title: "Stealth" alerts to improve warfarin monitoring when initiating interacting medications.
abstract: BACKGROUND
  As electronic health records (EHRs) become widely adopted, alerts and reminders can improve medication safety, but excessive alerts may irritate or overwhelm clinicians, thereby reducing their effectiveness. We developed a novel "stealth" alert in an EHR to improve anticoagulation monitoring for patients prescribed a medication that could interact with warfarin. Instead of alerting the prescribing provider, the system notified a multidisciplinary anticoagulation management service, so that the prescribing clinicians never saw the alerts. We aimed to determine whether these "stealth" alerts increased the frequency of anticoagulation monitoring following the co-prescription of warfarin and a potentially interacting medication.
  
  
  METHODS
  We conducted a pre-post intervention study, analyzed using an interrupted time-series, within a large, multispecialty group practice that uses a common EHR. The study included a 12-month period preceding the intervention, a 2-month period during intervention implementation, and a 6-month post-intervention period. The primary outcome measure was the proportion of patients completing anticoagulation monitoring within 5 days of a new co-prescribing event.
  
  
  RESULTS
  Prior to implementation of the stealth alert, 34 % of patients completed anticoagulation monitoring within 5 days after the prescription of a medication with a potential warfarin interaction. After implementation of the alert, 39 % completed testing within 5 days (odds ratio 1.24, 95 % confidence interval 1.12-1.37).
  
  
  CONCLUSIONS
  Stealth alerts increased the proportion of patients who underwent anticoagulation monitoring following the prescription of a medication that could potentially interact with warfarin. This team-based approach to clinical-decision support directs alerts away from prescribing clinicians and toward individuals who can directly implement them.
authors: Harvard Vanguard Medical Associates, Atrius Health, 275 Grove Street, Suite 3-300, Auburndale, Newton, MA 02466, USA. kate_koplan@atriushealth.org
authors: Kate E
authors: KE
authors: Koplan
authors: Alan D
authors: AD
authors: Brush
authors: Marvin S
authors: MS
authors: Packer
authors: Fang
authors: F
authors: Zhang
authors: Margaret D
authors: MD
authors: Senese
authors: Steven R
authors: SR
authors: Simon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004347:Drug Interactions; D016903:Drug Monitoring / Q000379:methods*; D004359:Drug Therapy, Combination; D064420:Drug-Related Side Effects and Adverse Reactions / Q000517:prevention & control*; D005260:Female; D006801:Humans; D008297:Male; D050316:Medical Order Entry Systems; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000639:trends; D058996:Quality Improvement; D014481:United States; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects; D055815:Young Adult
chemical_list: D014859:Warfarin