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Journal of the American Medical Informatics Association Volume 11 Number 5 Sep / Oct 2004
Computer Alerts for Potassium Testing: Resisting the Temptationof a Blanket Approach
ASHISH ATREJA, MD, MPH, NEIL MEHTA, MD, ANIL JAIN, MD, C. MARTIN HARRIS, MD, MBA
J Am Med Inform Assoc. 2004;11:433–434. DOI 10.1197/jamia.M1585.
In the Nov/Dec, 2003 issue of JAMIA, Hoch et have re-
low-up on the laboratory tests, make changes to patients’
ported the effectiveness of computer alerts to improve potas-
medications (if required), and order a repeat laboratory test
sium testing in patients receiving diuretics. The underlying
after medication change. Hence, there are many implicit costs
hypothesis of the study was that diuretics can cause hypoka-
and much time associated with computer alerts.Before physi-
lemia, which can lead to adverse drug events (ADEs) includ-
cian reminders are extended to include a variety of medications
ing atrial and ventricular arrhythmias. The authors suggest
requiring laboratory investigation of medication level or side
that computer alerts to physicians would increase the rate
effects (as suggested by the authors), it is more important that
of annual potassium testing for patients on diuretics, which
users reach a consensus on appropriate guidelines than that
would, in turn, prevent such ADEs. However, we wish to
they accept the computer as a way of delivering reminders.
draw readers’ attention to the following details.
The primary outcome of the study was not a clinical outcome
First, it is conceivable that physicians deliberately decided not
but annual potassium testing in patients receiving diuretics.
to test their patients annually based on their clinical judg-
This may not necessarily translate to better patient outcomes
ment. The patients might have had stable serum potassium
because treatment with hydrochlorothiazide by itself rarely
levels for many years or may have been asked to follow
causes marked hypokalemia or ventricular arrhythmias.
a high-potassium diet. Hence, the physicians may have
Also, there is no strong evidence that mild hypokalemia sec-
changed behavior to avoid repeat alerts and not solely on
ondary to diuretics is associated with increased ventricular
clinical grounds. Such a trend toward increased testing would
ectopyor that its correction reduces the occurrence of ec-
not have a long-lasting effect if physicians perceive them to be
topy.The evidence quoted by the authors is from a study
frequently irrThe authors could have made a much
of 35 patients, who were monitored for arrhythmias after
stronger argument by reporting the potassium values of pa-
treadmill exercise.The study found increased premature
tients for whom computer alerts were sent. If a substantial
ventricular contractions under maximum stress conditions,
number of these patients had critically low serum potassium
but this can hardly be translated into clinical practice without
values, it would also have made physicians understand the
other major studies showing direct effect on patient out-
benefit of routinely testing potassium rather than having
comes. This lack of discrete evidence is the main reason that,
them order tests that they did not think pertinent in the first
apart from the pharmaceutical industry, none of the promi-
place. We were surprised to see this valuable information
nent medical societies recommends routine annual potassium
on patient outcomes missing from the results of the study.
testing in all patients on diuretics.
Second, computer alerts should not be considered simple and
However, there may be a subset of patients for whom potas-
cheap interventions. In the current study, every computer
sium testing studies are appropriate, such as those with mod-
alert required physicians to check their electronic messaging
erate or severe hypokalemia.The authors could have chosen
system, open patients records, order laboratory tests, fol-
to target such patients, along with other patients who aremore likely to suffer from complications of diuretic use.
These patients include those who have just begun diuretic
Affiliation of the authors: Department of General Internal Medicine
therapy, those who have a previously low serum potassium
and Information Technology Division, Cleveland Clinic Foundation,
level without a repeat level in the last 12 months, or those
who are on concomitant digoxin.This could reduce the
Correspondence and reprints: Ashish Atreja, MD, MPH, A 91, 9500
number of overall alerts remarkably while targeting the right
Euclid Avenue, Cleveland, OH 44195; e-mail: <email@example.com>.
patient population, thus decreasing the burden of care and in-
Received for publication: 03/22/04; accepted for publication:
creasing overall efficiency. Such a decision support system
has been reported in the literature.
Computer-based reminders to prompt physicians to imple-
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ment preventive and other services have been available
cellular electrolyte levels, and ventricular arrhythmias in hyper-
since the late 1970s and offer promise for improved patient
tensive men. JAMA. 1992;267:1083–9.
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clinic workflow without reaching a consensus. A targeted
outpatients on various diuretics. Correlation between incidence
and tailored approach rather than a blanket approach to
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computer alerts may prove to be better and more effective
10. Papademetriou V, Notargiacomo A, Heine D, Fletcher RD, Freis
ED. Effects of diuretic therapy and exercise-related arrhythmiasin systemic hypertension. Am J Cardiol. 1989;64:1152–6.
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Computer Alerts for Potassium Testing:
Resisting the Temptation of a Blanket
Ashish Atreja, Neil Mehta, Anil Jain, et al.
J Am Med Inform Assoc
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Curriculum Vitae - Kevin J. Haworth, Ph.D. University of Michigan - Ann Arbor, MichiganPh.D. (Applied Physics), May 2009Dissertation: Medical Ultrasound Aberration Correction via Acoustic Droplet Vaporization andTime-Reversal Acoustics, advised by Oliver D. Kripfgans and Paul L. Carson, available at:http://deepblue.lib.umich.edu/bitstream/2027.42/62409/1/khaworth 1.pdfTruman State University - K
ASSOCIAZIONE ITALIANA OSPEDALITA’ PRIVATA ASSOCIAZIONE RELIGIOSA ISTITUTI SOCIO-SANITARI FONDAZIONE DON CARLO GNOCCHI-onlus CONTRATTO COLLETTIVO NAZIONALE DI LAVORO PER IL PERSONALE DIPENDENTE DELLE STRUTTURE SANITARIE ASSOCIATE ALL’AIOP, ALL’ARIS E ALLA FONDAZIONE DON CARLO GNOCCHI - onlus 1998-2001 l’ A.I.O.P. nella persona del Presidente, G.Sciachì, assist