(Management Case Study) Development and Implementation of a Drug Interaction Alert for a Multi-Site Anticoagulation Service

Purpose: It is not uncommon for drug interactions to result in critically high international normalized ratio (INR) values in the ambulatory setting. Often patients are left to coordinate communication about an interaction with their anticoagulation provider. This case describes the creation and implementation of an automated alert system to notify the appropriate anticoagulation clinic when an interacting medication was prescribed to facilitate earlier management of the interaction.

Methods: The electronic health record team was engaged to facilitate development of the alert system. Members of the anticoagulation clinic leadership team for the health system provided clinical guidance on which drug interactions had clinical significance and should generate an alert. This list was carefully curated through three separate reviews to identify those highest impact medications, reduce alert fatigue, and promote optimal utilization of pharmacist resources. The electronic health record team took this list of interacting medications and developed a trigger for the alert based on prescribing of the interacting medication and specific data points that identified the patient as an anticoagulation clinic patient. Each alert that was generated was automatically routed to the specific anticoagulation clinic where the patient was attributed.

Results: This alert system was implemented at one location as a pilot then expanded to nine hospital-based anticoagulation clinics that care for approximately 3600 anticoagulation patients across the region. The alert system encompassed patients being managed on either warfarin or direct oral anticoagulants. After implementation, there were unexpected alerts that were received. At that time, the drug interaction list was reviewed and further refined. The alert system also allows the number of triggered alerts to be reported on. Standard documentation practices make retrieval of management of drug interactions easier to obtain or retrieve.

Conclusion: This alert system has been well-received across the system anticoagulation clinics and was implemented with minimal adjustments needed. Future directions include exploring this same functionality to trigger alerts when procedures are scheduled to facilitate optimal perioperative anticoagulation management.