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Research: EHRs with Decision Support Help Optimize Care for Ischemic Stroke Patients

September 8, 2015
by Rajiv Leventhal
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The timely administration of a clot-dissolving treatment for ED patients with acute ischemic stroke nearly doubled following the introduction of new technology, according to a study from the Clinical Research in Emergency Services and Treatments (CREST) Network, a group of emergency medicine physician-researchers affiliated with the Kaiser Permanente Division of Research.

The study, published in the Annals of Emergency Medicine, was conducted during the staged implementation of computerized physician order entry (CPOE) when integrated into electronic health records (EHRs) across 16 Kaiser Permanente Northern California medical centers from 2007 to 2012. After implementation, emergency department stroke guidelines were made available to physicians using an electronic template, known as an “order set.” Order sets are designed to provide standardized laboratory, radiographic and drug ordering as well as information to help guide doctors in making clinical decisions.

A systematic approach to the acute management of patients with ischemic stroke—including the timely administration of intravenous tissue plasminogen activator (IV tPA) for eligible patients—can help avoid complications and improve outcomes, the researchers said. IV tPA helps to thin the blood and dissolve clots, with the goal of restoring blood flow through blocked arteries in the brain. Emergency department evaluation of patients with suspected stroke is focused on rapidly assessing eligibility for time-sensitive interventions such as IV tPA, which has been shown to improve neurological outcomes for acute ischemic stroke.

Of the 10,081 patients during the study period, 6,686 (66.3 percent) were treated in medical centers after computerized physician order entry had been implemented. IV tPA was administered in the ED to 8.9 percent of these patients, compared to 3.3 percent of patients in EDs at medical centers without the new technology—more than doubling the rate of IV tPA administration. When the stroke order set was employed in combination with the computerized physician order entry, IV tPA administration increased to 12.7 percent—a nearly three-fold increase. Even after accounting for variable factors, these differences held steady, according to the research.

“This study demonstrates that computerized physician order entry generally—and an order set embedded with decision support specifically—can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors,” said lead author Dustin Ballard. “In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke.”

Co-author David Vinson, M.D., an emergency medicine physician at the Kaiser Permanente Roseville Medical Center, added, “While the technology is not likely to be solely responsible for the improved outcomes observed in this study, it may represent a proxy measure for optimum care for certain patients, in particular those for whom the speed of initiating therapy, the completeness of information available to the clinician, and the intensity of inpatient care make a real difference in short-term outcomes.”

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