How to Improve Patient Provider Communication Continuity of Care
Hosp Pharm. 2015 Oct; 50(9): 751–752.
Communicating to Improve Continuity of Care
Brittany L. Melton
*Assistant Professor, School of Pharmacy, University of Kansas, 3901 Rainbow Boulevard, Wescoe 6012, Kansas City, KS 66160; phone: 913-588-5392; fax: 913-588-2355; e-mail: ude.cmuk@2notlemb
George Bernard Shaw once said, "The single biggest problem in communication is the illusion that it has taken place."1(p71) In the recent past, health care providers operated in silos, and communication, as well as collaboration, was limited. Despite new care models centering on collaborative care and the concept of effective and real-time communication, the application of such communication methods is limited to computerized provider order entry (CPOE) and clinical decision support (CDS). CPOE and CDS systems are meant to assist providers with their decision making and facilitate communication. Although the goal of these systems is to provide communication, it may be an illusion of communication not only for the administrators, but also for the providers and patients. There are 3 areas in which communication breakdown can occur ( Figure 1 ).
Areas where communication breakdown can occur in computerized provider order entry and clinical decision support.
First is the intent of CDS. There is a belief by administrators and providers that CDS will eliminate their communication woes and protect providers from missing information central to safe patient care. When the CDS is both well designed and patient specific, it is an effective tool that presents the needed information in a format that can be readily understood by the provider. This gives hospitals the illusion that CDS is an effective interaction and will meet all their needs. The intent of CDS and the expectation of administrators is that it is effectively interacting with providers, however the CDS is actually creating an opportunity for more medication errors because important information is lost due to poor design. It has also been shown that changes in communication practices and patterns occur and can be an unintended adverse consequence of CPOE and CDS implementation.2 For example, a physician may chose a response from a drop-down list and unknowingly select the wrong option, something that did not occur when orders were written on paper.3 In this regard, pharmacists face the same challenges as physicians; pharmacists expect the CDS to interact with them as needed, when in fact it may not fulfill their needs. Redesigning CDS to present only necessary information in a format that is rapidly interpreted, such as presenting laboratory information in a table rather than a string of text, can cut the number of errors almost in half and improve provider satisfaction. 4 Systems can reduce error by providing redundancies and limiting the amount of information presented in a drop-down list or in an alert.
Second is when the CDS is actually transmitting information. In a good system, only relevant and necessary information is presented along with options for addressing the patient safety issue. In truth, CDS may not be designed well; it may provide too much or vague information or not take into account the needs of the providers who will be using the CDS. This can result in frustration or alert fatigue. It is estimated that up to 96% of CDS alerts are overridden, often due to fatigue.5 Even in a well-designed system, when the physician has a more complete picture of the patient, he/she may decide not to act upon the CDS information and will appropriately override an alert. These overrides can include a rationale to justify the physician's action, such as indicating that the patient-reported medication allergy is non–life threatening or is not a true allergy and the medication can safely be administered. When physicians enter a rationale or reason for overriding a CDS alert, that rationale is often visible to the pharmacist who is processing the order as part of care coordination and information sharing. However, the physician may enter the most expedient rationale rather than the most clinically valid, not realizing that a pharmacist will review the override rationale and rely upon the information provided. This can result in a delay in care, as the pharmacist may have to spend time deciphering the physician's rationale or calling the physician. In a well-designed system, the pharmacist, like the physician, can see the necessary information and make a well-informed decision; but in some systems, pharmacists may not be able to view laboratory results or notes from providers, forcing them to rely upon CDS to inform them of important information. Hospitals often set their CDS to display more alerts to pharmacists than physicians in an effort to avoid overburdening the physicians. Whereas physicians may only see life-threatening drug-drug interactions and allergies, the pharmacists may see alerts for creatinine clearance, dose outside range, pregnancy/lactation, and less serious drug-drug interactions. This can lead to failed interactions when pharmacists lose track of the important information, because they are misdirected by too many alerts. Smarter alerts to specific medications, rather than similar classes or conditions, can reduce the number of alerts presented to physicians and pharmacists. Further, physician awareness and understanding of communication with pharmacists that occurs through the CDS can improve its use and ultimately patient safety.
Third is the patient outcome of CDS utilization. This is where we expect there to be an increase in patient safety, which is part of the intent behind CDS. The literature is peppered with studies identifying specific instances where CDS effectively reduced errors, improved safety, or improved adherence to best practice guidelines and that body of evidence continues to grow, reinforcing the belief that CDS systems provide the necessary communication in health care. The system is in place and the information is presented, but if providers do not act on it due to fatigue or confusion, the effect is a decrease in patient safety, not an increase. Wrong patient and wrong drug errors can be more common with CPOE systems than paper orders due to the provider unknowingly picking the wrong selection from a crowded screen, attempting to multitask when multiple patient records are open on the computer, or having to move between multiple windows to complete one task.
CDS systems are omnipresent, whether one practices in a hospital or community setting. These systems have repeatedly shown they can facilitate communication to providers and between providers. At the same time, these systems require continual surveillance, evaluation, and revision to ensure that what happens in a health care setting is always the desired interaction and not an illusion. Providers and their patients deserve effective communication, rather than a shell game.
References
1. Caroselli M. Leadership Skills for Managers. New York: McGraw-Hill; 2000. [Google Scholar]
2. Campbell EM, Sittig DF, Guappone KP, et al. Overdependence on technology: An unintended adverse consequence of computerized provider order entry. AMIA Annu Symp Proc. 2007;11:94–98. [PMC free article] [PubMed] [Google Scholar]
3. Campbell EM, Sittig EF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547–555. [PMC free article] [PubMed] [Google Scholar]
4. Russ AL, Zillich AJ, Melton BL, et al. Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation. J Am Med Inform Assoc. 2014;21(e2):e287–296. [PMC free article] [PubMed] [Google Scholar]
5. Van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138–147. [PMC free article] [PubMed] [Google Scholar]
Articles from Hospital Pharmacy are provided here courtesy of SAGE Publications
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750821/
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