Early insights from a qualitative evaluation of a primary care-based clinical decision support system initiative in England.
Prescribing errors in general practice are an important and expensive cause of preventable safety incidents and patient harm. Many errors can be detected using prescribing safety indicators which can be deployed in general practice electronic health records to identify patients at risk of potentially hazardous prescribing. When embedded within clinical decision support (CDS) systems, prescribing safety indicators can be presented to health professionals as alerts at the point of prescribing. It is known that computerised alerts may improve the safety of prescribing in hospitals; in contrast, their implementation and sustainable use in general practice is less well understood. We therefore aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system designed to enhance appropriate prescribing.
Participants were purposively recruited from Clinical Commissioning Groups (CCG) in the North West and East Midlands of England and from the CDS software developers. We conducted either face-to-face or by telephone, semi-structured qualitative interviews with twenty six stakeholders including general practice, CCG and software developer staff. Analysis was thematic, iterative and conducted alongside data collection with themes developed into coding frameworks.
Twenty two interviews were conducted with general practice staff (16), CCG staff (7) and software developer staff (3) Preliminary findings indicated that engagement and disengagement with the CDS was related to the perceived relevance and appropriateness of alerts. Some prescribers found the CDS system easy to use and that it successfully operated unobtrusively in the background, whereas others found the alerts excessive and intrusive. Whilst the prescribing safety alerts were perceived by some as timely and relevant, they could be ignored if cost-saving and local formulary messages became too persistent leading to alert fatigue and disengagement. Prescribers felt alerts needed to be considered within the context of individual patients and might be more difficult to act upon for patients with complex needs. As a result, the information in alerts was balanced against the prescriber’s expertise. At a strategic level the engagement and communication between the developers, CCGs and general practices was seen as important in sustaining the use of the CDS. Emphasis was placed upon the management of the profile of alerts adopted by the CCG to avoid alert fatigue and to maintain engagement from prescribers.
These findings suggest that the use and sustainability of the CDS is related to prescriber’s perceptions of the relevance of alerts. At a strategic level such relevance might be achieved by careful profile management of the suite of alerts in the system. Within general practices prescribers balanced out what they considered relevant and important in the prescribing alerts against their own judgement, experience and expertise and the more holistic needs of the patient.