Non-Interruptive CDS EHR Integration Boosts ED Naloxone Prescribing

A study published in JAMIA found that clinical decision support (CDS) EHR integration helped increase prescribing of take-home naloxone (THN) in the ED, a recommended but under-utilized practice for opioid-related overdose (OD).

Researchers developed the Opioid Overdose Decision Support Tool (OODST). This non-interruptive intervention combined an OD documentation template with a reminder to use the template automatically inserted into a provider's note by decision rules.

In 736 OD cases (247 pre-reminder and 489 post-reminder), clinicians used the documentation template in 0.0 percent and 21.3 percent, respectively. Clinician use of the documentation template led to twice the rate of prescribing of THN.

The researchers used a trigger with relatively high sensitivity (78.5 percent) and specificity (99.8 percent) to insert a reminder into the note.

"There was no interruption of the time-sensitive ordering workflow during OS care, but instead, the prompt occurred during the documentation process," the study authors noted.

"Our experience showed that some kind of reminder was necessary to ensure that emergency clinicians use the documentation template," they said. "The impact of the OODST reminder and template was relatively similar in the presence and absence of accompanying clinician training on the tools, and usability and satisfaction data were also similar."

According to the researchers, the mechanism for the CDS intervention's effect warrants further study.

"The OODST ties the automated generation of documentation for the visit and order of a discharge naloxone kit together," they wrote. "Given that the ordering of immediate care for a patient and the documentation of that care typically occur at separate times in the ED, it may be that reminders for longer-term care of the patient are better accepted during documentation activities."

CDS at documentation time may result in clinicians failing to receive a reminder for some patients if they complete EHR documentation after patient discharge.

"Even with this limitation, documentation time might be a preferred time for decision support for providers for some applications," the authors suggested.

The researchers noted that non-interruptive alerts might be more effective for CDS in certain care settings.

"During the process of care for patients in demanding environments, such as the ED, physicians may be operating in a rapid pattern-matching mode, based on the so-called 'system-1' reasoning ('thinking fast')," the authors wrote.

"An interruptive alert during system-1 reasoning is truly a distraction from the specific care activity that the provider is trying to complete," the researchers emphasized.

At the time of documentation, a clinician may be more likely to use "system-2 reasoning processes" (ie, thinking "slow") and, as a result, may be more open to reminders to make care more complete.