Implementing prescriber-pharmacist collaboration to improve evidence-based medication prescribing using asynchronous,...

Inappropriate prescribing of Direct Oral Anticoagulants (DOACs) is a leading cause of adverse outcomes. Electronic health record (EHR)-based notification strategies may support evidence-based prescribing and reduce adverse events. Engaging clinical pharmacists (vs. prescribers) through EHR-based notifications that review inappropriate DOAC prescribing may be an effective strategy for ensuring evidence-based medication prescribing.

We conducted a pragmatic, single-center, parallel-group, randomized implementation trial using notifications (asynchronous EHR-based notifications) to prompt correction of inappropriate DOAC prescriptions that had arisen after the initial prescription of the DOAC (e.g., due to changes in patient condition). Notifications were sent for adult ambulatory patients with DOAC prescriptions not adhering to the package insert instructions or having significant drug-drug interactions. Notifications directed either to the prescribing clinician or to the clinical anticoagulation pharmacist, randomized at the prescriber level. The primary outcome was the proportion of notifications adopting any prescription change within 7 days. Moderator analyses examined the influence of prescriber, patient, and prescription characteristics.

From May 2023 to December 2024, 388 notifications for potentially inappropriate DOAC prescriptions among 183 prescribers were analyzed. Overall, 23.2% of notifications led to a prescription change within 7 days, 26% among prescriber-directed and 21% among pharmacist-directed notifications (p = 0.36). Nearly all (97.8%) changes made were clinically appropriate changes aligned with notification recommendations. Subgroup and moderator analyses showed that pharmacists made more changes than prescribers when errors were further from dosing cutoffs and managed cases with polypharmacy or complex thresholds more consistently. Clinical pharmacists spent an average of 7.9 min per notification.

Prescribers and clinical pharmacists both responded similarly and consistently to correct inappropriate DOAC prescriptions in response to EHR asynchronous notifications. While pharmacists did not outperform prescribers overall, they demonstrated more nuanced application of medication prescribing guidelines in complex cases. Engaging clinical pharmacists directly may be an efficient implementation strategy for addressing medication prescribing issues. Optimal EHR-based implementation strategies for complex prescribing guidelines should consider both workflow integration and recipient expertise.

(ClinicalTrials.gov: NCT05351749).