Provider variation in responses to warnings: do the same providers run stop signs repeatedly?
OBJECTIVE
Variation in the use of tests and treatments has been demonstrated to be substantial between providers and geographic regions. This study assessed variation between outpatient providers in overriding electronic prescribing warnings.


METHODS
Responses to warnings were prospectively logged. Random effects models were used to calculate provider-to-provider variation in the rates for the decisions to override warnings in 6 different clinical domains: medication allergies, drug-drug interactions, duplicate drugs, renal recommendations, age-based recommendations, and formulary substitutions.


RESULTS
A total of 157 482 responses were logged. Differences between 1717 providers accounted for 11% of the overall variability in override rates, so that while the average override rate was 45.2%, individual provider rates had a wide range with a 95% confidence interval (CI) (13.7%-76.7% ). The highest variations between providers were observed in the categories age-based (25.4% of total variability; average override rate 70.2% [95% CI, 29.1%-100% ]) and renal recommendations (24.2%; average 70% [95% CI, 29.5%-100% ]), and provider responses within these 2 categories were most often clinically inappropriate according to prior work. Among providers who received at least 10 age-based recommendations, 64 of 238 (27%) overrode ≥ 90% of the warnings and 13 of 238 (5%) overrode all of them. Of those who received at least 10 renal recommendations, 36 of 92 (39%) overrode ≥ 90% of the alerts and 9 of 92 (10%) overrode all of them.


CONCLUSIONS
The decision to override prescribing warnings shows variation between providers, and the magnitude of variation differs among the clinical domains of the warnings; more variation was observed in areas with more inappropriate overrides.
Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Research Center for Medical Informatics, University Hospital Zurich, Switzerland.
Patrick E
PE
Beeler
Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA.
E John
EJ
Orav
Partners Healthcare Systems, Inc, Wellesley, Massachusetts, USA.
Diane L
DL
Seger
Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
Patricia C
PC
Dykes
Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Partners Healthcare Systems, Inc, Wellesley, Massachusetts, USA dbates@partners.org.
David W
DW
Bates
D001291:Attitude of Health Personnel; D020000:Decision Support Systems, Clinical; D004342:Drug Hypersensitivity; D004347:Drug Interactions; D004360:Drug Therapy, Computer-Assisted; D055695:Electronic Prescribing; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control; D010818:Practice Patterns, Physicians'
attitude of health personnel; clinical decision support systems; clinical practice variation; computer-assisted drug therapy; medical order entry systems