How to Improve DUR Alerts

Clinical decision support (CDS) tools have not reached their full potential, and they need significant improvements to achieve a more efficient DUR alerting system, says Michael Rupp, PhD, Professor of Pharmacy Administration, Midwestern University, Glendale, AZ. 

“Prospective DUR is the single most important contemporary clinical role that pharmacists have,” said Rupp, because ensuring patient safety “has to be job one” for the pharmacist, Rupp asserts.

“There is no more important contemporary clinical role of the pharmacist in any practice setting than reviewing prescribed drug therapy prior to dispensing to ensure that at the very least it doesn’t harm the patient,” Rupp told Drug Topics.

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When the DUR provisions of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) legislation were implemented in January of 1993, Rupp said that they legally codified the pharmacist’s responsibilities.

OBRA 90 stimulated a growth in development and use of CDS tools.

In the article,Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert, in the January 2017 edition Journal of Managed Care and Specialty Pharmacy, Rupp and his co-author, Jenna Reynolds, BS, BA, looked back at the progress made in the 25 years since the implementation of OBRA 90. The intent was to see how much better the DUR systems are now in terms of supporting pharmacists in this critical clinical role.

“I was not surprised, but I was somewhat disappointed to find that most of the problems we had 20 years ago with these systems still exist. And it puts practicing pharmacists in a very difficult position, not having better computer DUR systems to support them in their clinical decisions with respect to this critically important role,” said Rupp.

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One of the biggest concerns regarding these systems has to do with alert fatigue.

And it’s not just pharmacists who suffer from this fatigue, said Rupp. “These automated system alerts are now being pushed out to prescribers at the point of care and now they are demonstrating the same response.”

Up next: Suggestions to improve DUR alerts

Rupp suggests a series of recommendations designed to improve DUR alerts:

• Database vendors and systems administrators should ensure the validity of alerts through a systematic, transparent, and ongoing review of clinical literature to assure users that workflow interruptions are warranted by the potential threat to patient safety that is represented in the alert.

• The sophistication of system logic that is used to generate pro-DUR alerts should be improved to make increased use of statistical probability models and branching algorithms to improve accuracy. 

• Database vendors and systems administrators should provide users with the flexibility to selectively suppress alerts that are determined to be unnecessary or inappropriate in their practice. 

• Pharmacy organizations should enlist clinical staff to report inappropriate or irrelevant alerts and create an expert committee within the organization to review questionable or frequently overridden alerts for the purpose of recommending system customizations and providing feedback to database providers. 

• DUR alerts should be delivered and integrated at the point in workflow that is most amenable to taking the desired action, and should include all requisite contextual patient information to support optimal decision making. 

• Pharmacists must clearly understand that CDS tools such as computer-assisted pro-DUR systems are intended to assist and support the clinical judgment of the pharmacist, not supplant that judgment. 

• Pharmacists should be adequately trained to use CDS tools such as computer-assisted pro-DUR, and training should be integrated into the curricula of pharmacy schools rather than being relegated to on-the-job training. 

• Human factor principles should be applied to pro-DUR systems design that consider the importance of color, size, font, and placement of displayed alerts. 

• Displayed alerts should be quickly interpretable and actionable and should include the patient safety consequences of ignoring the alert. 

• Continuous quality improvement of pro-DUR systems should be the shared goal of database and system vendors, systems administrators, pharmacy organizations, and clinicians.

Joe Moose, PharmD, owner of Moose Pharmacy in Concord, NC, agrees that improvements need to be made to DUR alerts.

This is true,“especially with alert fatigue, which can lead to routine override of alerts without specific detailed information regarding the reasoning behind the override. In some cases, important alerts may be overlooked as irrelevant ones,” Moose said.

Recommendation list reproduced with permission from the Journal of Managed Care and Specialty Pharmacy