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The Clinical Alerts that Cried Wolf

March 20, 2012
by Gabriel Perna
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As clinical alerts pose physician workflow problems, healthcare IT leaders look for answers
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Across the U.S., as healthcare providers implement computerized physician order entry (CPOE) systems, they find themselves dealing with the growing issue of clinical alert fatigue. With patient care alerts proliferating within clinical decision support (CDS) systems, physicians have often come to ignore all alerts. Healthcare IT leaders are working to resolve this important issue to everyone’s benefit, increasingly implementing systems that put out only effective alerts or apply asynchronous alerting strategies.

What happens when something designed for patient safety ends up having the exact opposite effect? In what can best be described as a “boy who cried wolf”-type scenario, this is exactly what is happening in some healthcare communities with CPOE systems.

Systems are implemented with patient-safety alerts, a CDS tool that helps physicians recognize when a physician needs to be made aware of any of a variety of possible situations, such as when a patient shouldn’t take a prescription order for reasons such as drug interaction, drug allergies or dose-range checking. However, the alerts can often become excessive to the point where physicians will simply override them as not to disrupt their workflow.

The phenomenon is called “alert fatigue,” and it’s become a significant issue in hospitals that have implemented CDS systems. Studies, like a 2009 report from the Boston-based Beth Israel Deaconess Medical Center (BIDMC) and the Dana-Farber Cancer Institute, document the seriousness and scope of the issue. The researchers looked at the safety alerts generated by 2,872 clinicians through 3.5 million electronic prescriptions over a nine-month period. Of the 233,537 alerts, 98 percent were drug-drug interaction issues, more than 90 percent of which were overridden. Clinicians overrode more than 77 percent of the allergy alerts as well.

“It would be easy to think that more alerts equals more safety, but alert fatigue—fatigue is probably too generous of a word, I’ve seen wholesale ignoring in some cases—presents the doctor with trying to weed out the meaningful alerts from the meaningless ones, and I’ve seen articles quoting 98 percent alerts that weren’t acted upon,” explains Mark Van Kooy, M.D., director of informatics, Aspen Advisors (Denver, Colo.). “That means if you have 100 alerts, you have to go through 98 until you find two that are justifiable. At some point, you just start missing alerts. That’s a worst-case scenario, but it’s real-world.”

Acting on two percent of alerts isn’t doing anyone any favors, and analysts like Van Kooy say hospitals need to figure out a situation where the alerts that are coming up, are acted on approximately four out of five times. In all likelihood, this strategy would mean cutting down on the number of alerts that come up in current CPOE systems.

Many hospitals have begun to work on this sort of thing already. One such institution is the Altamonte, Fla.-based Adventist Health System (AHS), a faith-based hospital system with 44 hospital campuses across 10 states. AHS' vice president and CMIO, Phillip A. Smith, M.D., says the organization rolled out its CPOE across 26 states and saw issues with alert fatigue shortly thereafter. Despite a conscious effort to be “more effective” with its alerts, AHS found out physicians were getting 80 alerts per 100 medications.

Phillip A. Smith, M.D.

Smith said the organization immediately recognized this was far too many to avoid alert fatigue. “We knew what our target was, about 10 alerts for every 100 medications ordered,” he says. “That’s where doctors actually change their behavior.” After getting it down to 34 alerts per 100 medications and then 22 alerts per 100 medications, where there was a 50-50 chance the doctor would ignore the alert, the group worked with its CPOE vendor Cerner (Kansas City, Mo.) to reach its target level.

With Cerner’s help, AHS implemented multi-functional tools called MCDS, which refines the alerts and allows the organization to go after and reduce “nuisance” alerts. Thanks to this tool, AHS was able to get itself down to 14 alerts per every 100 medications, with an average of 10 ignored and four overridden. The tools, which Smith says will be available shortly from Cerner for customers who upgrade their systems, were able to eliminate certain duplicates and other unnecessary alerts.

In California, leaders at the 311-bed Lucile Packard Children’s Hospital (LPCH) in Palo Alto, Calif. have recognized the issue of alert fatigue, citing studies that appeared in the Journal of American Medical Informatics Association, which had physicians overriding numbers of allergy alerts occurring approximately 60-95 percent of the time. Natalie Pageler, M.D., medical director of clinical informatics at LPCH, and Christopher Longhurst, M.D., CMIO at LPCH, say clinical alerts can be divided into either synchronous or asynchronous decision support, the latter of which they say is a better solution for fixing alert fatigue.

Christopher Longhurst, M.D.


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The issues raised in this article are very real and very problematic. One path forward, which is being proven effective is the continued evolution away from simple rules-based alerts to clinical process management using a BPM engine. Properly developed BPM managed processes can reduce the burden on the clinician while improving the efficiency and the effectiveness of the care that is delivered. There are now several EMR vendors who have, or claim to have, these capabilities. The use of this technology is a way forward to address the alert fatigue issue.
Ray Hess
V.P., Information Management
The Chester County Hospital

Hi Ray,

Thanks for your comments. I've heard a lot about a BPM engine and its possible capabilities in terms of solving the clinical alert fatigue problem. No one I talked to for this piece mentioned it for their own solution, but I read a little bit about it. if you know anyone who has used it, I'd love to hear more about their experience.