title: Physicians' use of computerized clinical decision supports to improve medication management in the elderly - the Seniors Medication Alert and Review Technology intervention.
abstract: BACKGROUND
  Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety.
  
  
  METHODS
  Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers' Criteria for medication management and the Cockcroft-Gault formula for estimating glomerular filtration rates (GFR). The "Seniors Medication Alert and Review Technologies" (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed.
  
  
  RESULTS
  Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check.
  
  
  CONCLUSIONS
  While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers' Criteria in ambulatory care EMRs.
authors: Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Kannayiram
authors: K
authors: Alagiakrishnan
authors: Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Patricia
authors: P
authors: Wilson
authors: Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
authors: Cheryl A
authors: CA
authors: Sadowski
authors: Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Darryl
authors: D
authors: Rolfson
authors: Chief Medical Information Office, Alberta Health Services, University of Alberta, Edmonton, AB, Canada; Division of Critical Care, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Mark
authors: M
authors: Ballermann
authors: Department of Family Medicine, University of Alberta, Edmonton, AB, Canada; Lynwood Family Physician, University of Alberta, Edmonton, AB, Canada.
authors: Allen
authors: A
authors: Ausford
authors: Lynwood Family Physician, University of Alberta, Edmonton, AB, Canada.
authors: Karla
authors: K
authors: Vermeer
authors: eClinician EMR, Alberta Health Services-Information Systems, University of Alberta, Edmonton, AB, Canada.
authors: Kunal
authors: K
authors: Mohindra
authors: Department of Medicine, Division of Endocrinology, University of Alberta, Edmonton, AB, Canada.
authors: Jacques
authors: J
authors: Romney
authors: Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Robert S
authors: RS
authors: Hayward
mesh_terms: D000368:Aged; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D004347:Drug Interactions; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D054539:Medication Therapy Management / Q000592:standards*; D010820:Physicians; D019338:Polypharmacy; D000067561:Potentially Inappropriate Medication List; D011320:Primary Health Care / Q000592:standards*
keywords: Beers’ Criteria; Cockcroft–Gault formula; clinical decision support; medication management; polypharmacy