The Clinical Alerts that Cried Wolf

“When we talk about alerts, most people are thinking of synchronous alerts, which happen when someone is actually placing an order. You place a medication order, get a pop-up that says the patient is allergic to this medication,” Dr. Pageler says. “But the fact is, there’s a lot of information you’d like to get to the provider that happens at times when they’re not actually entering an order. Like for instance, you enter an order based on a particular level of renal function, and then the renal function changes three days later. How do you get that information to the provider, who isn’t at the computer making the order? There’s lots of ways to do this type of asynchronous alert.”

LPCH has tested asynchronous alerting through various methods including the development of a “highly elaborate tab,” according to Pageler. The tab includes information on the patient’s vitals, medications, care providers names, and other critical information. On the tab, Pageler says, are alerts, but they aren’t interruptive. “So if the kidney function isn’t normal, for instance, it will be highlighted in red on the tab,” she says. “It’s an alert, it’s highlighted in red, but it doesn’t interrupt their workflow.”

Natalie Pageler, M.D.

In addition, LPCH has developed a patient care and quality dashboard, which has an enhanced healthcare related checklist included in the EMR. The non-interruptive checklist provides information on vital information, both general and specific to the patient. The dashboard, which was sponsored by Hewlett-Packard (Palo Alto, Calif.), is currently in pilot.

COMPLEX SOLUTION
Even with their focus on asynchronous alerts, both Pageler and Longhurst say the focus on alerts comes down to improving clinical outcomes and not the process. Longhurst was quick to point out a study conducted by LPCH that found pop-up messages, which are synchronous, built into an EMR could prevent physicians from ordering unnecessary treatment, in this case blood transfusions. In the study, the pop-up alert saved LPCH from conducting 460 unnecessary red blood cell transfusions—$165,000 in one year.

The moral of the story, as Aspen’s Van Kooy says, is that there is no simple solution. “The solution requires thought, effort, analysis, and engaging all the stakeholders—pharmacy, nursing, physicians—as key success factors. There are systems that are doing this well and they (healthcare providers) should keep their eyes on the literature to keep informed, and they should look for continuing development  of evidence based guidelines on how to approach this problem,” he says.