Alert fatigue
Alert fatigue or otherwise known as "pop-up" fatigue is a commonly perceived occurrence with the recent implementation of EMRs (electronic medical records) and specifically CDS (decision support). Given that medical errors receive much press in reality many of the errors are secondary to a provider's difficulty with knowledge management. Clearly, the volume of information an average ambulatory provider must remember is too much. The volume increases daily and in order to keep current a provider needs help. Decision support is one type of help that has evolved. As stated by Dr Eric Rose, "where human brains fail, computers excel." One form of tools to aid the provider is alerts. Alerts can be in the form of "pop-ups," contact-dependent (during access of patient's record), and/or contact-independent (alert "delivered" to provider). The alerts, while found to be beneficial in some cases, can result in a type of "fatigue" whereby the provider, after receiving too many alerts, begins to ignore and/or override the alerts. Receiving too many alerts can result in slowing the provider down rendering the alert useless. A recent review stated that safety alerts are overridden by clinicians 49-96% of the time (1). For example, in Portland, Oregon the Multnomah County Health Department, which recently implemented an EMR, decided to significantly reduce the number of drug-drug interactions providers were seeing during order entry. The providers felt in order to "get through their daily work," they were forced to override several of the drug-drug interactions. Likewise, as studied in ambulatory settings alert overrides were secondary to poor specificity and CPOEs need to suppress alerts for renewals of medication combinations that patients currently tolerate (2). By changing the severity level of drug-drug interactions Multnomah County Health Department providers have commented positively on the drug-drug interaction alerts. Some suggestions to avoid alert fatigue are alerts should be not overused, not repeated several times a day, alert gives enough time to make a decision, and creating selectively targeted alerts. Similarly, Shah NR, et al found, in a 6-month study, that by changing the alert setting to critical/high severity (i.e. high specificity) led to 71% of the alerts being non-interruptive (3). This study and others show the need for the distinction between appropriate and useful alerts. A recent example of a useful alert was the acceptance and highly successful alert of cancelling a medication order when the creatinine clearance of a patient made the medication order not safe (4). While studies on the cognitive processes ["fatigue"] playing a role in overriding drug safety alerts are lacking, an in depth analysis of the practice/provider's needs may result in a significant "buy-in" resulting in an effective alert with improved outcomes (1). In summary, overriding of alerts is a common practice, but whether "alert fatigue" is a reality remains to be proven. Future studies to address the cognitive effects may elucidate the root of overrides and possibly reveal the perceived "fatigue."
Amit Shah, MD [As001]
References:
Rose E. "Life after Go-Live, Part 4: Preventing Error in an EMR." Journal of Healthcare Information Management. Vol 17, No.4.
Krall M. "Clinicians' Assessments of Outpatient Electronic Medical Alert and Reminder Usability and Usefulness Requirements: A Qualitative Study." May 2002.
1. Heleen van der Sijs, et al. "Overridding of Drug Safety Alerts in Computer Physician Order Entry." J Am Med Inform Assoc. 2006;13:138-147.
2. Weingart, et al. "Physicians' decisions to override computerized drug alerts in Primary Care." Arch Intern Med. 2003 Nov 24;163(21):2625-31.
3. Shah NR, et al. "Improving Acceptance of Computerized Prescribing alerts in Ambulatory Care." J Am Med Inform Assoc. 2006 Jan-Feb;13(1):5-11.
4. Galanter, et al. "A trial of Automated Decision Support Alerts for Contraindicated Medications Using Computerized Physician Order Entry." J Am Med Inform Assoc. 2005; 12:269-274.
