title: Making pharmacogenomic-based prescribing alerts more effective: A scenario-based pilot study with physicians.
abstract: To facilitate personalized drug dosing (PDD), this pilot study explored the communication effectiveness and clinical impact of using a prototype clinical decision support (CDS) system embedded in an electronic health record (EHR) to deliver pharmacogenomic (PGx) information to physicians. We employed a conceptual framework and measurement model to access the impact of physician characteristics (previous experience, awareness, relative advantage, perceived usefulness), technology characteristics (methods of implementation-semi-active/active, actionability-low/high) and a task characteristic (drug prescribed) on communication effectiveness (usefulness, confidence in prescribing decision), and clinical impact (uptake, prescribing intent, change in drug dosing). Physicians performed prescribing tasks using five simulated clinical case scenarios, presented in random order within the prototype PGx-CDS system. Twenty-two physicians completed the study. The proportion of physicians that saw a relative advantage to using PGx-CDS was 83% at the start and 94% at the conclusion of our study. Physicians used semi-active alerts 74-88% of the time. There was no association between previous experience with, awareness of, and belief in a relative advantage of using PGx-CDS and improved uptake. The proportion of physicians reporting confidence in their prescribing decisions decreased significantly after using the prototype PGx-CDS system (p=0.02). Despite decreases in confidence, physicians perceived a relative advantage to using PGx-CDS, viewed semi-active alerts on most occasions, and more frequently changed doses toward doses supported by published evidence. Specifically, sixty-five percent of physicians reduced their dosing, significantly for capecitabine (p=0.002) and mercaptopurine/thioguanine (p=0.03). These findings suggest a need to improve our prototype such that PGx CDS content is more useful and delivered in a way that improves physician's confidence in their prescribing decisions. The greatest increases in communication effectiveness and clinical impact of PGx-CDS are likely to be realized through continued focus on content, content delivery, and tailoring to physician characteristics.
authors.affiliation: Program in Personalized & Genomic Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States. Electronic address: coverby@medicine.umaryland.edu.
authors.forename: Casey Lynnette
authors.initials: CL
authors.lastname: Overby
authors.affiliation: Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Pharmacy, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States.
authors.forename: Emily Beth
authors.initials: EB
authors.lastname: Devine
authors.affiliation: Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States.
authors.forename: Neil
authors.initials: N
authors.lastname: Abernethy
authors.affiliation: Department of Pharmacy, University of Washington, Seattle, WA, United States.
authors.forename: Jeannine S
authors.initials: JS
authors.lastname: McCune
authors.affiliation: Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Computer Science & Engineering, University of Washington, Seattle, WA, United States.
authors.forename: Peter
authors.initials: P
authors.lastname: Tarczy-Hornoch
mesh_terms: D016303:Clinical Pharmacy Information Systems / Q000458:organization & administration; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D004360:Drug Therapy, Computer-Assisted / Q000379:methods*; D057286:Electronic Health Records / Q000458:organization & administration*; D055695:Electronic Prescribing / Q000706:statistics & numerical data*; D050316:Medical Order Entry Systems / Q000458:organization & administration; D008498:Medical Record Linkage / Q000379:methods; D010597:Pharmacogenetics / Q000379:methods*; D010820:Physicians / Q000706:statistics & numerical data; D010865:Pilot Projects; D014584:User-Computer Interface; D014600:Utilization Review
keywords: Clinical decision support systems; Computer-assisted drug therapy; Computerized physician order entry; Drug safety; Electronic health records; Personalized medicine; Pharmacogenomics; Physician’s practice patterns