title: Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.
abstract: OBJECTIVE
  Computerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug-drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug-drug interactions when ordering medications in an electronic medical record.
  
  
  METHODS
  In this prospective, randomized crossover study, providers were randomized into cohorts that required a reason for overriding a medication alert from a customized or non-customized list of override reasons and/or by free-text entry. The primary outcome was to compare override responses that appropriately correlate with the alert type between the customized and non-customized configurations. The appropriateness of a subset of free-text responses that represented an affirmative and active acknowledgement of the alert without further explanation was classified as "indeterminate." Results were analyzed in three different ways by classifying indeterminate answers as either appropriate, inappropriate, or excluded entirely. Secondary outcomes included the appropriateness of override reasons when comparing cohorts and individual providers, reason selection based on order within the override list, and the determination of the frequency of free-text use, nonsensical responses, and multiple selection responses.
  
  
  RESULTS
  Twenty-two clinicians were randomized into 2 cohorts and a total of 1829 alerts with a required response were generated during the study period. The customized configuration had a higher rate of appropriateness when compared to the non-customized configuration regardless of how indeterminate responses were classified (p<0.001). When comparing cohorts, appropriateness was significantly higher in the customized configuration regardless of the classification of indeterminate responses (p<0.001) with one exception: when indeterminate responses were considered inappropriate for the cohort of providers that were first exposed to the non-customized list (p=0.103). Free-text use was higher in the customized configuration overall (p<0.001), and there was no difference in nonsensical response between configurations (p=0.39).
  
  
  CONCLUSIONS
  There is a benefit realized by using a customized list for medication override reasons. Poor application design or configuration can negatively affect provider behavior when responding to important medication alerts.
authors.affiliation: Froedtert and the Medical College of Wisconsin, Department of Pharmacy, Froedtert Health Woodland Prime Building, 200 N74 W12501 Leatherwood CT, Menomonee Falls, Milwaukee, WI 53051, USA. Electronic address: Brian.dekarske@froedtert.com.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Dekarske
authors.affiliation: University of Michigan Health System, Department of Pharmacy Services, Ann Arbor, MI, USA.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Zimmerman
authors.affiliation: University of Michigan Health System, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Chang
authors.affiliation: University of Michigan Health System, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Grant
authors.affiliation: University of Michigan Health System, Department of Pharmacy Services, Ann Arbor, MI, USA.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Chaffee
mesh_terms: D004282:Documentation / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D014481:United States; D014584:User-Computer Interface; D014600:Utilization Review
keywords: Clinical documentation; Computerized provider order entry systems; Electronic health record; Medication alert systems; Override responses