Variation in high-priority drug-drug interaction alerts across institutions and electronic health records

Abstract

Objective: The United States Office of the National Coordinator for Health Information Technology sponsored the development of a “high-priority” list of drug-drug interactions (DDIs) to be used for clinical decision support. We assessed current adoption of this list and current alerting practice for these DDIs with regard to alert implementation (presence or absence of an alert) and display (alert appearance as interruptive or passive).Materials and methods: We conducted evaluations of electronic health records (EHRs) at a convenience sample of health care organizations across the United States using a standardized testing protocol with simulated orders.Results: Evaluations of 19 systems were conducted at 13 sites using 14 different EHRs. Across systems, 69% of the high-priority DDI pairs produced alerts. Implementation and display of the DDI alerts tested varied between systems, even when the same EHR vendor was used. Across the drug pairs evaluated, implementation and display of DDI alerts differed, ranging from 27% (4/15) to 93% (14/15) implementation.Discussion: Currently, there is no standard of care covering which DDI alerts to implement or how to display them to providers. Opportunities to improve DDI alerting include using differential displays based on DDI severity, establishing improved lists of clinically significant DDIs, and thoroughly reviewing organizational implementation decisions regarding DDIs.Conclusion: DDI alerting is clinically important but not standardized. There is significant room for improvement and standardization around evidence-based DDIs.

Best Paper Selection

“…Four papers were finally selected as best papers for 2016. Three papers [4][5][6] were selected from PubMed and one paper [7] from WoS in a journal which is not indexed in PubMed. The four papers are listed in Table 1 in the alphabetical order of the first author's surname, and they are discussed in the next section.…”

Navigating the Minefield of QTc Interval‐Prolonging Therapy in Nursing Facility Residents

“…As many as 95% of EMR warnings are overridden, some perhaps appropriately, but many due to alert fatigue . In follow‐up to the publication of high‐priority drug‐drug interaction pairs, an investigation found inconsistent implementation and display of alerts (27%‐93% implementation) . QT‐QT drug interactions were deactivated in 58% of health systems studied.…”

“…47,48 In follow-up to the publication of high-priority drug-drug interaction pairs, an investigation found inconsistent implementation and display of alerts (27%-93% implementation). 49 QT-QT drug interactions were deactivated in 58% of health systems studied. The lack of a standard of care for even high-priority drug-drug interactions is concerning, given that risk is sustained for the duration of concomitant drug administration and for about five half-lives following discontinuation of the interfering medication.…”

Identifying Common Methods Used by Drug Interaction Experts for Finding Evidence About Potential Drug-Drug Interactions: Web-Based Survey (Preprint)

“…These factors may contribute to the greater than 90% override rate consistently reported for clinicians [4]. Moreover, variability across electronic prescribing and pharmacy drug interaction alerting software systems is well-documented and leads to clinician frustration and dissatisfaction [5][6][7][8][9]. A 2017 study of three commercial knowledge bases found substantial variability in the numbers of alerts generated for contraindicated and major/severe PDDIs, with 25, 84, and 145 alerts per 1000 prescriptions for the three systems [10].…”