Many physicians equate clinical decision support (CDS) with pop-up alerts. They seem like one and the same to doctors who have been dealing with them for years, or at least since electronic health records (EHRs) came on the scene. Pop-up alerts take over the screen, forcing the user to stop whatever they were doing and deal with the new task; we professionals who like to use big words (guilty as charged!) call these modal windows. The worst pop-up alerts are those that remind clinicians to do something that they were just about to do. Even well-reasoned and appropriate alerts typically interrupt the user’s flow, so it’s easy to understand why they haven’t been universally loved.
Over a decade ago, Robert Campbell outlined the Five “Rights” of Clinical Decision Support: the right information, to the right person, in the right intervention format, through the right channel, at the right time in the workflow. For purposes of this discussion, let me focus on the third right: the right intervention format. There are clearly times when a clinician should be stopped in their tracks. For example, if a doctor signs an order for a medicine that is likely to cause a serious allergic reaction or if a nurse is about to administer a drug to the wrong patient, a sudden stop is indicated. But often, it’s the case that a gentle push in the right direction is all that’s needed for a clinical expert.
In this month’s Journal of the American Medical Informatics Association, researchers from the Medical University of South Carolina (MUSC) wrote of their research to use non-interruptive CDS to learn if they could increase the rate at which emergency medicine physicians prescribe take-home naloxone for patients who may have had a drug overdose (OD). They specifically attempted to suggest the order at a point in the clinical workflow when the doctor might most easily be receptive to it: during documentation of the emergency department (ED) encounter.
For background, naloxone is a medicine that can reverse the effects of opioid overdose. It’s a lifesaver, but for it to work, it must be administered soon after the patient starts overdosing. Many first responders now routinely carry naloxone because it can safely be given when OD is suspected (side effects are minimal, so even if there was no opioid overdose, no serious harm will come from the drug). The goal of this research was to give a patient who might be at risk of overdosing in the future the naloxone that they or their friends or family might administer if it was needed.
Instead of popping up a modal window, the MUSC researchers embedded a reminder into the progress note that the ED physician would likely use to document the visit. This may seem simple, but it’s not obvious that overdose is the likely diagnosis when a patient is first presenting to the emergency department. Recall that a typical workflow in the ED is to start documenting a note as soon as the physician starts collecting the patient’s history. Hence, the researchers looked for clues in the chart. They settled on a field in their EHR that collects both a discrete reason for the visit and a free-text description of the chief complaint. If the reason for the visit as documented by the triage nurse was “drug overdose” or if the words “naloxone” or “Narcan” (brand name for naloxone) appeared in the free-text box, the clinical decision support reminder kicked in.
Once the encounter was identified as a possible OD, in the history of present illness (HPI) section of the routine emergency medicine note, text appeared suggesting that the physician might want to use a short documentation template (“dot phrase”) to collect the necessary information regarding the event and also might want to send the patient home with the take-home naloxone. The key from the clinician's perspective is that this is a good point in the workflow to make these suggestions, as the doctor is likely receptive to these prompts at this time.
What were the results of the CDS prompt in the documentation template? Before the intervention, naloxone kits were distributed 25.7% of the time; afterward, the rate almost doubled to 50%. Obviously, the goal is to give take-home naloxone kits every time, but this was a significant improvement. Further, they found that physicians actually appreciated the advice. The majority were net promoters, and 74% scored the CDS intervention in the excellent or good range on a survey.
Non-interruptive clinical decision support needs to become the norm, and as our EHRs get more sophisticated, I think we’ll see fewer pop-up alerts that annoy physicians. CDS that reminds physicians to do the “right thing” at the right time will be embraced by clinical staff, leading to a decrease in cranky comments and a rise in the awareness of the benefits that the EHR can bring to patients and those who care for them.