in the intervention group was 49.9€ (95% CI: 46.6–53.2) compared with 52.6€ (95% CI: 46.6–58.6) in the control group. The difference between the groups was not statistically significant (p = 0.09). Sensitivity analysis consistently showed TCs favoring the intervention. The dispensing error proportion was 9.7% (95% CI: 7.9–11.6) in the intervention group compared with 12.8% (95% CI: 10.9–15.6) in the control group. The difference was statistically significant (p = 0.02). The analysis also found changes in the perceptions regarding medication (indicating higher medication adherence), increased satisfaction, and fewer patients with deviations in the medication list at follow-up. No statistically significant differences between the groups in relation to readmissions and GP contacts within 30 days were observed.

Conclusions:

SAM seems to cost less although the cost difference was small and not statistically significant. As SAM had positive effects on patient outcomes, the results indicate that SAM may be cost-effective.

Plain language summary

Self-administration of medication: a research study of the costs and consequences

Objectives

To evaluate the costs and consequences of introducing “self-administration of medication” (SAM) during hospitalization compared to medication dispensed by nurses.

Methods

This research study included patients ≥18 years capable of self-administering medication and was performed in a Danish cardiology unit. Patients self-administered their own medication during hospitalization in the intervention group, whereas nurses dispensed and administered the medication in the control group. Patients were allocated between groups by randomization. The costs of SAM were analyzed from a hospital perspective and included costs for medication, materials, and nursing time. The consequences included the proportion of dispensing errors, patients’ perceptions regarding medication, patient satisfaction, deviations in the medication list at follow-up, the number of readmissions and general practitioner (GP) contacts within 30 days after discharge.

Results

The total cost per patient was 49.9€ in the intervention group compared to 52.6€ in the control group (p = 0.09). The cost difference between groups was not significant. The proportion of dispensing errors was significantly lower in the intervention group compared to the control group. In addition the research study found changes in the perceptions regarding medication, increased satisfaction, and fewer patients with deviations in the medication list at follow-up. For readmissions and GP contacts within 30 days no significant differences between groups were found.

Conclusion

SAM cost less or equal to medication dispensing and administration by nurse. SAM had positive impacts on patient outcomes. Therefore, SAM may be cost-effective.

Revealing Novel IDEAS: A Fiduciary Framework for Team-Based Prescribing

The importance of safe, effective, and cost-effective prescribing habits can hardly be overstated in the current pay-for-value environment. The prescribing process taught in most medical curricula focuses primarily on accurate medical indications. While this may be of utmost importance from the clinician's perspective, it falls short of addressing the other key elements of highly effective prescribing. These other elements are often paramount in the minds of patients. A patient-centric framework that associates and incorporates the necessary components of optimal prescribing is overdue. Building this framework into medical curricula will foster increased teamwork among providers and enhance shared decision making between patients and clinicians. In addition to establishing accurate medical indications, prescribing teams need to assure every prescribed medication is desired, effective, affordable, and safe for patients who receive them. Prescription writing is an honorable prerogative, and doing so safely, effectively, and cost-effectively requires both teamwork and technology. Highly effective prescribing teams can implement the IDEAS (Indicated, Desired, Effective, Affordable, Safe) framework through appropriate and deliberate delegation. By empowering members of the care team to support and educate patients, this framework will allow physicians to focus on ensuring appropriate indications and real-world effectiveness. This novel IDEAS framework serves as an important mental model for medical trainees and reinforces sound prescribing habits among seasoned clinicians. High-touch and high-tech partnerships have the potential to maximize the triple aim (i.e., improving the patient's experience of care, improving the health of populations, and reducing the per capita cost of health care). In an era when costs overwhelm quality, providing a fiduciary framework to instill responsibility for optimal prescribing, especially among young physician-leaders, is invaluable.

An overview of clinical decision support systems: benefits, risks, and strategies for success

Computerized clinical decision support systems, or CDSS, represent a paradigm shift in healthcare today. CDSS are used to augment clinicians in their complex decision-making processes. Since their first use in the 1980s, CDSS have seen a rapid evolution. They are now commonly administered through electronic medical records and other computerized clinical workflows, which has been facilitated by increasing global adoption of electronic medical records with advanced capabilities. Despite these advances, there remain unknowns regarding the effect CDSS have on the providers who use them, patient outcomes, and costs. There have been numerous published examples in the past decade(s) of CDSS success stories, but notable setbacks have also shown us that CDSS are not without risks. In this paper, we provide a state-of-the-art overview on the use of clinical decision support systems in medicine, including the different types, current use cases with proven efficacy, common pitfalls, and potential harms. We conclude with evidence-based recommendations for minimizing risk in CDSS design, implementation, evaluation, and maintenance.

Use of mind maps and iterative decision trees to develop a guideline-based clinical decision support system for routine surgical practice: case study in thyroid nodules

OBJECTIVE

The study sought to develop a clinical decision support system (CDSS) for the treatment of thyroid nodules, using a mind map and iterative decision tree (IDT) approach to the integration of clinical practice guidelines (CPGs).

MATERIALS AND METHODS

Thyroid nodule CPGs of the American Thyroid Association and Korean Thyroid Association were analyzed by endocrine surgeons (domain experts) and computer scientists. Clinical knowledge from the CPGs was expressed using mind maps. The mind maps were analyzed and converted into IDTs. The final IDT was implemented as a set of candidate rules (3700) for a knowledge-based CDSS. The system was evaluated via a retrospective review of the medical records of 483 patients who had undergone thyroidectomy between January and December 2015 at a single tertiary center (Seoul National University Hospital Bundang, Korea).

RESULTS

Concordance between CDSS recommendations and treatment in routine clinical practice was 78.9%. In the 21.1% discordant cases, deviation from the CDSS treatment recommendation was mainly attributable to (1) refusal of the patient to undergo total thyroidectomy and (2) conversion from lobectomy to total thyroidectomy following an unexpected histological finding during intraoperative frozen biopsy lymph node analysis.

CONCLUSIONS

The present study demonstrated that a knowledge-based CDSS is feasible in the treatment of thyroid nodules. A high-quality knowledge-based CDSS was developed, and medical domain and computer scientists collaborated effectively in an integrated development environment. The mind map and IDT approach represents a pioneering method of integrating knowledge from CPGs.

The usability aspects of medication-related decision support systems in the inpatient setting: A systematic review

Effort has been made to study the effect of medication-related clinical decision support systems in the inpatient setting; however, there is not much known about the usability of these systems. The goal of this study is to systematically review studies that focused on the usability aspects such as effectiveness, efficiency, and satisfaction of these systems. We systematically searched relevant articles in Scopus, Embase, and PubMed from 1 January 2000 to 1 January 2016, and found 22 articles. Based on Van Welie’s usability model, we categorized usability aspects in terms of usage indicators and means. Our results showed that evidence was mainly found for effectiveness and efficiency. They showed positive results in the usage indicators errors and safety and performance speed. The means warnings and adaptability also had mostly positive results. To date, the effects satisfaction of clinical decision support system remains understudied. Aspects such as memorability, learnability, and consistency require more attention.

Evaluation of computerized provider order entry systems: assessing the usability of systems for electronic prescription

BACKGROUND

The field of medicine has been influenced by the growth and development of information systems such as the Computerized Provider Order Entry (CPOE) System.

OBJECTIVE

This study aimed to evaluate the usability of CPOE systems for electronic prescription in Tehran, Iran.

METHODS

This was an evaluation study conducted in 2017. The research population consisted of the CPOE systems used in hospitals of Tehran (Iran) and nurses who had access to, and used, the CPOE systems. Five hospitals with CPOE systems were included in the research sample. The data were collected using a questionnaire, and included a total of 50 questions. The questionnaires were distributed among 254 nurses who were the users of the systems. Data analysis was performed by IBM-SPSS version 21, using independent-samples t-test. A p-value of ≤0.05 was considered statistically significant.

RESULTS

Among the four aspects assessed, the "user-friendliness" (3.87±0.59) had the highest mean score. The lowest mean score (2.01±0.58) was related to the "decision support" feature of the systems. The highest and lowest mean scores for "prescription support" criterion belonged to system E (3.26±0.23) and system C (1.90±0.16), respectively. There was a statistically significant difference between the usability of the systems used in the private and the public hospitals (p<0.001). It was found that the CPOE systems in private hospitals had a higher level of usability (3.42+0.10) compared to those in public hospitals (2.91+0.25).

CONCLUSION

Two main functions of the studied CPOE systems i.e., decision support and prescription support should be developed to make electronic prescription safer and more intuitive. Addressing usability aspects of CPOE systems in practice could improve the usability of these systems for prescription.

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting

INTRODUCTION

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice.

METHODS

The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period.

RESULTS

With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation.

CONCLUSION

The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

Quality of Decision Support in Computerized Provider Order Entry: Systematic Literature Review

Background

Computerized decision support systems have raised a lot of hopes and expectations in the field of order entry. Although there are numerous studies reporting positive impacts, concerns are increasingly high about alert fatigue and effective impacts of these systems. One of the root causes of fatigue alert reported is the low clinical relevance of these alerts.

Objective

The objective of this systematic review was to assess the reported positive predictive value (PPV), as a proxy to clinical relevance, of decision support systems in computerized provider order entry (CPOE).

Methods

A systematic search of the scientific literature published between February 2009 and March 2015 on CPOE, clinical decision support systems, and the predictive value associated with alert fatigue was conducted using PubMed database. Inclusion criteria were as follows: English language, full text available (free or pay for access), assessed medication, direct or indirect level of predictive value, sensitivity, or specificity. When possible with the information provided, PPV was calculated or evaluated.

Results

Additive queries on PubMed retrieved 928 candidate papers. Of these, 376 were eligible based on abstract. Finally, 26 studies qualified for a full-text review, and 17 provided enough information for the study objectives. An additional 4 papers were added from the references of the reviewed papers. The results demonstrate massive variations in PPVs ranging from 8% to 83% according to the object of the decision support, with most results between 20% and 40%. The best results were observed when patients’ characteristics, such as comorbidity or laboratory test results, were taken into account. There was also an important variation in sensitivity, ranging from 38% to 91%.

Conclusions

There is increasing reporting of alerts override in CPOE decision support. Several causes are discussed in the literature, the most important one being the clinical relevance of alerts. In this paper, we tried to assess formally the clinical relevance of alerts, using a near-strong proxy, which is the PPV of alerts, or any way to express it such as the rate of true and false positive alerts. In doing this literature review, three inferences were drawn. First, very few papers report direct or enough indirect elements that support the use or the computation of PPV, which is a gold standard for all diagnostic tools in medicine and should be systematically reported for decision support. Second, the PPV varies a lot according to the typology of decision support, so that overall rates are not useful, but must be reported by the type of alert. Finally, in general, the PPVs are below or near 50%, which can be considered as very low.

Barriers and facilitators to hospital pharmacists' engagement in medication safety activities: a qualitative study using the theoretical domains framework

Background

Hospital pharmacists play a central role in medication safety activities. However, in Ethiopia, this role has been launched recently and little is known regarding the current status of this extended service. Using the Theoretical Domains Framework (TDF), we aimed to identify the barriers and facilitators to hospital pharmacists’ engagement in medication safety activities across various public hospitals in the Amhara region of Ethiopia.

Methods

Eight focus group discussions, using an interview guide that was drawn upon the TDF, were conducted with 44 hospital pharmacists to explore their beliefs regarding their involvement in clinical services. Group discussions were audio-recorded, transcribed verbatim, and analysed using directed content analysis based on the TDF. Relevant domains were identified by applying relevance criteria to each of the domains in the TDF.

Results

Content analysis revealed six domains that influence hospital pharmacists’ engagement in medication safety activities. These domains included ‘Knowledge’, ‘Skills’, ‘Environmental context and resources’, ‘Motivations and goals’, ‘Social influences’ and ‘Social/professional role’. Most hospital pharmacists believed knowledge gap was an issue, as was the lack of training and supportive skills although some expressed as they were competent enough for their skills in identifying medication related problems. Most participants were very much enthusiastic for their extended roles and were positive towards the future of the profession; however, competing priorities along with the lack of remuneration and awareness (of other health care professionals) regarding the profession’s role were barriers to service delivery. There were also a number of resource constraints, such as staffing, infrastructure and government funding, and acceptance rate of pharmacist’s recommendation that were likely to influence the clinical practice of pharmacists.

Conclusion

Using the TDF, this study identified a wide range of barriers and facilitators to hospital pharmacists’ engagement in medication safety activities in resource-limited settings. There existed considerable interrelationships between domains that were perceived to influence hospital pharmacists’ behaviours, and this may assist in designing behaviour change interventions that target common behavioural domains.

Electronic supplementary material

The online version of this article (10.1186/s40545-018-0129-y) contains supplementary material, which is available to authorized users.

Impact of IPMOE on nursing tasks in the medical ward: A time-motion study

Introduction

The In-patient Medication Order Entry System (IPMOE) was first implemented in the medical ward of Princess Margaret Hospital, Hong Kong. It was a local developed close-loop system including prescription, dispensing and administration modules. Evaluation on its impact on nursing tasks would be important for practice improvement and subsequent system enhancement.

Objective

The study was conducted to quantify the nursing times across medication-associated tasks for paper-based MAR and computer-based IPMOE, including change in the tasks and time patterns before and after IPMOE implementation.

Methods

This was a prospective observation study in medical wards before (Jan 2014–Jun 2014) and after (Mar 2015–Jun 2015) the implementation of IPMOE. We conducted 8-hr observation studies of individual nurses with a customized application to time various pre-categorized nursing tasks. Statistical inferences and interrupted time series analysis was performed to identify the change in the intercept and trends over time after implementation.

Result

The average number of medication-related tasks was significantly reduced from 61.07 to 29.81, a reduction of 31.26 episodes per duty (P < 0.001, 95% CI 22.9–39.63). The time for the medication-related tasks was reduced from 32 min (SD = 21.57) to 26.57 min (SD = 11.35) and the medication administration time increased from 37.93 min (SD = 14.78) to 44.37 min (SD = 19.45), but there was no overall significant difference in the time spent on each duty (P = 0.315) between the two groups. An improving trend in the delayed effect was observed (P = 0.03), which indicated a run-in period for new application was needed in clinical setting.

Conclusion

Our study had shown the time motion observation could be applied to measure the impact of the IPMOE in a busy clinical setting. Through classification of activities, validation, objective measurement and longitudinal evaluation, the method could be applied in various systems as well as different clinical settings in measure efficiency.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

OBJECTIVES

This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care.

METHODS

We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support.

RESULTS

We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness.

CONCLUSIONS

Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.

Cost-Effectiveness Analysis of an Automated Medication System Implemented in a Danish Hospital Setting

OBJECTIVES

To evaluate the cost-effectiveness of an automated medication system (AMS) implemented in a Danish hospital setting.

METHODS

An economic evaluation was performed alongside a controlled before-and-after effectiveness study with one control ward and one intervention ward. The primary outcome measure was the number of errors in the medication administration process observed prospectively before and after implementation. To determine the difference in proportion of errors after implementation of the AMS, logistic regression was applied with the presence of error(s) as the dependent variable. Time, group, and interaction between time and group were the independent variables. The cost analysis used the hospital perspective with a short-term incremental costing approach. The total 6-month costs with and without the AMS were calculated as well as the incremental costs. The number of avoided administration errors was related to the incremental costs to obtain the cost-effectiveness ratio expressed as the cost per avoided administration error.

RESULTS

The AMS resulted in a statistically significant reduction in the proportion of errors in the intervention ward compared with the control ward. The cost analysis showed that the AMS increased the ward's 6-month cost by €16,843. The cost-effectiveness ratio was estimated at €2.01 per avoided administration error, €2.91 per avoided procedural error, and €19.38 per avoided clinical error.

CONCLUSIONS

The AMS was effective in reducing errors in the medication administration process at a higher overall cost. The cost-effectiveness analysis showed that the AMS was associated with affordable cost-effectiveness rates.

Systematic Review of Medical Informatics-Supported Medication Decision Making

This systematic review sought to assess the applications and implications of current medical informatics-based decision support systems related to medication prescribing and use. Studies published between January 2006 and July 2016 which were indexed in PubMed and written in English were reviewed, and 39 studies were ultimately included. Most of the studies looked at computerized provider order entry or clinical decision support systems. Most studies examined decision support systems as a means of reducing errors or risk, particularly associated with medication prescribing, whereas a few studies evaluated the impact medical informatics-based decision support systems have on workflow or operations efficiency. Most studies identified benefits associated with decision support systems, but some indicate there is room for improvement.

Making electronic health records support quality management: A narrative review

BACKGROUND

Since the 1990s many hospitals in the OECD countries have introduced electronic health record (EHR) systems. A number of studies have examined the factors impinging on EHR implementation. Others have studied the clinical efficacy of EHR. However, only few studies have explored the (intermediary) factors that make EHR systems conducive to quality management (QM).

OBJECTIVE

Undertake a narrative review of existing studies in order to identify and discuss the factors conducive to making EHR support three dimensions of QM: clinical outcomes, managerial monitoring and cost-effectiveness.

METHOD

A narrative review of Web of Science, Cochrane, EBSCO, ProQuest, Scopus and three Nordic research databases.

LIMITATION

most studies do not specify the type of EHR examined.

RESULTS

39 studies were identified for analysis. 10 factors were found to be conducive to make EHR support QM. However, the contribution of EHR to the three specific dimensions of QM varied substantially. Most studies (29) included clinical outcomes. However, only half of these reported EHR to have a positive impact. Almost all the studies (36) dealt with the ability of EHR to enhance managerial monitoring of clinical activities, the far majority of which showed a positive relationship. Finally, only five dealt with cost-effectiveness of which two found positive effects.

DISCUSSION AND CONCLUSION

The findings resonates well with previous reviews, though two factors making EHR support QM seem new, namely: political goals and strategies, and integration of guidelines for clinical conduct. Lacking EHR type specification and diversity in study method imply that there is a strong need for further research on the factors that may make EHR may support QM.

Individualized versus standardized risk assessment in patients at high risk for adverse drug reactions (IDrug) - study protocol for a pragmatic randomized controlled trial

Background

Elderly patients are particularly vulnerable to adverse drug reactions, especially if they are affected by additional risk factors such as multimorbidity, polypharmacy, impaired renal function and intake of drugs with high risk potential. Apart from these clinical parameters, drug safety and efficacy can be influenced by pharmacogenetic factors. Evidence-based recommendations concerning drug-gene-combinations have been issued by international consortia and in drug labels. However, clinical benefit of providing information on individual patient factors in a comprehensive risk assessment aiming to reduce the occurrence and severity of adverse drug reactions is not evident. Purpose of this randomized controlled trial is to compare the effect of a concise individual risk information leaflet with standard information on risk factors for side effects.

Methods/Design

The trial was designed as a prospective, two-arm, randomized, controlled, multicenter, pragmatic study. 960 elderly, multimorbid outpatients in general medicine are included if they take at least one high risk and one other long-term drug (polymedication). As high risk “index drugs” oral anticoagulants and antiplatelets were chosen because of their specific, objectively assessable side effects. Following randomization, test group patients receive an individualized risk assessment leaflet evaluating their personal data concerning bleeding- and thromboembolic-risk-scores, potential drug-drug-interactions, age, renal function and pharmacogenetic factors. Control group patients obtain a standardized leaflet only containing general information on these criteria. Follow-up period is 9 months for each patient. Primary endpoint is the occurrence of a thromboembolic/bleeding event or death. Secondary endpoints are other adverse drug reactions, hospital admissions, specialist referrals and medication changes due to adverse drug reactions, the patients’ adherence to medication regimen as well as health related quality of life, mortality and resulting costs.

Discussion

Despite extensive evidence of risk factors for adverse drug reactions, there are few prospective trial data about an individualized risk assessment including pharmacogenetic information to increase patient safety. By conducting a health economic analysis, we will evaluate if the application of an individualized drug therapy in daily routine is cost-effective.

Trial registration

German Clinical Trials Register: DRKS00006256, date of registration 09/01/15.

Cost-effectiveness analysis of a hospital electronic medication management system

Objective To conduct a cost–effectiveness analysis of a hospital electronic medication management system (eMMS).

Methods We compared costs and benefits of paper-based prescribing with a commercial eMMS (CSC MedChart) on one cardiology ward in a major 326-bed teaching hospital, assuming a 15-year time horizon and a health system perspective. The eMMS implementation and operating costs were obtained from the study site. We used data on eMMS effectiveness in reducing potential adverse drug events (ADEs), and potential ADEs intercepted, based on review of 1 202 patient charts before (n = 801) and after (n = 401) eMMS. These were combined with published estimates of actual ADEs and their costs.

Results The rate of potential ADEs following eMMS fell from 0.17 per admission to 0.05; a reduction of 71%. The annualized eMMS implementation, maintenance, and operating costs for the cardiology ward were A$61 741 (US$55 296). The estimated reduction in ADEs post eMMS was approximately 80 actual ADEs per year. The reduced costs associated with these ADEs were more than sufficient to offset the costs of the eMMS. Estimated savings resulting from eMMS implementation were A$63–66 (US$56–59) per admission (A$97 740–$102 000 per annum for this ward). Sensitivity analyses demonstrated results were robust when both eMMS effectiveness and costs of actual ADEs were varied substantially.

Conclusion The eMMS within this setting was more effective and less expensive than paper-based prescribing. Comparison with the few previous full economic evaluations available suggests a marked improvement in the cost–effectiveness of eMMS, largely driven by increased effectiveness of contemporary eMMs in reducing medication errors.

Health information technology in oncology practice: a literature review

The adoption and implementation of information technology are dramatically remodeling healthcare services all over the world, resulting in an unstoppable and sometimes overwhelming process. After the introduction of the main elements of electronic health records and a description of what every cancer-care professional should be familiar with, we present a narrative review focusing on the current use of computerized clinical information and decision systems in oncology practice. Following a detailed analysis of the many coveted goals that oncologists have reached while embracing informatics progress, the authors suggest how to overcome the main obstacles for a complete physicians' engagement and for a full information technology adoption, and try to forecast what the future holds.