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Some Methods For Improving EMR Alerts

Posted on June 25, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study appearing in the Journal of the American Medical Informatics Association has made some points that may turn out to be helpful in designing those pesky but helpful alerts for clinicians.

Making alerts useful and appropriate is no small matter. As we reported on a couple of years ago, even then EMR alert fatigue has become a major source of possible medical errors. In fact, a Pediatrics study published around that time found that clinicians were ignoring or overriding many alerts in an effort to stay focused.

Despite warnings from researchers and important industry voices like The Joint Commission, little has changed since then. But the issue can’t be ignored forever, as it’s a car crash waiting to happen.

The JAMIA study may offer some help, however. While it focuses on making drug-drug interaction warnings more usable, the principles it offers can serve as a model for designing other alerts as well.

For what it’s worth, the strategies I’m about to present came from a DDI Clinical Decision Support conference attended by experts from ONC, health IT vendors, academia and healthcare organizations.

While the experts offered several recommendations applying specifically to DDI alerts, their suggestions for presenting such alerts seem to apply to a wide range of notifications available across virtually all EMRs. These suggestions include:

  • Consistent use of color and visual cues: Like road signs, alerts should come in a limited and predictable variety of colors and styles, and use only color and symbols for which the meaning is clear to all clinicians.
  • Consistent use of terminology and brevity: Alerts should be consistently phrased and use the same terms across platforms. They should also be presented concisely, with minimal text, allowing for larger font sizes to improve readability.
  • Avoid interruptions wherever possible:  Rather than freezing clinician workflow over actions already taken, save interruptive alerts that require action to proceed for the most serious situation. The system should proactively guide decisions to safer alernatives, taking away the need for interruption.

The research also offers input on where and when to display alerts.

Where to display alert information:  The most critical information should be displayed on the alert’s top-level screen, with links to evidence — rather than long text — to back up the alert justification.

When to display alerts: The group concluded that alerts should be displayed at the point when a decision is being made, rather than jumping on the physician later.

The paper offers a great deal of additional information, and if you’re at all involved in addressing alerting issues or designing the alerts I strongly suggest you review the entire paper.

But even the excerpts above offer a lot to consider. If most alerts met these usability and presentation standards, they might offer more value to clinicians and greater safety to patients.

Medication Alerts in EMRs Are Especially Prone to Creating “Alert Fatigue”

Posted on April 6, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

New research is drawing to attention to a critical subset of  “alert fatigue,” a problem which has dogged medical devices since well before EMRs/EHRs rolled into the picture.  The research, which appears in this month’s issue of the International Journal of Medical Informatics, finds that providers are becoming particularly numb to the high volume of EMR-based medication alerts they get.

To draw this conclusion, researchers followed 30 doctors, nurse practitioners and pharmacists as they treated 146 patients in outpatient settings run by the Indianapolis VA center. The study took place from August 2008 to August 2009.

After watching providers for a year, researchers came up with several different features characteristic of a poorly designed alert:

*  The system generates too many alerts
*  The alert provides far more information than the clinician needs
*  The system produces alerts that appear to go against standard clinical practice
*  The alert doesn’t apply to the patient
*  The alert isn’t needed (such as a warning about a drug a patient has already received and responded to safely)

Another failing found by researchers — which seems particularly acute in my opinion — is that alerts are typically designed to meet the needs and training of pharmacists, even though physicians and nurse practitioners were doing the prescribing.

Yet another issue that stood out was timing. On the one hand, alerts often interrupted the prescribing process, and wouldn’t go away until addressed.  Meanwhile, other alerts disappeared once addressed, and couldn’t be retrieved once they’ve left the screen.

As most readers know, I’m not a clinician, so I’m just reacting to the research data, but the situation sounds pretty dire. If an EMR is guilty of half of these medication alert “sins,” much less all of them, I’d bet it increases the potential for patient harm significantly.

Maybe this is a good place to start addressing the kind of potentially harmful design flaws identified by NIST. After all, virtually every patient takes meds, and  most every clinician touches them. Why not address some of these nagging problems before someone gets hurt?

101 Tips to Make Your EMR and EHR More Useful – EHR Tips 31-35

Posted on October 12, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

35. CPOE is important, but every EMR will have it.
I think that the CPOE discussion hit a head for me when I saw the CPOE requirements that were baked into meaningful use. Then, I heard someone from the often lauded (appropriately so) IHC in Utah who said that IHC didn’t have CPOE and it would be hard for them to meet that benchmark. Ok, so I’m more of an ambulatory guy than I am hospital, but this surprised me. In the clinics I’ve helped with EHR, CPOE is one of the first things we implemented. No doubt that every EMR has CPOE capabilities.

34. Make sure adverse drug events reporting is comprehensive
Yes, not all drug to drug, drug to allergy, etc databases are created equal. Not to mention some EHR vendors haven’t actually implemented these features (although, MU is changing that). I’d really love for a doctor and an EMR company to go through and rate the various drug database companies. How comprehensive are they? How good can you integrate them into your EHR? etc etc etc.

33. Make certain drug interactions are easy to manage for the physician
I won’t go into all the details of alert fatigue in detail. Let’s just summarize it this way: You must find the balance between when to alert, what to alert, how to alert and how to ignore the alert. Plus, all of the opposites of when not to alert, what not to alert, and how to not ignore the alert.

32. Ensure integration to other products is possible
Is it possible that you could buy an EMR with no integration? Possibly, but I have yet to see it. At a bare minimum clinics are going to want to have integration with lab software and ePrescribing (pharmacies). That doesn’t include many of the other common interfaces such as integration with practice management systems, hospitals, radiology, etc. How well your EMR handles these integration situations can really impact the enjoyment of your EHR.

31. Ensure information sharing is easy
This tip could definitely be argued, but I believe we’re headed down the road of information sharing. It’s going to still take a while to get to the nirvana of information sharing, but we’ve started down the road and there’s no turning back. Kind of reminds me of Splash Mountain at Disneyland where the rabbit has a sign that says there’s no turning back now. My son didn’t like that sign so much and I’m sure many people won’t like that there’s no turning back on data sharing either. However, it’s going to happen.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.