Qualitative Evaluation of Real-Time Provider Responses to Interruptive Clinical Decision Support (CDS) for Opioid Prescribing

HEATHER TOLLE, PhD
University of Colorado

Interruptive alerts within an electronic health record (EHR) provider workflow are a form of clinical decision support (CDS) that can be implemented to support delivery of evidence-based practices. When implementing CDS, it can be challenging and time-consuming to collect sufficient user feedback to iteratively improve CDS in real-world situations. Inclusion of a free-text box for user-response to bypass the alert was examined to determine the feasibility of this source of feedback in maintaining CDS.

EHR embedded CDS alerts fired when providers selected an opioid or benzodiazepine prescription to order on discharge in outpatient and inpatient settings. Alerts reminded the provider to check the patient’s prescription drug monitoring program (PDMP) prescription history and identify patient risk for adverse events. Data was pulled for providers in the UCHealth system exposed to CDS during normal clinical care. Comments entered by providers in the CDS free-text box were examined. Oncology, hospice/palliative care, and pediatric practices were excluded.

User entered responses to a CDS alert during the process of controlled medication prescribing were thematically analyzed looking for common trends and patterns in responses. Percentages of responses falling into identified themes are examined for their implications on CDS.

A total of 54,516 CDS alerts fired for 1,894 unique providers providing 15,492 comments in the CDS alert textbox. Valid responses (not single characters or random strings of text) were categorized into three main groups. The majority of responses (60%) indicated they checked the patient’s PDMP as prompted by the CDS. Thirty-four percent of responses gave a justification for the prescription, and 6% gave a complaint about the CDS. Among those complaints, 68% indicated they wanted to review the PDMP at a later time, 24% expressed frustration with having checked the PDMP and still receiving the alert, and 8% reported a technical error with checking the PDMP such as PDMP data not loading.

The utilization of a textbox during rollout of interruptive CDS can provide additional opportunities to improve use within the EHR to promote evidence-based practices. Alert responses can be used to identify providers who are struggling to understand the purpose or navigation of the CDS, as well as identify changes that may be needed in the CDS to better support providers in their workflow.