Clinical decision support in community pharmacy

Abstract

The occurrence of preventable patient harm caused by drug use has been shown over and over again. Clinical risk management is a concept to prevent patient harm by risk-reducing strategies. It is a systematic approach including risk detection, assessment, management and evaluation. One of the risk-reducing strategies in clinical risk management of drug therapy is the use of clinical decision support systems (CDSSs), which help health care professionals to detect drug therapy related problems. However, both the limited specificity and the limited sensitivity of current CDSSs give rise to problems. Continuous development of CDSSs is essential, firstly to improve their intrinsic performance in detecting drug therapy related problems, and secondly for alignment with changes in society and clinical practice. With the studies presented in this thesis we aimed to provide evidence to give direction to the further development of CDSSs. The investigations in this thesis show that the current alert rate in CDSSs is very high and that improvement strategies are needed. These should be directed at the patients and therapeutic drug classes with the highest alert rates. Moreover, the results show that large-scale implementation of advanced clinical decision support including laboratory values is feasible. In addition, there are two promising approaches for reduction of the alert rate: alert clustering, and alert triggering by changes in the patient situation. These approaches deserve further investigation to assess their consequences and applicability in daily practice. Finally, the investigations show that preferences of patients and pharmacists with regard to the management of drug therapy alerts are divergent. This insight can be used for incorporation of the patient perspective in the development and application of management recommendations for drug therapy related problems. Based on these finding it is concluded that CDSS redesign is needed and priority should be given to the implementation of two approaches: multifactorial risk assessments, and change-based alerting. In a multifactorial risk assessment, all risk-modifying factors are taken into account in one integrated approach. Change-based alerting makes changes in the patient’s situation the leading principle, rather than generating repeat alerts for every repeat prescription for patients in stable condition. To realize CDSS redesign, better coordination and collaboration between software suppliers, professional organizations and health care professionals is urgently needed. Improvements in clinical decision support should also address privacy, accountability and transparency. As incorrect use of medication by patients is the most important reason for inappropriate drug use, the patient perspective needs more attention. Patients should be facilitated to participate in the decision making process as much as possible, given their preferences and capabilities. Integrated risk assessments – which should also include the patient perspective –by educated, watchful health care professionals are essential for safe drug therapy. Therefore, both competent health care professionals and continuously developing CDSSs are essential for clinical risk management of drug therapy. A joint effort of all involved actors is needed, with a central position and responsibility for pharmacists in every position in health care.