Discussion
This pragmatic, EHR-based trial aims to optimize two types of communications related to improving evidence-based DOAC prescribing, with a specific focus on whether, how, and when to deploy communications that encourage collaboration with specialty anticoagulation pharmacists. To our knowledge, this is the first implementation trial related to optimizing safe DOAC prescribing, despite there being more than 3000 anticoagulation clinics in existence across the USA and millions of patients prescribed DOAC medications. Notifications that encourage prescriber-pharmacist collaboration will allow expert pharmacists to review unsafe DOAC use and recommend safe, evidence-based DOAC prescribing. Combining this with a system of novel, well-designed medication alerts has the potential to address multiple barriers to evidence-based DOAC use and receipt, and improve patient clinical outcomes. Exploratory moderators’ analyses will also allow the identification of characteristics of the patients and/or prescribers that most benefit from prescriber-pharmacist collaboration, which will help inform tailored deployment of alerts and notifications encouraging prescriber-pharmacist collaboration, especially in resource-constrained health systems.This trial is designed to experimentally test two novel implementation strategies to ensure evidence-based DOAC prescribing: (1) EHR-facilitated collaboration between prescribers and pharmacists, and (2) EHR medication alerts/notifications with evidence-based DOAC prescribing information. Both strategies target different implementation barriers that prevent optimal prescriber and health system functioning, but neither strategy has been thoroughly investigated, despite being recommended by health informatics experts [Beyond testing these strategies, however, this study will also inform a broader understanding of the role EHR alerts and health care system communications can play in improving adherence to evidence-based prescribing. A key innovation of this study is the deployment of a system that monitors DOAC patients Our study also has some important limitations. First, given that our study is being conducted within one health care system, results from our analyses may not generalize. However, more than 3000 anticoagulation clinics exist nationwide that can likely benefit from and build on the knowledge generated here. Second, data collection will primarily rely on our EHR, which has known limitations as data are collected for clinical and administrative (rather than research) purposes. This includes concerns about the accuracy and completeness of data and documentation related to DOAC prescribing. We have attempted to minimize this limitation through the manual abstraction processes described above, but recognize that limitations likely still exist. Third, our alerts are limited only to patients prescribed apixaban or rivaroxaban. While these are overwhelmingly the most common DOACs used in the USA, other DOACs (dabigatran and edoxaban) are not being tested explicitly. Finally, it is important to note that because our trial only randomizes prescribers that have a DOAC prescribing error, the causal effects for the alerts and notifications are only relevant conditional on the presence of an error. Thus we are not able to evaluate experimentally whether either alert decreases the overall probability of a future DOAC prescribing error (though we will address this question through our observational ITSA analyses).