Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. MATERIALS AND METHODS: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. RESULTS: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). DISCUSSION: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. CONCLUSION: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. TRIAL REGISTRATION: NCT02709772.

Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts.

Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record.

Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing.

Importance: Electronic health records (EHRs) often include default alerts that can influence physician selection of antibiotics, which in turn may be associated with a suboptimal choice of agents and increased antibiotic resistance. Objective: To examine whether removal of a default alert in the EHR to avoid cephalosporin use in patients with penicillin allergies is associated with changes in cephalosporin dispensing or administration in these patients. Design, Setting, and Participants: This retrospective cohort study of a natural experiment included data on patients who had received antibiotic treatment in the hospital or outpatient setting in 2 regions of a large, integrated health system in California from January 1, 2017, to December 31, 2018. Of 4 398 792 patients, 4 206 480 met the eligibility criteria: enrollment in the health system during antibiotic use, availability of complete demographic data, and use of antibiotics outside of the washout period. Interventions or Exposures: Oral or parenteral antibiotics dispensed or administered after removal of an EHR alert to avoid cephalosporin use in patients with a recorded penicillin allergy. Main Outcomes and Measures: Probability that an antibiotic course was a cephalosporin. A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions. Temporal changes in use rates were controlled for by comparing changes in cephalosporin use among patients with or without a penicillin allergy at the site that removed the warning and among patients at a comparison site that retained the warning. Regression models were used to examine adverse events. Results: Of the 4 206 480 patients who met all inclusion criteria, 2 465 849 (58.6%) were women; the mean (SD) age was 40.5 (23.2) years. A total of 10 652 014 antibiotic courses were administered or dispensed, divided approximately evenly between the period before and after removal of the warning. Before removal of an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy at 1 of the 2 sites, 58 228 courses of cephalosporins (accounting for 17.9% of all antibiotic use at the site) were used among patients with a penicillin allergy; after removal of the alert, administration or dispensing of cephalosporins increased by 47% compared with cephalosporin administration or dispensing among patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56) . No significant differences in anaphylaxis (9 total cases), new allergies (RROR, 1.02; 95% CI, 0.93-1.12), or treatment failures (RROR, 1.02; 95% CI, 0.99-1.05) were found at the course level. No significant differences were found in all-cause mortality (ratio of ratios of rate ratios [RRRR], 1.03; 95% CI, 0.94-1.13), hospital days (RRRR, 1.04; 95% CI, 0.99-1.10), and new infections (Clostridioides difficile: RRRR, 1.02; 95% CI, 0.84-1.22; methicillin-resistant Staphylococcus aureus: RRRR, 0.87; 95% CI, 0.75-1.00; and vancomycin-resistant Enterococcus: RRRR, 0.82; 95% CI, 0.55-1.22) at the patient level. Conclusions and Relevance: In this cohort study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased administration and dispensing of cephalosporin. This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship.

Developing an Integrated Electronic Medication Reconciliation Platform and Evaluating its Effects on Preventing Potential Duplicated Medications and Reducing 30-Day Medication-Related Hospital Revisits for Inpatients.

The aims were to develop an integrated electronic medication reconciliation (ieMR) platform, evaluate its effects on preventing potential duplicated medications, analyze the distribution of the potential duplicated medications by the Anatomical Therapeutic and Chemical (ATC) code for all inpatients, and determine the rate of 30-day medication-related hospital revisits for a geriatric unit. The study was conducted in a tertiary medical center in Taiwan and involved a retrospective quasi pre-intervention (July 1-November 30, 2015) and post-intervention (October 1-December 31, 2016) study design. A multidisciplinary team developed the ieMR platform covering the process from admission to discharge. The ieMR platform included six modules of an enhanced computer physician order entry system (eCPOE), Pharmaceutical-care, Holistic Care, Bedside Display, Personalized Best Possible Medication Discharge Plan, and Pharmaceutical Care Registration System. The ieMR platform prevented the number of potential duplicated medications from pre (25,196 medications, 2.3%) to post (23,413 medications, 3.8%) phases (OR 1.71, 95% CI, 1.68-1.74; p < .001). The most common potential duplicated medications classified by the ATC codes were cardiovascular system (28.4%), alimentary tract and metabolism (26.4%), and nervous system (14.9%), and by chemical substances were sennoside (12.5%), amlodipine (7.5%), and alprazolam (7.4%). The rate of medication-related 30-day hospital revisits for the geriatric unit was significantly decreased in post-intervention compared with that in pre-intervention (OR = 0.12; 95% CI, 0.03-0.53; p < .01). This study indicated that the ieMR platform significantly prevented the number of potential duplicated medications for inpatients and reduced the rate of 30-day medication-related hospital revisits for the patients on the geriatric unit.

Assessing Prescriber Behavior with a Clinical Decision Support Tool to Prevent Drug-Induced Long QT Syndrome.

OBJECTIVE: Clinical decision support (CDS) alerts built into the electronic health record (EHR) have the potential to reduce the risk of drug-induced long QT syndrome (diLQTS) in susceptible patients. However, the degree to which providers incorporate this information into prescription behavior and the impact on patient outcomes is often unknown. METHODS: We examined provider response data over a period from October 8, 2016 until November 8, 2018 for a CDS alert deployed within the EHR from a 13-hospital integrated health care system that fires when a patient with a QTc ≥ 500 ms within the past 14 days is prescribed a known QT-prolonging medication. We used multivariate generalized estimating equations to analyze the impact of therapeutic alternatives, relative risk of diLQTS for specific medications, and patient characteristics on provider response to the CDS and overall patient mortality. RESULTS: The CDS alert fired 15,002 times for 7,510 patients for which the most common response (51.0%) was to override the alert and order the culprit medication. In multivariate models, we found that patient age, relative risk of diLQTS, and presence of alternative agents were significant predictors of adherence to the CDS alerts and that nonadherence itself was a predictor of mortality. Risk of diLQTS and presence of an alternative agent are major factors in provider adherence to a CDS to prevent diLQTS; however, provider nonadherence was associated with a decreased risk of mortality. CONCLUSION: Surrogate endpoints, such as provider adherence, can be useful measures of CDS value but attention to hard outcomes, such as mortality, is likely needed.

The human resource costs of implementing autopend clinical decision support to improve health maintenance.

OBJECTIVES: Sutter Health developed a novel autopend, or automated laboratory test ordering, clinical decision support (CDS) tool to coordinate the patient and physician process of completing preventive services. This study estimated the costs of developing and implementing the autopend functionality within an existing electronic health maintenance (HM) reminder system. STUDY DESIGN: Human resource time was measured by triangulating in-depth key informant interviews with Microsoft Outlook Calendar metadata (meetings attended) for managers and hourly data from a time-based project management tool (Project Web App) for Epic programmers. Employee time spent was multiplied by the Bureau of Labor Statistics California state hourly wages. Sutter Health is an integrated health care delivery network with more than 12,000 physicians across 100 communities serving 3 million patients. METHODS: Activity-based costing methodology was used to divide the implementation into activities and the human resources required to complete them. RESULTS: Developing and implementing the autopend CDS took more than 3 years, involved 6 managers and 3 Epic programmers, and cost $201,500 (2013 US$) (2670 total hours), which excluded the costs of implementing the initial HM reminder system. Managers spent 90.5% of the total costs (86.6% of total hours) integrating autopend into the health system compared with 9.5% of the total costs (13.4% of total hours) spent programming the functionality. CONCLUSIONS: The autopend CDS might be similarly costly for other organizations to implement if their managers need to complete comparable activities. However, electronic health record vendors could include autopend as a standard package to reduce development costs and improve the uptake of this promising CDS tool.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study.

OBJECTIVE: To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS: We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION: While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

Improving thiamine prescribing at an academic hospital network using the computerized provider order entry system: a cohort study.

BACKGROUND: Oral thiamine therapy is frequently prescribed to patients at risk for thiamine deficiency despite recommendations emphasizing the need for high doses of parenteral thiamine to reverse brain thiamine deficits. We evaluated the effect of changes to the computerized provider order entry system on the proportion of prescriptions for parenteral thiamine treatment (primary outcome) and dosages prescribed (secondary outcome) within our academic hospital network. METHODS: We obtained data from the pharmacy information system recording thiamine prescribed to inpatients at University Health Network hospitals (Toronto, Ontario) before (Jan. 1, 2010, to Dec. 31, 2011) and after (Nov. 21, 2013, to Apr. 30, 2017) changes to the computerized provider order entry system promoting the use of higher dosages (≥ 200 mg) of parenterally administered thiamine. Patients receiving thiamine as part of total parenteral nutrition were excluded from analyses, as thiamine prescribing was automated and unlikely to be affected by the intervention. RESULTS: A total of 6105 thiamine prescriptions were written for 2907 patients before the intervention and 12 787 thiamine prescriptions for 8032 patients after the intervention. The proportion of prescriptions for parenteral treatment increased from 55.5% (3386/6105) to 92.5% (11 829/12 787) after the intervention (p < 0.001). Increases in prescribing of parenteral thiamine treatment were sustained or enhanced across the 3.4-year observation period and were realized across all hospital services. Prescriptions for higher dosages of thiamine increased from 1.1% (65/6105) to 61.4% (7845/12 787) after the intervention (p < 0.001). INTERPRETATION: Changes to the computerized provider order entry system were associated with sustained increases in the proportion of prescriptions for high-dose parenteral thiamine therapy. Similar approaches may be leveraged to align prescriber behaviour with well-accepted practice parameters in other areas of medicine.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting.

INTRODUCTION: Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults. OBJECTIVE: To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting. METHODS: A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up. RESULTS: A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05). CONCLUSION: No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Differences, Opportunities, and Strategies in Drug Alert Optimization-Experiences of Two Different Integrated Health Care Systems.

BACKGROUND: Concerns about the number of automated medication alerts issued within the electronic health record (EHR), and the subsequent potential for alarm fatigue, led us to examine strategies and methods to optimize the configuration of our drug alerts. OBJECTIVES: This article reports on comprehensive drug alerting rates and develops strategies across two different health care systems to reduce the number of drug alerts. METHODS: Standardized reports compared drug alert rates between the two systems, among 13 categories of drug alerts. Both health care systems made modifications to the out-of-box alerts available from their EHR and drug information vendors, focusing on system-wide approaches, when relevant, while performing more drug-specific changes when necessary. RESULTS: Drug alerting rates even after initial optimization were 38 alerts and 51 alerts per 100 drug orders, respectively. Eight principles were identified and developed to reflect the themes in the implementation and optimization of drug alerting. CONCLUSION: A team-based, systematic approach to optimizing drug-alerting strategies can reduce the number of drug alerts, but alert rates still remain high. In addition to strategic principles, additional tactical guidelines and recommendations need to be developed to enhance out-of-the-box clinical decision support for drug alerts.

The impact of a medication reconciliation programme at geriatric hospital admission: A pre-/postintervention study.

AIMS: The aim of this study was to improve medication reconciliation and reduce the occurrence of duplicate prescriptions by pharmacists and physicians within 72 hours of hospital admission using an intelligent prescription system combined with the National Health Insurance PharmaCloud system to integrate the database with the medical institution computerized physician order entry (CPOE) system. METHODS: This 2-year intervention study was implemented in the geriatric ward of a hospital in Taiwan. We developed an integrated CPOE system linked with the PharmaCloud database and established an electronic platform for coordinated communication with all healthcare professionals. Patients provided written informed consent to access their PharmaCloud records. We compared the intervention effectiveness within 72 hours of admission for improvement in pharmacist medication reconciliation, increased at-home medications documentation and decreased costs from duplicated at-home prescriptions. RESULTS: The medication reconciliation rate within 72 hours of admission increased from 44.0% preintervention to 86.8% postintervention (relative risk = 1.97, 95% confidence interval [CI]: 1.69-2.31; P < .001). The monthly average of patients who brought and took home medications documented in the CPOE system during hospitalization increased by 7.54 (95% CI 5.58-20.49, P = .22). The monthly average of home medications documented increased by 102.52 (95% CI 38.44-166.60; P = .01). Savings on the monthly average prescription expenditures of at-home medication increased by US$ 2,795.52 (95% CI US$1310.41-4280.63; P < .01). CONCLUSION: Integrating medication data from PharmaCloud to the hospital's medical chart system improved pharmacist medication reconciliation, which decreased duplicated medications and reduced in-hospital medication costs.

Randomized Clinical Trial of a Clinical Decision Support Tool for Improving the Appropriateness Scores for Ordering Imaging Studies in Primary and Specialty Care Ambulatory Clinics.

OBJECTIVE. The objective of our study was to evaluate whether the use of a clinical decision support (CDS) tool improved the appropriateness scores of orders for advanced imaging in clinical practice. MATERIALS AND METHODS. We used a stepped-wedge, cluster randomized clinical trial to evaluate the effectiveness of a CDS tool in an integrated health care system. Clinicians entered structured indications for each CT and MRI order, and the indications were electronically scored against appropriateness criteria to assign an appropriateness score. We compared the proportion of orders with adjusted appropriateness scores of 7 or greater (on a 1-9 scale) before and after activation of best practice alerts (BPAs) triggered for orders with low or marginal appropriateness scores. Secondary outcomes included the rate per month of orders for advanced imaging and the proportion of orders for which the radiology department requested changes. RESULTS. Between October 2015 and February 2016, 941 clinicians ordered 22,279 CT or MRI studies that met eligibility criteria. Before activation of the BPA, the mean proportion of appropriate orders (adjusted for time and clinic effect) was 77.0% (95% CI, 75.5-78.4%), which increased to 80.1% (95% CI, 78.7-81.5%) after activation (p = 0.001). There was no significant change in the rate of orders per month for advanced imaging. The proportion of order changes requested by the radiology department decreased from 5.7% (95% CI, 5.6-5.9%) before CDS implementation to 5.3% (95% CI, 5.1-5.5%) after CDS implementation (p < 0.001). CONCLUSION. Using an evidence-based CDS tool in clinical practice was associated with a modest but significant improvement in the appropriateness scores of advanced imaging orders.

Reducing red blood cell folate testing: a case study in utilisation management.

Mandatory enrichment of wheat flour in Canada with folic acid since 1998 has caused folate deficiency to be rare. There were 3019 red blood cell (RBC) folate tests performed during an 18-month period at London Health Sciences Centre (LHSC)/St. Joseph's Healthcare London (SJHC) without any folate deficiency detected. We implemented a quality improvement initiative to reduce RBC folate testing at LHSC/SJHC. We began with a retrospective review of RBC folate tests performed during the previous 18 months. We identified physicians who had ordered more than five tests during this period and sent them an educational email to inform them of our intentions and solicit their input. We then discontinued RBC folate testing in-house and a pop-up window was introduced to the computerised physician order entry system stating that biochemist approval would be needed before samples would be sent out for testing. During the audited 18-month period, the average monthly test volume was 168 (SD 20). The three departments ordering the most RBC folate testing were nephrology (15%), haematology (7%) and oncology (7%). Physician feedback was supportive of the change, and during the 2 months after targeted email correspondence, the average monthly test volume decreased 24% (p<0.01) to 128 (SD 1). On discontinuation of the test in-house and implementation of the pop-up, the average monthly test volume decreased another 74% (p<0.01) to 3 (SD 2). In the 10 months following discontinuation of the test on-site, there were only 39 RBC folate tests performed with no deficiency detected. This initiative significantly reduced unnecessary RBC folate orders. The change in ordering on email contact suggests that physician education was an important factor reducing overutilisation. However, the most significant decrease came from restricting the test so that only orders approved by a biochemist would be performed.

Exploring Different Approaches in Measuring EHR-based Adherence to Best Practice - A Case Study with Order Sets and Associated Outcomes.

In connection with a recent enterprise-wide rollout of a new electronic health record, Intermountain Healthcare is investing significant effort in building a central library of best-practice order sets. These order sets represent best practice guidelines for specific clinical scenarios and are deployed with the intent of standardizing care, reducing variation, and consistently delivering good clinical outcomes to the populations we serve. The importance of measuring their use and the level to which caregivers adhere to these standards becomes an important factor in understanding and characterizing the impact that they deliver. Notwithstanding the importance of these metrics, well- defined methods for measuring adherence to a given clinical guideline as delivered through an order set are not fully characterized in the medical literature. In this paper, we describe initial efforts at measuring compliance to a defined 'best practice' standard by means of content utilization analysis, a calculated adherence model, and relevant clinical key performance indicators. The degree to which specified clinical outcomes vary across these measurement models are compared for a group of order sets tied to treating coronary artery bypass graft patients and heart failure patients. While the patterns derived from this analysis show some uncertainty, more granular methods that look at line-item, or 'order level' detail reveal more significant differences in the corresponding set of outcomes than higher-level adherence surrogates.

Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke.

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS: In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS: We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS: Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Optimizing drug-dose alerts using commercial software throughout an integrated health care system.

All default electronic health record and drug reference database vendor drug-dose alerting recommendations (single dose, daily dose, dose frequency, and dose duration) were silently turned on in inpatient, outpatient, and emergency department areas for pediatric-only and nonpediatric-only populations. Drug-dose alerts were evaluated during a 3-month period. Drug-dose alerts fired on 12% of orders (104 098/834 911). System-level and drug-specific strategies to decrease drug-dose alerts were analyzed. System-level strategies included: (1) turning off all minimum drug-dosing alerts, (2) turning off all incomplete information drug-dosing alerts, (3) increasing the maximum single-dose drug-dose alert threshold to 125%, (4) increasing the daily dose maximum drug-dose alert threshold to 125%, and (5) increasing the dose frequency drug-dose alert threshold to more than 2 doses per day above initial threshold. Drug-specific strategies included changing drug-specific maximum single and maximum daily drug-dose alerting parameters for the top 22 drug categories by alert frequency. System-level approaches decreased alerting to 5% (46 988/834 911) and drug-specific approaches decreased alerts to 3% (25 455/834 911). Drug-dose alerts varied between care settings and patient populations.

Sustained User Engagement in Health Information Technology: The Long Road from Implementation to System Optimization of Computerized Physician Order Entry and Clinical Decision Support Systems for Prescribing in Hospitals in England.

OBJECTIVE: To explore and understand approaches to user engagement through investigating the range of ways in which health care workers and organizations accommodated the introduction of computerized physician order entry (CPOE) and computerized decision support (CDS) for hospital prescribing. STUDY SETTING: Six hospitals in England, United Kingdom. STUDY DESIGN: Qualitative case study. DATA COLLECTION: We undertook qualitative semi-structured interviews, non-participant observations of meetings and system use, and collected organizational documents over three time periods from six hospitals. Thematic analysis was initially undertaken within individual cases, followed by cross-case comparisons. FINDINGS: We conducted 173 interviews, conducted 24 observations, and collected 17 documents between 2011 and 2015. We found that perceived individual and safety benefits among different user groups tended to facilitate engagement in some, while other less engaged groups developed resistance and unsanctioned workarounds if systems were perceived to be inadequate. We identified both the opportunity and need for sustained engagement across user groups around system enhancement (e.g., through customizing software) and the development of user competencies and effective use. CONCLUSIONS: There is an urgent need to move away from an episodic view of engagement focused on the preimplementation phase, to more continuous holistic attempts to engage with and respond to end-users.

Electronic Alerts with Automated Consultations Promote Appropriate Antimicrobial Prescriptions.

BACKGROUND: To promote appropriate antimicrobial use in bloodstream infections (BSIs), we initiated an intervention program consisting of electronic alerts and automated infectious diseases consultations in which the identification and antimicrobial susceptibility test (ID/AST) results were reported. METHODS: We compared the appropriateness of antimicrobial prescriptions and clinical outcomes in BSIs before and after initiation of the program. Appropriateness was assessed in terms of effective therapy, optimal therapy, de-escalation therapy, and intravenous to oral switch therapy. RESULTS: There were 648 BSI episodes in the pre-program period and 678 in the program period. The proportion of effective, optimal, and de-escalation therapies assessed 24 hours after the reporting of the ID/AST results increased from 87.8% (95% confidence interval [CI] 85.5-90.5), 64.4% (95% CI 60.8-68.1), and 10.0% (95% CI 7.5-12.6) in the pre-program period, respectively, to 94.4% (95% CI 92.7-96.1), 81.4% (95% CI 78.4-84.3), and 18.6% (95% CI 15.3-21.9) in the program period, respectively. Kaplan-Meier analyses and log-rank tests revealed that the time to effective (p<0.001), optimal (p<0.001), and de-escalation (p = 0.017) therapies were significantly different in the two periods. Segmented linear regression analysis showed the increase in the proportion of effective (p = 0.015), optimal (p<0.001), and de-escalation (p = 0.010) therapies at 24 hours after reporting, immediately after program initiation. No significant baseline trends or changes in trends were identified. There were no significant differences in time to intravenous to oral switch therapy, length of stay, and 30-day mortality rate. CONCLUSION: This novel form of stewardship program based on intervention by infectious disease specialists and information technology improved antimicrobial prescriptions in BSIs.