Development and application of desiderata for automated clinical ordering.

Abstract

Introduction: Automation of clinical orders in electronic health records (EHRs) has the potential to reduce clinician burden and enhance patient safety. However, determining which orders are appropriate for automation requires a structured framework to ensure clinical validity, transparency, and safety.

Objective: To develop and validate a framework of desiderata for assessing the appropriateness of automating clinical orders in EHRs and to demonstrate its operational value in a live health system dataset.

Materials and methods: The study comprised 4 phases to move from concept generation to real-world demonstration. First, we conducted focus group analyses using ground theory to identify themes and developed desiderata informed by these themes and existing literature. We validated the desiderata by surveying clinicians at a single institution, presenting 10 use cases to and assessing perceived appropriateness, cognitive support, and patient safety using a 4-point Likert scale. Survey results were compared to a priori appropriateness designations using t-tests. To evaluate operational impact, we analyzed one year of order-based alerts and orders (1.4 million firings alert and 44.1 million orders, respectively) using filtering rules and association rule mining to identify candidate orders for automation and their impact.

Results: We identified 8 desiderata for automated order appropriateness: logical consistency, data provenance, order transparency, context permanence, monitoring plans, trigger consistency, care team empowerment, and system accountability. Use cases deemed appropriate based on these criteria received significantly higher scores for appropriateness (3.13 ± 0.84 vs 2.30 ± 0.99), cognitive support (3.08 ± 0.82 vs 2.25 ± 0.94), and patient safety (3.08 ± 0.86 vs 2.21 ± 0.98) (all P < .001) compared to those considered inappropriate. Operational analysis revealed an alert firing 19 109 times annually, with a 96% signed order rate, where automation could save an estimated 26.5 provider hours per year. Additionally, an association rule with 16 628 occurrences (68.4% confidence) suggested automation could save 15.8 hours annually and yield 8000 additional appropriate orders.

Discussion: The desiderata align with clinician perceptions and provide a structured approach for evaluating automated orders. Our findings highlight the potential for automation of certain clinical orders to improve cognitive support while maintaining patient safety.

Conclusion: Healthcare systems should use these desiderata, coupled with data mining techniques, to systematically identify and govern appropriate automated orders. Further research is needed to validate operational scalability.