Integrated System of Automated Alerts Needed

OB/GYN News, Dec 15, 1999 by Heather Lindsay

CHICAGO -- Automated alerts may be one solution for keeping up with drug indications, contraindications, dosages, and side effects, Dr. Gordon D. Schiff said at the Midwestern regional meeting of the American Federation for Medical Research.

Over 120 new drugs have been approved by the Food and Drug Administration in the past 3 years, noted Dr. Schiff, director of Clinical Quality Research at Cook County Hospital in Chicago. "There's no way doctors can remember all this stuff."

Dr. Schiff administered a test of well-known drug side effects and interactions to 43 PG2 and PG3 residents. Despite generous grading," the average score was 40%. Two-thirds of the questions were answered incorrectly by more than half the residents. More than half the questions involving serious or fatal reactions to drugs were answered incorrectly.

Such data challenge the assumption that physicians can recall important drug information from memory when presented with a case. In order to prescribe with confidence, physicians need automated alerts that will keep track of drug updates for them, Dr. Schiff said in an interview.

He briefly outlined his ideal system-a fully integrated network that would be linked to pharmacies; medical labs; demographic records; and patient information such as allergies, concurrent medical conditions, renal capacity and weight.

Every time a new report came out linking a drug with a certain side effect, it would be incorporated into the system's database. Automated alerts would report not only drug contraindications but local patterns of antibiotic resistance, flu strains, and more. The system could perform dosing calculations and help make risk-benefit decisions in borderline cases.

So far, the system is just "a fantasy" Dr. Schiff admitted.

None of the many packages that are currently on the market has overcome the challenge of honing software to eliminate the clutter, he said. Even one of his favorites, Medicalogic's Logician, lacks the proper balance of sensitivity and specificity-in short, too many annoying alerts and not enough useful ones. As a result, sooner or later physicians start ignoring the alerts or trying to circumvent them.

The hot spots of research and development out of which he thinks a good design might actually come include the Regenstrief Institute in Indianapolis, Brigham and Women's Hospital in Boston, and the Latter Day Saints Hospital in Salt Lake City. These institutions have built their own electronic information systems over the past 20 years and are working on refinements.

Someday, different systems might even be screened in randomized clinical trials, like drug therapies, to judge the benefit they offer patients.

The continuous updates that Dr. Schiff envisions are another hurdle. A task as enormous as deciding which updates should be incorporated into the system, and the task of adding them in a timely manner, should not fall on the shoulders of individual doctors, nor should the company that manufactures the software be making medical decisions, he said.

Rather, the updating is "the responsibility of the medical profession as a whole." He described publicly accountable production of guidelines, with task forces run either by the government or by independent contractors staffed by physicians-a system that might well take years to put in place.

Throughout the process, we must keep in mind that an automated alert system is best used to improve the quality of care for patients, Dr. Scuff warned. "Using it to spy on doctors to see how well they're prescribing, or to cut drug costs, is a prostitution of a very beautiful tool," he stated.