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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 protected]>.
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.
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Resisting the Temptation of a Blanket
Approach
Ashish Atreja, Neil Mehta, Anil Jain, et al.
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