COVID-19 Telehealth Boom Stymied Clinical Decision Support Alerts

Increased telehealth adoption and use during COVID-19 had a negative impact on clinical decision support (CDS) alerts, often resulting in missed alerts by clinicians, according to a study published in JMIR Publications.

Throughout the COVID-19 pandemic, telehealth use skyrocketed as overcrowded hospitals worked to create social distancing to help limit the spread of the virus. Telehealth also helped primary care clinicians maintain relationships with patients when outpatient services were paused.

Telehealth triggers a dramatic difference with the EHR workflows, the communication between clinicians, and the different types of patient data that is available to clinicians.

Because of these differences, CDS alerts might be triggered at different times, or not trigger at all during telehealth visits. Effective alerts such as admission, discharge, and screening reminders can enhance clinical efficiency by opening up communication through the EHR.

This is why constant CDS alert evaluation is crucial for patient safety and patient care.

“This is perhaps even more important during the pandemic, when our CDS is at higher risk of malfunctioning, and when these aspects of care are at risk of being neglected,” the researchers said. “Due to practicing medicine during the pandemic, significant competing priorities by necessity force us to employ a time-sparing and straightforward approach to evaluate the health of our outpatient CDS program in the context of the COVID-19 telemedicine expansion.”

Researchers evaluated CDS alerts at NYU Langone Health based on increased telehealth use during the first wave of COVID-19. Between March and May 2020, 2,100 providers completed 244,425 telehealth visits, which ultimately accounted for 59 percent of the health system’s visit volume.

“To evaluate how this shift toward telemedicine impacted ambulatory CDS at NYULH, our clinical informatics team developed a basic framework for assessing our CDS program's fitness to navigate the transformation,” explained the study authors.

The framework included the following 4 steps:

• Evaluating CDS alert firing volumes and firing rates in telehealth visits
• Examining action taken rates between office visits and telehealth visits
• Reviewing alerts with significant discrepancies in firing volume
• Reviewing CDS optimization opportunities through the existing CDS governance structures to enhance alerts

Researchers found 10 of the top 40 CDS alerts by volume did not fire during telehealth visits. In fact, three of the top five alerts did not trigger properly during telehealth visits and providers were significantly less likely to take action than they would be during an office visit.

Telehealth alerts had an action taken rate of 5.3 percent, compared to 8.3 percent for office visits.

The research team said telehealth visits have different EHR workflows than office visits and some office-based alerts were not triggering at the optimal time during the telehealth workflow. Additionally, researchers said missing patient data is a common reason for the decreased number of alerts during telehealth visits and patient-reported data entered through the patient portal could replace office collected data.

“Based on our findings, we would advocate for other organizations to consider performing their own targeted ambulatory CDS checkup,” the researchers recommended. “We provide several vital themes that institutions can target when conducting their own evaluations of CDS in ambulatory telemedicine.”

Although there were limitations, such as the type of evaluated CDS alerts, researchers said they were able to identify and fix or optimize significant CDS alert malfunctions. The study authors said this study might increase conversations about telehealth quality measurement and hopefully lead to increased attention on CDS performance.

According to the researchers, this is the first known study that showed the impact that telemedicine had on CDS alerts.

“The COVID-19 pandemic presents many new challenges for the management of chronic diseases,” the researchers concluded. “We have demonstrated that an ambulatory CDS checkup focused on telemedicine can positively impact the provision of preventative and chronic care. Our practical framework for reviewing CDS in light of the telemedicine expansion helped identify significant CDS malfunctions and important optimization opportunities.”