How targeted EHR alerts can close practice gaps and improve patient care: insights from an expert at Yale School of Medicine

Although heart disease has long been known a leading cause of morbidity worldwide, it takes too long for evidence-based research to translate into direct patient care when it comes to pharmaceutical therapies.

During the Becker's Hospital Review 7th Annual Health IT + Digital Health + RCM Annual Meeting, in a session sponsored by Amgen, Dr. Ralph J. Riello III, PharmD, BCBS, a clinical pharmacy specialist in cardiorenal and metabolism at the Yale University School of Medicine, Clinical and Translational Research Accelerator (CTRA) (New Haven, Conn.), discussed the importance of soliciting clinical input and tailoring EHR alerts to increase adherence to recommended treatment guidelines.

Four key takeaways were:

1. It takes about 17 years for evidence to become the standard of care. "Randomized controlled trial evidence is the highest quality standard on which regulatory approval of new pharmacotherapies is dependent," Dr. Riello said. However, once evidence emerges, he said, it takes almost two decades until that evidence becomes embedded into guidelines that become the standard of care. 

2. The EHR has the potential to shrink this implementation gap and improve adherence to proven therapies, but overuse and negative perception of EHR alerts is a barrier. According to Dr. Riello, the EHR could help providers "essentially do the right thing in real time for the patient" in prescribing medications that have been proven through rigorous clinical trials to be effective. But too many existing alerts is a problem. "Frequent alerts contribute to alert fatigue," he said. "The perception is that alerts are annoying and aren't helpful.  Our research hopes to change that."

3. An EHR-based-alert trial showed an increase in prescribing recommended medications for heart failure. The PROMPT-HF (PRagmatic Trial Of Messaging to Providers about Treatment of Heart Failure) solicited front-line clinician input about alerts, displayed patient-specific clinical data and linked to SmartSet, which displayed only the guideline-directed medical therapies that a specific patient was eligible for but not currently prescribed. "This alert only fires when you're actively adjusting a patient's medication orders and is only triggered if you're missing Class 1A recommended guideline-based therapies that your patient rightfully ought to be on," Dr. Riello said.

As a result of this best practice advisory (BPA), providers were 41 percent more likely to prescribe an additional guideline-directed medical therapy class and 79 percent of alerted providers agreed the alert was effective at enabling improved prescription of guideline-directed medical therapies for heart failure. "Most alerts are ignored at least 90 percent of the time," Dr. Riello said. "In this case, providers followed our recommendations exactly as provided 25 percent of the time."

4. The PROMPT-LIPID trial used EHR-based alerts to promote intensification of evidence-based lipid-lowering therapy (LLT) in outpatients with very high-risk atherosclerotic cardiovascular disease not at lipid goals. Although the American Heart Association and the American College of Cardiology have promoted optimal LLTs for decades, only about half of secondary prevention patients are prescribed any statin and only 22.5 percent are appropriately prescribed a high-intensity statin. 

Again, a user-centered BPA was designed with front-line clinician input. The targeted EHR alert appears in real time, incorporates pertinent patient-specific laboratory data, and is linked to SmartSet for tailored LLT recommendations. Results of this trial are pending.

By using the EHR to create targeted alerts, health systems can close the gap between evidence-based guideline recommendations and real-world clinical practice for appropriate patients. "The EHR is the only provider in the entire healthcare system that sees every patient all the time," Dr. Riello said. "We need to stop treating it like a barrier and start leveraging the technology available within it to help improve care at a population health level."



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