Hospital Pharmacy - June 2019 - 149

791556
Editorial2018

HPXXXX10.1177/0018578718791556Hospital PharmacyDougherty and Bonfiglio

Editorial

The Future CPOE Workflow: Augmenting
Clinical Decision Support With
Pharmacist Expertise

Hospital Pharmacy
2019, Vol. 54(3) 149-152
© The Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/0018578718791556
DOI: 10.1177/0018578718791556
journals.sagepub.com/home/hpx

John A. Dougherty1 and Mark Bonfiglio1
The advent of computerized provider order entry (CPOE)
brought substantial changes to the medication order processing workflow. Much of the justification for these changes
included improvements in medication safety. CPOE for medications has reduced errors contributing to improvements in
patient safety.1-5 The benefits of CPOE include a reduction in
prescribing and transcription errors and the ability to manage
medication-related problems in real time through alerts to
the user.3 Benefits to patient care have been noted with many
alert types including the following: drug-allergy, drug-drug
interaction, drug-dose, drug-duplication, and formulary
compliance alerts.6
The many different categories of alerts generated by computer decision support are designed to cast a wide net to
catch potential medication-related problems.6 Computer
decision support may be thought of as a nuisance, until it
catches a medication-related problem important for the care
of the patient. How many, and what type, of alerts to provide
can be viewed from different perspectives. First, there is the
risk management and hospital administration perspective.
Risk managers and health care administrators would like to
alert health care providers to as many risks as possible to
protect patients. In this way, there is a "perception" that all
alerts have clinical utility. Clinicians would like to review
ONLY alerts that have "actual" clinical utility at the time
they are making a decision (ie, initiating a medication order,
changing a medication order, etc.). Many clinicians find the
signal-to-noise relationship generated by the alerts overwhelming. Health systems must often make decisions on
whether an alert is to be interruptive, noninterruptive, or not
to fire at all.6,7 Due to considerations of risk, some alerts may
be designated to be interruptive simply to ensure that issues
are addressed before an order is processed. Unfortunately,
the volume of alerts may de-sensitize providers to their
potential impact resulting in "alert fatigue" and automatic
overriding of alerts.8-14 Optimization of the alerts presented
in the medication order entry workflow has been the subject
of considerable discussion, activity, and publication.15
Specifically, there has been much work to decrease alert
fatigue and provide more relevant and contextual information to the provider during the CPOE process.16-19
Pharmacists are well equipped to manage medicationrelated problems.2,20 This ability combined with computer
system experience places pharmacists in an optimal position

to augment computer-driven decision support during medication order entry. To accomplish safer and more efficacious
drug therapy during CPOE, we propose a longitudinal context and priority structure to provide significant advantages
over current medication workflows.
Efforts to integrate pharmacists more prominently in the
automated decision support alert workflow in a seamless,
longitudinal strategy can add incremental benefit to work
being considered on the generation and contextual nature of
alerts. Alert data can be accurate, but not useful. It becomes
useful when complete information is available in the correct
context and at the appropriate time. For example, it is virtually impossible to establish whether some drug interactions
are clinically significant without monitoring them over time.
They may have a delayed onset or an unpredictable association with dose. Some medication-related problems are not
apparent until laboratory data or microbiology results are
available. This is not at the time of initial ordering. In addition, consider the following scenario: a patient initiated on a
potassium supplement who is receiving an angiotensin-converting enzyme (ACE) inhibitor prompts an alert. The alert
has far more meaning if the context of the alert notes the
patient has a serum potassium level which is above the therapeutic range. If the serum potassium level is within the normal range or below the normal laboratory range, the alert
should not generate at the time of CPOE.
If an appropriate and reliable alert workflow were established, much of the need to address alerts and medication
information related to medication-related problems can be
accomplished by pharmacists. As discussed above, much
effort has been placed on improving drug alerts, their specificity and information provided with the alerts, but the same
effort has not been directed toward how pharmacists can
assist with drug alerts. Pharmacists can support alert management based on the clinical condition of the patient and when
new data become available. This workflow can have a profound impact on the number of alerts presented to the
1

Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm
Beach, FL, USA
Corresponding Author:
John A. Dougherty, Lloyd L. Gregory School of Pharmacy, Palm Beach
Atlantic University, 901 S. Flagler Drive, West Palm Beach, FL 33401, USA.
Email: john_dougherty@pba.edu

https://us.sagepub.com/en-us/journals-permissions https://www.doi.org/10.1177/0018578718791556 http://journals.sagepub.com/home/hpx

Hospital Pharmacy - June 2019

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2019