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August 24, 2018

When doctors override EHR alerts, patients may suffer, study suggests

Daily Briefing

    When doctors do not follow EHR alerts that notify them when they are deviating from industry guidelines, their patients might experience higher inpatient complication rates and health care costs, according to an observational study published Wednesday in the American Journal of Managed Care (AJMC), FierceHealthcare reports.

    Your one-page cheat sheet on clinical decision support (CDS)

    Study details

    For the study, researchers from Cedars-Sinai Health System and Optum Advisory Services reviewed data on 26,424 inpatient visits from October 2013 to July 2016.

    The Daily Briefing is published by Advisory Board Research, a division of Optum.

    The researchers sought to determine associations between four outcome measures—length of stay, 30-day readmission, care complications, and total direct costs—and use of Choosing Wisely clinical decision support (CDS) software, which is embedded in EHRs to alert physicians when they are not following industry guidelines. The CDS software was developed by the American Board of Internal Medicine Foundation.

    The researchers said the study was not designed to measure the effect of specific alerts on outcomes or whether the providers who followed the alerts were more engaged in quality and efficiency practices.


    The researchers found few instances—6% of all inpatient visits examined—during which the physician adhered to all CDS alerts. Conversely, the researchers found that physicians did not follow any of the alerts during the majority of inpatient visits (94%).

    When comparing those two groups, the researchers found patients whose physicians did not follow CDS alerts saw a:

    • 29% increase in the odds of complications;
    • 14% increase in the risk of readmission within 30 days;
    • 7.3% increase in total encounter cost, or more than $900 per patient; and
    • 6.2% increase in length of stay.


    The researchers said the study suggests CDS software might have an effect on costs and quality, but added that more research is needed to examine how alerts directly affect outcomes.

    Harry Sax, a senior author of the study and executive vice chair of surgery at Cedars-Sinai, said, "Sometimes doctors order tests that they think are in the patient's best interest, when research doesn't show that to be the case." He added, "This work is about giving the right care that patients truly need."

    Scott Weingarten, another senior author of the study and senior vice president and chief clinical transformation officer at Cedars-Sinai, added, "We have seen that real-time aids for clinical decision-making can potentially help physicians reduce low-value care and improve patient outcomes while lowering costs."

    Anne Wellington, a co-author of the study and managing director of the Cedars-Sinai accelerator, said, "The next step is to look at the characteristics of overall alerts and say, 'We see a positive impact. Now let's look at what's most effective about clinical decision support in order to maximize the positive impact on both for patients and providers'" (Kim Cohen, Becker's Health IT & CIO Report, 8/16; Tahir, "Morning eHealth," Politico, 8/16; Reed, FierceHealthcare, 8/16; Bryant, Healthcare Dive, 8/15; Bartholomew, Los Angeles Business Journal, 8/15; AJMC release, 8/15; Optum release, 8/15).

    Next, access our cheat sheet on CDS

    CDS is an electronic tool that helps providers make informed ordering decisions based on established clinical guidelines, and it also has the ability to alert providers about the appropriateness of exams. Download the cheat sheet to learn how your organization can implement CDS.

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