Grand Rounds December 16, 2022: The Use of EHR-Agnostic Clinical Decision Support to Prevent Thromboembolism in Hospitalized Medically Ill Patients (Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC; Jeffrey Solomon, BFA)

Posted on by Elizabeth Mccamic

Speakers

Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC
Professor of Medicine – The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Professor – Institute of Health System Science – The Feinstein Institutes for Medical Research
System Director – Anticoagulation and Clinical Thrombosis Services
Northwell Health at Lenox Hill Hospital

Jeffrey Solomon, BFA
Senior Director, Usability Lab
Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY

 

 

Keywords

Pragmatic Clinical Trials, Cluster Randomized Trial, EHR solutions

 

Key Points

  • The majority of hospital-acquired Venous Thromboembolism (VTE) occurs in non-surgical medical inpatients, but Thromboprophylaxis for medically ill patients during and after hospital stays is underutilized. Electronic alerts incorporating VTE risk models could increase appropriate use of Thromboprophylaxis and reduce symptoms of VTE.
  • The study team’s health informatics group developed a novel clinical decision support (CDS) tool, called IMPROVE-DD VTE CDS, which can be integrated into different electronic health record (EHR) systems. The effectiveness of the intervention was then evaluated through a cluster randomized trial at four academic tertiary hospitals from December 21, 2020 to January 21, 2022.
  • This trial tested the hypothesis that the use of a platform-agnostic, EHR-embedded VTE risk model with integrated CDS would 1) increase rates of appropriate Thromboprophylaxis, and subsequently 2) reduce thromboembolism, compared to usual medical care in hospitalized, medically-ill patients.
  • The study team developed the tool using high-quality evidence from randomized trials related to risk factors for subpopulations and guideline recommendations. The solution’s interface was developed using workflow analysis, multiple iterations of the tool and usability testing.
  • The trial is the first to show that a universal EHR-integrated CDS tool using a validated VTE risk model (IMPROVE-DD) had a high adoption rate (77%), significantly increased rates of in-hospital appropriate Thromboprophylaxis and significantly reduced major Thromboembolic events without an increase in major bleeding at 30 days post-discharge compared to usual medical care. Thirty-day mortality was higher in the intervention hospital group.
  • The study team spoke about the tension that often exists between solutions that are tightly integrated into a specific EHR and the ability to disseminate them widely. Developers worked to find the “sweet spot” in a solution that balanced the two priorities. The tool’s success is attributed to workflow analysis, rapid prototyping, usability testing and its integration with the EHR.
  • The high baseline rate of appropriate in-hospital and at-discharge Thromboprophylaxis in the academic control hospitals suggests that the solution has an even greater potential for positive impact at non-academic or rural hospital settings.

 

Discussion Themes

– How was usability tested and how does the tool fit into a clinician’s daily routine? With every iteration of testing, the team worked to identify barriers in provider workflow. The number of testing rounds, as well as the quality of usability testing, was critical in understanding workflows and the best moment to launch the tool. The team also engaged with a diverse array of providers from multiple hospitals and specialties. It was important to observe behaviors in real time and be open to making changes at multiple points during the design and testing process.

– How did you derive and evaluate the evidence that was used in the IMPROVE-DD VTE CDS tool? The team derived the evidence based on a multivariate analysis from an international prospective registry. The team also conducted multiple external validation projects using the same weights and scores. In doing this, they were able to replicate the data among different populations.

– How can tools like this contribute to clinical decisions based on data for subgroups instead of broader guidelines? The study team is hopeful that this effort and others like it will promote clinical decisions that are based on evidence for patient subgroups. Clinical recommendations should be based on more specific data, as there are public health implications for guideline statements that are too broad.

-What is the explanation for the excess deaths at 30 days in the intervention group? The trial was designed before the COVID-19 pandemic, but it was conducted during the height of the pandemic in New York. Because of rebalancing of physicians, there were more COVID-19 patients in the intervention group. Researchers considered this an epiphenomenon that likely reflects the imbalance of the COVID-19 patients in the intervention group. More analysis is needed to confirm that hypothesis

Tags

#pctGR, @Collaboratory1