The influence of computerized decision support on prescribing during ward-rounds: are the decision-makers targeted?

Objective: To assess whether a low level of decision support within a hospital computerized provider order entry system has an observable influence on the medication ordering process on ward-rounds and to assess prescribers' views of the decision support features. Methods: 14 specialty teams (46 doctors) were shadowed by the investigator while on their ward-rounds and 16 prescribers from these teams were interviewed. Results: Senior doctors were highly influential in prescribing decisions during ward-rounds but rarely used the computerized provider order entry system. Junior doctors entered the majority of medication orders into the system, nearly always ignored computerized alerts and never raised their occurrence with other doctors on wardrounds. Interviews with doctors revealed that some decision support features were valued but most were not perceived to be useful. Discussion and conclusion: The computerized alerts failed to target the doctors who were making the prescribing decisions on ward-rounds. Senior doctors were the decision makers, yet the junior doctors who used the system received the alerts. As a result, the alert information was generally ignored and not incorporated into the decision-making processes on ward-rounds. The greatest value of decision support in this setting may be in non-ward-round situations where senior doctors are less influential. Identifying how prescribing systems are used during different clinical activities can guide the design of decision support that effectively supports users in different situations. If confirmed, the findings reported here present a specific focus and user group for designers of medication decision support.