“Stealth” Alerts to Improve Warfarin Monitoring When Initiating Interacting Medications

Abstract

BACKGROUND: As electronic health records (EHRs) become widely adopted, alerts and reminders can improve medication safety, but excessive alerts may irritate or overwhelm clinicians, thereby reducing their effectiveness. We developed a novel "stealth" alert in an EHR to improve anticoagulation monitoring for patients prescribed a medication that could interact with warfarin. Instead of alerting the prescribing provider, the system notified a multidisciplinary anticoagulation management service, so that the prescribing clinicians never saw the alerts. We aimed to determine whether these "stealth" alerts increased the frequency of anticoagulation monitoring following the co-prescription of warfarin and a potentially interacting medication. METHODS: We conducted a pre-post intervention study, analyzed using an interrupted time-series, within a large, multispecialty group practice that uses a common EHR. The study included a 12-month period preceding the intervention, a 2-month period during intervention implementation, and a 6-month post-intervention period. The primary outcome measure was the proportion of patients completing anticoagulation monitoring within 5 days of a new co-prescribing event. RESULTS: Prior to implementation of the stealth alert, 34 % of patients completed anticoagulation monitoring within 5 days after the prescription of a medication with a potential warfarin interaction. After implementation of the alert, 39 % completed testing within 5 days (odds ratio 1.24, 95 % confidence interval 1.12-1.37). CONCLUSIONS: Stealth alerts increased the proportion of patients who underwent anticoagulation monitoring following the prescription of a medication that could potentially interact with warfarin. This team-based approach to clinical-decision support directs alerts away from prescribing clinicians and toward individuals who can directly implement them.

Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism

“…When drugs with known interaction potential are added or discontinued during warfarin therapy, or there is uncertainty regarding a drug’s potential to alter the response to warfarin, more frequent INR testing should be performed until INR stability is re-established [ 1 , 84 ]. Incorporating drug interaction alerts into electronic health records has been shown to improve the rate of subsequent INR monitoring [ 85 ]. Acute infections or other changes in health status (e.g.…”

Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection

“…Most prior studies have used objective measures to trigger CTAs, such as age, medication ordered, patient physical attributes, test results, prior diagnoses and patient location [17][18][19][20][21][22][23][24][25]. These criteria can be highly accurate, in particular when all inclusion criteria are objective, discrete and entered into the EHR prior to the time at which the alert criteria are assessed.…”

“…Accurate trigger criteria are important in order to minimize the number of times clinicians ignore seemingly excessive alerts (known as "alert fatigue") [4][5][6][7][8][9][10][11][12][13][14][15][16]. In prior studies, criteria for initiating alerts, both clinical alerts and CTAs, have included more well-defined criteria such as age, medication ordered, physical attributes of a patient such as weight or body mass index, social history, medical diagnoses, test results or location of patient encounter [17][18][19][20][21][22][23][24][25]. These criteria are discretely documented in the EHR and their use in research is more clearly defined than are CCs.…”

Electronic risk assessment for venous thromboembolism: investigating physicians’ rationale for bypassing clinical decision support recommendations

“…This might help to establish whether it may be necessary to design a parallel system for these patients, which may lead to the prescription being made/decision not to prescribe due to the time of surgery. It might be interesting to utilise stealth alerts/stealth processes 24 through a third party in order to alert the patient's regular doctor/consultant to a lack of VTE prophylaxis or, for example, alert a pharmacist to check the dose where an enoxaparin prescription is present but the dose is not what would normally be recommended.…”