Erratum to: On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop

An Assessment of Different Decision Support Software from the Perspective of Potential Drug-Drug Interactions in Patients with Chronic Kidney Diseases

Chronic kidney disease (CKD) is a multifaceted disorder influenced by various factors. Drug-drug interactions (DDIs) present a notable risk factor for hospitalization among patients with CKD. This study aimed to assess the frequency and attributes of potential DDIs (pDDIs) in patients with CKD and to ascertain the concordance among different Clinical Decision Support Software (CDSS). A cross-sectional study was conducted in a nephrology outpatient clinic at a university hospital. The pDDIs were identified and evaluated using Lexicomp® and Medscape®. The patients' characteristics, comorbidities, and medicines used were recorded. The concordance of different CDSS were evaluated using the Kendall W coefficient. An evaluation of 1121 prescribed medications for 137 patients was carried out. The mean age of the patients was 64.80 ± 14.59 years, and 41.60% of them were male. The average year with CKD was 6.48 ± 5.66. The mean number of comorbidities was 2.28 ± 1.14. The most common comorbidities were hypertension, diabetes, and coronary artery disease. According to Medscape, 679 pDDIs were identified; 1 of them was contraindicated (0.14%), 28 (4.12%) were serious-use alternative, and 650 (9.72%) were interventions that required closely monitoring. According to Lexicomp, there were 604 drug-drug interactions. Of these interactions, 9 (1.49%) were in the X category, 60 (9.93%) were in the D category, and 535 (88.57%) were in the C category. Two different CDSS systems exhibited statistically significant concordance with poor agreement (W = 0.073, p < 0.001). Different CDSS systems are commonly used in clinical practice to detect pDDIs. However, various factors such as the operating principles of these programs and patient characteristics can lead to incorrect guidance in clinical decision making. Therefore, instead of solely relying on programs with lower reliability and consistency scores, multidisciplinary healthcare teams, including clinical pharmacists, should take an active role in identifying and preventing pDDIs.

User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study

BACKGROUND

Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities.

OBJECTIVE

In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting.

METHODS

We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS.

RESULTS

Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary.

CONCLUSIONS

User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.

NHS Scotland's Decision Support Platform: a formative qualitative evaluation

Context

The Scottish Government has identified computerised decision support as a strategic priority in order to improve knowledge management in health and social care settings. A national programme to build a pilot Decision Support Platform was funded in 2015.

Aims

We undertook a formative evaluation of the Decision Support Platform to inform plans for its national roll-out in primary care.

Methods

We conducted a series of in-depth semistructured interviews and non-participant observations of workshops demonstrating decision support systems. Participants were policymakers and clinical opinion leaders from primary care. As the Platform was in its early stages of development at the time of data collection, we focused on exploring expectations and drivers of the pilot decision support system tested in primary care. Our methodological approach had to be tailored to changing circumstances and offered important opportunities for realising impact through ongoing formative feedback to policymakers and active engagement of key clinical stakeholders. We drew on sociotechnical principles to inform data analysis and coded qualitative data with the help of NVivo software.

Findings

We conducted 30 interviews and non-participant ethnographic observations of eight stakeholder engagement workshops. We observed a strong sense of support from all stakeholders for the Platform and associated plans to roll it out across NHS Scotland. Strategic drivers included the potential to facilitate integration of care, preventive care, patient self-management, shared decision-making and patient engagement through the ready availability of clinically important information. However, in order to realise these benefits, participants highlighted the need for strong national eHealth leadership to drive a coherent strategy and ensure sustained funding, system usability (which stakeholders perceived to be negatively affected by alert fatigue and integration with existing systems) and ongoing monitoring of potential unintended consequences emerging from implementations (eg, increasing clinical workloads).

Conclusions and implications

In order to address potential tensions between national leadership and local usability as well as unintended consequences, there is a need to have overall national ownership to support the implementation of the Platform. Potential local tensions could be addressed through allowing a degree of local customisation of systems and tailoring of alerts, and investing in a limited number of pilots that are carefully evaluated to mitigate emerging risks early.

The impact of electronic health records on diagnosis

Diagnostic error may be the largest unaddressed patient safety concern in the United States, responsible for an estimated 40,000-80,000 deaths annually. With the electronic health record (EHR) now in near universal use, the goal of this narrative review is to synthesize evidence and opinion regarding the impact of the EHR and health care information technology (health IT) on the diagnostic process and its outcomes. We consider the many ways in which the EHR and health IT facilitate diagnosis and improve the diagnostic process, and conversely the major ways in which it is problematic, including the unintended consequences that contribute to diagnostic error and sometimes patient deaths. We conclude with a summary of suggestions for improving the safety and safe use of these resources for diagnosis in the future.

Presenting multiple drug alerts in an ambulatory electronic prescribing system: a usability study of novel prototypes

OBJECTIVE

This study explores alternative approaches to the display of drug alerts, and examines whether and how human-factors based interface design can be used to improve the prescriber's perception about drug alert presentation, signal detection from noisy alert data, and their comprehension of clinical decision support during electronic prescribing.

METHODS

We reviewed issues with presenting multiple drug alerts in electronic prescribing systems. User-centered design, consisting of iterative usability and prototype testing was applied. After an iterative design phase, we proposed several novel drug alert presentation interfaces; expert evaluation and formal usability testing were applied to access physician prescribers' perceptions of the tools. We mapped drug alert attributes to different interface constructs. We examined four different interfaces for presenting multiple drug alerts.

RESULTS

A TreeDashboard View was better perceived than a text-based ScrollText View with respect to the ability to detect critical information, the ability to accomplish tasks, and the perceptional efficacy of finding information.

CONCLUSION

A robust model for studying multiple drug-alert presentations was developed. Several drug alert presentation interfaces were proposed. The TreeDashboard View was better perceived than the text-based ScrollText View in delivering multiple drug alerts during a simulation of electronic prescribing.