You Can’t Handle the Truth: The Discordance Between EMR Orders and Reality

From the 2023 HVPA National Conference

Tahir Malik MD (NYU Langone Health), Olivia Korostoff-Larsson BA, Maya Hatley BA, Yunan Zhao MA, Aamina Ahmed BA, Saul Blecker MD, Kevin P. Eaton MD

Background:
Cardiac telemetry monitoring has frequently been identified as an area of overutilization and still remains a limited resource in many hospitals. To help reduce overutilization, we added clinical decision support to our health system’s telemetry order with guidance on appropriate indications and duration for monitoring. The new order required the selection of an appropriate clinical indication.

Objective:
In this study, we aimed to understand the use of this clinical decision support tool in daily practice by assessing the concordance between selected order indications and the actual clinical presence of those conditions.

Methods:
We randomly selected 100 telemetry orders from July to October 2022 across all hospitals at NYU Langone Health. We then reviewed the corresponding charts to identify the documented presence of actual indications for telemetry. We calculated the rate of concordance between selected indications and actual indications that were clinically present.

Results:
There were 30,839 telemetry orders placed during this timeframe. Of the selected indications, 21.4% (6592) were labeled “Confirmed Stroke”, 18.4% (5670) “Other Arrhythmia”, 12% (3691) “Other”, and 10.6% (3276) “Post-Invasive Cardiac Procedure”. On chart review, overall concordance between the selection within the order and the actual indication was 48%. Of the highest volume selections, “Other” and “Confirmed Stroke” had the lowest concordance rates, at 0% and 11.8% respectively. “Post-Invasive Cardiac Procedure” had 100% concordance.

Conclusions:
“Confirmed Stroke” was the only indication that allowed for continuous telemetry without a defined duration, suggesting that providers are more likely to select an indication that reduces downstream work regardless of a patient’s true clinical indication. Providers are also more likely to select less concrete indications such as “Other”. The overall concordance was low suggesting a disconnect between the support tool and actual clinical events.

Clinical Implications:
Understanding how providers engage with decision support within the EMR may help identify ways to better align clinical decision support tools with clinical practice.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog