"Stealth" alerts to improve warfarin monitoring when initiating interacting medications

Abstract

Background: As electronic health records (EHRs) become widely adopted, alerts and reminders can improve medication safety, but excessive alerts may irritate or overwhelm clinicians, thereby reducing their effectiveness. We developed a novel "stealth" alert in an EHR to improve anticoagulation monitoring for patients prescribed a medication that could interact with warfarin. Instead of alerting the prescribing provider, the system notified a multidisciplinary anticoagulation management service, so that the prescribing clinicians never saw the alerts. We aimed to determine whether these "stealth" alerts increased the frequency of anticoagulation monitoring following the co-prescription of warfarin and a potentially interacting medication.

Methods: We conducted a pre-post intervention study, analyzed using an interrupted time-series, within a large, multispecialty group practice that uses a common EHR. The study included a 12-month period preceding the intervention, a 2-month period during intervention implementation, and a 6-month post-intervention period. The primary outcome measure was the proportion of patients completing anticoagulation monitoring within 5 days of a new co-prescribing event.

Results: Prior to implementation of the stealth alert, 34 % of patients completed anticoagulation monitoring within 5 days after the prescription of a medication with a potential warfarin interaction. After implementation of the alert, 39 % completed testing within 5 days (odds ratio 1.24, 95 % confidence interval 1.12-1.37).

Conclusions: Stealth alerts increased the proportion of patients who underwent anticoagulation monitoring following the prescription of a medication that could potentially interact with warfarin. This team-based approach to clinical-decision support directs alerts away from prescribing clinicians and toward individuals who can directly implement them.

Figure 1.

The screen shot (from a "test" patient in the "test" EHR) shows the stealth alert generated for patients in the post-intervention period. Whenever a patient enrolled in the anticoagulation management service (AMS) received a prescription for a medication that could potentially interact with warfarin (see Table 1), this stealth alert was generated in the InBasket (left side of the screen) of the AMS nurse, who would then contact the patient to arrange appropriate follow-up of the international normalized ratio (INR).

Figure 2.

The interrupted time-series analysis shows the monthly percentage of patients undergoing international normalized ratio (INR) testing within 5 days of co-prescribing event before and after the implementation of the stealth alerts. The figure shows a significant increase in the level, but not the slope, of the trend line. This Finding corresponds to a statistically significant increase in the monitoring rate following the implementation of the stealth alerts.