Dec 25, 2015
Electronic health record (EHR) pop-up notices, intended to help physicians by providing timely reminders and alerts, could end up actually compromising patient care. Customizing the system and integrating it into the practice workflow is one of the best strategies for appropriately and efficiently using alerts—and avoiding potential alert fatigue.
If you are a physician experiencing alert fatigue—or feel you may succumb to it—you are not alone. “Alert fatigue is a major issue, and part of the reason is that there is a general overload of warnings and pop-up messages for clinicians throughout the work day,” says Mike Zalis, MD, an interventional radiologist at Massachusetts General Hospital. “The avoidance of liability leads to a multiplicity of alerts that are presented to a user while they’re doing their work. The problem with those alerts is that they’re not very well tailored in context or acuity, so there are too many that pop up.”
Fortunately, physicians can preserve the benefits of EHR-generated alerts while maintaining a smooth workflow in their practice by employing some simple strategies.
Acclimating to the right system
Physicians acknowledge that alert fatigue can be a problem, so many have found ways to work with the system instead of against it. Rather than immediately writing off all alerts as useless, it’s essential to understand what EHR systems are capable of doing.
“We find there are often capabilities in software that are not very well understood by clinicians,” says Michael McCoy, MD, chief health information officer with the Office of the National Coordinator for Health Information Technology (ONC.)
ONC grants are available to educate physicians and support staff in managing the potential torrent of alerts. “We’re trying to help individuals understand that balance between sufficient alerting and the overwhelming burden of looking at everything, and that’s where you have to have that adjustability in the software product,” McCoy says.
For many practices, this becomes an issue of time management, workflow coordination, and clear delineation of job duties. System administrators can determine what kinds of alerts each person in the practice sees based on his or her assigned roles. Appropriately and specifically identifying everyone’s responsibilities is far better than giving everyone access to everything—and therefore producing a flood of unneeded and inappropriate alerts.
Most EHR systems now allow users or administrators to filter these warnings based on importance and sensitivity, often on a sliding scale ranging from a low to a high filtration setting that shows only the most critical and relevant alerts.
“The key criteria would be to make sure that what you’re presenting has value,” says Kenneth Kubitschek, MD, an internist in Asheville, North Carolina, and a member of the Medical Economics editorial advisory board. In his practice, for example, nurses receive alerts related to care management such as the need to update vaccinations, but physicians do not.
Physicians need to use these filtration systems responsibly to ensure that the reminders they receive are relevant, helpful, and not distracting. “If you set your level of alerts too low, that does become something you click right through,” Kubitschek says.
Additionally, Kubitschek uses pop-up reminders he has created for each patient to alert him to details regarding the patient’s family, work, and interests. “These are my own little alerts to make these more personal visits and help remind me of things that are important to the patient at that particular time,” he says. “That’s one type of alert that’s very helpful, and I turn those on and off. It’s a choice.”
Some systems also have a built in workflow option allowing physicians to choose the types of alerts to allow for a soft stop—notices that pops up but don’t require action and therefore have minimal adverse effect on workflow—versus those that block forward progress until they take an action, such as accepting or acknowledging alerts.
James Legan, MD, an internist with Northwest Physicians in Great Falls, Montana, uses customized reminder alerts that are color-coded based on severity (red for immediate needs, yellow for maintenance requirements, etc.) and set by a nurse so they pop up at an appropriate time. “I haven’t really experienced alert fatigue,” he says, “especially when they’re used in a common-sense way.”
Many physicians recall working with paper and pencil to keep track of patient records and spending hours researching drugs they weren’t intimately familiar with in reference books to guarantee they made sound patient care decisions. EHRs do this work for doctors, saving time and ensuring potential interactions aren’t overlooked, no matter how inconsequential they might be.
It’s important to place frustration in the appropriate place, however: Digital systems are just computer programs, and as such cannot discreetly and quickly make the same observations and decisions as physicians, which isn’t the fault of the EHR technology itself.
Setting alert sensitivity
Kubitschek initially set his EHR to a “low” severity, meaning his practice received all alerts in the system. However, “we quickly evolved to ‘moderate’ within days because we didn’t need to see all this stuff related to medicine we already knew,” he says. From there, they moved quickly to the highest setting, because, he says, “we don’t really want to know the simple interactions or problems that don’t greatly impact risk for the patient, but we certainly want to know about anything that is a true risk.” At this alert level, Kubitschek says he finds reminders useful and can get through them efficiently.
“When the alerts are appropriate, tested, validated, and allowed to be edited such that what is really important fires and what’s not particularly important is not disruptive, it’s very helpful,” says Peter Basch, MD, chair of the American College of Physicians’ Medical Informatics Committee and a primary care physician at MedStar Physician Partners in Washington, D.C. “On the other hand, if there’s no ability to edit or filter, it can be very annoying and distracting.”
All certified EHR systems must have an alert system. However, McCoy says, “the granularity is not something that the federal government, either through meaningful use or through the certification program, says what that level needs to be. That’s a business practice and liability question for the individual practice or hospital.”
Practices can, in fact, turn off all alerts, but the more appropriate option often is something in between. “There is an appropriate balance to getting alerts. When you get too many, you just click through them and you never actually see the important ones,” McCoy says. “One size does not fit all, and that’s the problem. You’ve got to tailor a lot of these alerts.”
In addition to setting alert sensitivity, some systems allow physicians to enter override alerts, such as “alert not significant” or “patient is already taking drug with no adverse reactions,” that appear for specific patients or under specific circumstances. “If you’ve already filtered them, hopefully you’re getting less of them, but at least you owe it to your patients, in my opinion, to read and document an override,” Basch says. “If your system is smart, you won’t get pestered with that alert for that patient again.”
For physicians who have adjusted their EHR settings so that fewer alerts appear, those that do pop up receive greater attention. “It certainly helps to have them be more significant,” Kubitschek says, “and it helps me notice them much more.”
Basch says he enters reminders to help maintain the primary care standard of practice. “We wrote in a series of reminders that are embedded into the EHR that aren’t interruptive,” he says. For example, for a female patient over age 40 who has come in for treatment of a sore throat, a reminder for the physician pops up for the patient to make an appointment for a mammogram based simply on the patient’s gender and age. If the patient already has had the recommended procedure no reminder appears.
“My message to the docs was to provide care that is most appropriate,” Basch says. “I’m not there to take care of your patients but only to make it easier to do the right thing.”
An increasing number of vendors are introducing systems that are designed for specialties such as gynecology and cardiology, and the alerts embedded in these EHRs are more appropriately tailored to those physicians. “They understand the workflows and specific design of alerts that are appropriate for those individuals,” McCoy says.
Steve Waldren, MD, director of the American Academy of Family Physicians Alliance for eHealth Innovation, says vendors’ two biggest opportunities for product development are creating smarter alerts and ensuring that alerts are more efficient within the office workflow. These issues are part of an ongoing effort to create the perfect alert system, which is why, Waldren says, “the communication among the front-line users and developers is important.”
This dialogue between what physicians want and need from alerts and what vendors provide in their EHRs may pave the way for systems that learn from users’ past actions and can provide alerts that are more likely to be relevant and acted upon.
Creative patient-centric care
Many physicians lament the loss of patient interactions that aren’t distracted by a computer screen, but instead of letting these alerts derail appointments, some physicians use them as a conversation vehicle.
One of the biggest complaints regarding alert fatigue is that many pop-ups interrupt the patient encounter, which is, in part, what makes them so annoying. Legan did extensive research before choosing his small practice’s EHR, which, he says, aligns well with his workflow. Legan has integrated his CRM system with his EHR to improve his office’s efficiency. By using a Chromebook and wall-mounted televisions, he can project everything he does in the EHR in real time in front of the patient. “They help build their own chart when they’re right there with me,” he says.
“We have to change our perception of what the electronic record is there for,” he adds. “In my opinion, it’s a wonderful occupational tool.” Together, Legan and his patients talk through medical data collected over the years and discuss any pop-up alerts, especially as they relate to prescription medications, to create an effective wellness plan of action. “We see these alerts together. That’s worked extremely well, and patients like to see that,” Legan says. “They find it very interesting.”
Legan says he does not suffer from fatigue because he has turned alerts into real-time teachable moments with patients. “The electronic record is used primarily for documentation and billing purposes. This needs to change. It needs to be an educational platform tool with the patient,” he says.
Basch thinks there is an opportunity to find a middle ground for both physicians and their patients when it comes to alert fatigue. “I think it’s up to not just EHR designers but also EHR implementers and the medical community as a whole to make sure that, as we reach this next phase of user technology that we’re not just left with a desire to do away with alerts,” he says. “We need to remember a visit guided by the absence of information—just what you and the patient remember—is not necessarily the right answer either.”
Alert fatigue: What the research says
The most widely-cited study on alert fatigue was published in the April 2012 issue of the International Journal of Medical Informatics. The study looked at how physicians, nurse practitioners, and clinical pharmacists responded to EHR-generated alerts related to patient allergies, drug interactions and duplicate prescriptions while treating patients at a Veterans Administration Medical Center outpatient clinic. During the observation periods, which took place from August 2008 to August 2009, researchers observed that these alerts didn’t assist physicians as intended. Instead, the system tended to generate too many alerts, provided too much extra information and sometimes didn’t even apply to the patient in question.
Moreover, the researchers found that medical practitioners were sometimes confused by the alerts, especially when they contradicted common and known clinical practice. “Too many alerts and overly detailed alerts are a common source of frustration across electronic medical record systems,” wrote Alissa Russ, PhD, coauthor of the study from the Richard L. Roudebush VA Medical Center in Indianapolis, in a press release accompanying the study.