Hello everyone.
Thank you for tuning in to the Becker's Healthcare podcast series.
My name is Mariah Mohammed, writer at Becker's Healthcare,
and today we'll be discussing how alerts in the E H R system may help bridge the
17 year gap between publication of evidence-based guidelines and consistent
implementation and practice by healthcare providers.
We are thrilled to be joined by Dr. Ralph Rlo and Dr. Nihar Desai.
Before we get started, Dr. Rlo and Dr. Desai,
can you please share a bit more about yourself, starting with you, Dr. Rlo?
Certainly. Yeah. So my name is Ralph Frio. I'm a clinical pharmacy specialist,
uh, that's been working, uh, with Yale Health System for over a decade. Um, and,
and tr transitioned a few, uh,
years ago over to the School of Medicine to partner with, uh,
some wonderful cardiologists like niha on,
on some exciting trials like Prompt Lipid.
Perfect. Thank you very much. And then Dr. Desai?
Sure. Uh, Nihar Desai.
I'm a cardiologist here at the Yale School of Medicine and Vice Chief of
Cardiology here. And, um,
also very interested in implementation science and doing pragmatic clinical
trials, which we're really excited to talk about, um, today.
Yeah, absolutely.
Thank you again so much for joining us today to the both of you and Dr. Desai.
If I could ask you the first question for those tuning in who may have not seen
the featured presentation at the American Heart Association Conference,
can you please explain the objective of the Prompt Lipid trial and summarize
the key findings for us?
Sure. Merh delighted too. So,
prompt Lipid was really designed to evaluate whether automated
electronic alerts with guideline based recommendations could help to improve
the management of hyperlipidemia among patients with established cardiovascular
disease at very high risk for cardiovascular events.
And what we were very excited to see in this trial of about 100 providers
and over 2000 patients is a significant increase in
the use of evidence-based lipid lowering therapies. In fact,
we saw that those providers who received this decision
alert were about 40% more likely to intensify lipid
lowering therapy.
And then amongst the subset of providers who sort of more favorably interacted
with the alert,
we saw a more than twofold increase in the use of evidence-based lipid lowering
therapies.
Wonderful. Yeah. Thank you so much for that background information. Now, Dr.
Rlo,
the prompt lipid research team felt strongly that patients with
very high risk atherosclerotic cardiovascular disease would make for a
compelling population to test an innovative approach to quality improvement.
Can you explain why that is?
Yes, it certainly can, uh, Mariah, and that patients with atheros, uh,
sclerosis, uh, cardiovascular D uh, disease or A S C B D, um,
we know that their, their l LDL well, um, L D L cholesterol L LDL C is,
has been a critical modifiable risk factor, um, for their disease that,
that we as providers can control. And in lipid lowering therapy,
particularly intensive lipid lowering therapy for this high risk patient
population, you know, it's been recommended by,
by clinical practice guidelines for years. Um, however,
the evidence practice gap between what the guidelines say we should be doing and
the therapies our patients actually receive in, in real world practice, um,
is vast. Um,
only about half of patients with A S C V D are actually prescribed any statin
whatsoever in the United States. Um,
and fewer than a quarter of these patients are, are even prescribed, uh,
the appropriately recommended high-intensity statin. So as it currently stands,
sort of passive diffusion of these guidelines, um, to, to our providers and, uh,
to make sure that these therapies reach patients, um, just really isn't enough.
And, and clinical inertia really, um, you know,
prevents our providers from, from passing on these therapies to patients. Um,
so, so we were hoping that the C H R alert might do something to change that.
Yes. Thank you for those insights. Dr. Rlo, Dr.
Desai of the many E H R alerts that fire every day for clinicians using
the electronic health record system.
Very few are ever subject to thorough evaluation after they're deployed.
What prompted your research team to go through the extra effort?
Yeah, it's a great question, and I think as you heard from Ralph,
that there was a real sense of urgency that our team felt that, you know,
patients with high risk atherosclerotic cardiovascular disease really needed
intensification of their lipid lowering therapy.
We thought that an alert like this that was real time,
that was targeted and tailored, um, would be helpful to providers,
but we were committed to actually testing it in a very rigorous way to actually
define and determine whether an alert like this would actually do the things
that we wanted it to do. And again, we were very pleased with, um,
the results of prompt lipid that really again showed, um,
the benefits of an alert like this to improve the quality of care for our
patients with very high risk A C B D.
Yeah, and to, to dovetail off Neer's point there as well,
I think all too often when, uh,
when health systems look to implement alerts like these in the,
in electronic health record, um, very rarely are they ever actually, you know,
formally studied in a, in a prospective fashion,
let alone in a randomized controlled trial. And, and, you know,
I think the consequence of that is, is, you know, contributes to alert fatigue.
Many of these alerts, you know, as important as they may be, tend to get ano uh,
ignored. You know, for instance, we're, we're,
we're in deep flu season right now. Uh,
I can't even tell you how many charts I've opened up just to get pinged with
these alerts that, that I know most of our clinicians click through. So,
so it's important to understand in a,
in a well controlled setting how these alerts actually perform and, and,
you know, do what they're intended to do.
Absolutely. Yeah, I completely agree. And it seems that that actually,
that really did pay off, thankfully. Um, if I could come back to you actually,
Dr. Rlo, the providers, uh,
surveyed in both the Prompt HF and prompt lipid trials seem to view the
alert quite favorably and often accepted the recommendations as suggested.
What about your team's approach enabled that user finding what you say.
? Yeah, Mariah, that was a really good point. Um, um,
that might've been one of the most surprising things I think that we came away
with. Um, uh, some of the results from our,
our various prompt studies for 'em and promptly it's, uh,
certainly notwithstanding, um, I I think it has to do with our secret sauce and,
and that's, that's engaging our, you know,
highest volume cardiology stakeholders upfront and early in that process.
You know, give them a seat at the table, listen to them, uh, you know,
engage them, you know, recruit them for feedback. And, and we actually had a,
a couple separate focus groups with, with, you know, the busiest, um, you know,
lipid lowering therapy prescribers to make sure, you know,
these are the ones in the front lines of healthcare doing the work that,
that we think is important and, and that we wanna see more of. So, you know,
by asking them for their input on not just the build of the alert, but you know,
when it should fire what the order set should look like,
what labs should display, um, we felt like, you know, their input was,
was incredibly valuable to make sure we designed something that was
user-friendly for the people who would actually use it and buy the people that
used it. Because cuz sure, you know, Nihar and I have, you know,
spent our careers caring for cardiovascular patients, but,
but we want to ask what others think about that too, to make sure that,
you know, it, it,
it helps facilitate their clinical workflow rather than hinder it in any way.
Yeah. Yeah,
making sure everyone feels heard is definitely essential for these types of
trials. And Dr. Desai, if I could ask you,
alert fatigue is a pressing concern for many frontline clinicians and may have
consequences for patient safety as well as contribute to provider pa uh,
burnout. How did the prompt lipid trial help address this barrier?
Yeah, it's a great question and a great point and I'll,
I'll build on much of what Ralph, you know,
just started to discuss about the design of the alert.
And so alert fatigue is a real concern. I think all of us, you know,
practicing on the front lines are, are loathe to get additional alerts,
you know, especially those that interrupt or interfere, um, you know, with,
with direct clinical workflow. And I think one of the things that we did,
you heard about from Ralph was we engaged frontline providers and said, Hey,
what, what do you wanna see? What should the alert look like? Um,
what time in your clinical encounter should it fire?
I think the other thing that we did was very helpful was we brought and pulled
information from the medical record that might otherwise take 2, 3, 4
other clicks and actually brought that into the alert.
And I think the final piece of it is that we made the alert pretty easy to
interact with that if you wanted to do the right thing,
if you wanted to open the order set,
that the orders were actually embedded within the alert itself. Um, and so that,
that step from interacting with the alert to then doing the right thing was
about as simple and straightforward as could be. And so I think, you know,
many of the in secret ingredients as, as Ralph calls them, um, ,
you know, kind of, you know, get, getting the engagement of,
of clinicians upfront, um, really thinking deep about, you know,
what the alert itself looks like,
pulling information into it and then embedding,
ordering capability within the alert to really make it a very seamless
experience. So that at least I hope, you know,
gives you a sense of what we were trying to do to try and overcome that kind of
intrinsic fear that everyone has about alert fatigue.
Yeah. And, and I think another point to add on there,
there ni at least to emphasize again cause I I think it's so important,
is that the, the alert only fires when the patient has, you know,
low hanging fruit, you know, guideline recommended but not yet implemented,
um, change with their therapy. So you know, it,
the alert's not gonna suggest them to do something that would be duplicative or,
you know, the patient's already on a statin.
Why is this telling me to prescribe another one? Um, it,
it's really just a meaningful easy change at the point of care only when
it's indicated for the patient.
Yeah. Yeah. Thank you very much to, to both of you for that information, Dr.
Relo, before I let you both go,
I must ask now that the prom lipid trial is completed,
what are the next steps for your research team to further explore opportunities
on these findings?
Yeah, great question, right?
We always need to look beyond sort of our own house, um, to, to,
to make sure that we can then extrapolate these findings to,
to other systems as well. And, and I think the, the, the prompt research team,
et cetera, definitely has some big plans for that. Um, for, for one, this, uh,
the prompt lipid trial was conducted exclusively at Yale Health System and the
outpatient, uh, clinic's, uh, both cardiology and medicine. Um,
but we would certainly like to see, you know, how this, you know,
study performs beyond our own, you know, neighborhood beyond our community, um,
and expand that to, to other interested sites. Um, additionally the,
the study only took place, um, on, on Epic as our E H R platform across Yale.
Um, but certainly wouldn't be nice if, if we could expand that to other eh,
h r platforms as well.
It's not sort of pigeonhole ourselves just to one particular eh,
r platform and make it more interoperable for other sites that that may be using
different ones. Um, and, you know, expand it to, to other clinical settings.
You know, maybe focus on primary care or endocrine,
but we know a lot of these patients, um, you know,
may also frequently see providers as well.
Yeah. And I, I I, I might just add, you know,
I think there's a lot of important work ahead and,
and I think we're very excited to build on the results of prompt, um,
and prompt lipid to then, you know, think about what else can be done. I mean,
I think Mariah, you very nicely kind of said right at the front of, you know,
how do we bridge the gap between evidence and practice?
How do we shorten that time from when things go into the guidelines and they're
actually received by patients? And so I think there's a lot of work to do, um,
and we're really excited to build on, you know,
the exciting results for Prompt Lipid.
Absolutely. And I'm also excited to hear back on what you finds. Um,
and I wanna thank both of you, Dr. Rlo and Dr.
Desai for your time and thought provoking conversation today.
We also wanna thank our podcast sponsor Amgen.
You can tune into more podcasts from Becker's Healthcare by visiting our podcast
page at becker's hospital review.com/podcast.
Thank you both again.