UMMS Affiliation

Meyers Primary Care Institute; Department of Medicine, Division of Geriatric Medicine; Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Health Communication | Health Information Technology | Health Services Administration | Health Services Research


BACKGROUND: Electronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR-based clinical decision support (CDS), shedding light on whether and why CDS is effective.

OBJECTIVE: This study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians' (PCPs') opening of and response to noninterruptive alerts delivered to EHR InBaskets.

METHODS: We conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs' InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients' posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs' follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use.

RESULTS: We successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation.

CONCLUSIONS: EHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR-based study. .


electronic health records, health care communication, health information technology, health services research

Rights and Permissions

© Azraa Amroze, Terry S Field, Hassan Fouayzi, Devi Sundaresan, Laura Burns, Lawrence Garber, Rajani S Sadasivam, Kathleen M Mazor, Jerry H Gurwitz, Sarah L Cutrona. Originally published in JMIR Medical Informatics (, 07.02.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.

DOI of Published Version



JMIR Med Inform. 2019 Feb 7;7(1):e12650. doi: 10.2196/12650. Link to article on publisher's site

Journal/Book/Conference Title

JMIR medical informatics

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Link to Article in PubMed

PubMed ID


Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.



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