Original Article

Evaluation of an Electronic Health Record Alert to Improve Screening and Management of Cardiovascular Disease and Stroke Factors in a High-Risk Population

Authors: Warren L. Felton, MD, Susan G. Kornstein, MD, Tamala Gondwe, PhD, MPH, Christine Huynh, MD, Jordyn T. Wallenborn, PhD, MPH, Jeneane Henry, RN, BSN

Abstract

Objectives: Cardiovascular disease and stroke risk factor screening and management by primary care providers (PCPs) have a significant impact on their patients’ health. The objective of this study was to investigate the effectiveness of an electronic health record (EHR) cardiovascular disease and stroke risk alert in improving the ability of PCPs to manage risk factors among women and men aged 45 years and older.

Methods: PCPs at a tertiary care hospital were randomized. The intervention group received an EHR alert, which calculated the individual patient risk and provided an order set incorporating the American Heart Association and American Stroke Association guidelines, whereas the control group used the EHR in the usual manner. Multilevel analysis compared the rate of prescriptions between the intervention and control groups.

Results: A total of 23 PCPs were randomized: 12 in the intervention group and 11 in the control group, attending to 7190 patients between September 2016 and January 2017. None of the providers in the intervention group used the programmed order set. Intervention group providers were significantly more likely to prescribe smoking cessation medication to women than to the control group (adjusted odds ratio 2.37, 95% confidence interval 1.23–4.57). There were no statistically significant differences between the intervention and control groups in the rate of other medication prescriptions.

Conclusions: As measured by prescriptions for medications, other than those for smoking cessation, the EHR alert was not shown to be successful in increasing the management of high-risk patients. Physicians receiving numerous messages in the EHR may experience alert desensitization.
Posted in: Cardiovascular Disease28

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Heron M. Deaths: leading causes for 2016. Natl Vital Stat Rep 2018;67:1–77.
 
2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics— 2017 update: a report from the American Heart Association. Circulation 2017; 135:e146–e603.
 
3. Danaei G, Ding EL, Mozaffarian D, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 2009;6:e1000058.
 
4. Kroenke K. The many C’s of primary care. J Gen Intern Med 2004;19:708–709.
 
5. Sox HC. The future of primary care. Ann Intern Med 2003;138:230–232.
 
6. Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754–3832.
 
7. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S49–S73.
 
8. Wolf PA, D’Agostino RB, Belanger AJ, et al. Probability of stroke: a risk profile from the Framingham Study. Stroke 1991;22:312–318.
 
9. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(25 Suppl 2):S1–S45.
 
10. Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation. Chest 2010;137:263–272.
 
11. Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HASBLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138:1093–1100.
 
12. Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012;126:860–865.
 
13. Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q 1989;67:268–317.
 
14. Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to reduce ‘alert fatigue’ while still minimizing the risk of litigation. Health Aff (Millwood) 2011;30:2310–2317.
 
15. Weingart SN, Toth M, Sands DZ, et al. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003;163:2625–2631.
 
16. Foraker RE, Kite B, Kelley MM, et al. EHR-based visualization tool: adoption rates, satisfaction, and patient outcomes. EGEMS (Wash DC) 2015;3:1159.
 
17. Embi PJ, Leonard AC. Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. J Am Med Inform Assoc 2012;19:e145–e148.
 
18. McGreevey JD 3rd, Mallozzi CP, Perkins RM, et al. Reducing alert burden in electronic health records: state of the art recommendations from four health systems. Appl Clin Inform 2020;11:1–12.
 
19. Sharifi M, Adams WG, Winickoff JP, et al. Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke. Acad Pediatr 2014;14:478–484.
 
20. Kunstler BE, Lennox A, Bragge P. Changing prescribing behaviours with educational outreach: an overview of evidence and practice. BMC Med Educ 2019;19:311.
 
21. Thomson O’Brien MA, Oxman AD, Davis DA, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;2:CD000409.
 
22. Gorelick PB, Goldstein LB, Ovbiagele B. New guidelines to reduce risk of atherosclerotic cardiovascular disease: implications for stroke prevention in 2014. Stroke 2014;45:945–947.