HEALTH-SYSTEM EDITION
PROFESSIONAL PRACTICE

E-alerts can help relieve drug shortages, save money

In the past decade, the number of drug shortages plaguing the nation's hospitals has increased significantly. "Short-term back orders and long-term availability of drug products have been a challenge to pharmacy managers for years," said Scott M. Mark, Pharm.D., who wrote guidelines for ASHP on the management of drug shortages. "The challenge," he added, "is to enable the provision of seamless equivalent drug therapy at comparable costs."

One solution to that challenge was found at the 324-bed Cincinnati Children's Hospital Medical Center (CCMHC). Finding traditional methods of response—such as posted notices—inadequate, hospital pharmacists used an unconventional solution to cope with a continuing national shortage of methylprednisolone, a commonly prescribed asthma medication. They issued a browser-based clinical information system alert to physicians and nurses every time a prescription for the medication was ordered, warning clinicians that there was a critical shortage and offering a recommendation for two therapeutically equivalent drugs, dexamethasone and hydrocortisone.

The hospital maintains a systemwide browser-based integrated clinical information system (ICIS) that includes clinical data, computerized physician order entry, clinical documentation, an electronic medication administration record, clinical decision support, and a data storage repository. "The first and most important lesson we learned was the immense value of using that available technology in unconventional ways [for pharmacists] to communicate with physicians," said John Hingl, R.Ph., a CCMHC pharmacy operation specialist who helped lead the study. "It can be extremely effective to transmit shortage data at the point of care."

When a physician entered an order for methylprednisolone into ICIS, he or she received the following alert: "Warning: Methylprednisolone is in critical short supply and should be reserved for the following uses: spinal cord injury or transplant induction. Please choose one of the steroids below for other uses." The computer screen then offered a choice among methylprednisolone, dexamethasone, and hydrocortisone.

The result was a 55% relative reduction in the number of methylprednisolone orders in the post-alert period of July 2003, compared with the control period in April 2003. Orders for alternative drugs dexamethasone and hydrocortisone increased 12% and 49%, respectively. Because of the significantly greater cost of the medication in short supply, the reduction in methylprednisolone orders saved the hospital more than $36,000 in annual costs, said the pharmacists and some of their physician colleagues in an article describing their study, published in the July/August 2004 issue of the Journal of the American Medical Informatics Association. The article was titled "Computerized Reminders Reduce the Use of Medications During Shortages."

"[Our] results ... suggest that clinical decision support systems (CDSSs) are an effective tool in conserving medications during times of national shortage by rapidly changing prescribing practices.... The ICIS methylprednisolone alert provided a fast and reliable clinician reminder and was effective in cutting parenteral methylprednisolone orders nearly in half by an average of more than three orders each day," reported Hingl and his coauthors. The Cincinnati researchers called their results "dramatic" but added that financial savings might not be applicable in every situation, as alternative drugs might not always be available.

And Hingl pointed to a couple of other lessons learned: "Physicians receive a lot of alerts through CDSSs, such as for potential allergies or contraindications, and can become somewhat numb to the process. So we found that color-coding alerts related to shortages was helpful. Another thing was the importance of turning the alert off after a shortage ends. Failure to do so can create a credibility problem," he said.

Martin Sipkoff

Martin Sipkoff. E-alerts can help relieve drug shortages, save money.

Drug Topics

Aug. 23, 2004;148:HSE10.