Clinical Decision Support and Malpractice Risk

Clinical decision support (CDS) refers to electronic technology used to enhance clinical decision making. An important feature of CDS in computerized physician order entry (CPOE) involves automated warnings issued whenever potential drug interactions or other contraindications arise. In practice, many CDS systems have often been overinclusive in the warnings they generate, such that physician "alert fatigue" may undermine the utility the systems offer. One paradoxical result of overly abundant warnings may be to exacerbate malpractice risk for physicians who either ignore or turn off CDS alerts. Technology vendors, on the other hand, may nevertheless resist any efforts to curtail CDS alerting, because of their own fears regarding tort liability. Taken together, the results may be perverse: namely, the proliferation of CDS systems that providers are reluctant to use, and that do not achieve the safety benefits that those systems are capable of offering. From a policy perspective, the basic challenge is to ensure that liability concerns do not derail the clinical value of new CDS technology. The first step toward ameliorating the problem is to develop an expert-consensus list of which drug-drug interactions (DDI) should be reported by CDS systems. The second step involves endorsement of the consensus DDI list by relevant professional societies and certification or endorsement of related CDS technologies by regulators like the Office of the National Coordinator for Health Information Technology, the Centers for Medicare & Medicaid Services, and the Joint Commission. Legislation to create a liability safe harbor for physicians who use CDS is another option. Whether a legislative exemption from tort liability would actually be prudent or practical remains to be seen. What does seem clear, however, is that CDS represents a situation in which malpractice and products liability can lead to a perverse equilibrium: One in which the law has a detrimental effect on technology, and in which patients, physicians, and institutions are all made worse off as a result.