- During EHR implementation and optimization projects, hospitals and health systems have the option of integrating a variety of different types of EHR alerts into clinical workflows and clinical decision support functionality.
While alerts can offer providers useful updates and reminders, EHR notification overload has been a problem in the past for clinicians already struggling with high cognitive workloads. Low-value EHR alerts can unnecessarily detract from patient care and contribute to physician burnout.
However, effective EHR alerts such as admission, discharge, and transfer (ADT) notifications or screening reminders can help to streamline clinical efficiency and care coordination by quickly communicating critical patient information to providers through the EHR interface.
The following are three ways EHR alerts can be used to effectively improve patient health outcomes and streamline clinical operations:
Transitions of Care
Provider communication during transitions of care is imperative to ensuring care teams across the continuum have the information necessary to make well-informed clinical decisions as patients are admitted, transferred or discharged to different hospitals or facilities.
ADT notifications and alerts can help to keep different care teams updated during these times to improve care coordination and reduce hospital readmissions.
In a 2017 editorial, Utah Health Information Network (UHIN) President and CEO Teresa Rivera related the benefits of using ADT notifications to improve care coordination after ten years of experience with the alerts.
Integrating ADT notifications into EHR systems through a connection with a health information exchange (HIE) can streamline and expedite provider communication.
“This level of care coordination quite literally saves both lives and money,” said Rivera. “However, for it to be successful, all of Utah’s hospital systems must be willing to securely share their admission and discharge transactions with the appropriate health care community responsible for the patient’s care — including those outside their own system.”
Primary care physicians, care managers, and community hospitals that may have seen or recently admitted a patient previously can connect through an HIE to share ADT information across the care continuum and track a patient’s movement and progress.
“This secure and cost-effective method provides the patient’s entire medical team, regardless of where they work, with the important information they need to coordinate care,” wrote Rivera. “That coordination is important to reducing readmission rates, and helps health care professionals provide a better experience to patients.”
Other HIEs including the Idaho Health Data Exchange (IHDE), Nebraska Health Information Initiative (NeHII), Nevada-based HealthHIE, and others also offer network participants access to ADT capabilities.
Great Lakes Health Connect (GLHC) in Michigan also offers providers ADT notifications through its Patient Centered Data Home model.
GLHC receives information from six area HIEs in the Midwest through the Heartland Project and stores information in the Virtual Integrated Patient Record (VIPR).
Providers across the Midwest can access ADT notifications and alerts with basic demographic information and details about a patient’s status.
ADT messages are transmitted between HIE organizations in real-time and are available to any other organization or user with the ability to access VIPR. Providers that access health information must also have a treatment, payment, or operations relationship with a specific patient.
By connecting with an HIE and integrating ADT notifications into EHR systems, providers can gain access to timely information about a patient’s status during crucial transitions of care.
EHR alerts can also help to keep providers informed about a patient’s health status to yield long-term improvements in chronic care management.
Chronic Care Management
EHR-integrated alerts offering providers clinical decision support about disease management can help providers treat both high and low-risk patients dealing with a variety of chronic illnesses.
Alerts can also help providers to diagnose and start treatment for chronic diseases earlier by reminding clinicians to screen or test for different conditions.
A 2017 study about the effects of EHR alerts on screening and treatment for hepatitis C virus (HCV) infection among baby boomers found EHR alerts can streamline patient diagnoses.
After seeing evidence of low rates of HCV screening in the baby boomer population, researchers at the University of Michigan developed an EHR-based prompt in primary care clinics to encourage HCV screening and streamline care for patients diagnosed with the condition.
The alert eliminated the need for clinicians to remember to screen patients for HCV or verify prior HCV testing or diagnosis of individual patients.
Researchers compared data on 22,488 baby boomer patients six months prior to the alert’s implementation with 227,789 patients seen after the implementation.
HCV screening rates jumped from 7.6 percent to 72 percent following the implementation of the EHR system alert. The alert also enabled 100 percent of newly-diagnosed patients to gain referrals to specialty care, with 67 percent of patients receiving prescribed HCV treatment as a result of this care.
“Our EHR prompt was successful in significantly increasing overall HCV screening rates and in helping to get newly diagnosed patients connected with care and curative treatment for HCV,” the team said. “This type of EHR-based intervention represents a low cost, efficient, and effective means to improve HCV screening, diagnosis, and access to care, which ultimately can lead to mitigation of the associated morbidity and mortality of chronic hepatitis C.”
Implementing alerts or prompts into the EHR system assisted in increasing screening rates, streamlining specialty referrals, and improving chronic disease treatment and management for the population.
Clinical decision support alerts built into EHR technology can also be useful for assisting clinicians with making risk-appropriate care.
A 2018 study in the American Journal of Managed Care highlighted the effectiveness of a quality improvement program combining EHR-integrated tools and patient engagement strategies when treating patients with chronic kidney disease.
Over a one-year period, Sequist et al. observed 153 primary care physicians treating 3,947 high-risk patients and 3,744 low-risk patients with stage III chronic kidney disease across 13 ambulatory health centers at Harvard Vanguard Medical Associates in Massachusetts.
As part of the study, participating physicians received a set of EHR-integrated alerts through the practice’s Epic EHR system during office visits with recommendations for risk-appropriate chronic kidney disease care.
When treating high-risk patients, physicians received EHR alerts recommending a referral to a nephrologist if the patient had not visited the specialist in the past 12 months. Physicians also received an EHR alert recommending specific prescriptions if the patient had a diagnosis of hypertension or albuminuria and had not been prescribed the medications in the last year.
For low-risk patients, physicians received prescription recommendation alerts as well as alerts suggesting certain overdue lab tests.
Low-risk patients who had participated in the quality improvement program were about 25 percent more likely to have received urine microalbumin testing than patients not enrolled in the program.
Additionally, participating high-risk patients were over 10 percent more likely to have seen a nephrologist in the past 12 months than those not enrolled in the program.
Utilizing EHR alerts to deliver recommendations to physicians specific to a patient’s condition and level of risk can help to facilitate more accurate care delivery for improved patient health outcomes.
Alerts can also help providers cut down on unnecessary testing and reduce potential instances of patient harm.
While EHR alerts have been associated with information overload and fatigue, some hospitals and health systems have taken steps to implement alerts that help to cut down on unnecessary testing and procedures to improve patient safety, save providers time, and reduce hospital spending.
The Choosing Wisely Campaign launched by the American Board of Internal Medicine (ABIM) foundation and Consumer Reports in 2012 aimed to reduce medical test ordering by prompting providers to identify and cut back on five tests or procedures that are frequently ineffectual.
Several California hospitals — including Cedars-Sinai Medical Center in Los Angeles — took part in the initiative and attempted to cut costs and instances of patient harm through slight changes to their EHRs.
Cedars-Sinai reduced test ordering through an alert built directly into clinical workflows.
The EHR alerts notified doctors electronically when ordering tests or drugs that did not align with 18 Choosing Wisely recommendations embedded into the software. In the study, Cedars-Sinai analyzed alerts from 26,424 patient encounters between 2013 and 2016. All Choosing Widely guidelines were followed in 6 percent of those cases, or 1,591 encounters.
In groups that did not comply with Choosing Wisely guidelines, patients had a 14 percent higher rate of readmission and a 29 percent higher risk of complications.
Other California hospitals including Sharp Rees-Stealy Medical Group in San Diego and Los Angeles County-University of Southern California Medical Center also achieved positive results.
Sharp Rees-Steely cut excessive test ordering by over 10 percent, while Los Angeles County USC Medical Center eliminated needless preoperative testing before routine cataract surgery.
Implementing EHR alerts related to Choosing Wisely recommendations into clinical workflows improved efficiency and allowed patients to get into surgery an average of 6 months sooner due to reductions in preoperative testing.
Offering patients useful reminders about patient status updates, test screening, care delivery, and guideline recommendations through EHR alerts is a simple way to improve quality of care and boost patient health outcomes.