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Cánovas-Segura B, Morales A, Juarez JM, Campos M. Meaningful time-related aspects of alerts in Clinical Decision Support Systems. A unified framework. J Biomed Inform 2023:104397. [PMID: 37245656 DOI: 10.1016/j.jbi.2023.104397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/11/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
Alerts are a common functionality of clinical decision support systems (CDSSs). Although they have proven to be useful in clinical practice, the alert burden can lead to alert fatigue and significantly reduce their usability and acceptance. Based on a literature review, we propose a unified framework consisting of a set of meaningful timestamps that allows the use of state-of-the-art measures for alert burden, such as alert dwell time, alert think time, and response time. In addition, it can be used to investigate other measures that could be relevant as regards dealing with this problem. Furthermore, we provide a case study concerning three different types of alerts to which the framework was successfully applied. We consider that our framework can easily be adapted to other CDSSs and that it could be useful for dealing with alert burden measurement thus contributing to its appropriate management.
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Affiliation(s)
| | - Antonio Morales
- AIKE Research Group (INTICO), University of Murcia, Murcia, Spain.
| | - Jose M Juarez
- AIKE Research Group (INTICO), University of Murcia, Murcia, Spain.
| | - Manuel Campos
- AIKE Research Group (INTICO), University of Murcia, Murcia, Spain; Murcian Bio-Health Institute (IMIB-Arrixaca), Murcia, Spain.
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Smith DM, Wake DT, Dunnenberger HM. Pharmacogenomic Clinical Decision Support: A Scoping Review. Clin Pharmacol Ther 2023; 113:803-815. [PMID: 35838358 DOI: 10.1002/cpt.2711] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/10/2022] [Indexed: 11/06/2022]
Abstract
Clinical decision support (CDS) is often cited as an essential part of pharmacogenomics (PGx) implementations. A multitude of strategies are available; however, it is unclear which strategies are effective and which metrics are used to quantify clinical utility. The objective of this scoping review was to aggregate previous studies into a cohesive depiction of the current state of PGx CDS implementations and identify areas for future research on PGx CDS. Articles were included if they (i) described electronic CDS tools for PGx and (ii) reported metrics related to PGx CDS. Twenty of 3,449 articles were included and provided data on PGx CDS metrics from 15 institutions, with 93% of programs located at academic medical centers. The most common tools in CDS implementations were interruptive post-test alerts. Metrics for clinical response and alert response ranged from 12-73% and 21-98%, respectively. Few data were found on changes in metrics over time and measures that drove the evolution of CDS systems. Relatively few data were available regarding support of optimal approaches for PGx CDS. Post-test alerts were the most widely studied approach, and their effectiveness varied greatly. Further research on the usability, effectiveness, and optimization of CDS tools is needed.
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Affiliation(s)
- D Max Smith
- MedStar Health, Columbia, Maryland, USA.,Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
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Nguyen JQ, Crews KR, Moore BT, Kornegay NM, Baker DK, Hasan M, Campbell PK, Dean SM, Relling MV, Hoffman JM, Haidar CE. Clinician adherence to pharmacogenomics prescribing recommendations in clinical decision support alerts. J Am Med Inform Assoc 2022; 30:132-138. [PMID: 36228116 PMCID: PMC9748527 DOI: 10.1093/jamia/ocac187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 12/15/2022] Open
Abstract
Thoughtful integration of interruptive clinical decision support (CDS) alerts within the electronic health record is essential to guide clinicians on the application of pharmacogenomic results at point of care. St. Jude Children's Research Hospital implemented a preemptive pharmacogenomic testing program in 2011 in a multidisciplinary effort involving extensive education to clinicians about pharmacogenomic implications. We conducted a retrospective analysis of clinicians' adherence to 4783 pharmacogenomically guided CDS alerts that triggered for 12 genes and 60 drugs. Clinicians adhered to the therapeutic recommendations provided in 4392 alerts (92%). In our population of pediatric patients with catastrophic illnesses, the most frequently presented gene/drug CDS alerts were TPMT/NUDT15 and thiopurines (n = 3850), CYP2D6 and ondansetron (n = 667), CYP2D6 and oxycodone (n = 99), G6PD and G6PD high-risk medications (n = 51), and CYP2C19 and proton pump inhibitors (omeprazole and pantoprazole; n = 50). The high adherence rate was facilitated by our team approach to prescribing and our collaborative CDS design and delivery.
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Affiliation(s)
- Jenny Q Nguyen
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ben T Moore
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Nancy M Kornegay
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Donald K Baker
- Department of Information Services, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Murad Hasan
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Patrick K Campbell
- Department of Information Services, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Shannon M Dean
- Department of Information Services, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, St. Jude Children’s Research Hospital, Memphis, Tennesse, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - James M Hoffman
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of the Office of Quality and Patient Safety, St. Jude Children’s Research Hospital, Memphis, Tennesse, USA
| | - Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Keeling NJ, Dunn TJ, Bentley JP, Ramachandran S, Hoffman JM, Rosenthal M. Approaches to assessing the provider experience with clinical pharmacogenomic information: a scoping review. Genet Med 2021; 23:1589-1603. [PMID: 33927377 DOI: 10.1038/s41436-021-01186-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/11/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Barriers to the implementation of pharmacogenomics in clinical practice have been thoroughly discussed over the past decade. METHODS The objective of this scoping review was to characterize the peer-reviewed literature surrounding the experiences and actions of prescribers, pharmacists, or genetic counselors when using pharmacogenomic information in real-world or hypothetical research settings. RESULTS A total of 33 studies were included in the scoping review. The majority of studies were conducted in the United States (70%), used quantitative or mixed methods (79%) with physician or pharmacist respondents (100%). The qualitative content analysis revealed five major methodological approaches: hypothetical clinical case scenarios, real-world studies evaluating prescriber response to recommendations or alerts, cross-sectional quantitative surveys, cross-sectional qualitative surveys/interviews, and a quasi-experimental real-world study. CONCLUSION The findings of this scoping review can guide further research on the factors needed to successfully integrate pharmacogenomics into clinical care.
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Affiliation(s)
- Nicholas J Keeling
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS, USA
| | - Tyler J Dunn
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS, USA.
| | - John P Bentley
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS, USA
| | - Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS, USA
| | - James M Hoffman
- Department of Pharmaceutical Sciences and Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Meagen Rosenthal
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS, USA
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Roosan D, Hwang A, Law AV, Chok J, Roosan MR. The inclusion of health data standards in the implementation of pharmacogenomics systems: a scoping review. Pharmacogenomics 2020; 21:1191-1202. [PMID: 33124487 DOI: 10.2217/pgs-2020-0066] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: Despite potential benefits, the practice of incorporating pharmacogenomics (PGx) results in clinical decisions has yet to diffuse widely. In this study, we conducted a review of recent discussions on data standards and interoperability with a focus on sharing PGx test results among health systems. Materials & methods: We conducted a literature search for PGx clinical decision support systems between 1 January 2012 and 31 January 2020. Thirty-two out of 727 articles were included for the final review. Results: Nine of the 32 articles mentioned data standards and only four of the 32 articles provided solutions for the lack of interoperability. Discussions: Although PGx interoperability is essential for widespread implementation, a lack of focus on standardized data creates a formidable challenge for health information exchange. Conclusion: Standardization of PGx data is essential to improve health information exchange and the sharing of PGx results between disparate systems. However, PGx data standards and interoperability are often not addressed in the system-level implementation.
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Affiliation(s)
- Don Roosan
- Assistant Professor, Department of Pharmacy Practice & Administration, College of Pharmacy, Western University of Health Sciences, 309 E 2nd street, Pomona, CA 91766, USA
| | - Angela Hwang
- Research Assistant, Department of Pharmacy Practice & Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Anandi V Law
- Professor, Department of Pharmacy Practice & Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Jay Chok
- Associate Professor, School of Applied Life Sciences, Keck Graduate Institute, Claremont Colleges, Pomona, CA 91711, USA
| | - Moom R Roosan
- Assistant Professor, School of Pharmacy, Department of Pharmacy Practice, Chapman University, Irvine, CA 92618, USA
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Abstract
OBJECTIVES This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout. METHODS We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria. RESULTS Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS. CONCLUSIONS CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.
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Affiliation(s)
- Ivana Jankovic
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research and Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Hoffman JM, Flynn AJ, Juskewitch JE, Freimuth RR. Biomedical Data Science and Informatics Challenges to Implementing Pharmacogenomics with Electronic Health Records. Annu Rev Biomed Data Sci 2020. [DOI: 10.1146/annurev-biodatasci-020320-093614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pharmacogenomic information must be incorporated into electronic health records (EHRs) with clinical decision support in order to fully realize its potential to improve drug therapy. Supported by various clinical knowledge resources, pharmacogenomic workflows have been implemented in several healthcare systems. Little standardization exists across these efforts, however, which limits scalability both within and across clinical sites. Limitations in information standards, knowledge management, and the capabilities of modern EHRs remain challenges for the widespread use of pharmacogenomics in the clinic, but ongoing efforts are addressing these challenges. Although much work remains to use pharmacogenomic information more effectively within clinical systems, the experiences of pioneering sites and lessons learned from those programs may be instructive for other clinical areas beyond genomics. We present a vision of what can be achieved as informatics and data science converge to enable further adoption of pharmacogenomics in the clinic.
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Affiliation(s)
- James M. Hoffman
- Department of Pharmaceutical Sciences and the Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Allen J. Flynn
- Department of Learning Health Sciences, Medical School, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Justin E. Juskewitch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Robert R. Freimuth
- Division of Digital Health Sciences, Department of Health Sciences Research, Center for Individualized Medicine, and Information and Knowledge Management, Mayo Clinic, Rochester, Minnesota 55905, USA
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