Implementing evidence‐based anticoagulant prescribing: User‐centered design findings and recommendations

Abstract

Background Direct oral anticoagulants (DOACs) are widely used medications with an unacceptably high rate of prescription errors and are a leading cause of adverse drug events. Clinical decision support, including medication alerts, can be an effective implementation strategy to reduce prescription errors, but quality is often inconsistent. User‐centered design (UCD) approaches can improve the effectiveness of alerts. Objectives To design effective DOAC prescription alerts through UCD and develop a set of generalizable design recommendations Methods This study used an iterative UCD process with practicing clinicians. In three rapid iterative design and assessment stages, prototype alert designs were created and refined using a test electronic health record (EHR) environment and simulated patients. We identified key emergent themes across all user observations and interviews. The themes and final designs were used to derive a set of design guidelines. Results Our UCD sample comprised 13 prescribers, including advanced practice providers, physicians in training, primary care physicians, and cardiologists. The resulting alert designs embody our design recommendations, which include establishing intended indication, clarifying dosing by renal function, tailoring alert language in drug interactions, facilitating trust in alerts, and minimizing interaction overhead. Conclusions Through a robust UCD process, we have identified key recommendations for implementing medication alerts aimed at improving evidence‐based DOAC prescribing. These recommendations may be applicable to the implementation of DOAC alerts in any EHR systems.

Improving Prescribing through User-Centered Design: Design Guide and Interface Examples for Anticoagulant Medication Alerts

“…Other principles include recommendations addressing layout of alerts, language used, inclusion of supporting data through user modeling, system transparency, and principles of humancomputer interaction. Clinical considerations regarding DOAC medication alerts, such as which laboratory values should be displayed and clinical reasoning behind that design choice is addressed elsewhere (Seagull et al, 2022).…”

Implementing pharmacist-prescriber collaboration to improve evidence-based anticoagulant use: a randomized trial

“… • For new prescribing errors, prescribers will be shown an EHR alert immediately upon entry of a new prescription that does not meet current evidence-based guidelines. Alerts were designed through a user-centered design process [ 17 ] to ensure they are clear and usable. All alerts inform the prescriber of the potential reason for inappropriate prescribing (e.g., drug-drug interaction) and recommended actions the prescriber can take (e.g., ordering an alternative DOAC or another drug) (Fig.…”

“…Currently available DOAC medication alerts suffer from three fundamental design flaws, which together lead to incorrect DOAC dosing both at the time of the initial prescription and at subsequent moments in time where clinical changes should lead to modification of the DOAC medication or dose. These flaws include (1) alerts intrude or interrupt prescriber workflow with low-yield information without actionable tools, often leading to alert dismissal without action; (2) alerts occur only at the time of prescribing, ignoring changes to the clinical scenario that may occur after the initial prescription is written; and (3) alerts do not promote collaboration between prescribers and pharmacists [ 17 ]. As a result, many patients receive unsafe prescriptions that can cause significant harm.…”