Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients

Abstract

Objectives To compare the ability ofdifferent electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. Methods A validated question asking if the user would be surprised by the patient's 6- month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions -(1) Required onOpen chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as Yes or No, rather than deferral. Data were extracted over 6 months. Results Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of No, suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). Conclusion Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates ofmeaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.