Electronic Health Record Intervention Research Articles

Electronic alerts to improve management of heparin-induced thrombocytopenia

BackgroundHeparin-induced thrombocytopenia (HIT) is a difficult clinicopathologic diagnosis to make and to treat. Delays in identification and appropriate treatment can lead to increased morbidity and mortality. MethodsThis quality improvement initiative developed 3 electronic health record-based interventions at our 750-bed academic medical center to improve the initial management of suspected HIT between 2018 and 2021: 1. an interruptive alert to recommend discontinuation of active heparin products when signing a heparin-platelet factor 4 test (PF4) order, 2. integrated 4T score calculation in the heparin-PF4 test order, and 3. interruptive alert suggesting not to order heparin-PF4 tests when the 4T score is <4. Changes in practice were assessed over defined time periods pre and post each intervention. ResultsIntervention 1 resulted in heparin discontinuation in more patients, with 65% (191 heparin orders/293 heparin-PF4 enzyme-linked immunosorbent assay tests) of cases continuing heparin prealert and only 54% (127 heparin orders/235 heparin-PF4 enzyme-linked immunosorbent assay tests) continuing it postinterruptive alert (P = .02). Intervention 2 increased appropriate heparin-PF4 test ordering from 40.4% (110/272) preintervention to 79.1% (246/311; P < .00001), with inappropriate heparin-PF4 ordering defined as testing when 4T score was <4. Intervention 3 did not lead to reduction in heparin-PF4 testing in the control group (96 inappropriate orders/402 total orders, 24%) compared with that in the randomized alert group (56 inappropriate orders/298 total orders; 19%; P = .13). ConclusionImplementation of unique electronic health record interventions, including both diagnostic and management interventions, led to improved guideline-based, accurate care delivery with 4T score calculation and cessation of heparin for patients with suspected HIT.

Clinician Barriers to Ordering Pulmonary Function Tests for Adults with Suspected Asthma.

Primary care clinicians do not adhere to national and international guidelines recommending pulmonary function testing (PFTs) in patients with suspected asthma. Little is known about why that occurs. Our objective was to assess clinician focused barriers to ordering PFTs. An internet-based 11-item survey of primary care clinicians at a large safety-net institution was conducted between August 2021 and November 2021. This survey assessed barriers and possible electronic health record (EHR) solutions to ordering PFTs. One of the survey questions contained an open-ended question about barriers which was analyzed qualitatively. The survey response rate was 59% (117/200). The top 3 reported barriers included beliefs that testing will not change management, distance to testing site, and the physical effort it takes to complete testing. Clinicians were in favor of an EHR intervention to prompt them to order PFTs. Responses to the open-ended question also conveyed that objective testing does not change management. PFTs improve diagnostic accuracy and reduce inappropriate therapies. Of the barriers we identified, the most modifiable is to educate clinicians about how PFTs can change management. That in conjunction with an EHR prompt, which clinicians approved of, may lead to guideline congruent and improved quality in asthma care.

Making the EHR Work for You-Modifications of an Electronic Health Record System to Improve Tracking and Management of Patients Receiving Outpatient Parenteral Antibiotic Therapy.

Managing the complex needs of outpatient parenteral antibiotic therapy (OPAT) patients is challenging and time-consuming. We describe development of multimodal interventions to facilitate patient management within an Epic® (Epic Systems Corporation)-based electronic health record (EHR) platform. During 2016-2018, a multidisciplinary team created several modifications in our local EHR to improve gaps in OPAT care, including shared note templates, shared patient lists, automatically triggered notifications, and comprehensive order sets. A SmartForm was created, allowing collection of discrete, self-contained extractable data about each OPAT episode. We reviewed OPAT episodes from January 2019 through December 2022. The multimodal EHR interventions culminated in the creation of a patient report, the "OPAT Monitoring View" collating OPAT-relevant data from multiple sections of the chart onto 1 screen display. This view is accessible both within the patient chart and from multiple list-based, in-basket, and snapshot-anchored preview functions in the EHR. Implementation of the EHR bundle facilitated management of 3402 OPAT episodes from 2019 to 2022 (850 episodes/year), about 50% higher than anticipated based on 540 OPAT courses in 2016. The OPAT EHR bundle allowed efficient (<3 hours) multidisciplinary rounds for management of 130-145 patients each week, streamlining of care transitions, and increasing staff satisfaction. Bundled multimodal modifications to the local EHR increased patient care efficiency and staff satisfaction and facilitated data collection to support a large OPAT program. These modifications apply commonly available EHR functionalities to OPAT care and could be adapted to other settings with different EHR platforms.

WIC staff and healthcare professional perceptions of an EHR intervention to facilitate referrals to and improve communication and coordination with WIC: A qualitative study.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals. WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis. Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access. A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.

Standardizing Medication Reconciliation in a Pediatric Emergency Department.

Medication errors are common during transitions of care, such as discharge from the emergency department (ED) or urgent care (UC). The Joint Commission has identified medication reconciliation as a key safety practice. Our aim was to increase the percentage of patients with completed medication reconciliation at discharge from our pediatric ED and 4 UCs from 25% to 75% in 12 months. Key stakeholders included ED and UC physicians and nurses, informatics, and quality management. The baseline process for medication reconciliation was mapped and modified to create a standard process for nurses and physicians. An Ishikawa diagram was created to assess potential failures. Electronic health record interventions included adapting an inpatient workflow and using a clinical decision support tool. Educational interventions included just-in-time training, physician education via division meeting presentations, video tutorials, and physician-specific and group feedback using funnel plots. The secondary process measure was the proportion of patients discharged from the ED and UCs with completed home medication nursing review. We used statistical process control to analyze changes in measures over time. In the UCs, home medication nursing review increased from 91% to 98% and medication reconciliation increased from 35% to 82% within 4 months. In the ED, home medication nursing review increased from 2% to 83% within 8 months and medication reconciliation increased from 26% to 64% within 18 months. We successfully increased the proportion of UC and ED discharged patients with completed medication reconciliation.

A SCOPING REVIEW OF SYSTEMS-LEVEL INTERVENTIONS FOR FALL PREVENTION IN LONG-TERM CARE

Abstract Older adults residing in long-term care facilities (LTCFs) are at high risk for falls. In addition to individual resident-level interventions to prevent falls and fall-related injury (FRI), system-focused interventions are also necessary to adequately address fall prevention. Relatively little attention has been given to research involving systems-focused interventions. We aimed to synthesize studies on the effects of system-focused interventions for fall and FRI prevention in LTCFs with the goal of identifying promising strategies and gaps. We searched Medline, CINAHL, and EMBASE databases from 2017 to 2022 following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guideline. We conducted a narrative synthesis to summarize included studies. In the initial review, 301 studies were identified and underwent title and abstract screening resulting in 98 articles were retrieved for full-text review. Fifteen studies were included in data extraction. Fall prevention interventions evaluated in LTCF settings include: (1) multicomponent fall prevention programs, (2) staff education programs, (3) training in safe handling/transfers, (4) environmental adaptations, (5) electronic health record algorithms and prompts, (6) local culture change, (7) video analysis of falls to change local interventions, and (8) facility-level physical activity programs. About half of reported studies reported significant effects of system-focused interventions to reduce fall and FRI in LTCFs. Multicomponent fall prevention programs and physical activity interventions are the most effective systems-level interventions, while electronic health record interventions were the least effective. Overall, little attention has been given in the literature to evaluation of environmental adaptations at the systems level.

Clinical impacts of an integrated electronic health record-based smoking cessation intervention during hospitalisation

ObjectiveTo assess the effects of an electronic health record (EHR) intervention that prompts the clinician to prescribe nicotine replacement therapy (NRT) at hospital admission and discharge in a large integrated...

Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study

BackgroundPrescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain...

Optimizing Uptake of Multimodal Pain Management After Surgery Using the Electronic Health Record

This quality improvement study evaluates the effect of an electronic health record intervention on multimodal pain management following surgery in 2 randomized clinical trials.

Reducing Overuse of 3-Day Repeat Type and Screen Testing across an 11-Hospital Safety Net System.

According to the American Association of Blood Banks, a Type and Screen (T&S) is valid for up to three calendar days. Beyond a limited number of clinical indications such as a transfusion reaction, repeat T&S testing within 3days is not warranted. Inappropriate repeat T&S testing is a costly medical waste and can lead to patient harm. To reduce inappropriate duplicate T&S testing across a large, multihospital setting. The largest urban safety net health system in the USA, with 11 acute care hospitals. Our first intervention involved adding the time elapsed since the last T&S order into the order and the process instructions that described when a T&S was indicated. The second intervention was a best practice advisory that triggered when T&S was ordered before the expiration of an active T&S. The primary outcome measure was the number of duplicate inpatient T&S per 1000 patient days. Across all hospitals, the weekly average rate of duplicate T&S ordering decreased from 8.42 to 7.37 per 1000 patient days (12.5% reduction, p < 0.001) after the first intervention and to 4.32 per 1000 patient days (48.7% reduction, p < 0.001) after the second intervention. Using linear regression to compare pre-intervention to post-intervention 1, the level difference was - 2.46 (9.17 to 6.70, p < 0.001) and slope difference was 0.0001 (0.0282 to 0.0283, p = 1). For post-intervention 1 to post-intervention 2, the level difference was - 3.49 (8.06 to 4.58, p < 0.001) and slope difference was - 0.0428 (0.0283 to - 0.0145, p < 0.05). Our intervention successfully reduced duplicate T&S testing using a two-pronged electronic health record intervention. The success of this low effort intervention across a diverse health system provides a framework for similar interventions in various clinical settings.

Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments

BackgroundThe United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US. MeasuresThe primary outcome measure was the rates of oxycodone-acetaminophen 5–325 mg prescriptions exceeding 50 morphine milligram equivalents per day (MMED) pre- vs. post-intervention; and stratified by individual hospitals and provider type. InterventionThe defaults for dose and frequency were uniformly changed to ‘every 6 hours as needed’ and ‘1 tablet’, respectively, across 11 EDs. OutcomesThe percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p < 0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p < 0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p < 0.001). Conclusions/Lessons LearnedDefault nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.

Reducing duplicate genetic testing in inpatient and outpatient settings across a large safety-net system.

To develop a system-wide electronic health record (EHR) intervention at a large safety-net hospital system to reduce wasteful duplicate genetic testing. This project was initiated at a large urban public health care system. An EHR alert was designed to be triggered when a clinician attempted to order any of 16 specified genetic tests for which a previous result existed within the EHR system. Measurements included the proportion of completed genetic tests that were duplicates and alerts per 1,000 tests. Data were stratified by clinician type, specialty, and inpatient vs ambulatory setting. Across all settings, the rate of duplicate genetic testing decreased from 2.35% (1,050 of 44,592 tests) to 0.09% (21 of 22,323 tests) (96% relative reduction, P < .001). The alert rate per 1,000 tests was 277 for inpatient orders and 64 for ambulatory orders. Among clinician types, residents had the highest alert rate per 1,000 tests at 166 and midwives the lowest at 51 (P < .01). Among clinician specialties, internal medicine had the highest alert rate per 1,000 tests at 245 and obstetrics and gynecology the lowest at 56 (P < .01). The EHR intervention successfully reduced duplicate genetic testing by 96% across a large safety-net setting.

A multi-site trial of an electronic health integrated physical activity promotion intervention in breast and endometrial cancers survivors: MyActivity study protocol

Despite the known benefits of moderate-to-vigorous physical activity (MVPA) for breast and endometrial cancer survivors, most are insufficiently active, interventions response is heterogeneous, and MVPA programming integration into cancer care is limited. A stepped care approach, in which the least resource-intensive intervention is delivered first and additional components are added based on individual response, is one strategy to enhance uptake of physical activity programming. However, the most effective intervention augmentation strategies are unknown. In this singly randomized trial of post-treatment, inactive breast and endometrial cancer survivors (n = 323), participants receive a minimal intervention including a Fitbit linked with their clinic's patient portal and, in turn, the electronic health record (EHR) with weekly feedback delivered via the portal. MVPA progress summaries are sent to participants' oncology team via the EHR. MVPA adherence is evaluated at 4, 8, 12, 16 and 20 weeks; non-responders (those meeting ≤80% of the MVPA goal over previous 4 weeks) at each timepoint are randomized once for the remainder of the 24-week intervention to one of two “step-up” conditions: (1) online gym or (2) coaching calls, while responders continue with the minimal Fitbit+EHR intervention. The primary outcome is ActiGraph-measured MVPA at 24 and 48 weeks. Secondary outcomes include symptom burden and functional performance at 24 and 48 weeks. This trial will inform development of an effective, scalable, and tailored intervention for survivors by identifying non-responders and providing them with the intervention augmentations necessary to increase MVPA and improve health outcomes.Clinical Trials Registration # NCT04262180

Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach.

While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. A quality improvement initiative was implemented across 11 safety net hospitals in New York City. The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.

An Electronic Health Record Intervention to Limit Viral Testing of Cerebrospinal Fluid.

Meningitis and encephalitis are neurologic emergencies that require immediate management and current guidelines recommend empiric treatment with broad-spectrum antimicrobials. Cerebrospinal fluid (CSF) testing algorithms are heterogeneous and largely institution-specific, reflecting a lack of consensus on how to effectively identify CSF pathogens while conserving resources and avoiding false positives. Moreover, many lumbar punctures (LPs) performed in the inpatient setting are done for noninfectious workups, such as evaluation for leptomeningeal metastasis. As such, tailoring CSF testing to clinical context has been a focus of multiple prior reports and several healthcare systems have focused on efforts to limit low-yield diagnostic testing when a positive result is unlikely. To curb ordering viral PCRs when pre-test probability is low, some peer institutions have implemented pleocytosis criteria for virus-specific polymerase chain reaction (PCR) tests from CSF. In this report, we retrospectively analyzed the diagnostic testing of CSF from patients who had an LP while admitted to a single, large academic medical center and found that many cases of Herpes Simplex Virus (HSV) meningoencephalitis were diagnosed by non-neurologists. The rate of positive virus-specific PCR tests was very low, and tests were frequently ordered in duplicate with a multiplexed meningitis/encephalitis PCR panel (M/E panel, BioFire, Salt Lake City, UT). We designed and implemented a systems-level intervention to promote a revised stepwise testing algorithm that minimizes unnecessary tests. This intervention led to a significant reduction in the number of low-yield virus-specific PCR tests ordered without implementing a policy of cancelling virus-specific PCRs.

Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system.

Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing. This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA)that would fire after the recommended time period for reassessment had passed. The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-hreorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner). We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

Implementation of Electronic Alerts to Improve Clinician Management of Heparin Induced Thrombocytopenia

Introduction: Heparin induced thrombocytopenia (HIT) is often a difficult clinicopathologic diagnosis to make, which can result in poor patient outcomes due to delays in identification and treatment. Platelet factor 4 (PF4) antibody ELISA tests are routinely used to diagnose HIT. PF4 ELISAs have high sensitivity but low specificity; therefore, to guide appropriate ordering of PF4 tests ASH guidelines recommend calculating a 4T score to assess the pre-test probability, but this is not always done. We implemented and studied the impact of three electronic health record (EHR) based strategies to improve diagnosis and treatment of HIT at our institution. Methods: At Brigham and Women's Hospital, we created 1. an interruptive alert to recommend discontinuation of active heparin products when signing a PF4 order (Figure 1), 2. integrated 4T score calculations with PF4 test ordering, and 3. through randomization, investigation of the efficacy of an interruptive alert advising clinicians not to order the PF4 test if the 4T score was low. Pre and post implementation groups for each intervention were identified and compared. The heparin discontinuation alert went live on December 20, 2018; the pre-intervention group included patients with PF4 tests in the previous 12 months, and the post-intervention group for 12 months following. The 4T score elements were integrated into the PF4 ELISA order on August 31, 2020; the pre-intervention group included patients with PF4 tests ordered 9 months prior and the post-intervention for 9 months following. In the pre-intervention group, we performed chart review to assess whether the ordering provider documented a 4T score; if a 4T score was not documented in the EHR, it was calculated retrospectively by the research team. Groups were compared to determine the proportion of appropriate PF4 orders (4T score > 3), and the efficacy of the randomized alert recommending no PF4 ordering if the 4T score was < 4. For both alert-based interventions, Chi-squared analysis was performed to determine statistical significance between defined groups. Results: 1. Heparin discontinuation: For the heparin discontinuation alert analysis, of 781 orders for PF4 tests in the pre-heparin discontinuation alert group, 293 eligible orders were used, and of 708 orders in the post-alert group, 235 orders were included. Eligible orders were those that had heparin ordered at the time of PF4 testing and those that were not cancelled. Implementation of the heparin discontinuation alert increased heparin discontinuation from 35% to 46 % (p = 0.015) (Figure 2). 2. 4T Score Documentation and Associated PF4 Appropriateness: Of the patient charts reviewed prior to integration of the 4T score elements into the PF4 order, only 31% (85/272) had a 4T score documented in the EHR. Of the 547 patients post-intervention, by design 100% had a documented 4T score. In the pre-intervention group, of those with calculated 4T scores before PF4 test ordering, 69.4% (59/85) were appropriate, while for those without a 4T score calculated just 27.2% (51/187) were appropriate based on retrospective 4T calculation, for a composite 40.4% appropriate pre-intervention PF4 test ordering, as compared to 79.1% (246/311) appropriate PF4 test ordering post-intervention (p <0.00001). Subspecialties with the highest inappropriate ordering of PF4 tests were: Surgical ICU (32.3%), Oncology (25.6%), the Cardiac Critical Care Unit (24.5%), and Adult Medicine (23.8%). 3. Alert to Not Order PF4 With Low 4T Score: Rates of appropriate PF4 ordering were similar between the group randomized to see the interruptive alert advising clinicians not to order the PF4 test if the 4T score <4 (242 appropriate orders/ 298 completed orders, 81%) and the control group that did not see the alert (306 appropriate orders/ 402 completed orders, 76%; p=0.13). Conclusions: Heparin product continuation can be life-threatening in patients with HIT. Implementation of electronic decision support significantly increased discontinuation of heparin products in patients in whom HIT was suspected. Forced calculation of the 4T score resulted in increased appropriateness of PF4 test orders by 40%. The impact of randomized guidance not to order a PF4 test when the 4T score was low was not as successful. Overall, the EHR interventions resulted in improved patient care for those suspected of having HIT at our institution. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system

Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients. This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1,000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate. The number of C. difficile tests decreased by 27.3% from 1.1 per 1,000 patient days preintervention (May 25, 2020-May 24, 2021) to 0.8 per 1,000 patient days postintervention, (May 25, 2021-March 25, 2022), P < .001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, nonsignificant decrease in C. difficile rates from preintervention, 0.33 per 1,000 patient days compared to postintervention, 0.29 per 1,000 patient days, P=.32. Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system.Variation existed among hospitals and by provider type.

Reducing unnecessary routine laboratory testing for noncritically ill patients with COVID-19.

Reducing unnecessary routine laboratory testing is a Choosing Wisely® recommendation, and new areas of overuse were noted during the COVID-19 pandemic. To reduce unnecessary repetitive routine laboratory testing for patients with COVID-19 during the pandemic across a large safety net health system. This quality improvement initiative was initiated by the System High-Value Care Council at New York City Health + Hospitals (H + H), the largest public healthcare system in the United States consisting of 11 acute care hospitals. four overused laboratory tests in noncritically ill hospitalized patients with COVID-19 were identified: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. A two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. The average of excess tests per encounter days (ETPED) for each of four target laboratory testing only in patients with COVID-19. Interdisciplinary System High-Value Care Council identified four overused laboratory tests (inflammatory markers) in noncritically ill hospitalized patients with COVID-19: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. Within an 11-hospital safety net health system, a two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. The preinterventionperiod (March 16, 2020 to January 24, 2021) was compared to the postintervention period (January 25, 2021 to March 22, 2022). Time series linear regression showed decreases in CRP (-17.9%, p < .05), ferritin (-37.6%, p < .001), and LDH (-30.1%, p < .001). Slope differences were significant (CRP, ferritin, and LDH p < 0.001; procalcitonin p < 0.05). Decreases were observed across weekly averages: CRP (-19%, p < .01), ferritin (-37.9%, p < .001), LDH (-28.7%, p < .001), and procalcitonin (-18.4%, p < .05). This intervention was associated with reduced routine inflammatory marker testing in non-intensive careunit COVID-19 hospitalized patients across 11 hospitals. Variation was high among individual hospitals.

The Impact of Electronic Health Record Interventions on Patient Access to Post-Hospital Discharge Prescriptions.

Purpose: Assess the impact of electronic health record interventions on patient access to post-hospital discharge prescriptions. Methods: Five interventions were implemented in the electronic health record to improve patient access to prescriptions after discharge from hospital: electronic prior authorization, alternative medication suggestions, order sets, mail order pharmacy alerts, and medication interchange instructions. This was a retrospective cohort study of patient responses from discharges during 6 months before the first intervention implementation and 6 months after the last intervention implementation documented in the electronic health record and a transition-in-care platform. Primary endpoint was the proportion of discharges with patient-reported issues that would have been prevented by the studied interventions out of number of discharges with at least one prescription, analyzed using Chi-squared test (level of significance .05). Results: Discharges with patient-reported issues that would have been prevented by the studied interventions decreased from 1.68 to 1.07 out of 1000 discharges with prescriptions (P < .001). Conclusion: Interventions in the electronic health record reduced barriers faced by patients to picking up prescriptions post-discharge from hospital, potentially leading to improved patient satisfaction and improved health outcomes. Important factors to consider for electronic health record intervention implementation are workflow development and intrusiveness of clinical decision support. Multiple targeted electronic health record interventions can improve patients' access to prescriptions after discharge from hospital.