A Clinical Case of Electronic Health Record Drug Alert Fatigue: Consequences for Patient Outcome
ABSTRACT Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.
[Show abstract] [Hide abstract]
ABSTRACT: Shared decision making (SDM) is an approach to medical care based on collaboration between provider and patient, with both sharing in medical decisions. When patients' values and preferences are incorporated in decision making, care is more appropriate, ethically sound, and often lower in cost. However, SDM is difficult to implement in routine practice because of the time required for SDM methods, the lack of integration of SDM approaches into electronic health record (EHR) systems, and absence of explanatory mechanisms for providers on the results of patients' use of decision aids. This article discusses potential solutions, including the concept of a "personalize button" for EHRs. Leveraging a 4-phase clinical model for SDM, this article describes how computer decision support (CDS) technologies integrated into EHRs can help ensure that health care is delivered in a way that is respectful of those preferences. The architecture described herein, called CDS for SDM, is built on recognized standards that are currently integrated into certification requirements for EHRs as part of meaningful use regulations. While additional work is needed on modeling of preferences and on techniques for rapid communication models of preferences to clinicians, unless EHRs are redesigned to support SDM around and during clinical encounters, they are likely to continue to be an unintended barrier to SDM. With appropriate development, EHRs could be a powerful tool to promote SDM by reminding providers of situations for SDM and monitoring ongoing care to ensure treatments are consistent with patients' preferences.Medical Decision Making 09/2014; 34(8). DOI:10.1177/0272989X14550102 · 2.27 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Background: Interruptive drug interaction alerts may reduce adverse drug events and are required for Stage I Meaningful Use attestation. For the last decade override rates have been very high. Despite their widespread use in commercial EHR systems, previously described interventions to improve alert frequency and acceptance have not been well studied. Objectives: (1) To measure override rates of inpatient medication alerts within a commercial clinical decision support system, and assess the impact of local customization efforts. (2) To compare override rates between drug-drug interaction and drug-allergy interaction alerts, between attending and resident physicians, and between public and academic hospitals. (3) To measure the correlation between physicians' individual alert quantities and override rates as an indicator of potential alert fatigue. Methods: We retrospectively analyzed physician responses to drug-drug and drug-allergy interaction alerts, as generated by a common decision support product in a large teaching hospital system. Results: (1) Over four days, 461 different physicians entered 18,354 medication orders, resulting in 2,455 visible alerts; 2,280 alerts (93%) were overridden. (2) The drug-drug alert override rate was 95.1%, statistically higher than the rate for drug-allergy alerts (90.9%) (p < 0.001). There was no significant difference in override rates between attendings and residents, or between hospitals. (3) Physicians saw a mean of 1.3 alerts per day, and the number of alerts per physician was not significantly correlated with override rate (R2 = 0.03, p = 0.41). Conclusions: Despite intensive efforts to improve a commercial drug interaction alert system and to reduce alerting, override rates remain as high as reported over a decade ago. Alert fatigue does not seem to contribute. The results suggest the need to fundamentally question the premises of drug interaction alert systems.Applied Clinical Informatics 01/2014; 5(3):802-13. DOI:10.4338/ACI-2013-12-RA-0103 · 0.39 Impact Factor
12/2014; 2(4):201-211. DOI:10.1007/s40142-014-0051-9