Abstract
BackgroundElectronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR–based clinical decision support (CDS), shedding light on whether and why CDS is effective.ObjectiveThis study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians’ (PCPs’) opening of and response to noninterruptive alerts delivered to EHR InBaskets.MethodsWe conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs’ InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients’ posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs’ follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use.ResultsWe successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation.ConclusionsEHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR–based study.
Highlights
Audit and access logs in the electronic health record (EHR) have primarily been used for security purposes [1,2,3], but recent studies [4,5,6,7] indicate that a broad range of additional research and clinical questions may be answered using this relatively untapped data source
JMIR Med Inform 2019 | vol 7 | iss. 1 | e12650 | p. 4 classified as alerts not followed by timely primary care physicians’ (PCPs) action (Figure 1)
AActions that we considered as viewing relevant patient information included opening a section of the electronic medical record or choosing one of several options on the alert that served as direct links to summaries of components of that patient’s record. bActions that we considered as not viewing relevant patient information included opening a notification related to a different patient, opening a section of a different patient’s medical record, or doing nothing further in the Electronic health record (EHR) for 5 minutes
Summary
Audit and access logs in the electronic health record (EHR) have primarily been used for security purposes [1,2,3], but recent studies [4,5,6,7] indicate that a broad range of additional research and clinical questions may be answered using this relatively untapped data source. Data from access and audit logs can be used to better understand how various forms of clinical decision support (CDS) impact physician behavior This is especially relevant for noninterruptive EHR alerts, where assessments of the effectiveness of these alerts have found mixed results [9,10,11,12]. In contrast to alerts that “pop-up” and interrupt workflow when a specific EHR action is taken, noninterruptive alerts deliver information to an EHR InBasket, requiring the receiver to open and review them This information may include warnings about out-of-range test results [9,13,14], abnormal findings on diagnostic imaging and screening [10,15,16,17], important changes in patient health [18], and safety concerns during transition of care [19]. These data can be used to better understand provider responses to EHR–based clinical decision support (CDS), shedding light on whether and why CDS is effective
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