Examining clinician choice to follow-up (or not) on automated notifications of medication non-adherence by clinical decision support systems

Abstract

Background: Maintaining medication adherence can be challenging for people living with mental ill-health. Clinical decision support systems (CDSS) based on automated detection of problematic patterns in Electronic Health Records (EHRs) have the potential to enable early intervention into non-adherence events (“flags”) through suggesting evidence-based courses of action. However, extant literature shows multiple barriers—perceived lack of benefit in following up low-risk cases, veracity of data, human-centric design concerns, etc.—to clinician follow-up in real-world settings. This study examined patterns in clinician decision making behaviour related to follow-up of non-adherence prompts within a community mental health clinic. Methods: The prompts for follow-up, and the recording of clinician responses, were enabled by CDSS software (AI2). De-identified clinician notes recorded after reviewing a prompt were analysed using a thematic synthesis approach—starting with descriptions of clinician comments, then sorting into analytical themes related to design and, in parallel, a priori categories describing follow-up behaviours. Hypotheses derived from the literature about the follow-up categories’ relationships with client and medication-subtype characteristics were tested. Results: The majority of clients were Not Followed-up (n = 260; 78%; Followed-up: n = 71; 22%). The analytical themes emerging from the decision notes suggested contextual factors—the clients’ environment, their clinical relationships, and medical needs—mediated how clinicians interacted with the CDSS flags. Significant differences were found between medication subtypes and follow-up, with Anti-depressants less likely to be followed up than Anti-Psychotics and Anxiolytics (χ2 = 35.196, 44.825; p < 0.001; v = 0.389, 0.499); and between the time taken to action Followed-up0 and Not-followed up1 flags (M0 = 31.78; M1 = 45.55; U = 12,119; p < 0.001; η2 =.05). Conclusion: These analyses encourage actively incorporating the input of consumers and carers, non-EHR data streams, and better incorporation of data from parallel health systems and other clinicians into CDSS designs to encourage follow-up.