Doctors override most e-Rx safety alerts

Dr. Weingart

If an electronic prescribing system pops up a medication safety alert but no doctor heeds it, does it ever sound the alarm?

That question appears more salient than ever, as research continues to show that the clinical decision support systems intended to protect patients from medication errors prove in some ways to be more of a hindrance than a help to doctors.

The latest example is a study of the electronic prescribing records of nearly 2,900 community physicians and other prescribers in Massachusetts, New Jersey and Pennsylvania. Nearly 230,000 times these doctors were warned about potential drug interactions, and 90% of the time they decided to proceed as if the alert had never appeared.

"The systems and the computers that are supposed to make [physicians'] lives better are actually torturing them," said Saul N. Weingart, MD, PhD, co-author of the study, which was published in the Feb. 9 Archives of Internal Medicine.

The results, Dr. Weingart said, do not show that physicians are recklessly ignoring warnings. Rather, too many of the electronic alerts are irrelevant to the clinical circumstances doctors face and the patients they treat.

"Given the high override rate of all alerts, it appears that the utility of electronic medication alerts in outpatient practice is grossly inadequate," the study said.

A Nov. 24, 2003, study Dr. Weingart published in the same journal found that one-third of all alerts lacked "adequate scientific basis or were not clinically useful." Override rates are similar in hospitals.

The challenge of preventing medical errors is daunting. One-quarter of adult outpatients prescribed medicine experience an adverse event within three months, according to an April 17, 2003, New England Journal of Medicine study. And a July 2006 Institute of Medicine report estimated that medication errors harm 1.5 million patients annually, with 7,000 deaths. The IOM said electronic prescribing, especially clinical decision support, is central to reducing the toll of drug errors.

Based on that premise, the Centers for Medicare & Medicaid Services in January began offering a 2% bonus to doctors who prescribe electronically under Medicare Part D. The bonuses drop to 1% in 2011 and to half a percent in 2013, then they stop. The American Medical Association has said a Medicare e-prescribing mandate should only take effect two years after CMS has finalized e-prescribing standards for physicians.

Health information technology got a $19 billion boost from the stimulus package President Obama signed into law in February. Most of the money will go to help hospitals, doctors and other health professionals leave pen and paper behind.

Between 5% and 20% of physicians prescribe electronically. Estimates vary based on the survey and how e-prescribing is defined. For example, many experts do not consider systems that fax orders to the pharmacy to be true e-prescribing.

About 30,000 physicians and other health professionals use the Web-based system offered free by Chicago-based software firm Allscripts as part of its National ePrescribing Patient Safety Initiative. That number is growing by 30% per month, Allscripts executives said.

Dr. Weingart said he and his co-authors are "bullish on electronic systems and e-prescribing," but noted that the evidence for e-prescribing's safety impact in ambulatory care is limited so far. And then there is the question of cost.

"If doctors are overriding 90% of alerts, of the 10% they're accepting, what's the chance that those led to improvement in care and in turn prevented health care utilization to save money?" Dr. Weingart said. "Is the juice worth the squeeze? I think safety should always trump convenience, but the question is, what's the magnitude of the benefit we're getting?"

Combating "alert fatigue"

Experts said the new findings show that too many e-prescribing systems fire off a bevy of warnings.

"Many organizations, especially in the inpatient setting, have turned off clinical decision support for theirprescribers. So many alerts come through that people automaticallybypass them," said Stuart Levine, PharmD, an informatics specialist with the Horsham, Pa.-based Institute for Safe Medication Practices. "Having too many alerts is like having no alerts at all."

Levine said that e-prescribing still helps protect patients because it can prevent errors such as handwriting mix-ups and dosage miscalculations.

Steven E. Waldren, MD, director of the American Academy of Family Physicians' Center for Health Information Technology, said physicians may be able to end irrelevant alerts. Some programs can be customized to show only the highest-severity alerts. Also, it is possible to review which drug interactions doctors ignore, and have those suppressed.

Ross Koppel, PhD, at the University of Pennsylvania School of Medicine's Center for Clinical Epidemiology and Biostatistics, is principal investigator of a study of hospital-workplace culture and medication errors. Koppel and other experts said that medical liability fears may discourage e-prescribing software makers from cutting back on the number of safety alerts.

"My joke about [e-prescribing systems] is that sometimes I think they're written by liability lawyers and not by clinicians," Koppel said. "And so doctors have to face that."