In designing the new CPOE system, the authors were mindful of the risks posed by information overload. "We did not want to overdo the warnings," explains Mattison. "Too many 'alerts' just lead to user fatigue and people stop paying attention, which makes a warning system useless." The authors, therefore, carefully selected a small group of 18 medications from the Beers list that are commonly prescribed in the inpatient hospital setting and for which alternative medications were available. Since 2005, doctors at BIDMC who attempt to order one of these 18 Beers drugs for a patient 65 years of age or older, receive a "warning" on their computer screen, informing them of potential risks. Although the doctor can override the warning and continue to prescribe the medication, he or she must provide an explanation for the decision, which is selected from a list that is provided by the system.

Mattison and her colleagues then formally tested this system. "For three and a half years, we measured the number of orders of the 18 selected Beers medications that were made each day," she explains. "We also monitored the use of several medications that were part of the original Beers list, but were not flagged in our warning system." Their results showed that orders for flagged medications dropped from 11.56 to 9.94 total orders per day, and dropped from 0.070 to 0.045 orders per total number of patients per day, amounting to a decrease of approximately 20 percent in the use of flagged medications. They found that the number of orders for unflagged medications did not change.

"To our knowledge, no CPOE system has previously been described that utilizes a warning system built around PIMs [potentially inappropriate medications] in older, hospitalized adults," the authors write. "Up to 60 percent of adverse drug events occur at the time that medications are ordered. CPOE provides an opportunity for intervention to change prescribing practices."

Adds Mattison, "Historically speaking, medical schools do not provide students with much training in the unique needs of geriatric patients. Yet, with the exception of pediatrics or obstetrics, you can't name a field in medicine where doctors are not routinely caring for older individuals, and as the population ages, this will only increase. Using CPOE to guide care at the point of ordering - to steer clinicians to choose potentially better alternative medications and treatments - is an exciting opportunity to improve care for this vulnerable population."

SOURCE Beth Israel Deaconess Medical Center