The Alert That Cried Wolf: Optimization of Clinical Decision Support Alerts Juanqin (Stephanie) Wei, PharmD Stephanie.Wei@RWJBH.org PGY-1 Pharmacy Resident

Disclosures Neither the presenter nor the planning committee has received any commercial support associated with this educational activity.

Objectives List the roles of clinical decision support alerts in practice Identify actions that can be taken to reduce the risk of alert fatigue

Outline Background RWJUH Somerset: CDS in test mode Conclusion Clinical decision support (CDS) Alert fatigue RWJUH Somerset: CDS in test mode Cumulative acetaminophen CDS alert Order set revision Pre-alert and post-alert evaluation Conclusion

Background: Clinical Decision Support (CDS)

What is Clinical Decision Support? Health information technology (IT) function that builds on the foundation of an electronic health record (EHR) Presents information at appropriate times Filters and organizes information Enhances patient health and healthcare Assists providers to make higher quality decisions Does NOT replace clinical judgement 75 Fed. Reg. 144 (July 28, 2010).

Meaningful Use Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program Stage 3 Use of multiple CDS interventions to apply quality measures Enable drug-drug and drug-allergy interaction checks 75 Fed. Reg. 144 (July 28, 2010).

Goals of CDS In order to provide benefit, CDS must provide: The right information To the right people Through the right channels In the right intervention formats At the right points in workflow Osheroff J, Teich J, Levick D, et al. 2012.

Types of CDS Computerized alerts and reminders Clinical guideline based order sets Condition-specific order sets Documentation templates Relevant reference information Osheroff J, Teich J, Levick D, et al. 2012.

CDS Alerts: Advantages and Disadvantages Variety of automated alert types and checks Additional layer of safety Customization tailored to site of use Disadvantages Excessive number of alerts Slows workflow Maintenance of custom alerts

Background: Alert fatigue

What is “Alert Fatigue”? Desensitization to significant alerts due to an overload of insignificant or irrelevant alerts Leads to: False sense of safety Increased risk of adverse events

CDS Alerts: Outcomes Bates DW et al., 1994 Weingart SN et al., 2003 Evaluated potential for preventability by computerized information systems 81% potential medication error reduction Weingart SN et al., 2003 91.2% override rate of drug-allergy interactions 89.4% override rate of high severity drug-drug interactions 36.5% of alerts evaluated by physicians to be inappropriate Bates: Analysis of 133 adverse events

CDS Alerts: Outcomes Beccaro MA et al., 2010 Customization of CDS alerts for 250 medications Dose range checking alert firing rate decreased from 23.4% to 7.4% Drug-drug interaction alert firing rate decreased from 13.5% to 4.8% No significant increase in reported medication errors Retrospective analysis of CDS alerts (dose range checks, drug-drug interactions, and drug-allergy) Customization based on clinical judgement No increase in errors despite an increase in reporting and total orders

RWJUH Somerset: cds alerts in test mode

RWJUHS: Monitoring Total Daily Dose (TDD) of Acetaminophen January 2014: FDA alert Discontinue the use of combination products containing greater than 325 mg of acetaminophen (APAP) Zhou L et al., 2012 6% of hospitalized patients exceeded the APAP maximum TDD of 4000 mg 22% of 65 years or older exceeded the APAP maximum TDD of 3000 mg 17% of patients with chronic liver disease

RWJUHS: Monitoring TDD of APAP Medication safety committee Multiple orders of APAP-containing medications prescribed for multiple indications Discussed need for APAP dosing restriction Cerner APAP cumulative dosing alert Calculated daily cumulative dose based on eMAR Maximum TDD defined as 4000 mg for ≥ 50 kg and 75 mg/kg/day for < 50 kg Suppressed until defined threshold of 3000 mg reached

RWJUHS: Monitoring TDD of APAP Alert test mode run 0.2% incidence of APAP TDD administrations over 4000 mg Multiple cases of exceeding the TDD occurred in Labor and Delivery Review of order sets to reduce risk Oxycodone/Acetaminophen 5/325 mg Original: 2 tablets by mouth every 3 hours as needed Revision: 2 tablets by mouth every 4 hours as needed predisposition to exceed maximu

RWJUHS: Monitoring TDD of APAP Post alert and order set revision study evaluation Cumulative dosing alert run in test mode Revisions were implemented July 2014 Pre-alert period: January 1st, 2014 – June 4th, 2014 Post-alert period: January 1st, 2015 – June 4th, 2015

RWJUHS: Monitoring TDD of APAP Outcomes Pre-Alert (n = 8,122) Post-Alert (n = 8,456) Odds Ratio (95% CI) p-value Primary Outcome TDD ≥ 3 grams (%) 194 (2.4) 99 (1.2) 0.50 (0.39 - 0.64) < 0.001 Age ≥ 65 years old (%) 81 (41.7) 37 (37.7) 0.83 (0.51-1.37) 0.4700 Chronic liver disease (%) 6 (3.1) 1 (1.0) 0.32 (0.04 - 02.69) 0.2943 Secondary Outcome TDD ≥ 4 grams (%) 16 (0.2) 4 (0.05) 0.24 (0.08 - 0.72) 0.0107

Conclusions Running the CDS alert in test mode allowed identification and correction of root causes Significant reductions were seen in supratherapeutic APAP dosing A live alert did not need to be implemented, reducing alert fatigue risk

Assessment Question 1 Which of the following is NOT an appropriate role for CDS alerts? Alerting providers to drug-drug interactions Acting as a replacement for clinical judgement Listing alternative recommendations Reminding providers of incomplete tasks or orders

Assessment Question 1 Which of the following is NOT an appropriate role for CDS alerts? Alerting providers to drug-drug interactions Acting as a replacement for clinical judgement Listing alternative recommendations Reminding providers of incomplete tasks or orders

Assessment Question 2 Of the following, which is the most appropriate method to reduce the risk of alert fatigue from CDS alerts? Remove CDS alerts entirely from the EHR Exempt all providers from receiving CDS alerts Resize CDS alert pop-ups to be smaller Customize the specificity of CDS alert triggers

Assessment Question 2 Of the following, which is the most appropriate method to reduce the risk of alert fatigue from CDS alerts? Remove CDS alerts entirely from the EHR Exempt all providers from receiving CDS alerts Resize CDS alert pop-ups to be smaller Customize the specificity of CDS alert triggers

References Medicare and Medicaid Programs: Electronic Health Record Incentive Program, 75 Fed. Reg. 144 (July 28, 2010). Federal Register: The Daily Journal of the United States. Web. 2 February 2017. Osheroff J, Teich J, Levick D, et al. Improving outcomes with CDS: an implementer's guide. 2nd ed. Chicago: HIMSS Publishing; 2012. Bates DW, O'Neil AC, Boyle D, et al. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994 Sep-Oct;1(5):404–411. Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med. 2003 Nov 24;163(21):2625– 2631. Beccaro MA, Villanueva R, Knudson KM, et al. Decision Support Alerts for Medication Ordering in a Computerized Provider Order Entry (CPOE) System. Appl Clin Inform. 2010;1(3):346-62 U.S. Food and Drug Administration [Internet]. Silver Spring (MD): U.S. Department of Health and Human Services;c2016. FDA recommends health care professionals discontinue prescribing and dispensing prescription combination drug products with more than 325 mg of acetaminophen to protect consumers [cited 2017 Feb 02]; [1 screen]. Available from: https://www.fda.gov/Drugs/DrugSafety/ucm394916.htm. Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012 Dec;172(22):1721-8.

The Alert That Cried Wolf: Optimization of Clinical Decision Support Alerts Juanqin (Stephanie) Wei, PharmD Stephanie.Wei@RWJBH.org PGY-1 Pharmacy Resident