A 'prompt' solution: How EHR alerts may help bridge the evidence-implementation gap in clinical care

It takes an average of 17 years for scientific evidence to reach clinical practice. While cultivating evidence to improve care guidelines is paramount, the healthcare industry is recognizing the value in bridging the implementation gap between evidence-based guidelines and routine clinical practices.

During Becker's Health IT + Digital Health + RCM Meeting, in a session sponsored by Amgen, clinical pharmacy specialist Ralph J. Riello III, PharmD of Yale University School of Medicine, discussed the utility of EHR alerts in bridging this gap.

Lack of guideline adherence is one of the main causes of care gaps

The time lag between new clinical guidelines and their integration into routine clinical practice can have critical consequences for patients. For example, a recent retrospective cohort study of pharmacy and medical claims data in the U.S. showed that only about 50% of patients with atherosclerotic cardiovascular disease, such as those with a history of myocardial infarction, are prescribed any statin therapy, while only 22.5% are actually prescribed a high-intensity statin.

"That implementation gap is a disservice to our patients when therapies are available but don't reach patients in a timely manner," Dr. Riello said. "How can we condense that timeframe and disseminate such therapies sooner to help improve health outcomes?"

With that question in mind, a cardiology group at Yale University School of Medicine, including Dr. Riello, explored whether EHR alerts could help guide prescriber behavior toward the practice of evidence-based medicine and launched the PRagmatic Trial Of Messaging to Providers About Treatment of Heart Failure (PROMPT-HF) clinical trial.

The PROMPT-HF trial showed the efficacy of EHR alerts in improving guideline adherence

The initiative was an EHR-embedded trial designed to examine the efficacy of an EHR-based alert system that informs front-line physicians about what evidence-based medications they can prescribe for patients with heart failure with reduced ejection fraction (HFrEF), compared to usual care that does not incorporate such alerts. It cluster-randomized 100 internal medicine and cardiology providers, who in turn recruited 1,310 patients and split them between EHR alert exposure and usual care.

The EHR alerts, referred to as best practice alerts or BPAs, displayed patient-specific clinical data, currently prescribed heart failure medications and indicated but omitted heart failure therapies. To reduce workflow interruption and alert fatigue, they were designed to pop up only during face-to-face clinical encounters when physicians were reviewing patients' current treatment plans. Based on feedback from cardiologists, Dr. Riello said it was "a great time in the clinical workflow to coach or prompt clinicians to make the right decisions for patients at the point of care."

The results of the trial showed that prescribers who viewed the EHR alerts were 41% more likely to prescribe an additional guideline-directed medical therapy class prescription. In the PROMPT-HF trial, nearly 80% of the providers receiving an alert agreed or strongly agreed that it was effective at enabling improved prescription of GDMT for patients with HFrEF. Of these providers, 25% accepted the recommendation as the prompt suggested.

In focus groups with participating physicians aimed at eliciting feedback about the alerts, one practitioner said the timing of the alerts, which appear only when the provider is looking at the patient's medication chart, made them much more inclined to agree with the recommended therapy.

A second trial, called PROMPT-LIPID, confirmed the effectiveness of EHR alerts for secondary prevention of atherosclerotic cardiovascular disease patients, where prescribing of high-intensity statins and other evidence-based lipid lowering therapy is recommended. Unfortunately, use of these agents to achieve recommended LDL-C levels are often neglected in real-world practice. The PROMPT-LIPID alert, however, increased the likelihood for prescribers to intensify lipid-lowering therapy by 42% compared to usual care. Moreover, prescribers who positively engaged with the lipid BPA, rather than dismissing the alert, were more than twice as likely to intensify lipid-lowering therapy.

Dr. Riello said that while current research around EHR-based alerts is focused in the cardiorenal and metabolic space, there is no reason why this approach cannot be expanded to other diseases with significant care gaps, such as osteoporosis, musculoskeletal diseases, pain management and other chronic diseases.

IT departments can be a crucial ally in implementing an EHR alerts system

For healthcare organizations interested in implementing an EHR-based alerts system like Yale's, this can be approached through an investigational pathway linked to research funding, a grant or other startup funding. That helps ensure the organization can properly compensate the team members designing and implementing the system, as well as permit enough protected time internally for them to do it right. (In the case of Dr. Riello's group, the program was developed through research funding provided by Amgen.)

However, for institutions that may not have funding available to design, test, pilot and deploy such systems from scratch, the IT department can be a critical partner. IT departments may have a long list of support tickets to attend to, and submitting a request for support with deploying an EHR alerts system may not take priority over other requests. Still, making a well-articulated business case requesting IT support to scale such interventions enterprise wide can help move things along.

“In my experience, through an investigational pathway, you catapult to the top of the list of pending Epic or Cerner tickets for quality improvement," Dr. Riello said in response to a question from a session attendee whose organization had a cardiology EHR alerts program that was well-received internally, and that the department of vascular surgery wanted to replicate but did not know how to go about it. "Without such a pathway, though, and unless you know somebody in IT, it's hard to jump that list. It takes a village to do this stuff."


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