Can a computerized physician-alert system lower the incidence of deep-vein thrombosis or pulmonary embolism among hospitalized patients? Yes, by about 41%, according to a study involving randomly selected patients conducted at Brigham and Women's Hospital, Boston, and published in the New England Journal of Medicine.
"Entering orders actually changed outcomes for the better," says Samuel Goldhaber, M.D., lead author of the study. "We did get a 41% reduction in clinically important DVTs with no increased risk of bleeding."
Goldhaber, a cardiologist at Brigham and Women's since 1976, says there has been a notable paucity of orders for DVT prophylaxis at the Harvard Medical School-affiliated hospital despite solid medical evidence that they improve patient outcomes. Also, the 725-bed hospital has had its computerized physician order-entry system wired with an alert to suggest DVT prophylaxis whenever a patient order for bed rest is entered.
"It wasn't enough," Goldhaber says. His article cites an earlier audit that found prophylaxis was used at Brigham and Women's with only 52% of patients who developed DVT while hospitalized for other reasons.
From September 2000 to January 2004, 2,506 patients identified as being at increased risk for DVT were selected for the study. The patients were assigned to 120 physicians who were not made aware of the trial. The clinicians were divided into two groups. An intervention group, whose physicians would see 1,255 at-risk patients, would receive new, risk-based alerts. A control group, whose physicians saw 1,251 at-risk patients, would receive no new alerts. The old global alerts ran on the CPOE system for both groups.
The new alerts were generated by a program that calculated a cumulative risk score based on eight common risk factors for DVT. Factors were weighted, and a target cumulative risk score was determined.
If the target score was reached, the program searched electronic orders for ongoing use of mechanical or pharmacological prophylactic measurers. If it found none, it produced an alert that required the physician's acknowledgement and an offer to place instructions to either withhold or order prophylaxis from the same computer screen.