The Pros and Cons of EHR Clinical Decision Support Alerts

Pros

According to ONC, CDS “provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.”

It also leverages several tools to boost clinical decision-making.

Identifying Adverse Drug Events

Adverse drug events (ADEs) transpire roughly 1.5 million times per year, according to a recent Journal of the American Medical Informatics (JAMIA) study. Some researchers say these injuries account for 5 to 17 percent of hospital admissions. However, nearly 400,000 of those 1.5 million ADEs are considered preventable.

EHR-integrated CDS tools could help prevent ADEs. According to the study authors, medication-related CDS tools can reduce up to 81 percent of medication errors. Although most EHRs include CDS alerts, most are vendor-developed and the majority do not address patients with renal insufficiency. Roughly one-third of patients receive incorrect renal function doses.

“Medication-related CDS represents an effective way to reduce errors and ADEs,” wrote the study authors. “However, this impact may be decreased or even extinguished if too many clinically inappropriate alerts are given. This problem represents an important one in informatics today, as EHRs are now broadly implemented, and almost all are vendor-developed.”

Promoting Patient Safety

Several CDS studies have demonstrated its effectiveness on clinician execution, but the impact on patient outcomes impact remains undefined. 

A literature review of 45 texts showed CDS alerts were adequate for patient outcomes and clinician practice performance for many diseases, such as cardiovascular disease, diabetes, and high blood pressure. CDS was also beneficial for other healthcare cases, such as prescribing medications to patients.

For cardiovascular disease, CDS alerts had a positive impact on clinician performance and treatment improvement for anti-inflammatory and lipid-lowering drugs, authors wrote. Short message alerts also had a positive effect on patient diet and medication prescribing.

“The system's user-friendliness environment and low running cost have resulted in its efficiency in the care delivery process,” explained the authors

For individuals with diabetes, short message alerts improved medication adherence and missed dosage, study authors wrote. Additionally, statin use and other diabetes problem areas improved with increased CDS use.

“The main reason for the effect of CDSS on improving patient adherence seems to be due to the fact that it raises patients’ awareness of taking medication,” explained the researchers.

CDS alerts immediately improved patient outcomes for individuals with hypertension.

Furthermore, CDS alerts had a positive impact on clinician performance when prescribing drugs for patients.

Improving Patient Awareness, Provider-Patient Communication

Implementing a CDS tool into the EHR could boost cardiovascular risk factor awareness in oncology settings and maintain or enhance cardiovascular health for breast cancer survivors, according to Stanford researchers.

Before the study, 65 percent of survivors said they did not know their cardiovascular levels or multiple health factors. Only 45 percent of survivors said they knew their cardiovascular health was at an ideal level. Over 50 percent of survivor respondents said they had ideal smoking status. Still, less than 50 percent knew if they had adequate blood pressure, body mass index, cholesterol level, diet, and physical activity.

Following the study, over 90 percent of survivors thought the mobile app was easy to understand, improved their understanding, and was helpful. Ninety-four percent of patients liked the mobile app overall.

Additionally, most survivors thought oncologists should be more open and discuss cardiovascular health during care.

Ninety percent of providers reported the tool provided helpful information, 90 percent said it was effective, 100 percent said it was easy to use, and 95 percent said it presented information in a useful format. Eighty-five percent of providers reported they would use the tool most or all of the time when providing survivorship care.

“Overall, our results suggest both the need for and suitability of a tailored cardiovascular health assessment tool to heighten awareness of cardiovascular health among oncology providers and breast cancer survivors,” wrote the Stanford researchers.

Cons

Although CDS has proven to improve clinical quality outcomes, it can be detrimental to the provider. CDS alerts are linked to alert fatigue, loss of autonomy, workflow changes, increased EHR usage, and anxiety due to potential legal repercussions of CDS suggestions.

Alert Fatigue and Low-Value Alerts

EHR fatigue caused by alerts has been a problem for clinicians already struggling with EHR usability overload. Low-value EHR alerts can negatively impact patient care and contribute to clinician burnout.

As a result, Vanderbilt Clinical Informatics Center (VCLIC) and Vanderbilt University Medical Center (VUMC) launched the Clickbusters program to reduce the number of EHR alerts at VUMC.

The goal was not only to reduce the number of CDS alerts but also to improve alert quality. According to VUMC, the program audited which signals are utilized and which ones are not. While Clickbusters deleted some warnings, it optimized others to enhance the impact on the user.

“We believe in alerts,” Adam Wright, PhD, professor of Biomedical Informatics, said at the time. “There should be a lot of good alerts in the system that are accepted a lot of the time and that people find to be useful.”

“Currently, BPAs are acted upon 8% of the time at VUMC. The Clickbusters goal is 30%,” Wright continued.

For example, a CDS alert urged a clinician to recommend a patient to lose weight, but it also fired off for an anesthesiologist working in the operating room.

“BPAs are always well meant, the motivation being to guard clinical safety and quality or reduce unnecessary costs,” said Neal Patel, MD, chief informatics officer with VUMC. “However, alert fatigue seems to have somewhere along the line became practically endemic in health care.”

Failure to Detect Medication Errors

As noted, a CDS alert ultimately aims to trigger a clinician about an adverse drug event or a medication error. If it cannot do that effectively, then patient safety is at risk.

While EHR optimization has increased in recent years, CDS alerts still fail to detect up to 33 percent of medication errors, according to a study published in JAMA Network Open.

Using simulated medical records, researchers from University of Utah Health, Harvard University, and Brigham and Women’s Hospital found that EHR systems continue to put patients in unfavorable and potentially deadly situations, due to the inability to consistently detect errors.

“EHRs are supposed to ensure safe use of medications in hospitals,” David C. Classen, MD, study corresponding author and a professor of internal medicine at University of Utah Health, said in a statement at the time of the study.

“But they’re not doing that. In any other industry, this degree of software failure wouldn’t be tolerated. You would never get on an airplane, for instance, if an airline could only promise it could get you to your destination safely two-thirds of the time.”

Commercial Influence

Lastly, CDS alerts can even have deadly consequences if integrated with a commercial influence.

The viewpoint, written by three healthcare experts from the Office of the Inspector General (OIG), explored why clinical decision support has been gone without scrutiny for far too long for its potential as a powerful marketing device.

In January 2020, Practice Fusion was fined a historic $145 million after admitting to a kickback scheme to increase opioid prescriptions.

Practice Fusion divulged that it solicited and received kickbacks from a significant, unnamed opioid company in exchange for utilizing its EHR software to manipulate physician prescribing of opioid pain medications.

The Department of Justice said the vendor implemented CDS alerts in its EHR software to increase the sales of specific opioids.

The pharmaceutical companies “sponsoring” Practice Fusion could design and develop the CDS alerts, develop guidelines and criteria to generate physician alerts during the treatment process.

The alerts promoted additional opioid prescribing that differed from usual medical standards by suggesting that the physician prescribe extended-release opioids to patients who did not need those specific opioids. In return, physicians would sell the extended-release opioids at a higher rate due to the relationship between the vendor and its “sponsor.”

CDS alerts are an imperfect EHR tool with several pros and cons. But increased stakeholder research could minimize the number of negatives and expand the number of positives.