This study showed that rates of VTE risk assessment documentation and guideline-compliant VTE prophylaxis prescribing significantly improved following implementation of an integrated electronic alert system linked to a CPOE-based order set for VTE risk assessment within the eMMS.

In typical practice, VTE risk assessments are documented separately within clinical forms or progress notes, often leading to oversight as physicians must prescribe VTE prophylaxis separately. Embedding VTE risk assessment into eMMS workflow through CPOE functionality ensures that documentation of risk assessments and medication prescribing can be completed at the same time, enhancing transparency and streamlining care. Additionally, electronic documentation of VTE risk assessments eliminates the need for manual auditing of paper-based medical records to assess compliance. Our service aims to generate monthly compliance reports to monitor organisational performance and formulate targeted interventions, ensuring continual optimisation of VTE prevention measures.

Reasons for non-compliant VTE prophylaxis prescribing were not formally reviewed, however common reasons included VTE prophylaxis being omitted or missed entirely, inappropriate delays in initiation of post-operative VTE prophylaxis among surgical patients or incorrect dosing of pharmacological prophylaxis.

Across all outcomes, effects of the intervention were more pronounced after accounting for potential confounders such as age, sex and clinical division, suggesting that demographic differences may have initially led to an underestimation of the intervention’s full impact.

Post-intervention, patients who had completed VTE risk assessments were significantly more likely to receive guideline-compliant VTE prophylaxis, compared to patients without completed assessments. Moreover, when VTE risk was accurately stratified, rates of guideline-compliant prophylaxis further improved. This finding highlights the role of the intervention in promoting comprehensive risk assessment documentation and its direct impact on subsequent clinical decision-making, contributing to a more systematic approach to patient care.

Our findings are consistent with studies examining CDS and CPOE-based interventions within EMR systems, supporting their use as effective quality improvement initiatives for VTE prevention [14,15,16,17,18,19].

In contrast, a study conducted in Switzerland found that electronic alert systems did not improve guideline-compliant VTE prophylaxis prescribing among hospitalised patients [22], most likely because alerts were ignored by ordering physicians due to alert fatigue. Similarly, another study reported no improvement in prescribing practice following the introduction of VTE CDS, likely due to additional time required by physicians to interact with the system [23].

A major shortcoming of our own previous system was the fundamental disconnect between paper-based and electronic systems; the alert appeared each time the eMMS was accessed, regardless of whether a VTE risk assessment was already documented on paper. Concern was noted surrounding this redundancy and its associated potential for inefficiencies, frustration and risk of alert fatigue. These studies, along with our experience, highlight key barriers to physician compliance including alert fatigue caused by the nonspecific, “blanket” nature of alerts and clinical workflow disruption. To address these challenges, our health service transitioned from unstandardised, paper-based documentation to a fully integrated electronic alert system that avoids redundant prompts and utilises CPOE functionality to enable electronic documentation of VTE risk assessments.

While the intervention led to significant improvements in the surgical patient population, results did not achieve statistical significance among medical patients. Higher compliance in both pre-and post-intervention surgical patient cohorts likely stemmed from heightened awareness among surgical teams of surgery as a known risk factor for VTE, prompting VTE risk assessment and thromboprophylaxis prescribing as part of routine surgical care. In contrast, poorer performance in the medical patient cohort, both before and after intervention, may be due to several factors. Medical patients often have multiple comorbidities and acute presenting conditions requiring prioritisation, causing physicians to potentially overlook VTE prophylaxis. Additionally, medical patients may have varied VTE risk profiles and stratifying risk as low, intermediate or high can be challenging for physicians resulting in reluctance to document a VTE risk assessment. This highlights a limitation of the system, as it lacks flexibility for cases where physicians exercise clinical judgement and choose to deviate from the local VTE prevention protocol based on individualised patient assessments. Although the system provides a free-text box for users to document override reasons, this feature was poorly utilised, likely due to physicians finding it time-consuming. This information was not formally reviewed as part of the study.

Pre- and post-intervention, non-compliant mechanical prophylaxis prescribing among medical patients was most evident in patients who had contraindications to pharmacological prophylaxis and therefore required mechanical prophylaxis instead. While it is common practice for physicians to withhold pharmacological prophylaxis due to concerns such as bleeding risk, they may overlook ordering of mechanical prophylaxis in its place. The proportion of these patients remained largely unchanged post-intervention, highlighting an additional gap with the intervention’s effectiveness.

To optimise CDS utility in this patient population, further improvements to the alert system could include implementing predefined options for alert overrides and an additional order within the orderset which prompts physicians to consider mechanical prophylaxis in cases where pharmacological options are contraindicated.

This study investigated co-prescribing of VTE risk assessment and VTE prophylaxis prescription orders, presenting an innovative approach for incorporating VTE risk assessment documentation into eMMS workflow. Our tool was developed within a commercial eMMS software, making it easily replicable and scalable for use within other hospitals. Additionally, the statistical analysis approach accounted for demographic differences between pre- and post-intervention populations. This study has several limitations. A major limitation is inherent in the retrospective observational study design. Results may be prone to misclassification bias due to potential for incomplete documentation of relevant data in medical records. The 10-month gap between the intervention and post-intervention audit may introduce potential confounding factors, however this was deliberately chosen to assess the long-term impacts and sustainability of the CDS intervention. As data were collected from a single tertiary site, this limits the external validity of our results and findings may not be applicable to other sites. Lastly, our study does not directly evaluate whether improved guideline compliance translates into reduction in VTE events within our health service, which is the intended goal of prophylaxis.

While this study demonstrated improvements in VTE prevention guideline compliance, future research should assess patient-centred outcomes such as actual incidence of VTE events, bleeding complications rates, length of stay and mortality rates. Exploring these broader clinical outcomes will provide valuable information as to whether increased compliance rates translate into meaningful reductions in VTE-related complications. Subgroup analyses to assess performance across different subspecialities could provide insights into how the system performs across different clinical areas, identifying opportunities for further adjustments according to specific patient needs.

Further research should assess the economic impacts of CDS interventions within eMMS, including potential cost savings from eliminated VTE events and reduced length of hospital stay. Exploring user experience through factors such as ease of use, clinical value of the tool and impact on daily workflow could help identify key barriers to healthcare provider acceptance and optimise workflow integration. Establishing user feedback mechanisms would facilitate real-time improvements to enhance CDS system functionality and effectiveness. Future work is also required to explore the long-term sustainability and scalability of VTE CDS integration across other health services utilising eMMS to determine its feasibility for more widespread adoption.