Changing how medication alerts are presented and managed in electronic health records (EHRs) can result in safer prescribing and increased efficiency for healthcare providers who placed the drug orders. While in theory these alerts should improve patient care, unhelpful alerts may be viewed as “noise” by providers and rarely lead to beneficial medication management changes.
Indeed, “alert fatigue,” which the Agency for Healthcare Research and Quality (AHRQ) describes as how busy clinicians become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings, usually occurs because of the sheer volume of alerts. This is then compounded by the fact that the vast majority of alerts generated by CPOE (computerized physician order entry) systems and other technologies are clinically inconsequential—meaning that in most cases, clinicians should ignore them. The problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the critical alerts that warn of impending serious patient harm, according to AHRQ.
Effectively managing alerts became an issue a few years ago for Sentara Healthcare, a Norfolk, Va.-based system with 12 hospitals, 10 of which are on Epic. Sentara also has more than 400 ambulatory practices in its system, with 4,000 providers in all. “We realized that the more than 4,000 providers they serve would quickly disengage from the EHR if they were bothered by a large number of alerts they deemed unnecessary,” says Raymond Chan, Pharm.D., Pharmacy IS (information systems) Specialist at Sentara. “Yet, at the same time, they understood that these providers would lose faith in the system if they didn't receive meaningful notifications when patients were in harm's way. And they wanted to reduce the amount of work it would take to catch an error.”
Raymond Chan, Pharm.D.
Chan notes that a key driver for improved alert management at Sentara was improving physician satisfaction. “When there is a useless or unnecessary alert that interrupts a provider’s workflow, it forces him or her to answer the alert and take an action on it,” he says. Sometimes the provider might even forget what he or she was doing prior to the alert, he adds. “Poor clinical decision support [CDS] is worse than no clinical decision support since we may have taken the provider down a path where he or she did not improve patient care,” he says.
As such, to get the "just right" mix of alerts, Sentara put a continuous alert optimization process in place. The program, which was led by Chan and Kathie Scott, senior clinical analyst at Sentara, aimed to increase the number of medication alerts acted upon (positive response rate) to greater than 20 percent of all medication alerts; improve safety; reduce alert fatigue; and decrease preventable adverse drug events (ADEs).
“We had a process in place where our pharmacy and therapeutics committee as well as our clinical administration, clinical specialists and drug information pharmacist would work together to evaluate new drugs that came out and what interactions we wanted to program into Epic,” says Chan.
Specifically, Sentara created nearly 2,000 custom drug-drug interaction (DDI) alerts, built 150 additional custom renal dosing alerts that enabled continuous monitoring, modified 77 duplicate therapy class alerts and developed 100 percent of the system's custom pregnancy (117 medications) and lactation (119 medications) alerts—an undertaking that took approximately 2,000 person-hours, notes Chan.
Nonetheless, regardless of how many hours they logged, the team at Sentara eventually realized that the finish line was still not in sight. The simple fact that drug information continually evolves and changes means that they would need to carefully monitor all their customizations—over and over again, explains Chan. “We liked having the ability to make the customizations directly in Epic. However, we realized that we just couldn't keep up with the maintenance of all the custom drug alerts as new information and new drugs were constantly being introduced. The maintenance burden had just become too much for us to handle,” he recalls.
What’s more, with Sentara increasingly adding ambulatory services, the staff struggled to create customized alerts with respect to prescriptions that were likely to be used in outpatient settings. “As we kept adding more ambulatory clinics, we had to account for the fact that providers could prescribe any medications they wanted,” notes Chan, adding that there was also a need to implement a variety of drug alerts to comply with various government regulations, specifically to meet meaningful use requirements.
Leaders at Sentara then decided to implement FDB AlertSpace, an alert management solution from the San Francisco-based First Databank, which offers an online platform to customize and track alerts. To start, FDB worked with Sentara to compare DDI alerts in the FDB database to those that were custom created by Sentara.
“We took the information to our pharmacy clinical director and said if we turn on all of FDB's contraindicated and severe [alerts], we'll have a certain number of additional alerts compared to what we currently have. And, here are the alerts that FDB did not think were globally applicable. We can either leave these alerts in place as custom DDIs or we can have them go away. It was a very collaborative process, a lot of back and forth. It was definitely helpful to have a party on both sides to work through and look through all of the differences,” says Chan.
Speaking to the results garnered, Chan says that the platform has helped manage the knowledge base and help Sentara leaders stay updated with the primary literature and the new studies and drug information is so helpful to them. “Since we got rid of a lot of this maintenance burden, we can now focus more on those additional customizations that we are controlling within Epic,” he says.
Further, given the same number of resources at Sentara to manage alert fatigue, the organization was also able to cut down the amount of maintenance and use that time to do additional customizations. Chan explains, “AlertSpace is freeing up time to focus on other alert customization projects. We cut the number of warfarin [a blood thinning medication]-related reactions in half and that, in turn, reduced the alert burden on the pharmacists.”
As a result, Sentara went from firing about 90 thousand alerts for warfarin per year to approximately 45 thousand a year by transitioning low-value alerts to passive CDS, Chan attests. “And, with industry studies indicating that it takes about 8 seconds to review each alert, the health system saved about 100 staff hours per year on reviewing warfarin alerts alone,” he says.