Implementation of DDInteract: A Shared-decision Making Tool for Anticoagulant Drug-Drug INTERACTions

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Project Summary: Both warfarin and direct-acting anti-coagulants (DOACs, i.e. apixaban, dabigatran, edoxaban, and rivaroxaban) are widely used to prevent thrombosis due to atrial fibrillation and other clotting disorders. Individuals receiving anticoagulants often have multiple comorbidities requiring other medications, and exposure to multiple therapies increases the risk of bleeding due to drug-drug interactions (DDIs). Current electronic health records (EHR) systems can provide warnings (i.e. alerts) about potential interactions, but these warnings are text-based, are non-specific beyond stating the interaction is “major” or “contraindicated”; and lack any medication or patient attributes that affect the likelihood of harm. Our team has developed and tested a novel share decision making (SDM) tool called DDInteract, designed to reduce exposure to anticoagulant DDIs. This tool is interoperable within existing EHR systems. Our project uses a practical, implementation science-based approach to promote the sustainable uptake of DDInteract to reduce exposure to clinically important anticoagulant DDIs. Through an implementation science framework, we will enable prescribers and patients to better understand the risk/benefit calculus so they can work together to minimize the risk of harm. Our approach is preferred over standalone web-based SDM tools because 1) DDInteract can be seamlessly launched within the EHR without having to open and authenticate against a separate application; 2) it automatically pulls relevant data (e.g., age, history of bleeding, other medications) from the patient’s record to calculate a patient-specific risk; 3) it writes medication orders back to the EHR; and 4) it automatically produces documentation for clinical notes and tailored patient instructions explaining the risk and shared decisions made during the visit. In essence, this tool is a scalable out-of-the-box solution to the issue of anticoagulant DDIs. The central hypothesis of this project seeks to evaluate whether DDInteract affects exposure to potential DDIs and risk for bleeding among patients receiving an anticoagulant from before to after implementation of DDInteract compared to providers from usual care sites. We will accomplish our objectives and test our hypothesis by pursuing the following aims: Specific Aim 1: Examine contextual factors and define relevant implementation strategies to facilitate integration of DDInteract within 3 University-based healthcare systems; Specific Aim 2: Evaluate DDInteract in production/real-world situations to identify barriers and facilitators to adoption and use of DDInteract and develop solutions to overcome those barriers; and Specific Aim 3: Conduct a cluster randomized, multi-system trial to evaluate the effectiveness of DDInteract to mitigate exposure to drug interactions involving oral anticoagulants. This project will greatly improve SDM for DDIs by implementing this novel tool (DDInteract) in the participating clinics.