When Infectious Disease Fellow Rebecca Linfield, MD, joined the Stanford Department of Medicine, she noticed a surprising pattern while leading a cost transparency initiative: clinicians were frequently ordering intravenous (IV) antibiotics - even when safe, equally effective oral alternatives were available.
"Through that work, we realized there was an opportunity to advocate for clinicians optimally switching to oral medications," Linfield explains.
In the high-pressure environment of a hospital, these IV preferences are often born from habit, not necessity. But they come at a price: IV medications cost significantly more, take longer to administer, increase risks for infections, and can prolong hospital stays.
"There is a large push in Infectious Diseases to use oral antimicrobials whenever they lead to the same outcomes," Linfield explained. "Increased utilization of oral medications helps decrease nursing time, pharmacist time, potential for complications from IV use, and helps ready the patient for discharge earlier. It's also a more sustainable practice with less waste."
So Linfield and a cross-disciplinary team of clinicians, pharmacists, and informatics experts designed a straightforward solution: a Best Practice Advisory (BPA) - a type of electronic alert that would gently interrupt a clinician ordering an IV antibiotic and suggest switching to a pill, if appropriate.
The tool was built to be informative, not punitive. "We saw an opportunity to harness the power of the electronic medical record for a systems-level solution," said Linfield. "We wanted to teach clinicians about the equivalence of oral antimicrobials in a non-judgmental, informative way at the time of ordering."
The BPA fired automatically when a provider ordered an IV antibiotic that had a safe oral counterpart and the patient could safely absorb oral medications through the gastrointestinal tract. If the provider declined the suggestion, they had to give a reason - most often, that the patient couldn't tolerate oral medications or that an infectious disease specialist had advised continued IV therapy.
The Results: Real Impact Without Disruption
Over 22 months, the alert popped up 6,585 times and was accepted 23.2% of the time - leading to over 1,500 switches and at least $66,976 in direct cost savings. Linfield noted, "This cost savings is an underestimate, because it does not account for labor savings."
The intervention had the strongest uptake in general medical wards (25.5%), compared to the intensive care unit (18.3%), where patients tend to be more critically ill.
"We noticed that providers in intensive care units were less likely to switch to oral medications," Linfield said. "That's not surprising - critically ill patients may not be able to take pills safely or have guaranteed enteral absorption."
She added that certain medications, like antifungals typically used in very sick patients, had much lower switch rates - sometimes below 10%. By contrast, for more commonly used antibiotics like azithromycin, providers accepted the switch to oral forms as much as 40% of the time.
Importantly, the shift to oral antibiotics did not appear to compromise patient safety. Among patients whose treatment triggered the BPA, the 30-day hospital readmission rate was about 3%, notably lower than the hospital-wide average of 15%. (Thirty-day readmission is commonly used as an indicator of care quality and treatment effectiveness, suggesting that the intervention maintained strong clinical outcomes while reducing unnecessary IV use).
Trainees, in particular, responded well to the tool. "They liked the BPA because it could prompt a conversation about the best uses of oral antimicrobials," said Linfield.
Designing Smarter, Not Louder
Importantly, the Stanford team built the BPA with awareness of a major risk in electronic alerts: alert fatigue. When clinicians are bombarded with too many notifications, they often begin ignoring all of them - useful or not.
Linfield and her collaborators were strategic. The widely used CDS Five Rights framework advocates "delivering the right information to the right person, in the right format, through the right channel, at the right moment in the workflow." That's why the team chose to integrate the guidance directly into the electronic health record (EHR). "BPAs can be especially impactful when they appear during the ordering process - they help prompt the right action in the moment," Linfield added.
Scaling Up and Looking Ahead
Based on the project's success, the Stanford team is now exploring ways to refine the BPAs, such as excluding patients who've recently received anti-nausea medication (a clue they may not tolerate pills well) or temporarily turning off the alert in the ICU. They're also investigating ways to apply similar alerts to non-antibiotic medications that have oral equivalents - particularly as IV shortages continue to strain hospital supply chains.
"We hope to see expanded Clinical Decision Support tools guiding clinicians to the best treatment choices for patients," Linfield said.
This kind of work exemplifies the quiet power of system-level changes that make medicine more efficient, sustainable, and patient-centered.
Or, as Linfield puts it, "We empowered our clinicians to better understand what we know about the equivalent efficacy between oral and IV antimicrobials - and why their patient would be a good candidate for an oral equivalent."
Sometimes, improving care doesn't require reinventing the system: just meeting clinicians with the right information at the right moment.
