Giving Your Electronic Health Record a Checkup After COVID-19: A Practical Framework for Reviewing Clinical Decision Support in Light of the Telemedicine Expansion

BACKGROUND: The transformation of health care during COVID-19, with the rapid expansion of telemedicine visits, presents new challenges to chronic care and preventive health providers. Clinical decision support (CDS) is critically important to chronic care providers, and CDS malfunction is common during times of change. It is essential to regularly reassess an organization's ambulatory CDS program to maintain care quality. This is especially true after an immense change, like the COVID-19 telemedicine expansion. OBJECTIVE: Our objective is to reassess the ambulatory CDS program at a large academic medical center in light of telemedicine's expansion in response to the COVID-19 pandemic. METHODS: Our clinical informatics team devised a practical framework for an intrapandemic ambulatory CDS assessment focused on the impact of the telemedicine expansion. This assessment began with a quantitative analysis comparing CDS alert performance in the context of in-person and telemedicine visits. Board-certified physician informaticists then completed a formal workflow review of alerts with inferior performance in telemedicine visits. Informaticists then reported on themes and optimization opportunities through the existing CDS governance structure. RESULTS: Our assessment revealed that 10 of our top 40 alerts by volume were not firing as expected in telemedicine visits. In 3 of the top 5 alerts, providers were significantly less likely to take action in telemedicine when compared to office visits. Cumulatively, alerts in telemedicine encounters had an action taken rate of 5.3% (3257/64,938) compared to 8.3% (19,427/233,636) for office visits. Observations from a clinical informaticist workflow review included the following: (1) Telemedicine visits have different workflows than office visits. Some alerts developed for the office were not appearing at the optimal time in the telemedicine workflow. (2) Missing clinical data is a common reason for the decreased alert firing seen in telemedicine visits. (3) Remote patient monitoring and patient-reported clinical data entered through the portal could replace data collection usually completed in the office by a medical assistant or registered nurse. CONCLUSIONS: In a large academic medical center at the pandemic epicenter, an intrapandemic ambulatory CDS assessment revealed clinically significant CDS malfunctions that highlight the importance of reassessing ambulatory CDS performance after the telemedicine expansion.