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How Does an Education Intervention (EI) vs. an Electronic Health Record (EHR) Best Practice Alert Impact Provider Use of an EHR Community Acquired Pneumonia (CAP) Order Set in a University Emergency Department (ED)?

Frank Thomas – University of Utah, Mr. Matt Sanford – University of Utah, Dr. Christy Hopkins – University of Utah, Dr. Claire Ciarkowski – University of Utah, Dr. Karli Edholm – University of Utah School of Medicine, Dr. Nathan Hatton – University of Utah School of Medicine, Mr. Steve Johnson – University of Utah, Mr. Dave Roach – University of Utah, Dr. Emily Spivak – University of Utah School of Medicine

Background
The Electronic Health Record (EHR) is evolving from a data storage resource to a clinical decision support (CDS) tool. EHR alerts can help guide healthcare providers toward better patient decision-making.1 However, research also warns that excessive use of alerts can cause alerts to be ignored due to “alert fatigue”.2-4

Objectives
The purpose of this value project was to compare the impact of (1) a two part educational intervention aimed at increasing awareness and utilization of an EHR CAP order set vs. (2) the use of an EHR alert to direct ED providers to the EHR CAP Order Set.

Methods
4-Study Periods were Evaluated in 2017-2018 (n= Number of Patients with CAP): Phase 1(February 1-March 31): Baseline analysis before the EHR CAP Order Set was implemented (n=70), Phase 2 (April 1- May 31): Educational Intervention before and during the early initiation of the EHR CAP Order Set (n=71), Phase 3 (June 1-Aug 31): EHR CAP Order Set implemented without Alert (n=95), Phase 4 (Sept 1-Jan 31): EHR CAP Order Set with Alert implemented (n=200).
Educational Intervention: Part 1: From April 1-May 31st, ED clinical staff (attendings, house officers, nurses, respiratory therapists, and medical assistants) and support personnel were educated by a powerpoint presentation in a classroom setting, division meeting, and faculty meeting describing how to use the EHR CAP Order Set. Part 2: From June, 2017-January, 2018, monthly e-mails were subsequently sent to newly rotating house officers reminding them of the EHR CAP Order Set.
EHR CAP Order Set Alert Intervention: Starting September  1, 2017-January 31, 2018 an ED patient who receives a chest radiograph and when the provider orders an antibiotic  an EHR CAP Order Set Alert is triggered, “If this antibiotic is for pneumonia, click ‘Open order set’.” If selected, the Order Set opens and suggests standard diagnostic testing (blood/sputum cultures, urinary antigen testing), and best practice antibiotics.

Results
436 patients admitted through the ED from February 1, 2017-January 31, 2018 with a CMS diagnosis of CAP were evaluated. (See Figure 1: % EHR CAP Order Sets Initiated In The ED)

Conclusion
Education Intervention and a monthly e-mail EHR CAP Order Set reminders appear to initially improve the rate of EHR CAP Order Set usage by providers within the ED. However, these early usage levels are not sustained with just the monthly e-mail EHR CAP Order Set reminders and eventually EHR CAP Order Set usage fall to levels approximately half the initial peak effect. The implementation of EHR CAP Order Set Alert has a dramatic effect on the usage rate of the EHR CAP Order Set. The use of EHR Alerts appears to sustain EHR CAP Order Set usage rates at 2.5-3.0 times the educational intervention.

Implications for Patient Care
The use of EHR order sets as a means of guiding patient clinical care is increasing. Organizations contemplating the implementation and use of an EHR order set can benefit from an educational intervention and the use of EHR Alerts as a means of increasing their utilization.