Optimizing Decision Support Alerts to Reduce Telemetry Duration: A Multicenter Evaluation.

Lipid-lowering therapy (LLT) is underutilized for very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) sought to determine whether electronic health record (EHR) alerts improve 90-day LLT intensification in patients with very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID was a pragmatic trial in which cardiovascular and internal medicine clinicians within Yale New Haven Health (New Haven, CT) were cluster-randomized to receive an EHR alert with individualized LLT recommendations or no alert for outpatients with very high-risk atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol), ≥70 mg/dL. The primary outcome was 90-day LLT intensification (change to high-intensity statin and addition of ezetimibe or PCSK9i [proprotein subtilisin/kexin type 9 inhibitors]). Secondary outcomes included LDL-C level, proportion of patients with LDL-C of <70 or < 55 mg/dL, rate of major adverse cardiovascular events, ED visit incidence, and 6-month mortality. Results were analyzed using logistic and linear regression clustered at the provider level. The no-alert group included 47 clinicians and 1370 patients (median age, 71 years; 50.1% female, median LDL-C, 93 mg/dL); the alert group included 49 clinicians and 1130 patients (median age, 72 years; 47% female, median LDL-C 91, mg/dL). The primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. There were no differences in any secondary outcomes at 6 months. Among 542 patients whose clinicians (n=46) did not dismiss the EHR alert recommendations, LLT intensification was significantly greater (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48-3.66]). With a real-time, targeted, individualized EHR alert as compared with usual care, the proportion of patients with atherosclerotic cardiovascular disease with LLT intensification was numerically higher but not statistically significant. Among clinicians who did not dismiss the alert, there was a > 2-fold increase in LLT intensification. EHR alerts, coupled with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04394715, https://www.clinicaltrials.gov/ct2/show/study/NCT04394715.

No study to date has examined the effectiveness of integrating clinical decision support tools, like electronic health record (EHR) alerts, into the clinical care of youth at-risk for suicide. This study aimed to examine the feasibility and acceptability of using an EHR alert to increase clinicians’ use of safety planning with youth at-risk for suicide in an outpatient pediatric psychiatry clinic serving an urban low-income Latino community. An alert intervention was developed to remind clinicians to complete a safety plan whenever they documented that their patient endorsed suicidal ideation, plan, or attempt during a visit in EHR notes. The alert appeared as a separate window containing a reminder message to complete a safety plan once a clinician finished visit documentation. There were 69 at-risk patients between the ages of 13–21 in the intervention period (M = 15.71; SD = 1.86; 66.7% female) and 64 (M = 15.38; SD = 1.93; 68.6% female) in the control period. Logistic regression analyses indicated that patients in the intervention period were significantly more likely than patients in the control period to receive a safety plan (p < .01). The pattern of results remained the same after adjusting for demographic variables (p = .01). Forty clinicians also completed a questionnaire assessing their satisfaction with the EHR alert, indicating moderate satisfaction (M = 3.01; SD = 0.63; range = 1.11–4.11). EHR alerts are associated with changes in clinicians’ behavior and improved compliance with best clinical practices for at-risk youth.

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

Guidelines recommend using telehealth for hypertension management, but insufficient evidence is available to guide strategies for incorporating telehealth data into clinical practice. To describe how primary care teams responded to elevated remote blood pressure (BP) alerts in the electronic health record (EHR) in a randomized clinical trial of BP telemonitoring conducted in routine practice settings. This retrospective cohort study reviewed EHR documentation from May 8, 2018, to August 9, 2019, in a single urban academic family practice site. Primary care teams comprising 28 attending physicians and nurse practitioners, residents, and nurses cared for 162 patients in a text-based clinical trial of remote BP monitoring remote BP monitoring. Data were analyzed from October 21, 2019, to April 30, 2021. Clinicians received a direct message in their EHR inbox when patients submitted at least 3 elevated BP readings. Categories and frequencies of clinician action, created via review of EHR-documented clinician responses to EHR alerts by 2 physicians. Patients in this study (n = 162) were predominantly female (111 [68.5%]) and Black or African American (146 [90.1%]), whereas attending physicians (n = 21) were predominantly female (13 [61.9%]) and non-Hispanic White (19 [90.5%]) with a mean (SD) age of 51.6 (11.1) years. Five hundred fifty-two alerts fell into 12 categories of clinical actions. Clinicians acted on 343 alerts (62.1%). Common remote activities were to reconcile medications and assess adherence (120 of 552 alerts [21.7%]) and verify BP measurement technique (65 of 552 alerts [11.8%]). Clinicians also commonly requested appointments (120 of 552 alerts [21.7%]) and/or saw the patient in a subsequent office visit (114 of 552 alerts [20.7%]). Ninety-six alerts (17.4%) resulted in medication changes; half of these changes were remote (48 of 96 [50.0%]), and the other half were visit-based. For 209 of 552 alerts (37.9%), no changes were made to the care plan, typically without documenting clinical rationale (196 of 209 instances [93.8%]). Exploratory EHR review was used to infer potential clinical rationale for 106 (54.1%) of such cases, but there was insufficient information for the remaining 90 (45.9%). These findings suggest that EHR alerts for elevated BP during remote monitoring were effective in prompting a mix of remote and office-based management. It was also common for the plan of care to remain unchanged, possibly suggesting need for more refined alerts and improved clinician support.

BackgroundAllergies to BLA may affect ∼10% of the population, few are IgE-mediated, and cross-reactivity between agents is low. Removing CSAs from EHRs may increase BLA use. Impact of such interventions on prescribing behavior, interactions with EHR alerts, and antibiotic administration patterns is poorly understood.Table 1.Characterization of Beta Lactam Cross-Sensitivity Alerts and Clinician Actions to Alert ContactsTable 2.Antibiotic and Epinephrine Administration during Inpatient Encounters within 24 Hours Following Index Cross Sensitivity Alert Triggered by Beta-Lactam Orders in Beta Lactam Allergic PatientsMethodsA quality improvement (QI) intervention consisting of suppression of CSAs for BLA orders within our Epic Systems™ EHR, clinician education, guideline and order set updates was undertaken at a large academic hospital. CSA contacts by clinicians (excluding verifying pharmacist and one step intraoperative anesthesiologist orders) during an index inpatient BLA order for BLA allergic patients pre- (10/1/2022 -3/31/23) and post- (10/1/2023 – 3/31/2024) were reviewed. Confounding alerts for multiple beta-lactam allergies were excluded, no exclusions were made for allergy type, severity, or treatment indication. Actions taken in response to the alert or lack thereof were compared pre and post intervention (Table 1). Systemic antibacterial administrations and intramuscular (IM) epinephrine within 24 hours of alert contact were evaluated. Statistical analysis was conducted using chi square and fisher’s exact test in GraphPad Prism version 2025.ResultsTotal 18761 CSA contacts were examined, encompassing 11255 inpatient encounters for 6539 unique patients. Baseline overall alert override rate was variable relative to clinician role, with an average of 57.52% override expectedly decreasing to 0.06% (p < 0.00001) postintervention (Table 1). Inpatient encounters for BLA allergic patients triggering an index CSA via a BLA order were more likely to incur documented administration of any antibacterial (57% vs 75%, P< 0.001) with higher proportion of beta lactams (82% vs 91.3%, P< 0.001). There was no difference in IM epinephrine administrations (Table 2).ConclusionA comprehensive QI intervention focused on suppression of frequently overridden BLA CSAs enhanced likelihood of allergic patients receiving BLA at index inpatient antibiotic prescribing, without an increase in severe immediate anaphylactic reactions requiring epinephrine. More studies are needed to evaluate the impact of such interventions on stewardship goals in BLA allergic patients.DisclosuresDavid Dobrzynski, Jr., MD, DynaMed: Advisor/Consultant|Innoviva Therapeutics Inc: Advisor/Consultant

Jody Jackson, RN, BSN1, Donna Bliss, PhD, RN2, Kenneth Hepburn, PhD3, Casey Arntson2, Jean Mullins2 and Sharon Rolnick, PhD, MPH1 1HealthPartners 2University of Minnesota 3Emory University

The proliferation of electronic health record (EHR) alerts has led to widespread alert fatigue and clinician burnout, undermining the effectiveness of clinical decision support and compromising patient safety. We introduce a comprehensive style guide for designing interruptive alerts (IAs) in EHR systems to improve clinician engagement and reduce alert fatigue that has been approved by our institutional alert governance committees. This style guide addresses critical aspects of IAs, including format, typography, color coding, title brevity, patient identification, and introductory text. It also outlines the use of typographic emphasis, response options, default actions, and opt-out mechanisms, emphasizing the need for clear, concise, and actionable alerts that consider clinician workflow and cognitive burden. A standardized style guide for IAs can enhance clinician experience and clinical outcomes by reducing alert fatigue. Incorporating feedback and continuous evaluation of alert effectiveness is essential for maintaining relevance and supporting patient care within a dynamic clinical environment.

Physicians frequently use cardiac monitoring, or telemetry, beyond the duration recommended by published practice standards, resulting in "alarm fatigue" and excess cost. Prior studies have demonstrated an association between multicomponent quality improvement interventions and safe reduction of telemetry duration. To determine if a single-component intervention, a targeted electronic health record (EHR) alert, could achieve similar gains to multicomponent interventions and safely reduce unnecessary monitoring. This cluster-randomized clinical trial was conducted between November 2016 and May 2017 on the general medicine service of the Division of Hospital Medicine at the University of California, San Francisco Medical Center and included physicians of 12 inpatient medical teams (6 intervention, 6 control). The EHR alert was randomized to half of the teams on the general medicine service. The alert displayed during daytime hours when physicians attempted to place an order for patients not in the intensive care unit whose telemetry order duration exceeded the recommended duration for a given indication. The primary outcome was telemetry monitoring hours per hospitalization, which was measured using time-stamped orders data from the EHR database. Physician responses to the alert were collected using EHR reporting tools. The potential adverse outcomes of rapid-response calls and medical emergency events were measured by counting the notes documenting these events in the EHR. Of the 1021 patients included in this study, in the intervention arm, there was a mean (SD) age of 64.5 (18.9) and 215 (45%) were women; in the control arm, there was a mean (SD) age of 63.8 (19.1) and 249 (46%) were women. The 12 teams were stratified to 8 house-staff teams and 4 hospitalist teams, with 499 hospitalizations analyzed in the intervention arm and 567 hospitalizations analyzed in the control arm. The alert prompted a significant reduction in telemetry monitoring duration (-8.7 hours per hospitalization; 95% CI, -14.1 to -3.5 hours; P = .001) with no significant change in rapid-response calls or medical emergency events. The most common physician response to the alert was to discontinue telemetry monitoring (62% of 200 alerts). A targeted EHR alert can safely and successfully reduce cardiac monitoring by prompting discontinuation when appropriate. This single-component electronic intervention is less resource intensive than typical multicomponent interventions that include human resources. ClinicalTrials.gov identifier: NCT02529176.

SAT0574 Improving Timely Follow-Up after High Blood Pressures in Rheumatology Clinics Using Staff Protocols

ObjectiveElevated lipoprotein(a) [Lp(a)] is an independent, genetically determined risk factor for atherosclerotic cardiovascular disease (ASCVD). We evaluated the frequency of testing for elevated Lp(a) and subsequent management at the Johns Hopkins Hospital, a large academic medical center, over a 5-year period. MethodsThe Johns Hopkins Hospital (JHH) electronic medical record was queried to identify patients with an encounter between 2017 and 2021, either with established ASCVD or at increased risk, defined as being on any lipid lowering medication or having LDL-C ≥ 190 mg/dL. The frequency of Lp(a) testing and of elevated levels were identified for each year. ResultsAmong 111,350 unique adult patients, 2,785 (2.5 %) had at least one Lp(a) test. Patients with Lp(a) testing, compared to those without testing, were younger (mean age 56 years vs. 66 years), more often female (49 % vs. 44 %), Black (24.7 % vs. 24.6 %) or “other” race/ethnicity (12 % vs 10 %), and had higher LDL-C levels (median 118 vs. 91 mg/dL; p < 0.001). The number and frequency of Lp(a) testing increased from 167 (0.57 %) in 2017 to 1155 (5.67 %) in 2021. Lp(a) levels were abnormal in 43.4 % of patients (moderate [75–125 nmol/L]: 10.3 %, high [126–600 nmol/L]: 32.2 %, severe [>600 nmol/L]: 0.9 %). Among 920 patients with high or severe Lp(a) levels, 200 (22 %) had a subsequent referral to cardiology or lipid specialist, and 180 (20 %) had a new lipid-lowering medication prescribed in the subsequent 18 months. ConclusionBased on a single-center experience, the frequency of incident Lp(a) testing among increased-risk patients was low but increased significantly over 5-years, likely due to Lipid Clinic referrals with reflex Lp(a) testing and greater awareness about this risk factor. Future work should target appropriate population based Lp(a) testing strategies and clinical decision-making regarding risk management once Lp(a) elevation is diagnosed.

Global Human papillomavirus (HPV) vaccination rates remain low despite available WHO-approved vaccines. Digital interventions for promoting vaccination uptake offer a scalable and accessible solution to this issue. Here we report a systematic review and meta-analysis examining the efficacy of digital interventions, comparing educational and reminder approaches, for promoting HPV vaccination uptake (HVU). This study also identifies factors influencing the effectiveness of these interventions. We searched PubMed, PsycInfo, Web of Science, and the Cochrane Library from each database’s inception to January 2023. Three raters independently evaluate the studies using a systematic and blinded method for resolving disagreements. From 1929 references, 34 unique studies (281,280 unique participants) have sufficient data. Client reminder (OR, 1.41; 95% CI, 1.23–1.63; P < 0.001), provider reminder (OR, 1.39; 95% CI, 1.11–1.75; P = 0.005), provider education (OR, 1.18; 95% CI, 1.05–1.34; P = 0.007), and client education plus reminder interventions (OR, 1.29; 95% CI, 1.04–1.59; P = 0.007) increase HVU, whereas client education interventions do not (OR, 1.08; 95% CI, 0.92–1.28; P = 0.35). Digital intervention effectiveness varies based on participants’ gender and the digital platform used. Interventions targeting male or mixed-gender participants demonstrate greater benefit, and reminder platforms (SMS, preference reminders, or electronic health record alerts) are more effective in increasing HVU. Digital interventions, particularly client and provider reminders, along with provider education, prove significantly more effective than client education alone. Incorporating digital interventions into healthcare systems can effectively promote HPV vaccination uptake. Reminder interventions should be prioritized for promoting HVU.

Congenital syphilis (CS) persists as a preventable cause of stillbirth and neonatal morbidity despite the availability of simple screening and curative treatment. Fragmented legal mandates, inconsistent payer coverage, and variable maternal–fetal medicine (MFM) workflows contribute to preventable transmission. This systematic review and policy synthesis integrates global evidence to define a modern framework for eliminating CS through coordinated action across law, financing, and clinical care. Comprehensive searches of biomedical databases, guidelines, and policy registers identified 2292 records; 27 studies met the inclusion criteria following Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 standards. Sources included systematic reviews, national guidelines, modeling studies, and legal documents. Data were extracted on screening schedules, treatment regimens, coverage mechanisms, and workflow integration. Quality was assessed using A Measurement Tool to Assess Systematic Reviews, version 2, Risk of Bias in Systematic Reviews, and Newcastle–Ottawa tools. Across studies, universal early testing, third-trimester and delivery rescreening, and benzathine penicillin access were consistently associated with improved outcomes. National mandates and payer reimbursement policies increased screening compliance, while electronic health record alerts and point-of-care testing shortened treatment delays. However, persistent inequities affected low-resource and minority population. Synthesized findings support a “triple-lock” model – binding legal mandates, guaranteed financial coverage, and digital workflow automation – as the pathway to sustainable elimination. The review calls for harmonized laws, procurement transparency, and integrated partner management within antenatal care. Although not registered in PROSPERO due to its cross-disciplinary scope, this review provides the most comprehensive evidence-policy bridge to date for the global eradication of CS.

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

Context: This literature review mostly emphasizes on the challenges and barriers for acceptance and implementation of electronic health records (EHRs) in developing countries. Although the willingness of developing countries for acceptance and implementation of EHRs is rising, they will face some challenges and barriers which can slow down their progress due to the multidisciplinary and complexity characteristics of EHRs. Some of these challenges and barriers can be seen in the past and present histories of EHRs acceptance process in developed countries too. Familiarity with these challenges and barriers will help developing countries to have better understanding of these problems towards successful EHRs. The main goal of this survey is to study the challenges and barriers of acceptance and implementation of EHRs in the developing countries and how they can overcome such problems. Evidence Acquisition: Two databases, Pub-Med and Scopus with Combination of terms such as Electronic Health Records, Developing Countries, Barriers, Challenges, Acceptance, and Adoption were searched. Totally, 514 articles extracted. Some exclusive criteria such as date of publication (year 2000 and above) and having a close relation to the subject of the study (through abstract) were applied. The result was eight articles from Scopus and 12 articles from Pub-Med. Also, 7 articles were extracted by general search in internet. Also, 11 articles with the same search policies were selected from Journal of Health informatics for Developing Countries (JHIDC) with no exclusion criteria. Results: Developing countries must be fully aware of challenges and barriers in their way towards EHRs. They also need to study the experiences of countries which are successful in acceptance and implementation of EHRs. Developing countries also need to provide infrastructures needed for a successful implementation of EHRs. Conclusions: Despite the positive effects of EHRs in healthcare services, the acceptance rate of EHRs in developing countries and even developed countries is still low. The developing countries are facing many problems in their way toward implementing successful EHRs. Lack of infrastructures in information and communication technology, cost, and cultural resistance are considered as main barriers for developing countries in their approach to accept and implement EHRs.

311 Background: Despite guidelines recommending germline genetic testing (GT) and genetic counseling for individuals with pancreatic ductal adenocarcinoma (PDAC), referrals remain suboptimal. This can have negative implications on treatment, particularly for patients with actionable mutations. This project aims to compare the referral rate to genetic services of MD Anderson Cancer Center at Cooper pre- and post-implementation of an electronic health record (EHR) physician best practice advisory (BPA) recommending a cancer genetics referral order for PDAC patients. Methods: Medical records, cancer genetics referrals (CGR), and germline and somatic testing results were retrospectively reviewed for patients with a PDAC diagnosis in 2019-2020, and prospectively for those diagnosed after BPA implementation from October 2021 through May 2022. The primary outcome was the rate of CGR, and the secondary outcomes were genetic counseling encounters and GT completion. Descriptive statistics were used for analysis. Results: Prior to BPA initiation, CGR were offered to 44 (24.3%) of 181 eligible patients with 39 (88.6%) of those accepting CGR. Germline testing represented 90.9% (30 patients) of the GT performed in the pre-BPA group. Post-BPA, CGR were offered to 23 (51.1%) of 45 eligible patients with 20 (86.95%) of those accepting CGR. Germline testing represented 100% (13 patients) of the GT performed in the post-BPA group. Conclusions: Only 24.3% of patients diagnosed with PDAC between 2019-2020 were referred to cancer genetics, showing that even after updated NCCN guidelines in 2018 the CGR rate remained low. Following BPA implementation, CGR increased to 51.1% over 8 months for newly diagnosed patients. Germline testing increased by 10%. These preliminary results show that implementing a physician BPA can increase CGR and germline GT, which could have positive implications on treatment. Limitations include a lack of a standardized referral process for the pre-BPA group and a limited timeframe to obtain GT for the post-BPA group.[Table: see text]