EP/Eligible Hospital Objective: Implement drug-drug, drug-allergy, drug-formulary checks
EP/Eligible Hospital Measure: The EP/eligible hospital has enabled this functionality
The capability of conducting automated drug-drug, drug-allergy, and drug-formulary checks is included in the certification criteria for certified EHR technology (to be determined by ONC in its upcoming interim final rule). This automated check provides information to advise the EP or eligible hospital's decisions in prescribing drugs to a patient. The only action taken by the EP or eligible hospital is to consider this information. Many current EHR technologies have the option to disable these checks and the certification process does not require the removal of this option. Therefore, in order CMS-0033-P 72 to meet this objective, an EP or eligible hospital would be required to enable this functionality. While this does not ensure that an EP or an eligible hospital is considering the information provided, it does ensure that the information is available.
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As described in the HIMSS publication “Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide,” clinical decision support in the electronic health record offers significant benefits in terms of improving medication safety. We applaud the inclusion of medication decision support by CMS in the proposed rule for Meaningful Use to encourage adoption of these capabilities. On the other hand, a known unintended consequence of electronic warnings is the phenomenon of alert fatigue. This occurs when users become desensitized to the prompts when many are inappropriate, which is often the case with typical implementations of drug safety checks. This ultimately undermines the safety benefits of the EHR. For this reason, the HIMSS CDS Task Force has advocated the judicious implementation of CDS interventions including drug alerts by following a systematic approach that considers the:
Opportunities and priorities for improving medication safety specific to an organization
Relevant workflows in the medication use cycle
Maturity of the CDS capabilities of the EHR
Effect of the CDS interventions through continuous monitoring, learning, and process improvement
We believe that the Meaningful Use objective and measure related to medication decision support can be strengthened by the following recommendations:
1. Clarify that “checks” does not necessarily imply intrusive alerts, since the presentation of this information can be delivered through other appropriate channels that are less disruptive to the clinical workflow or perhaps even be structurally incorporated into the design of the EHR’s CPOE system (e.g., exclusion of non-formulary drugs in a hospital preference list)
2. Indicate that the intended audience of the CDS interventions broadly consists of all participants in the medication use cycle. This will help to avoid the narrow view of CDS as being directed only to a single group (e.g., physicians performing computerized order entry).
Furthermore as a service to the healthcare provider community, we recommend including an appendix in the final rule listing resources that may be helpful in providing implementation assistance. Among these would include the HIMSS CDS Guidebook Series (www.himss.org/cdsguide) and the HIMSS CDS Wiki (http://himssclinicaldecisionsupportwiki.pbworks.com/).
Some organizations have made available their focused list of DDI on which they focus for alerting:
http://www.clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_Rules
Comments (2)
David A Collins said
at 1:01 pm on Feb 9, 2010
In addition to suggesting other things besides intrusive alerts to physicians via CPOE (as stated), is there a way to work in the idea of what many CMIOs do, i.e. focus on a smaller subset of high priority alerts?
Donald Levick, M.D., MBA said
at 12:20 pm on Feb 13, 2010
It may be worth mentioning the need for a staged approach to this. First - getting the rules in place that are related to high priority situations. For later years - measurement of effectiveness and modification of rules based on results.
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