Safer Prescribing for Hospitalized Older Adults with an Electronic Health Records‐Based Prescribing Context

Abstract

BACKGROUND/OBJECTIVES Hospitalized older adults are at risk of receiving potentially inappropriate medication (PIM) doses, driven in part by age‐independent dose defaults used by electronic health records (EHRs), leading providers to prescribe for older adults as they do for younger adults. We studied whether an automated EHR‐based medication support tool would reduce PIM dosing for hospitalized older adults. DESIGN Pre‐post study design. SETTING Tertiary care, level 1 trauma, academic medical center in Oregon. PARTICIPANTS Hospitalized adults 75 years and older in the inpatient, nonemergency setting prescribed medications with geriatric‐specific dose considerations. INTERVENTION An EHR‐based, automated set of evidence‐based, age‐specific dose and frequency defaults called the Geriatric Prescribing Context (GPC). MEASUREMENTS The process measure is percentage of orders consistent with geriatric dose recommendations, and outcome measures are average dose (AD) in milligrams and total daily dose (TDD) in milligrams in the 12 months before and after implementation. RESULTS Use of recommended geriatric doses with the context improved for all 10 of the most commonly ordered medications. In the year after implementation, there was a trend toward decreasing TDD and AD across all drug classes. CONCLUSION The GPC is a simple, elegant, and effective means to align prescribing practices with safety standards for older adults, improving prescribing safety for all. It works within the current prescriber workflow without triggering alert fatigue and requires minimal resources for development and maintenance.

In Pursuit of the Quadruple Aim: A Geriatric Prescribing Context’s Impact on Clinician Workflows and Alert Fatigue

“…Analysis of the GPC has shown 10–30% increases in age-appropriate orders for the 10 most commonly used medications across drug classes that translated to reductions in total daily doses and average dose strengths received by older patients. These results suggest that the GPC is a feasible method to improve safe prescribing for hospitalized older adults (Drago et al, 2020).…”

“…The GPC better aligns prescribing practice with recommendations for older adults and an important part of the design process was to avoid hard stop alerts. The initial investigation into the GPC’s impact focused on orders and actual doses received by patients but little was known about its impact on computerized prescribing and order verification experiences for end users (Drago et al, 2020). This study aimed to describe the GPC’s reported impact on usual electronic prescribing workflows and user experiences among our inpatient providers and pharmacists in both community and academic settings.…”

Validating ICD-10 codes for adverse drug events in hospitalised older adults: protocol for a cross-sectional study

“…[3][4][5][6][7][8] Our health system developed and embedded the Geriatric Prescribing Context (GPC) into the EHR in July 2017. 9 The GPC is an automated set of age-friendly default doses and frequencies triggered when prescribers write orders for patients 75 years and older admitted to the hospital or emergency department. There are no hard stops, alerts or extra steps prescribers have to take to write medication orders.…”

“…Initial investigation demonstrated 10%–30% improvement in the number of medication orders using the age-friendly defaults in the top 10 most commonly used inpatient medications adjusted by the GPC. 9 Little is yet known about the effect of the GPC on ADEs as this is a novel adaptation.…”

Tailoring the electronic health record to reduce inappropriate prescribing

“…3 EHR default doses are often higher than recommended for older adults. 4 Studies by Peterson et al, 2005 5 and Drago et al, 2020 6 have shown that computerized provider order entry (CPOE) defaults can increase safe prescribing. Literature exploring defaults' effectiveness in decreasing IP has largely occurred in non-Hispanic White adults.…”