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'Targeted' EHR use can reduce unnecessary tests
Focus on specific age groups with specific condition
A recent study conducted by Kaiser Permanente's Institute for Health Research has shown that unnecessary medical tests can be reduced when targeted alerts are used in electronic health record (EHR) systems. The study was published in The American Journal of Managed Care.1
The researchers conducted a randomized trial of 223,877 visits by patients ages 65 and older, and 564,264 visits by patients younger than age 65. In this particular study, they focused on the "D-dimer" blood test, which is used to diagnose deep-vein thrombosis and pulmonary embolism. (Previous studies had indicated a low rate of accuracy for this test.) When outpatient physicians ordered the test for elderly patients, Kaiser's EHR system sent an alert telling physicians that the test was inaccurate for elderly patients, and suggested conducting a radiology test. The percentage of physicians ordering the D-dimer tests fell by almost 70%.
Ted Palen, PhD, MD, MSPH, clinician researcher at the Institute for Health Research of Colorado Permanente Medical in Denver and lead author of the study, says the findings also would apply to the hospital setting. "While these patients came to the outpatient setting, the use of EHR is proliferating in hospitals, and there the use of alerts or advisories should also be used judiciously," he asserts. "Targeting," he explains, helps providers use the alert for specific age groups of patients for a specific condition, "so you deliver decision support advice at the point of care."
An additional take-home message, says Palen, is that "we not only targeted the alert to a specific test and a specific population, but we also included advisory information as to what you should do besides ordering this test."
How good is your system?
How do quality managers and providers determine which patient populations and which tests/conditions to target? "This is an important question in the sense that as these quality managers start investigating the capabilities of their EHRs and IT, they also have to start investigating whether or not the system has the capabilities of making the alert specific, or whether these are generalized alerts," Palen cautions. "If they are not specific for certain patients or conditions or parameters, you end up with a problem that's been written about a lot alert fatigue. Things will fire off whether they pertain to your particular case or not like all the pop-ups you see when you're surfing the net.
"If the pop-ups are generalized, a lot of times you get frustrated and ignore them," Palen continues. "The same thing can happen in EHRs. If there is not intelligent use of your alerts, providers may start to ignore the important ones."
So, your first step, says Palen, is to consult with your IT people to see if your system can do what you want it to. "If it can't, you need a different system, or you need to think about when you want to turn on certain alerts," he says.
If your system can provide targeted alerts, how do you choose your targets? "You have to go back to the adages of preventive medicine," Palen advises. "If it's a potentially lethal or very serious condition, obviously you want to target those. If there's something seen as a common issue arising in your system [where testing is] being chronically misused or misappropriated or a lot of people are doing something that is not optimal to quality delivery of care, you might be able to use alerts to help reduce over-utilization of inappropriate care."
Choose the right people
Besides the quality manager, who should be involved in the targeting process? "A lot of times it is thought to be a physician, but the physician is not always in the best point in the work flow of patient care through the system," says Palen. "What the quality manager has to look at is the work flow, and where through the multiple contact points is the most appropriate place for an alert to fire. It could be at check-in, it could be a nursing contact, or even ancillary staff contact like the lab, or it could be the physician."
Such an approach, Palen asserts, "can improve our delivery of care. It can improve our adherence to known, proved, evidence-based medicine techniques, and in the long run, hopefully improve patient outcomes and quality of care."
[For additional information, contact: Ted Palen, PhD, MD, MSPH, Clinician Researcher, Institute for Health Research of Colorado Permanente Medical, Denver. Phone: (303) 614-1215.]