Clinical Decision Support and Electronic Prescribing Systems: A Time for Responsible Thought and Action

Abstract

Electronic prescribing (e-prescribing) systems can provide computer-based support for the creation, transmission, dispensing, and monitoring of pharmacological therapies. In the United States and other countries, such systems have been documented, under certain conditions, to increase the safety and quality of patient care.1–5 The authors applaud the initial efforts of Teich and colleagues in the Joint Clinical Decision Support Workgroup (Joint CDS WG) to outline e-prescribing desiderata, as reported in this issue of JAMIA by Teich et al.6 Their article is published as an endorsed policy of the American Medical Informatics Association (AMIA). Previously, Bell et al. published an excellent list of desiderata for outpatient e-prescribing and sorted the desiderata into functional categories.7 Subsequently, Wang et al. surveyed e-prescribing vendor systems to determine that existing systems on average met only half the desiderata, with none exceeding 64% fulfillment.8 The recommendations outlined in the tables of the Joint CDS WG provide a useful point of departure for future discussions. Of note, the Joint CDS WG guidelines were developed as a “commissioned work” with externally determined foci, time limitations, and priorities, so that those guidelines do not fully cover all relevant areas. The Joint CDS WG document therefore represents an important first step in an evolving approach to a complex set of problems. The Joint CDS WG recommendations present a scenario of how e-prescribing features might be rolled out. The authors of this commentary would like to supplement, from what we believe is a broader perspective, the focused set of Joint CDS WG recommendations. The Joint CDS WG proposal has several strengths, including the recommendations that the United States should develop and promote shareable standards for e-prescribing and related decision support systems, a consensus should be developed on how to implement and evaluate decision support systems, and certain organizations, (such as the Office of the National Coordinator for Health Information Technology, the Agency for Healthcare Research and Quality, the U.S. Food and Drug Administration (FDA), the National Library of Medicine, AMIA, the e-Health Initiative, and the Health Information and Management Systems Society) should take leadership roles in the e-prescribing efforts. The authors note that developers and implementers should consider the variability that currently exists among users, clinical settings, information systems, and environments when determining how and when to install and support an e-prescribing system. For example, even when clinical systems provide net benefits to an institution, the implementation of electronic systems to improve the quality of care can introduce unwanted, potentially harmful side effects that must be detected, monitored, and addressed.9,10 It is therefore important to consider the potential adverse effects of e-prescribing implementation. Electronic prescribing systems represent only one genre of electronic health record system activity (others include departmental pharmacy, radiology, and laboratory systems and systems for record keeping, ordering, results display, monitoring, and decision support). Because the current state of the art for complex, comprehensive electronic health record systems is immature,11 there is not yet a scientific basis for selecting among the many potential courses of action related to implementation and use of e-prescribing systems. It is the authors' opinion that human (end-user) factors and electronic information interchanges among e-prescribing and other clinical systems play critically important roles in determining the success or failure of e-prescribing systems. These considerations should be combined with the Joint CDS WG suggestions when making implementation decisions. Several articles in the current issue of JAMIA illustrate how intricate and difficult it is to implement and evaluate such systems. There are few operational systems in place that have documented the success or failure of e-prescribing guidelines outlined. The authors note that e-prescribing systems alone may not suffice; more comprehensive electronic health systems may be required to address the needs of both healthcare facilities and individual practitioners. Clinicians should be wary of developing a false sense of security and unrealistic expectations based on use of e-prescribing applications alone, when more complex systems may be required. To reap the benefits of several decades of dedicated work by biomedical informaticians, commercial vendors, and health care providers (institutions and individuals), a responsible approach to e-prescribing must be advocated. All parties with a stake in e-prescribing must develop a common, overarching framework for its development and dissemination. The remainder of this commentary examines the environmental factors, technical factors, and strategic factors relevant to e