{"id":7708,"date":"2015-09-20T10:37:54","date_gmt":"2015-09-20T14:37:54","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=7708"},"modified":"2015-09-21T12:11:43","modified_gmt":"2015-09-21T16:11:43","slug":"ehr-and-drug-prescribing-warnings-the-good-the-bad-the-ugly","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/ehr-and-drug-prescribing-warnings-the-good-the-bad-the-ugly\/2015\/09\/20\/","title":{"rendered":"EHR and Drug Prescribing Warnings: The Good, the Bad, the Ugly"},"content":{"rendered":"


\n\"gbu\"<\/a><\/strong>Part 1. The Good.<\/strong><\/p>\n

Recently, an ENT colleague (fictionally named “Clint” below), sent me two emails triggered by drug-drug interaction warnings he received while seeing HIV patients.<\/p>\n

Here’s #1:<\/p>\n

Hey Paul, I saw Mark C yesterday for hoarseness, and his exam was negative. Thought we’d try a PPI for reflux, but when I wrote the script, I got a warning that it interacted with Complera. Is this a real interaction?
\nThanks,
\nClint<\/p><\/blockquote>\n

And #2:<\/p>\n

Paul, can’t believe I’m emailing you again. Same sort of question, different patient. Is there really an interaction between fluticasone\u00a0nasal inhaler and ritonavir?
\nC<\/p><\/blockquote>\n

The answer, of course, is absolutely yes to both queries — these are \u00a0very much “real” interactions, highly clinically significant. Rilpivirine (part of Complera) needs stomach acidity for adequate absorption. And the metabolism of fluticasone\u00a0(and most other inhaled, injected, or even topical steroids) is\u00a0blocked by ritonavir, raising systemic levels of the steroid\u00a0and\u00a0causing hypercortisolism — a very serious problem.<\/p>\n

Good job, EHR!<\/em> This is exactly what we want you to do, improve patient safety.<\/p>\n

Part 2: \u00a0The Bad.<\/strong><\/p>\n

But often\u00a0the drug warnings aren’t really clinically relevant, and you just have to override (some would say “ignore”)\u00a0them — which is why Clint the\u00a0ENT (who, for the record, had never emailed me before) asked if these were “real” interactions.<\/p>\n

Here’s a common example every HIV\/ID provider will recognize — the patient who has been receiving TDF\/FTC, atazanavir, and ritonavir for years,\u00a0is doing great, and needs a refill. Up comes the following:<\/p>\n

\"Medication_Warnings<\/a><\/p>\n

The first one, with “high” importance, warns of the drug-lowering effects of tenofovir on atazanavir, decreasing\u00a0its effectiveness — if given “without concurrent ritonavir.”\u00a0<\/em>(Emphasis mine.)<\/p>\n

Hey, EHR — can’t you tell that the patient is<\/em> receiving “concurrent ritonavir”? Certainly you’d think it were smart enough to do this, as the\u00a0next warning, of “medium” importance, tells you\u00a0that ritonavir<\/em> increases atazanavir levels — exactly what we want when we give atazanavir with tenofovir. Just check out the atazanavir package insert and all the HIV treatment guidelines.<\/p>\n

So practically we ignore both warnings, “high” and “medium” importance notwithstanding.<\/p>\n

With\u00a0warning messages like these, I suspect the following is going on: 1) No one has taken the time to teach the EHR that the complete regimen of tenofovir\/FTC, atazanavir, and ritonavir\u00a0should\u00a0cancel\u00a0these warnings; 2) the EHR doesn’t have the internal logic to check for multi-way interactions (the program generating the top-line “high” importance warning can’t read the “medium” one); or 3) some combination of the above, lost in a tangle of computer code and overwhelmed support staff.<\/p>\n

Bad job, EHR!<\/em> If warnings become too frequent, or are clinically irrelevant, this will generate “alarm fatigue.” A clinician\u00a0becomes so overwhelmed by the number of warnings that he or she inevitably starts ignoring even the important ones.<\/p>\n

Alarm fatigue\u00a0is emphatically not just a problem for\u00a0ICUs with their interminable beeps and buzzes, but also for EHRs.\u00a0I know several primary care doctors who say they virtually always ignore them (especially on their younger patients), and housestaff entering orders on admitted patients routinely complain these alerts slow\u00a0down their work, so they learn to click right through them.<\/p>\n

If one were feeling generous,\u00a0you could argue that with this “bad” example, it’s better for the EHR to err on the side of excessive caution, especially<\/em> since these drug-drug interactions do exist and are at times clinically relevant — just not in this case. This problem should\u00a0eventually sort itself out with greater human oversight and EHR sophistication.<\/p>\n

(I’m an optimist.)<\/p>\n

Part 3: The Ugly.<\/strong><\/p>\n

Finally,\u00a0sometimes the EHR alerts are just baffling. This occurred last week as I was renewing tenofovir\/FTC\u00a0for a patient who, for the record, has been receiving the medication\u00a0for years, has normal renal function, and normal weight.<\/p>\n

For\u00a0those of you who don’t prescribe it, the recommended dose is one tablet daily of the fixed-dose combination (only one form exists).<\/p>\n

Up came this alert:<\/p>\n

\"medication_warning<\/a><\/p>\n

What the …. is going on here? I’ve prescribed this medication hundreds (maybe thousands)\u00a0of times, and have never seen anything like it.<\/p>\n

On\u00a0what planet is the\u00a0recommended maximum dose of tenofovir\/FTC 0.627 tablets a day? Or the maximum frequency 0.57 doses a day? What does 0.57 doses a day\u00a0even mean?<\/p>\n

To make sure I’m wasn’t\u00a0missing something, I’ve had two smart PharmD’s review my order, and they too are perplexed.<\/p>\n

I reported the bogus alert, so right now,\u00a0somewhere in EHR support land, a group is huddling (at least I hope they’re huddling) to try and figure out\u00a0what generated this bizarre warning\u00a0— one, of course, that I ignored. Or more accurately, a warning I overrode by telling the EHR\u00a0that the\u00a0“benefit outweighs risk” when I completed\u00a0the prescription.<\/p>\n

In short, Ugly\u00a0EHR!\u00a0<\/em> And of course with this final example, this legendary quotation<\/a> comes to mind:<\/p>\n

To Err is Human; To Really Foul Things Up Requires a Computer<\/p><\/blockquote>\n

Great music here, even if you’re not a fan of Westerns:<\/p>\n

[youtube http:\/\/www.youtube.com\/watch?v=WCN5JJY_wiA&w=560&h=315]<\/p>\n","protected":false},"excerpt":{"rendered":"

Part 1. The Good. Recently, an ENT colleague (fictionally named “Clint” below), sent me two emails triggered by drug-drug interaction warnings he received while seeing HIV patients. Here’s #1: Hey Paul, I saw Mark C yesterday for hoarseness, and his exam was negative. Thought we’d try a PPI for reflux, but when I wrote the […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,8],"tags":[1075,312,320],"class_list":["post-7708","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-patient-care","tag-ehr","tag-electronic-health-record","tag-emr"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/7708","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=7708"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/7708\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=7708"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=7708"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=7708"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}