Comment on: Chow et al. Implementation hurdles of an interactive, integrated, point-of-care computerised decision support system for hospital antibiotic prescription. Int J Antimicrob Agents. 2016 Feb;47(2):132-9. PMID: 26774157
By Benedikt Huttner (Infection Control Program and Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine. ESGAP EC member)
Computerized decision support systems (CDSS) integrated into the electronic health record (EHR) seem like an excellent idea for antibiotic stewardship: they are available around the clock, can easily integrate relevant clinical information and can much easier intervene before a prescription is made than antibiotic stewards. Yet almost 20 years after the publication of the landmark paper by Evans et al. in the New England Journal of Medicine describing marked increases in the appropriateness of antibiotic use associated with the implementation of a CDSS in an ICU in Salt Lake City, CDSS are far from universal even in countries with widespread availability of EHRs.(1) In addition, there have been relatively few studies since 1998 describing successful implementation of antibiotic CDSS and some studies have had outright disappointing results.
In an article jut published in the International Journal of Antimicrobial Agents Chow and colleagues describe the implementation of an antibiotic CDSS integrated into the EHR in a 1500 bed tertiary care center in Singapore. The system recommends guideline concordant treatment based on data entered by the physician (eg the indication) and data retrieved from the EHR and provides guidance on renal adaption of antimicrobials (The exact functionalities of the system are difficult to understand based on the article – eg in how far is the patient’s microbiologic data taken into account?). The CDSS had to be used for prescription of certain restricted drugs (notably piperacillin / tazobactam) and carbapenems but could be used for any antibiotic prescription. In the article the authors aim to describe their experience with the implementation of the system, describe factors associated with the “voluntary” and “involuntary” use of the system and factors associated with the acceptance of the recommendation. The also describe the results of two focus groups with prescribers about the perceived utility of the system.
The first somewhat sobering finding is that physicians often did not complete the entire CDSS procedure and that higher completion rates where only achieved once aborting became practically impossible. Only 40% of suggestions for restricted antibiotics were accepted (as to be expected the percentage was better at 89% for voluntary use of the system). In a multivariate analysis being a prescriber from internal medicine (OR 1.20, 95%CI 1.04-1.37) and using the system outside the normal working hours (OR 1.90, 95% CI 1.21-1.61) was associated with higher acceptance of the recommendations. The focus groups showed the older physicians were more skeptical about the system.
What to make of all this? First, reports like this are urgently needed so that other hospitals can learn from them. The hospital should also be congratulated for developing and implementing such a system integrated into EHR and seemingly easy to use. Yet, the study also confirms how difficult it is to implement CDSS and that prescribers nearly have to be “forced” to use it. The resistance to CDSS may partly be a generational issue as shown by the focus group results. Based on my own experience there definitely is a generational gap in the use of technology in the hospital… even when it comes to simple things like using an electronic instead of a paper-based agenda. Unfortunately the study does not report data on appropriateness of use and patient outcomes (adverse drug reactions, mortality, length of stay, resistance, costs), these would be very welcome and useful.
Overall, I am confident that CDSS for antibiotic stewardship will eventually be standard, but we may have to wait another 20 years…