DNP 805 Topic 3 Discussion Question One
DNP 805 Topic 3 Discussion Question One
Describe how CPOE and CDSS embedded in the EHR can be useful towards a specific patient population of your choice. Identify one element of either the CPOE or CDSS you would improve that could enhance the effectiveness of the system for that patient population.
Prescribing of potentially inappropriate medications (PIMs) that pose more risk than benefit in older patients is a common occurrence across all healthcare settings. Reducing such prescribing has been challenging despite multiple interventions, including educational campaigns, audits and feedback, geriatrician assessment and formulary restrictions. With the increasing uptake of electronic medical records (EMRs) across hospitals, clinics and residential aged care facilities (RACFs), integrated with computerized physician order entry (CPOE) and e-prescribing, opportunities exist for incorporating clinical decision support systems (CDSS) into EMR at the point of care. This narrative review assessed the process and outcomes of using EMR-enabled CDSS to reduce the prescribing of PIMs. We searched PubMed for relevant articles published up to January 2018 and focused on those that described EMR-enabled CDSS that assisted prescribers to make changes at the time of ordering PIMs in adults.
Computerized systems offering only medication reconciliation, dose checks, monitoring for medication errors, or basic formulary information were not included. In addition to outcome measures of medication-related processes and adverse drug events, qualitative data relating to factors that influence effectiveness of EMR-enabled CDSS were also gathered from selected studies. We analysed 20 studies comprising 10 randomized trials and 10 observational studies performed in hospitals (n = 8), ambulatory care clinics (n = 9) and RACFs (n = 3). Studies varied in patient populations (although most involved older patients), type of CDSS, method of linkage
DNP 805 Topic 3 Discussion Question One
with EMR, study designs and outcome measures. However, assuming little publication bias, the totality of evidence favoured EMR-enabled CDSS as being effective in reducing the prescribing of PIMs in hospitals, although results were more mixed for ambulatory care settings and RACFs. While absolute effects in most positive studies were modest, they suggest EMR-enabled CDSS are feasible and acceptable to clinicians, and if certain design features are adhered to, there is potential for even greater impact.
PubMed was searched for articles, either single studies or systematic reviews, containing text words ‘electronic medical record’ and ‘deprescribing’ ‘polypharmacy’ ‘inappropriate prescribing’ ‘decision support systems’ and their related synonyms in the title or abstract, and which were published up to January 2018. The ‘related functions’ tab in PubMed, perusal of bibliographies of retrieved articles, and searches in Google Scholar using similar search terms were used to find additional articles, and personal files kept by the authors were also consulted. Articles were selected [initially by one author (IAS) and then confirmed by consensus with other authors] if they described electronic prescribing software integrated or interfaced with EMR (or its CPOE or e-prescribing components) and using CDSS in some form that enables prescribers to make changes at the time of prescribing in adults.
Studies describing stand-alone e-prescribing systems or EMR-linked systems devoid of CDSS targeting PIMs (i.e. offering only medication reconciliation, dose checks, monitoring for medication errors, or basic formulary information) were excluded, as were studies of CDSS for which data relating specifically to PIM prescribing were not reported, studies not written in English, or studies performed in non-developed countries. Articles were categorized according to hospital, ambulatory or residential care settings, and experimental versus observational studies. Outcomes were assessed in terms of process (medication-related) measures and patient outcomes. Qualitative data providing insights into factors that influence effectiveness of EMR-linked CDSS were also gathered from selected studies.