Electronic alerts reduce unneeded test in elderly

An electronic message sent to doctors the moment they order a blood test for elderly patients reduces the unnecessary use of a test for which results often are false-positive for the elderly, according to research published in the November edition of American Journal of Managed Care.

The D-dimer test, combined with a clinical risking algorithm, can help in the diagnosis of deep vein thrombosis and pulmonary embolism. The risk of developing a blood clot in the venous circulation increases with age, yet the overall accuracy of the D-dimer test worsens as patients get older. The accuracy of the test is 35% for patients aged at least 65 years. This reduction in accuracy can result in numerous false-positive results and additional, unnecessary testing.

The randomized trial detailed in the journal included 223,877 patient visits for patients aged at least 65 years and 564,264 patient visits for patients aged fewer than 65 years. It was conducted in 8 primary care clinics within the Kaiser Permanente healthcare system in Colorado, each with at least 3,000 patients aged at least 65 years.

Physicians received an alert in Kaiser Permanente’s electronic health record (EHR) system when ordering a D-dimer test for patients aged at least 65 years. The alert explained the inaccuracy of the test for this age group and suggested using a radiologic test as appropriate. As a result, the rate of D-dimer tests for patients aged more than 65 years decreased significantly, from 5.02 to 1.52 per 1,000 patient visits, a relative reduction of D-dimer orders of 69.7%. This decrease was maintained throughout the study period, and the result was similar when the control group later received the alert.

The results indicate that computerized alerts containing alternative diagnostic or treatment strategies to direct clinicians toward more appropriate alternative diagnostic strategies can be more effective in practice than simply providing “negative guidance.”

“Physicians sometimes find it hard to remember to follow evidence-based clinical practice guidelines. Many people have suggested that computer-generated alerts within [EHRs] may serve as reminders to improve adherence to best practices,” says study lead author Ted E. Palen, MD, PhD, MPSH, a clinician researcher at Kaiser Permanente’s Institute for Health Research. “However, too many alerts produce alert fatigue, where receiving too many alerts becomes frustrating, leading to ignoring or overriding the messages.”

“As the healthcare industry moves to widely adopt [EHR] technology, it is critical that physicians and other caregivers are given specific and relevant data at the point of care to avoid alert fatigue,” says Palen. “This study shows that delivering a very targeted electronic message for a particular patient profile can result not only in better use of the test in question, it can alter a physician’s ordering behavior and promote improved adherence to a clinical practice guideline. This finding is important when designing systems that will support better coordination of patient care.”

Other authors of the paper included David W. Price, MD, and Susan M. Shetterly, MS, both from Kaiser Permanente’s Institute for Health Research in Colorado, and Aaron J. Snyder, MD, from the Colorado Permanente Medical Group.