Association Between Real-Time Alerts in Electronic Prescribing Systems and Potentially Inappropriate Prescribing Among Older Adults

Zahra Aminzade, Reza Mehrizi, Saba Mirian, Iravan Masoudi Asl, Mohamad Mehdi Nasehi, Mohammad Effatpanah, Mohammad Gholamnezhad, Nezam Armand, Hossein Karami, Leila Ghamkhar
Journal of the American Geriatrics Society · 2026 · vol. 74(5) , pp. 1285–1293 · doi:10.1111/jgs.70379 · PMID:41944196
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This study assessed whether a national, real-time, non-interruptive electronic alert system integrated into outpatient e-prescribing in Iran was associated with changes in potentially inappropriate medication (PIM) prescribing among adults aged 65 years and older. Using 230,719 electronic outpatient prescriptions, the authors compared May–August 2023 (pre-alert) with May–August 2024 (post-alert), defining PIMs as prescriptions containing at least one medication listed on the 2023 AGS Beers Criteria and stratifying results by age, sex, physician specialty, and drug class. After alert implementation, the greatest relative reductions in PIM-containing prescriptions were seen among ages 85–100 (−9.85%) and women (−7.89%), with significant declines across several medication categories including gastrointestinal drugs and pain medications, as well as specific drugs such as ketorolac and nortriptyline. The paper does not present a randomized design and reports only an association between alert rollout and prescribing changes. The paper does not explicitly discuss endometriosis or adenomyosis; it was included in the corpus via a keyword match in the upstream search index.

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Abstract

BACKGROUND: Older adults are highly susceptible to adverse effects from potentially inappropriate medications (PIMs). Real-time clinical decision support systems (CDSS) may reduce unsafe prescribing; yet evidence from low- and middle-income countries is limited. This study assessed the association between a national electronic alert system and outpatient PIM prescribing in Iran. METHODS: We examined 230,719 electronic outpatient prescriptions for adults aged 65 years and older. Prescriptions from May to August 2023 (pre-alert) were compared with those from May to August 2024 (post-alert). The primary outcome was the proportion of prescriptions containing ≥ 1 PIM, defined using the 2023 AGS Beers Criteria. Subgroup analyses stratified outcomes by age, sex, physician specialty, and drug class. RESULTS: Across 2023-2024, 230,719 prescriptions were recorded. After alert implementation, the greatest reductions occurred in adults aged 85-100 years (-9.85%) and in women (-7.89%). Significant declines were also observed in gastrointestinal drugs (-14.14%), pain medications (-11.99%), central nervous system agents (-3.03%), antihistamines (-4.60%), and in specific medications including ketorolac, clidinium-chlordiazepoxide, methocarbamol, nortriptyline, chlorpheniramine, indomethacin, and dicyclomine. By specialty, the largest reductions were seen in Surgery (-18.13%), Internal Medicine (-12.56%), and General Practice (-6.99%). CONCLUSIONS: A national, real-time, non-interruptive alert system was associated with meaningful reductions in PIM prescribing among older adults. Scalable CDSS tools may enhance medication safety in resource-constrained settings.
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Abstract

Background Older adults are highly susceptible to adverse effects from potentially inappropriate medications (PIMs). Real-time clinical decision support systems (CDSS) may reduce unsafe prescribing; yet evidence from low- and middle-income countries is limited. This study assessed the association between a national electronic alert system and outpatient PIM prescribing in Iran.

Methods

We examined 230,719 electronic outpatient prescriptions for adults aged 65 years and older. Prescriptions from May to August 2023 (pre-alert) were compared with those from May to August 2024 (post-alert). The primary outcome was the proportion of prescriptions containing ≥ 1 PIM, defined using the 2023 AGS Beers Criteria. Subgroup analyses stratified outcomes by age, sex, physician specialty, and drug class.

Results

Across 2023–2024, 230,719 prescriptions were recorded. After alert implementation, the greatest reductions occurred in adults aged 85–100 years (−9.85%) and in women (−7.89%). Significant declines were also observed in gastrointestinal drugs (−14.14%), pain medications (−11.99%), central nervous system agents (−3.03%), antihistamines (−4.60%), and in specific medications including ketorolac, clidinium-chlordiazepoxide, methocarbamol, nortriptyline, chlorpheniramine, indomethacin, and dicyclomine. By specialty, the largest reductions were seen in Surgery (−18.13%), Internal Medicine (−12.56%), and General Practice (−6.99%).

Conclusions

A national, real-time, non-interruptive alert system was associated with meaningful reductions in PIM prescribing among older adults. Scalable CDSS tools may enhance medication safety in resource-constrained settings. Summary - Key points - ○ A national real-time alert system integrated into electronic prescriptions significantly reduced potentially inappropriate medication (PIM) use in older adults. - ○ Implementing a clinical decision support system (CDSS) across a national platform proved scalable, low-cost, and impactful, even in a resource-limited setting. - ○ The association was largest among the oldest age group (85+), who experienced the greatest relative decline in PIM prescriptions. - ○ The system used soft, non-blocking alerts (nudges) based on the 2023 AGS Beers Criteria, which aligned with clinician workflow and minimized alert fatigue. - ○ This study offers rare, population-level data from a low- and middle-income country, demonstrating that digital tools can enhance patient safety globally. - ○ Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement All data from this study are included in this published article and its Supporting Information.

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MeSH descriptors

Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Decision Support Systems, Clinical Electronic Prescribing Electronic Prescribing Electronic Prescribing Electronic Prescribing Electronic Prescribing Electronic Prescribing Electronic Prescribing Electronic Prescribing

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SciLite annotations

organisms 1
noordeloos 2009062
chemicals 8
ketorolac clidinium chlordiazepoxide methocarbamol nortriptyline levochlorpheniramine nimesulide dicyclomine

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