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HealthMay 29, 2019

Five Reasons EHR Surveillance Won't Improve Antimicrobial Resistance

It is well recognized that antimicrobial resistance is a significant threat to patient safety. With a limited number of novel antimicrobials in the development pipeline, relying on new drugs to overcome resistance is not a viable strategy. Additionally, many of these new antimicrobials cost significantly more than agents that have been on the market, and many have limited information about their efficacy and safety. As such, we should attempt to prevent the development of antimicrobial resistance in the first place. A key tactic in such an effort requires a measured, strategic approach in how we utilize antimicrobials in a clinical setting.

The Centers for Disease Control and Prevention (CDC), The Joint Commission, Infectious Diseases Society of America, and other organizations have all published guidelines and recommendations on core elements to include to build out your antimicrobial stewardship program. These structural components and recommendations are tremendously useful at a global level but tend not to detail how to perform such activities on a day-to-day basis. Subsequently, many hospitals rely on tools embedded in their electronic health records (EHR), since it is the path of least resistance. While this approach requires less planning up front, it often results in suboptimal daily workflows and can significantly limit your stewardship program's impact on patient outcomes and hospital financial performance. EHRs are solid repositories of patient data, but they often lack the clinical content and context for intelligent and precise clinical decision support.

To maximize the benefits of antimicrobial stewardship programs, many organizations turn to clinical surveillance solutions integrated with their EHRs to maximize patient data use and ultimately drive better outcomes. We've identified the top five reasons why organizations have found that their EHR alone is not enough to support their antimicrobial stewardship program:

1. False positive alerts result in clinician alert fatigue

Alerts that are bundled with EHRs often lack sophisticated logic resulting in high false positive rates; high false positive rates culminate in clinician alert fatigue, which is a significant threat to patient safety -- truly significant issues are hard to discern among the many alerts that are triggered. A recent study found that clinicians ignore as many as 96% of EHR based alerts, and those alerts are incorrect more than 90% of the time.

As such, some hospitals have opted to write their own alerts, but this is time-consuming and is often limited by the EHR rule writer design as well as the number of fields that can be incorporated into the logic. For example, many antimicrobial stewardship programs create rules to identify patients with positive urine cultures, but NOT on appropriate antimicrobials. If you cannot pair this rule with other criteria (such as a positive urine white blood cell (WBC) count), the result may be an inadvertent increase in the treatment of asymptomatic bacteriuria. Ideally, the performance and response rates of these alerts are continuously evaluated to identify underperforming alerts and subsequently modify the, to improve specificity and sensitivity. Third-party surveillance solutions can monitor these alerts and improve them continuously by leveraging lessons learned at other hospitals to benefit your program.

2. You need to compete with other projects and departments for internal IT resources to make changes.

Relying on your EHR to support your stewardship program requires substantial communication, patience, and negotiation with your IT department. Updating alerts, data queries, and reports often require IT involvement; additionally, hospitals often have multiple concurrent performance improvement initiatives in different departments competing for limited IT resources. In addition to your primary duties, you must champion the creation and modification of alerts every time guidelines are updated, the evidence is published, and new infectious disease threats (such as C. auris) emerge. This lag time adversely impacts the speed at which you can implement the latest information to improve patient care.

3. Alerts lack sufficient guidance to bedside clinicians to minimize care variations.

Patients identified by EHR alerts lack concise and clear evidence-based recommendations. Clinicians may interpret and respond to such alerts differently, ultimately resulting in significant care variations. Using a solution such as Sentri7 from Wolters Kluwer, you can be confident that your alerts are supported by evidence from trusted expert solutions such as Lexicomp and UpToDate. Alerts are delivered with concise, bulleted evidence-based recommendations to ensure that clinicians have the necessary information to make the right decisions. Sentri7's clinical content is flexible enough to include your protocols to ensure that a common clinical playbook is available at your clinicians' fingertips.

4. Clinical content requires constant grooming to stay up to date with latest evidence

In today's healthcare environment, clinicians are busy and overburdened with daily patient care - staying up to date with the latest evidence and publications can be challenging. Hospitals often lack content management and editorial control processes, and rarely have a single point of responsibility for updating clinical alerts. As such, alerts can become stale and may only be updated reactively when an adverse outcome occurs. Third-party surveillance solutions ensure you have access to evergreen clinical content that's updated regularly by expert clinicians.

5. It is difficult to track and measure the effectiveness of your program

A successful antimicrobial stewardship program needs to track process and outcome metrics to evaluate areas of high performance and improvement opportunities. Many hospital administrators and pharmacy leaders find that reports embedded in the EHR are difficult to use or simply lack relevant metrics. Process measures such as interventions, alert response rates, and time to completion are critical accountability tools necessary to identify non-adherence to protocols and to diagnose which processes may need to be redesigned. Outcome measures such as antimicrobial utilization are crucial to tracking your stewardship program's performance. Industry-leading reporting solutions require that this data is interactive and allows you to drill down quickly without outside data manipulation. For example, interactive analytics in Sentri7 enable clinicians to readily identify prescribers and care areas that use the most carbapenems with only a couple of clicks.

Having the right tools and technology can make all the difference in building a high-performing antimicrobial stewardship program. EHRs contain extensive caches of patient information that can be difficult to analyze, join, and compare. A trusted surveillance solution can give you an edge and help your hospital turn that data into actionable insights to improve your antimicrobial stewardship programs.

Manager of Pharmacy Services and Fellowship Director
Dr. Steve Mok has over a decade of experience in the areas of antimicrobial stewardship, infectious diseases and clinical pharmacy management. He has practiced in a variety of settings.

Trusted real-time alerts and evidence-based guidance to ensure at-risk patients receive the right care at the right time, every time.

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