While physicians in the focus groups on the whole claimed that triggers and evidenced-based treatment algorithms incorporated into their electronic medical record system would be useful in their practice, they clearly indicated that the triggers must be carefully designed to promote efficiency and reduce redundancy. A physician asserted, “Something pops up, gives you a little tutorial–it has to be short and sweet, something you can read in 30 s.”And another explained, “You want to provide a little more information, but you can't have it so long, in providing every explanation… . We don't want that because all you're gonna do is click on little boxes, saying ‘I don't care, I don't care’.
Participants described the frustration of receiving triggers and alerts about information that they were well aware of, alerts that were repetitive because of the frequency of the condition among patients or because the alert came up every time they saw particular patients, and from receiving alerts claiming that they had prescribed inappropriately when in fact they had made a specific decision to treat the patient in such a manner. Clinicians in the focus groups suggested suppressing alerts for renewals of medication combinations that patients were currently taking and tolerating, as well as for alerts related to medications that were used for short-term courses of therapy. We frequently heard the following sentiment, “Don't keep showing the same ones over and over again.”
Physicians repeated over and over the need for the data to be accurate and useful, “It would depend on how reliable we would perceive that data to be. Judging from other insurance data we get, it's pretty poor in terms of the accuracy of that.”
Another physician said, “Differentiate it from the usual. There's an interaction here, you know, non-steroidals and antihypertensives—we all know that. Quit doing that. It's annoying. Only if it's actually helpful. If this person has a serious side effect. And that's the only reason it (the alert) went up, and it really meant something, then yes (it's useful).”
A physician who approved of getting computer triggers nevertheless warned about ease of use,
I think that information would be extremely important…. So I think the information would have to be readily available, not having to be looked for, not physician-dependent, it really needs to be something brought to me by the prescreening technicians, and that information is on the chart—4/5 prescriptions filled, zero prescriptions filled… . All I need is the data.
Some physicians felt that having medication-related triggers on the computer at the time of the visit would aid them in counselling patients who were non-adherent with their medication therapy,
“A lot of patients don't want to bother the doctor… So a patient comes in and we see that there's significant progression of their disease. So we're assuming they're not taking their medication till they come to the office, the night before. To make me happy. They're treating me, they're not treating themselves… . There's some reason they're not telling me… . So if we had some information that we could broach with them, and we could say ‘Why aren't you filling your prescriptions?”
Of note, many of the physicians in the focus groups were not specifically aware or knowledgeable of the term, Beers criteria drugs, although they recognised that the drugs were older and less commonly prescribed.
Online figures 1–15 provide the treatment algorithms for each of the targeted medications or groups of medications. For each medication, the screen initially shows a short alert in a red font such as ‘WARNING—Dose Alert, Increased Sensitivity In The Elderly…MORE’ (). Clinicians then press a button to get more information about the alert in the form of a concise explanation about the specific issue with the drug that would make it potentially inappropriate for older adults. Several alternative medications are then shown on the screen with the intent to aid prescribers in easily identifying a potentially more appropriate drug therapy for the older patient. The one group of PIMs that lack appropriate alternatives was the skeletal muscle relaxants which are only minimally effective and have safety issues in older adults. Prescribers are alerted to try non-pharmacological alternatives.
Actual messages in e-prescribing software—benzodiazepines and anticholinergic medications
Actual messages in e-prescribing software—antidepressants
Actual messages in e-prescribing software—pain medications
Actual messages in e-prescribing software—cardiovascular medications