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Clinical Decision Support EHR Alert Doubles Heart Failure Drug Prescriptions

A banner-like EHR alert was a more effective form of clinical decision support than a monthly email for improving MRA prescription rates.

A clinical decision support (CDS) EHR alert helped increase prescription rates of a life-saving heart failure drug, according to a study published in The Journal of the American College of Cardiology (JACC).

Medications called mineralocorticoid receptor antagonists (MRAs) can greatly increase survival rates for patients with heart failure with reduced ejection fraction (HFrEF). However, previous studies have found that clinicians do not prescribe the drugs to two-thirds of eligible patients.

The researchers designed two automated EHR tools to improve MRA prescribing in eligible patients with HFrEF.

The research team tested the notification systems at over 60 cardiology outpatient clinics between April and October 2022. The study randomly divided adults with heart failure into three groups based on the kind of CDS the cardiologist received.

In the first group, banner-like alerts appeared on the top corner of patient EHRs. The notification included data for CDS around MRA therapy, such as blood pressure, estimated glomerular filtration rate (a measure of kidney function), and potassium levels in the blood.

In the second group of patients, cardiologists received a monthly message with a list of those eligible for MRAs. The email-like notification appeared within the healthcare system’s internal messaging platform, allowing healthcare providers to open patient medical charts and read information relevant to prescribing MRAs.

Cardiologists caring for patients in the third group received neither notification.

The banner-like EHR alert was most effective at improving rates of MRA prescription, with cardiologists in group one prescribing MRA therapy for about 30 percent of their patients.

Cardiologists who received monthly messages prescribed MRA 16 percent of the time, while those who received neither notification prescribed the therapy for 12 percent of their patients.

“Our findings highlight the importance of considering timing and delivery of CDS interventions and illustrate the tremendous potential of CDS interventions to transform practice in a low-cost and scalable manner,” the study authors wrote.

The researchers noted two key differences between the message and alert: timing and appearance.

The message allowed for the review of multiple patients between visits, limiting interruptions during patient visits and minimizing alert fatigue.

“However, because the patient was not with the provider at the time of the intervention, acting on the intervention would require the provider to either contact the patient to discuss new therapy, ask staff to call the patient or schedule an appointment, or wait until the patient’s next visit,” the study authors explained.

“These logistical burdens may have partially offset the advantages the message could have had in reducing interruptions when compared to the alert,” they said.

Another potential reason for the greater effectiveness of the alert compared to the message could be user interface limitations.

“The current functionality of our EHR did not allow for us to take advantage of some of the display techniques that were employed for the alert, such as a prominent banner, positioning to improve visibility, or preselecting orders,” the researchers wrote.

The study authors emphasized that future investigations should study the effectiveness of these interventions in other practice settings for heart failure and other diseases.  

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