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Improving clinical quality indicators through electronic health records: it takes more than just a reminder.
Dean F Sittig, Jonathan M. Teich, Jerome A Osheroff, Hardeep Singh
University of Texas School of Health Information Sciences andUT-Memorial Hermann Center for Healthcare Quality and Safety,Houston, Texas 77030, USA.
Journal Article: PEDIATRICS (impact factor: 4.47). 08/2009; 124(1):375-7. DOI: 10.1542/peds.2009-0339
Source: PubMed
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DOI: 10.1542/peds.2009-0339
2009;124;375-377 Pediatrics
Dean F. Sittig, Jonathan M. Teich, Jerome A. Osheroff and Hardeep Singh
Takes More Than Just a Reminder
Improving Clinical Quality Indicators Through Electronic Health Records: It
http://www.pediatrics.org/cgi/content/full/124/1/375
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
2009;124;375-377 Pediatrics
Dean F. Sittig, Jonathan M. Teich, Jerome A. Osheroff and Hardeep Singh
Takes More Than Just a Reminder
Improving Clinical Quality Indicators Through Electronic Health Records: It
http://www.pediatrics.org/cgi/content/full/124/1/375
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
Page 2
Improving Clinical Quality Indicators Through Electronic
Health Records: It Takes More Than Just a Reminder
State-of-the-art electronic health record systems with advanced clini-
cal decision support (CDS) capabilities can fundamentally improve
quality and reduce costs of health care.1,2 However, these outcomes
have not been universally achieved.3,4 As the study by Fiks et al5 in this
issue of Pediatrics demonstrates, providing CDS in the form of “alerts”
to encourage desired health care activities may not be sufficient to
make a substantial impact.6 Maximizing the potential of CDS for improv-
ing quality and safety of care requires attention to several factors, not
all of which are related to the computer system.7
The goal for the study by Fiks et al was to increase vaccination rates in
asthmatic children, so in examining the results onemust first consider
what caused the low vaccination rate in their population. Several fac-
tors could account for the low initial vaccination rates and, hence,
could explain the minimal improvements with alerting. Without knowl-
edge about these factors, it may be too much to expect alerts alone to
fix the problem. Alerts are helpful when an unusual occurrence must
come to a physician’s attention or when a necessary process might be
overlooked in a busy encounter. When other underlying problems lead
to low vaccination rates, such as poor patient acceptance, difference of
opinion about vaccinating patients late in the season, or low priority of
vaccination when a patient has an acute problem, they must be ad-
dressed before the alert can be successful. Indeed, studies of influenza
vaccination reminders in adults have had varying results, and in some
cases these results were directly attributable to such noncomput-
able factors.8,9 It would have been enlightening if the decision sup-
port used in this study also captured the reasons for failure of the
providers to act on the alert by having them select or enter a reason
for nonvaccination.10
In addition, one should also consider whether presentation of the vac-
cination alert as soon as the patient encounter was opened within the
electronic health record was the best CDS intervention to achieve the
desired objectives, compared with other intervention types such as
facesheet displays, order sets, patient education handouts, and end-
of-visit forms. In a guide to CDS implementation that we published in
2005,11 we suggested that different types of CDS presentation, applied
at different parts of the visit workflow, can have very different effects
depending on what it is that one is trying to encourage the physician to
do. Moreover, communication through group academic detailing (used
in this study) may not be the best strategy to educate and change the
behavior of clinicians regarding the concepts behind clinical alerts.12,13
To achieve a specific clinical objective by using a CDS intervention, one
must consider whether the communication and acceptance groundwork
has been laid to maximize the intervention’s impact, and also consider
CONTRIBUTORS: Dean F. Sittig, PhD,a Jonathan M. Teich, MD,
PhD,b,c Jerome A. Osheroff, MD,d,e and Hardeep Singh, MD, MPHf
aUniversity of Texas School of Health Information Sciences and
UT-Memorial Hermann Center for Healthcare Quality and Safety,
Houston, Texas; bElsevier Health Sciences, Philadelphia,
Pennsylvania; cDepartment of Medicine, Harvard University,
Boston, Massachusetts; dThomson Reuters, Ann Arbor, Michigan;
eDepartment of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania; and fHealth Policy and Quality
Program, Houston Veterans Affairs Health Services Research
and Development Center of Excellence, and Center of Inquiry to
Improve Outpatient Safety Through Effective Electronic
Communication, Michael E. DeBakey Veterans Affairs Medical
Center and Section of Health Services Research, Department of
Medicine, Baylor College of Medicine, Houston, Texas
Opinions expressed in these commentaries are those of the authors
and not necessarily those of the American Academy of Pediatrics or
its Committees.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0339
doi:10.1542/peds.2009-0339
Address correspondence to Dean F. Sittig, PhD, University of
Texas Health Sciences Center at Houston, School of Health
Information Sciences, 6410 Fannin St , Houston, TX 77030. E-mail:
dean.f.sittig@uth.tmc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
COMMENTARY
PEDIATRICS Volume 124, Number 1, July 2009 375
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
Health Records: It Takes More Than Just a Reminder
State-of-the-art electronic health record systems with advanced clini-
cal decision support (CDS) capabilities can fundamentally improve
quality and reduce costs of health care.1,2 However, these outcomes
have not been universally achieved.3,4 As the study by Fiks et al5 in this
issue of Pediatrics demonstrates, providing CDS in the form of “alerts”
to encourage desired health care activities may not be sufficient to
make a substantial impact.6 Maximizing the potential of CDS for improv-
ing quality and safety of care requires attention to several factors, not
all of which are related to the computer system.7
The goal for the study by Fiks et al was to increase vaccination rates in
asthmatic children, so in examining the results onemust first consider
what caused the low vaccination rate in their population. Several fac-
tors could account for the low initial vaccination rates and, hence,
could explain the minimal improvements with alerting. Without knowl-
edge about these factors, it may be too much to expect alerts alone to
fix the problem. Alerts are helpful when an unusual occurrence must
come to a physician’s attention or when a necessary process might be
overlooked in a busy encounter. When other underlying problems lead
to low vaccination rates, such as poor patient acceptance, difference of
opinion about vaccinating patients late in the season, or low priority of
vaccination when a patient has an acute problem, they must be ad-
dressed before the alert can be successful. Indeed, studies of influenza
vaccination reminders in adults have had varying results, and in some
cases these results were directly attributable to such noncomput-
able factors.8,9 It would have been enlightening if the decision sup-
port used in this study also captured the reasons for failure of the
providers to act on the alert by having them select or enter a reason
for nonvaccination.10
In addition, one should also consider whether presentation of the vac-
cination alert as soon as the patient encounter was opened within the
electronic health record was the best CDS intervention to achieve the
desired objectives, compared with other intervention types such as
facesheet displays, order sets, patient education handouts, and end-
of-visit forms. In a guide to CDS implementation that we published in
2005,11 we suggested that different types of CDS presentation, applied
at different parts of the visit workflow, can have very different effects
depending on what it is that one is trying to encourage the physician to
do. Moreover, communication through group academic detailing (used
in this study) may not be the best strategy to educate and change the
behavior of clinicians regarding the concepts behind clinical alerts.12,13
To achieve a specific clinical objective by using a CDS intervention, one
must consider whether the communication and acceptance groundwork
has been laid to maximize the intervention’s impact, and also consider
CONTRIBUTORS: Dean F. Sittig, PhD,a Jonathan M. Teich, MD,
PhD,b,c Jerome A. Osheroff, MD,d,e and Hardeep Singh, MD, MPHf
aUniversity of Texas School of Health Information Sciences and
UT-Memorial Hermann Center for Healthcare Quality and Safety,
Houston, Texas; bElsevier Health Sciences, Philadelphia,
Pennsylvania; cDepartment of Medicine, Harvard University,
Boston, Massachusetts; dThomson Reuters, Ann Arbor, Michigan;
eDepartment of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania; and fHealth Policy and Quality
Program, Houston Veterans Affairs Health Services Research
and Development Center of Excellence, and Center of Inquiry to
Improve Outpatient Safety Through Effective Electronic
Communication, Michael E. DeBakey Veterans Affairs Medical
Center and Section of Health Services Research, Department of
Medicine, Baylor College of Medicine, Houston, Texas
Opinions expressed in these commentaries are those of the authors
and not necessarily those of the American Academy of Pediatrics or
its Committees.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0339
doi:10.1542/peds.2009-0339
Address correspondence to Dean F. Sittig, PhD, University of
Texas Health Sciences Center at Houston, School of Health
Information Sciences, 6410 Fannin St , Houston, TX 77030. E-mail:
dean.f.sittig@uth.tmc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
COMMENTARY
PEDIATRICS Volume 124, Number 1, July 2009 375
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
Page 3
what type of CDS, applied when in the
encounter, is likely to have the great-
est impact.14 From the aforementioned
CDS guidebooks11,14 and other pub-
lished reviews of CDS effectiveness
factors,15,16 we support the following
list of questions to consider before the
implementation of any real-time, point-
of-care CDS intervention designed to
interrupt clinicians during their work.
Communication and acceptance:
1. Has the clinical rule or concept
that will be promoted by the inter-
vention been well communicated
to the medical staff in advance?
2. Does the intervention, if accepted,
change the overall plan of care, or
is it intended to cause a limited,
corrective action (such as pre-
venting an allergic reaction to a
drug)?
3. Are the data used to trigger the
alert likely to be accurate and re-
liable, and are they a reliable indi-
cator for the condition you are try-
ing to change?
4. What is the likelihood that the per-
son receiving the alert will actu-
ally change his or her patientman-
agement as a result of the alert?
5. Is the patient likely to agree that
the recommended actions are
beneficial?
Intervention technique:
6. Is an alert the right type of inter-
vention for the clinical objective,
and is it presented at the right
time?
7. Is the intervention presented to
the right person?
8. Is the alert presented clearly, and
with enough supporting informa-
tion, so that the clinician feels con-
fident in taking the recommended
action immediately?
9. Does the intervention slow down
the workflow?
10. Is the overall alert burden exces-
sive (“alert fatigue”)? Were the
study providers receiving other
types of alerts at the same time?
11. Is the clinical information system,
including the use of CDS (eg, the
alerts), well-liked and supported
by clinicians in general?
Monitoring:
12. Is there a way to monitor the re-
sponse to the alert on an ongoing
basis?
Real-time, point-of-care CDS interven-
tions can be highly effective if the right
intervention for the desired clinical ob-
jective is used, if the recommendation
has been accepted clinically by the
physician and patient, if the alert is ac-
curate and clearly understood, if it is
presented at a point in the encounter
at which the physician can confidently
take action on it, and if it makes it easy
for the physician to take such action
without prolonging or confusing the
workflow.
Improving clinical quality objectives
through CDS, such as increasing influ-
enza vaccination rates, can be sub-
stantially improved by using a systems
perspective to address aspects of
communication, medical acceptance,
clinical workflow, choice of computer-
ized display, and ongoing monitoring.
Taken together such extensive inter-
ventions can lead to better health out-
comes for our patients.
REFERENCES
1. Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technolo-
gies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108–114
2. Kaushal R, Jha AK, Franz C, et al; Brigham and Women’s Hospital CPOE Working Group. Return on
investment for a computerized physician order entry system. J AmMed Inform Assoc. 2006;13(3):
261–266
3. Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality
of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400–1405
4. Congressional Budget Office. Evidence on the costs and benefits of health information technology.
Available at: www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf. Accessed May 10, 2009
5. Fiks AG, Hunter KF, Localio AR, et al. Impact of electronic health record–based primary care
clinical alerts on influenza vaccination for children and adolescents with asthma: a cluster-
randomized trial. Pediatrics. 2009;124(3):159–169
6. Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical
imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14(4):
459–466
7. Gerard MN, Trick WE, Das K, Charles-Damte M, Murphy GA, Benson IM. Use of clinical decision
support to increase influenza vaccination: multi-year evolution of the system. J Am Med Inform
Assoc. 2008;15(6):776–779
8. Tape TG, Campbell JR. Computerized medical records and preventive health care: success de-
pends on many factors. Am J Med. 1993;94(6):619–625
9. Hak E, Hermens RP, Hoes AW, Verheij TJ, Kuyvenhoven MM, van Essen GA. Effectiveness of a
co-ordinated nation-wide programme to improve influenza immunisation rates in the Nether-
lands. Scand J Prim Health Care. 2000;18(4):237–241
376 SITTIG et al
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
encounter, is likely to have the great-
est impact.14 From the aforementioned
CDS guidebooks11,14 and other pub-
lished reviews of CDS effectiveness
factors,15,16 we support the following
list of questions to consider before the
implementation of any real-time, point-
of-care CDS intervention designed to
interrupt clinicians during their work.
Communication and acceptance:
1. Has the clinical rule or concept
that will be promoted by the inter-
vention been well communicated
to the medical staff in advance?
2. Does the intervention, if accepted,
change the overall plan of care, or
is it intended to cause a limited,
corrective action (such as pre-
venting an allergic reaction to a
drug)?
3. Are the data used to trigger the
alert likely to be accurate and re-
liable, and are they a reliable indi-
cator for the condition you are try-
ing to change?
4. What is the likelihood that the per-
son receiving the alert will actu-
ally change his or her patientman-
agement as a result of the alert?
5. Is the patient likely to agree that
the recommended actions are
beneficial?
Intervention technique:
6. Is an alert the right type of inter-
vention for the clinical objective,
and is it presented at the right
time?
7. Is the intervention presented to
the right person?
8. Is the alert presented clearly, and
with enough supporting informa-
tion, so that the clinician feels con-
fident in taking the recommended
action immediately?
9. Does the intervention slow down
the workflow?
10. Is the overall alert burden exces-
sive (“alert fatigue”)? Were the
study providers receiving other
types of alerts at the same time?
11. Is the clinical information system,
including the use of CDS (eg, the
alerts), well-liked and supported
by clinicians in general?
Monitoring:
12. Is there a way to monitor the re-
sponse to the alert on an ongoing
basis?
Real-time, point-of-care CDS interven-
tions can be highly effective if the right
intervention for the desired clinical ob-
jective is used, if the recommendation
has been accepted clinically by the
physician and patient, if the alert is ac-
curate and clearly understood, if it is
presented at a point in the encounter
at which the physician can confidently
take action on it, and if it makes it easy
for the physician to take such action
without prolonging or confusing the
workflow.
Improving clinical quality objectives
through CDS, such as increasing influ-
enza vaccination rates, can be sub-
stantially improved by using a systems
perspective to address aspects of
communication, medical acceptance,
clinical workflow, choice of computer-
ized display, and ongoing monitoring.
Taken together such extensive inter-
ventions can lead to better health out-
comes for our patients.
REFERENCES
1. Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technolo-
gies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108–114
2. Kaushal R, Jha AK, Franz C, et al; Brigham and Women’s Hospital CPOE Working Group. Return on
investment for a computerized physician order entry system. J AmMed Inform Assoc. 2006;13(3):
261–266
3. Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality
of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400–1405
4. Congressional Budget Office. Evidence on the costs and benefits of health information technology.
Available at: www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf. Accessed May 10, 2009
5. Fiks AG, Hunter KF, Localio AR, et al. Impact of electronic health record–based primary care
clinical alerts on influenza vaccination for children and adolescents with asthma: a cluster-
randomized trial. Pediatrics. 2009;124(3):159–169
6. Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical
imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14(4):
459–466
7. Gerard MN, Trick WE, Das K, Charles-Damte M, Murphy GA, Benson IM. Use of clinical decision
support to increase influenza vaccination: multi-year evolution of the system. J Am Med Inform
Assoc. 2008;15(6):776–779
8. Tape TG, Campbell JR. Computerized medical records and preventive health care: success de-
pends on many factors. Am J Med. 1993;94(6):619–625
9. Hak E, Hermens RP, Hoes AW, Verheij TJ, Kuyvenhoven MM, van Essen GA. Effectiveness of a
co-ordinated nation-wide programme to improve influenza immunisation rates in the Nether-
lands. Scand J Prim Health Care. 2000;18(4):237–241
376 SITTIG et al
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
Page 4
10. Tang PC, LaRosa MP, Newcomb C, Gorden SM. Measuring the effects of reminders for outpatient
influenza immunizations at the point of clinical opportunity. J Am Med Inform Assoc. 1999;6(2):
115–121
11. Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision
Support: An Implementer’s Guide. Chicago, IL: Health Information and Management and Systems
Society; 2005
12. McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability
of man. N Engl J Med. 1976;295(24):1351–1355
13. Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic
detailing to reduce the use of potentially inappropriate medications in older people. J Am Geriatr
Soc. 2006;54(6):963–968
14. Osheroff JA, ed. Improving Medication Use and Outcomes With Clinical Decision Support: A Step-
by-Step Guide. Chicago, IL: Health Information and Management Systems Society; 2009
15. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support:
making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10(6):
523–530
16. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized
physician order entry on prescribing practices. Arch Intern Med. 2000;160(18):2741–2747
COMMENTARY
PEDIATRICS Volume 124, Number 1, July 2009 377
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
influenza immunizations at the point of clinical opportunity. J Am Med Inform Assoc. 1999;6(2):
115–121
11. Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision
Support: An Implementer’s Guide. Chicago, IL: Health Information and Management and Systems
Society; 2005
12. McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability
of man. N Engl J Med. 1976;295(24):1351–1355
13. Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic
detailing to reduce the use of potentially inappropriate medications in older people. J Am Geriatr
Soc. 2006;54(6):963–968
14. Osheroff JA, ed. Improving Medication Use and Outcomes With Clinical Decision Support: A Step-
by-Step Guide. Chicago, IL: Health Information and Management Systems Society; 2009
15. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support:
making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10(6):
523–530
16. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized
physician order entry on prescribing practices. Arch Intern Med. 2000;160(18):2741–2747
COMMENTARY
PEDIATRICS Volume 124, Number 1, July 2009 377
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
Page 5
DOI: 10.1542/peds.2009-0339
2009;124;375-377 Pediatrics
Dean F. Sittig, Jonathan M. Teich, Jerome A. Osheroff and Hardeep Singh
Takes More Than Just a Reminder
Improving Clinical Quality Indicators Through Electronic Health Records: It
& Services
Updated Information
http://www.pediatrics.org/cgi/content/full/124/1/375
including high-resolution figures, can be found at:
References
http://www.pediatrics.org/cgi/content/full/124/1/375#BIBL
at:
This article cites 13 articles, 10 of which you can access for free
Subspecialty Collections
http://www.pediatrics.org/cgi/collection/computers
Computers
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.pediatrics.org/misc/Permissions.shtml
tables) or in its entirety can be found online at:
Information about reproducing this article in parts (figures,
Reprints
http://www.pediatrics.org/misc/reprints.shtml
Information about ordering reprints can be found online:
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
2009;124;375-377 Pediatrics
Dean F. Sittig, Jonathan M. Teich, Jerome A. Osheroff and Hardeep Singh
Takes More Than Just a Reminder
Improving Clinical Quality Indicators Through Electronic Health Records: It
& Services
Updated Information
http://www.pediatrics.org/cgi/content/full/124/1/375
including high-resolution figures, can be found at:
References
http://www.pediatrics.org/cgi/content/full/124/1/375#BIBL
at:
This article cites 13 articles, 10 of which you can access for free
Subspecialty Collections
http://www.pediatrics.org/cgi/collection/computers
Computers
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.pediatrics.org/misc/Permissions.shtml
tables) or in its entirety can be found online at:
Information about reproducing this article in parts (figures,
Reprints
http://www.pediatrics.org/misc/reprints.shtml
Information about ordering reprints can be found online:
at HAM-TMC Library on July 1, 2009 www.pediatrics.orgDownloaded from
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