Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' Computerized Patient Record System

Abstract

Objective: To measure critical order check override rates in VA Puget Sound Health Care System's computerized practitioner order entry (CPOE) system and to compare 2006 results to a similar 2001 study.

Design: Analysis of ordering and order check data gathered by a post-hoc logging program. Use of Pearson's chi-square contingency table test comparing results from this study and the earlier study.

Measurements: Factors measured were total number of orders, frequency of order check types, frequency of order check overrides by order check type and comparisons of these results with previous results.

Results: A total of 37,040 orders generated 908 (2.5%) critical order checks. Drug-drug critical alert override rate was 74/85 (87%) in 2006 compared to 95/108 (88%) in 2001 (X ( 2 )=0.04, df=1, p=0.85). The drug-allergy override rate was 341/420 (81%) compared to 72/105 (69%) in 2001 (X ( 2 )=7.97, df=1, p=0.005). In 2001, 0.25% (105/42,621) orders generated a drug-allergy order check compared to 1.13% (420/37,040) in 2006 (X ( 2 )=238.45, df=1, p<0.0001).

Conclusion: Override rates of critical drug-drug and drug-allergy order checks remain high at VA Puget Sound Health Care System including significant increases in drug-allergy order checks. We recommend that monitoring override rates be regular practice in clinical computing systems and conclude that qualitative research should be carried out to better understand how physicians interact with decision support at the point of ordering.

Figure 1

Medication selection in the CPRS ordering interface. The practitioner clicks the circled “Accept Order” button after selecting items for the order triggering the order checking functionality and the “Order Checking” window shown.

Figure 2

Order signing in the CPRS ordering interface. Practitioners must enter a free text justification for overriding orders with critical, high severity (Severity 1) order checks. Attempting to sign the order triggers order checking functionality. The order checks for this order are shown in the “Order Checks” window.