Impact of Electronic Health Record Interface Design on Unsafe Prescribing of Ciclosporin, Tacrolimus, and Diltiazem: Cohort Study in English National Health Service Primary Care

Background: In England, national safety guidance recommends that
ciclosporin, tacrolimus, and diltiazem are prescribed by brand name
due to their narrow therapeutic windows and, in the case of
tacrolimus, to reduce the chance of organ transplantation
rejection. Various small studies have shown that changes to
electronic health record (EHR) system interfaces can affect
prescribing choices. Objective: Our objectives were to assess
variation by EHR systems in breach of safety guidance around
prescribing of ciclosporin, tacrolimus, and diltiazem, and to
conduct user-interface research into the causes of such breaches.
Methods: We carried out a retrospective cohort study using
prescribing data in English primary care. Participants were English
general practices and their respective EHR systems. The main
outcome measures were (1) the variation in ratio of safety breaches
to adherent prescribing in all practices and (2) the description of
observations of EHR system usage. Results: A total of 2,575,411
prescriptions were issued in 2018 for ciclosporin, tacrolimus, and
diltiazem (over 60 mg); of these, 316,119 prescriptions breached
NHS guidance (12.27%). Breaches were most common among users of the
EMIS EHR system (breaches in 18.81% of ciclosporin and tacrolimus
prescriptions and in 17.99% of diltiazem prescriptions), but
breaches were observed in all EHR systems. Conclusions: Design
choices in EHR systems strongly influence safe prescribing of
ciclosporin, tacrolimus, and diltiazem, and breaches are prevalent
in general practices in England. We recommend that all EHR vendors
review their systems to increase safe prescribing of these
medicines in line with national guidance. Almost all clinical
practice is now mediated through an EHR system; further
quantitative research into the effect of EHR system design on
clinical practice is long overdue.

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Impact of Electronic Health Record Interface Design on
Unsafe Prescribing of Ciclosporin, Tacrolimus, and Diltiazem:
Cohort Study in English National Health Service Primary
Care