Open & Act: Tracking Health Care Team Response to EHR Asynchronous Alerts

Electronic health record (EHR)-based asynchronous messaging is a form of secure, email-style message exchange used by healthcare teams to communicate time-sensitive patient information without requiring the sender and receiver to engage simultaneously. Asynchronous alerts are a type of message whose primary goal is to prompt timely, relevant healthcare team action aimed at improving patient outcomes. Unlike alerts that interrupt users mid-task, asynchronous alerts are delivered to a secure electronic “InBasket” where they wait to be opened.

While numerous studies describe interruptive alerts, little is known about the use, impact, and risk of asynchronous alerts. Through previous AHRQ funding (Improving Post-Hospital Medication Management of Older Adults with Health Information Technology R18 HS017203), the study team implemented a post-hospital-discharge alert notifying primary care teams of medication safety concerns and the need for close followup in elderly patients. The study found that these alerts had no impact on patient outcomes, with 40 percent of staff-directed alerts and 19 percent of primary care provider (PCP) alerts remaining unopened 1day after delivery. This followup project was funded to identify factors related to timely opening of alerts, describe the immediate relevant PCP actions following alert opening, and assess the relationship between timely first responsive action and key patient outcomes.

The specific aims of the project were as follows:

• Identify contextual factors, types of alerts, and characteristics of providers, patients, and hospital discharges that relate to timely opening of alerts. 
• Identify contextual factors, types of alerts, and characteristics of providers, patients, and hospital discharges that relate to tim ely first responsive action opening of the alerts. 
• Track and describe the sequence of relevant actions taken by the healthcare providers immediately following alert opening. 
• Assess the relationship between timely first responsive action following opening of alerts and key patient outcomes, including completion of an office visit, rehospitalization, emergency department visits, urgent care visits, and adverse drug events. 

Secondary data analyses on data from the original study were conducted. Using EHR logs, the team tracked alert opening, physician behavior following opening, and responsive actions for 799 alerts. They performed bivariate and multivariate analyses calculating associations between various factors, asynchronous alert opening within 24 hours, and likelihood of subsequent PCP action.

It was found that more notifications in the PCPs’ InBasket and weekend alert delivery were associated with lower likelihood of opening within 24 hours. In a high-risk older population, time-sensitive alerts were not being opened in a timely manner, possibly because physicians were simply overwhelmed with the high numbers of InBasket notifications. Once opened, more than half of alerts recommending specific actions for medication changes or test ordering were directly followed by viewing of patient information. However, when examining the combination of timely opening with responsive action (i.e., alerts that were opened promptly and followed by responsive action), they found no significant association with rehospitalization or likelihood of an adverse drug event. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.