Computerized systems intended to stop doctors from prescribing dangerous drug combinations can cause potentially harmful treatment delays, new research shows.

The findings are a dramatic example of why such systems need to be evaluated in the real world before they are put into widespread use, Dr. Brian L. Strom, of the University of Pennsylvania School of Medicine in Philadelphia, told Reuters Health.

We need to study the side effects of these interventions and make sure they do more good than harm, said Strom, one of the report's authors.

Strom and his team were evaluating a computerized order-entry system that alerted doctors when they prescribed the blood-thinning drug warfarin and the antibiotic trimethoprim-sulfamethoxazole simultaneously. Giving patients both drugs at the same time ups bleeding risk.

Rather than just have a warning pop up on the computer screen that a doctor could easily override-a so-called soft alert-the researchers used a hard stop alert, which meant the doctor prescribing the drug combination could not continue the prescribing process without calling the pharmacy.

To investigate whether the system might cut down on potentially dangerous prescribing practices, the researchers randomly assigned doctors ordering the warfarin/antibiotic combination to receive a hard alert, or to get a call from the pharmacist warning them of the risks of the drug combination.

A total of 1,981 physicians and nurse practitioners participated in the study, which was published in the Archives of Internal Medicine. Among the providers given the hard-stop alert, nearly 60 percent did not proceed with prescribing the dangerous drug combination within 10 minutes of the alert, compared to 14 percent of providers in the control group.

But monitoring by the researchers showed that the computer alert system resulted in major delays of treatment for four patients, lasting up to three days. They stopped the study early due to the potential for harm to patients.

In an editorial accompanying the study, Dr. David W. Bates of Brigham and Women's Hospital in Boston notes that the delays in trimethoprim-sulfamethoxazole prescriptions were especially concerning given that this is the single best drug for treating some serious specific infections. The risk to these patients from not receiving the best treatment as quickly as possible, he added, was greater than the risks of the potentially harmful warfarin-antibiotic combo.

The delays likely occurred because providers got distracted in the middle of the prescribing process and didn't follow through with a call to the pharmacist, Strom said. Adjusting the system to make the process a bit less complicated could potentially reduce the risk of these delays.

Right now, Strom noted, many hospitals use commercial computerized physician order entry systems that include lots of alerts, not all of them clinically necessary. There are millions of different adverse drug interactions, very, very few of which have been proven to be of clinical importance, the researcher said. What happens, he added, is that prescribers see all these alerts and get alert sick.

Hard alerts like the one in the current study should be used extremely judiciously, he added, in situations where there is no alternative; for example if a doctor prescribes a pregnant women isotretinoin (Accutane), which can cause birth defects.

Computerized physician entry systems will be a major focus of the $50 billion investment in health information technology (HIT) planned by the US government, Bates notes. If the nation is to realize the desired benefits from the enormous investment in HIT, it will be critical to develop answers to many smaller questions, such as those posed in this study, and to share them widely, he adds.

Medicine Safety