Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

j J Am Med Inform Assoc. 2006;13:5–11. DOI 10.1197/jamia.M1868. Computerized prescribing applications that embed clinical decision support systems (CDSS) within computerized provider order entry reduce medication error rates both by structuring prescriptions and by checking them for potential problems such as drug interactions, allergies, and other issues. If a potential problem is found, the CDSS can provide clinicians with real-time alerts, allowing the clinician to make appropriate changes before the prescription is finalized. While computerized prescribing applications are commercially available (either as stand-alone applications or as part of an electronic medical record), these systems may not be as effective for improving safety if clinicians override clinically important alerts. When the threshold for alerting is set too low, clinicians are inundated with alerts of low clinical significance, leading to high override rates and the potential to override even important alerts. In one inpatient study, Payne et al. found an 88% override rate for drug interaction alerts, and a 69% override rate for drug-allergy alerts. Similarly, Weingart et al found ambulatory physicians overrode 91% of drug-allergy alerts, and 89% of high-severity drug-drug interaction alerts. Many CDSS use commercial knowledge bases to drive their alerting. These knowledge bases are often highly inclusive, placingmore emphasis on breadth of coverage than on clinical relevancy or severity of adverse events. However, this approach can have serious consequences. If too many alerts are delivered, in addition to missing important alerts, clinicians may refuse the application altogether due to disruptions in workflow. When designing knowledge bases for CDSS, caremust be taken todisplay alerts judiciously and tomaintain the right balance between useful alerting and overalerting. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of clinically significant drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to highseverity alerts to be interruptive to clinician workflow. In addition, we required prescribers to supply reasons for overriding alerts to better understand their rationale. This article reports on (1) the extent our alert design minimized workflow interruptions, (2) the clinician accept rate of our selective alerts, (3) the specific types of alerts clinicians accepted most frequently, and (4) the reasons clinicians gave for overriding alerts.