The Referral to Hepatology Can be Improved Through an Electronic Medical Record (EMR)-Based Best Practice Alert (BPA) for an Appropriate Referral

Nonalcoholic fatty liver disease (NAFLD) is an extremely common condition affecting 26% of the US general population but only 2% of the population has a more aggressive histological phenotype, nonalcoholic steatohepatitis (NASH) or evidence of liver fibrosis[1]. The American Association for the Study of Liver Diseases (AASLD) does not recommend routine screening of the general population for NAFLD[2] citing "uncertainties surrounding diagnostic tests and treatment options[3]", but does recommend referral to a hepatologist when there is a high index of suspicion for NASH and advanced fibrosis such as in patients with type 2 diabetes (T2D)[4-6], and in those with elevated fibrosis-4 index (FIB-4) [7, 8]. These aids are under-utilized by physicians that result in many patients who are at high risk for fibrosis and are not referred to hepatology[9]. Confusion regarding how to best define the population at risk is a major problem preventing the appropriate use of hepatology referral in the primary care setting.