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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?

A Report on ePrescribing Challenges

Posted on November 28, 2011 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

From the Center for Studying Health System Change (hschange.com) comes a study on e-prescriptions, and how providers and pharmacies work together to electronically transmit and fulfill prescriptions. Now, I don’t know how reliable this organization or its research is (the .com in its name, for example, is something that bothers me. Also the report focuses almost exclusively on SureScripts). But the study is interesting to me for what it reveals statistically.

HSChange.com conducted 114 phone interviews with 24 physician practices, 48 community pharmacies, divided between local and national companies. The national respondents included 3 mail-order pharmacies, and 3 chain pharmacy headquarters. Those of you who are interested in the numbers, the methodology and other sundries, go ahead and read the report in its entirety. Here’s a quick summary from the report’s results the rest of us. My comments are bolded.

According to the report:
Two-thirds of the practices sent at least 70% of their prescriptions electronically. Which means about 46.2% of the prescriptions are e-prescribed. Plenty of room for growth, methinks.

Pharmacists at more than 50% of Community said their pharmacies received less than 15% of their prescriptions electronically. The reasons: providers didn’t transmit electronically, or sent out computer-generated prescriptions by fax or mail. Interesting – could be indicative of either lack of knowhow, or infrastructure that allows for e-transmission.
New prescriptions are more likely to be e-prescribed than prescription refills (renewals). The report states that many pharmacies don’t use this feature in order to avoid SureScripts fees for renewals.

There are plenty of inefficiencies. E.g. a) multiple requests for the same prescription were sent (say by phone, fax and through SureScripts) by pharmacies b) providers mistakenly deny prescriptions and then re-send the same prescription as a new one.

E-prescribing to mail order pharmacies is a different process – (apparently providers need to be Surescripts certified to e-prescribe with community pharmacies, and also need to be certified to e-prescribe to mail order pharmacies. So, even when a provider selects a mail order pharmacy to fulfill an e-prescription, the prescription is delivered by fax to the the mail order pharmacy by Surescripts.)
Prescription specificity falls on the provider – tablets, capsules, and liquid formulations might have different costs. Pharmacists can’t change the prescription from a capsule to a tablet on their own, without consulting with the prescribing provider. This might result in unexpected costs.
Providers’ patient instructions are still incomprehensible! Pharmacists often have to play translator (maybe because as the report alludes to, the instructions are intended for pharmacist eyes, not the patient.)

an independent pharmacist explained, ‘A lot of times we can’t copy the directions word for word because the patient doesn’t understand them, just like with paper prescriptions. We have to go in and erase ‘t.i.d.’ and put in, ‘One tablet three times a day’.’