From Clinical Guideline to Order Set to Patient Harm:
JAMA published a case and editorial regarding the well-intentioned but flawed application of clinical guidelines to order sets and the perverse incentives that can lead to patient harm. Here is the reference:
JAMA. 2018;319(12):1207-1208. doi:10.1001/jama.2018.1666
In this particular case a patient was treated for an MI with a coronary artery stent and developed a complete heart block after the procedure. Medications that were not indicated to treat this complication were in the order set and the physician, when interviewed about his choice of medications, chose a beta-blocker (contraindicated based on robust data of use after a STEMI) that lead to worsening of the patient. He stated that he chose this medication as per the alert in the CDS that this was a "quality metric".
I think it is interesting that providers are swayed against their better judgement to choose a medication from a set of orders that was incomplete and flawed from the start.
This, in turn, led to the CDS committee to ask some basic questions:
1. What are the goals of each CDS intervention?
2. What is the minimal expected clinical benefit of an intervention to be included as part of the CDS program?
3. Is a CDS the right tool?
4. What measures are used to monitor the efficacy and safety of an intervention?
5. What is the role of an oversight CDS committee and how responsive and accountable are they willing to be to physicians, nurses and other clinical personnel who provide patient care?
Although patient harm from the use of EHR and order sets is a nascent area of research, a few studies mention that patient harm is rare. However, this case provides an opportunity to improve patient care and, I think, it is interesting to see the confluence of human behavior and decision making based on incentives such as an alert that a particular medication choice is a "quality metric" and the provider choosing it despite his knowledge that this medication was contraindicated.
JAMA published a case and editorial regarding the well-intentioned but flawed application of clinical guidelines to order sets and the perverse incentives that can lead to patient harm. Here is the reference:
JAMA. 2018;319(12):1207-1208. doi:10.1001/jama.2018.1666
In this particular case a patient was treated for an MI with a coronary artery stent and developed a complete heart block after the procedure. Medications that were not indicated to treat this complication were in the order set and the physician, when interviewed about his choice of medications, chose a beta-blocker (contraindicated based on robust data of use after a STEMI) that lead to worsening of the patient. He stated that he chose this medication as per the alert in the CDS that this was a "quality metric".
I think it is interesting that providers are swayed against their better judgement to choose a medication from a set of orders that was incomplete and flawed from the start.
This, in turn, led to the CDS committee to ask some basic questions:
1. What are the goals of each CDS intervention?
2. What is the minimal expected clinical benefit of an intervention to be included as part of the CDS program?
3. Is a CDS the right tool?
4. What measures are used to monitor the efficacy and safety of an intervention?
5. What is the role of an oversight CDS committee and how responsive and accountable are they willing to be to physicians, nurses and other clinical personnel who provide patient care?
Although patient harm from the use of EHR and order sets is a nascent area of research, a few studies mention that patient harm is rare. However, this case provides an opportunity to improve patient care and, I think, it is interesting to see the confluence of human behavior and decision making based on incentives such as an alert that a particular medication choice is a "quality metric" and the provider choosing it despite his knowledge that this medication was contraindicated.
Very interesting. Seems like a great opportunity for a "timeout" when something like this comes up. I'm wondering if there is a place to call in the heat of the moment if something like this needs to be reviewed. Kind of like in sports when they call the league office for video review of an officials call or for a rule interpretation.
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