We have described an innovative program designed to bring public health situational awareness into the clinical setting. Clinicians were given appropriate recommendations during urgent public health situations using BPAs in an outpatient EHR. Although we did not document the direct connection between the alert and the clinical reasoning leading to the action, a causal relationship may be inferred in Case 2 when a urine Legionella test was collected for the first time in five years soon after the alert firing. This project illustrates two key elements for success: the alert development process is rapid and flexible, and the alerts provide up-to-date local situational awareness, best practice management guidance, and DOH contact information. The benefits of providing these notifications include automated identification of potential cases and point-of-care distribution of DOH-recommended diagnostic testing.
While the creation of these alerts is performed manually, with the CMIO designated to translate HAN alerts into an operationalized alert, they can be proposed by any of the management team. Approaches to the alert development at other institutions have included internal committees of experts who develop and review protocols, which are then formulated into electronic tools7
and purchasing evidence-based clinical decision support content from outside vendors, governmental agencies, or specialty societies organizations.8
Both these practices may be inadequate to respond to the highly dynamic nature of emerging epidemics. Simplified review committee protocols and an easily customizable EHR alerting framework as demonstrated in our institution are necessary to provide timely point-of-care decision support.
Incorporating the newest national or local recommendations for treatment of diseases with public health implications is crucial. The alert not only guides clinicians toward diseases they would not typically consider, but as in the E coli case, the system was able to advise clinicians to use supportive care and avoid unnecessary antibiotic treatment. The appropriate lab tests in coordination with the DOH were also suggested in each case, improving diagnostic efficacy. This demonstrated the ability not only to help the DOH collect necessary lab tests, but also to guide a wide variety of clinicians to appropriate treatment during urgent situations, a two-way benefit from situational information exchange. Lab testing in coordination with the DOH can also improve timeliness of diagnosis, as some samples can be expedited by coordinating directly with the public health laboratory.
The low rates of alert response in this alerting system are worth noting. During the one-year period from July 1, 2007 to June 30, 2008, there were 43
315 patients that received an alert. Response rates (defined by the provider clicking on the alert in order to open the attached order set) varied from 2% to 65% depending on the particular alert. The number of patients with public health alerts represented less than 1% of total alert volume, so it is unlikely that this type of alert was a high additional burden to clinicians. We were also unable to determine whether clinicians acted appropriately or inappropriately when they ignored alerts. However, we suspect that the relatively crude triggers (chief complaints of fever and rash for measles, for example) generated large numbers of false positive alerts, which were appropriately rejected by providers who were aware of the full clinical context. This potentially could be improved by increased computer-interpretability of the patient history, providing more detailed clinical data points combined with more specific, evidence-based triggers.
The need for clinical guidelines to be expressed with high specificity has been well documented in the literature, and evidence suggests that clinicians are less likely to be responsive to non-specific guidelines. Future EHR alerts must be implemented with this in mind to minimize the potential for alert fatigue,9
and this can be done by targeting the alert to the appropriate patients. At the present time this task must be undertaken by the local medical practice leadership who must first filter out which health department notifications warrant alerts, and then decide how to convert notifications to alerts and order sets recognized by their facility's EHR. Technology to enable centralized decision rules created by public health organizations that can be plugged into generic EHR systems is currently elusive, but steps toward that solution are conceivable. Health departments could distribute alerts with tags specifying the demographic potentially impacted in addition to providing some decision support guidance, such as designating possible structured data triggers (chief complaint, vital sign parameters, diagnosis codes, or medication/procedure orders) that should be used in generating an alert.
In the context of a primary care ambulatory practice, the low number of directly applicable HAN messages allows the IFH clinical leadership to rapidly develop and roll out electronic decision support. As a direct consequence of this “just in time” support, we have demonstrated the ability to affect clinical behavior, and in one case rapidly supply clinical specimens back to the DOH, thereby providing critical data during disease outbreaks. Using the process described, the responsibility of setting priorities and clinical protocols for urgent public health situations could be more completely ceded to the central public health authority, allowing the clinical site to focus on operationalizing recommendations into workflow and disseminating context-appropriate information to clinicians in a form that allows immediate action. As use of electronic health records becomes the standard of care, clinical care could potentially benefit from further development of alerts originating from health departments, to be both tightly focused in addressing particular practice environments and automatically incorporated into patient care workflow.