July 6, 2011

Clinical Decision Support and Malpractice Risk

Author Affiliations

Author Affiliations: RAND Health (Dr Greenberg and Ms Ridgely); and RAND Institute for Civil Justice (Dr Greenberg), Pittsburgh, Pennsylvania.

JAMA. 2011;306(1):90-91. doi:10.1001/jama.2011.929

Clinical decision support (CDS) refers to electronic technology used to enhance clinical decision making. For example, computerized physician order entry with integrated CDS in principle offers an electronic layer of review for ordering prescriptions.

An important feature of CDS is automated warnings issued whenever potential drug interactions or other contraindications arise. In practice, however, CDS systems often have been overinclusive in the warnings they generate, to a point at which physician “alert fatigue” may in large part undermine the utility the systems offer.1,2 The current generation of CDS systems includes alert parameters for thousands of drug interaction types. Meanwhile, a recent review of empirical studies on computerized physician order entry with integrated CDS observed that physicians override automated warnings a substantial fraction of the time—according to one study,3 in as many as 19 out of 20 instances. One paradoxical result of overly abundant warnings may be to exacerbate malpractice risk for physicians who either ignore or turn off CDS alerts, even as CDS systems create an audit trail to show that those physicians have done so.3 Another paradoxical result may be impeded adoption of CDS technologies4 because of physician and institutional concerns about malpractice risk. These sorts of results could prevent the technologies from achieving their potential benefits in making patients safer and in reducing the risks of medication error.5

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