Towards Meaningful Medication-Related Clinical Decision Support: Recommendations for an Initial Implementation

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A review of the article titled "Towards Meaningful Medication-Related Clinical Decision Support: Recommendations for an Initial Implementation".[1]


Introduction

One of the main benefits in implementing a Clinical Decision Support (CDS) system in healthcare organizations is the ability to integrate it with a computerized provider order entry (CPOE) system which can help prevent medication errors that may cause harm to patients and improve quality and efficiency. However, despite the benefits of CDS systems, healthcare organizations are still struggling to adopt and implement CDS systems, especially medication-related ones, because of the time and resources needed to develop and manage the knowledge within the system. The article concentrates on a study that was performed to help collect content and recommendations for the development and implementation of a medication-related decision support system, in which could be used across different systems. The study focuses on two main types of medication-related decision support: drug-drug interaction (DDI) checking and therapeutic duplication[1].

Method

A panel of 7 individuals with CDS expertise from different healthcare settings and with a variety of professional backgrounds were asked to come together to develop a list of recommendations on the content and policies related to implementation of medication-related CDS, using the list and categories classes that were employed at Partners Healthcare. The study used a two phase approach to gather information from its panel members, first with an online discussion forum, in which panelists were asked to comment on content related DDI interactions and therapeutic duplication alerts. Second, the panelists were to describe how these two types of decision support were implemented in their own respective organizations. The online discussion was held for 4 months, audio taped and transcribed.

Results

Using the Partners Healthcare knowledge base, the panelists were able to recommend a final list of 27 DDI and categorized them into three levels. They also identified 16 drug classes for therapeutic duplication and with an addition of three pairs of classes that were new and added to the Partners Healthcare CDS knowledge base.

These were their final recommendations for starter sets when implementing a new CDS systems for DDIs[1]:

Level 1 Alerts - Hard stop alerts which physician cannot override.

1. Dextroamhetamine AND MAO Inhibitor

2. Linezolid AND Apraclonidine

3. Isosorbide Dinitrate AND Sildenafil

4. Linezolid AND Levodopa

5. Drotecogin Alfa (Activated) AND Warfarin

6. Tranylcypromine AND Furazolidone

7. Tranylcypromine AND Procarbazine

8. Ramelteon AND Fluvoxamine

9. Ciproflozacine AND Sotalol

Level 2 Alerts - Interruptive but the clinician can continue by providing a reason for ordering two interacting drugs. 1. Cyclobenzaprine AND Tramadol 2. Dofetilide AND Quinidine 3. Droperidol AND Cinoxacin 4. Droperidol AND Norfloxacin 5. Tizanidine AND Sotalol 6. Sibutramine AND Sumatriptan 7. Echothiophate AND Sucinylcholine 8. Indinavari AND Triazolam 9. Carbamazepine and NEvirapine 10. Phenytoin AND Fosamprenavir

Level 3 Alerts - Informational and non-interruptive. 1. Tramadol AND FLuphenazine 2. Tramadol AND Thiothizene 3. Rifampin AND Divalproex Sodium 4. Busalfan AND Itraconazole 5. Tracolimus AND Phenobarbital 6. Cyclosporine AND Foscarnet 7. Cabergoline AND Prochlorperzine 8. Warfarin AND Levothyroxine

The recommended therapeutic duplication starter sets recommended are as follows:[1]

1. Angiotension-converting enzyme (ACE) Inhibitors 2. Aniotensin 2 Receptor Blockers (ARB) 3. Benzodiazepines 4. Beta Blockers 5. Calcuium Channel Blockers 6. H2 blockers or H2 receptors agonists 7. 3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors 8. Hypnotics 9. Non-Steroidal anti-inflammatory drugs (NSAIDS) {Including COS-II Inhibitors} 10. Phenothiazine Antipsychotics 11. Proton Pump Inhibitors (PPIs) 12. Selective Serotonin Reuptake Inhibitors (SSRIs) 13. Sucralfates 14. Sulfonylurea Hypoglycemics 15. Tricyclic Antidepressants 16. Anticoagulants Benzodiapzepine + Hypnotic ACE Inihibitors + Angiotensin 2 Receptor Blockers H2Blockers + Proton Pump Inhibitors

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References

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