Unit 6c: Alerts and Clinical Reminders Decision Support for Quality Improvement This material was developed by Johns Hopkins University, funded by the.

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Unit 6c: Alerts and Clinical Reminders Decision Support for Quality Improvement This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

Objectives Analyze the benefits and shortfalls of alerts and clinical reminders Component 12/ Unit 62 Health IT Workforce Curriculum Version 2.0/Spring 2011

Reminders and Alerts “…the burden of reminders and alerts must not be too high…or alert fatigue may cause clinicians to override both important and unimportant alerts, in a manner that compromises the desired safety effect of integrating decision support into CPOE.” Component 12/ Unit 63 Health IT Workforce Curriculum Version 2.0/Spring 2011 Van der Sijs, et. al., 2006.

Alerts and Reminders Nuisance AlertAlert Fatigue “…provides little perceived benefit to the prescriber at the time of the alert” “…arise when clinicians, either consciously or unconsciously, begin to systematically bypass CDS alerts without regard to their importance, enabling the possibility that a clinically important alert is missed” Component 12/ Unit 64 Health IT Workforce Curriculum Version 2.0/Spring 2011 Chaffee, BW (2010)

Responses to Clinical Reminders Tendency to perform an action when a warning system instructs the user to do so Compliance Tendency to refrain from performing an action when the warning system does not indicate that it is necessary Reliance Component 12/ Unit 65 Health IT Workforce Curriculum Version 2.0/Spring 2011

Responses to Clinical Reminders Clinician performs an action even when not prompted by the reminder system Spillover Clinician refrains from performing an action due to a perceived threat to professional autonomy Reactance Component 12/ Unit 66 Health IT Workforce Curriculum Version 2.0/Spring 2011

Four Types of Alerts/Reminders Drug Alerts Lab Test Alerts Practice Reminders Administrative Reminders Component 12/ Unit 67 Health IT Workforce Curriculum Version 2.0/Spring 2011

Basic Drug Alerts Drug allergy warningsDrug-drug interactionsDuplicate medication or therapeutic duplication alertBasic medication order guidance Component 12/ Unit 68 Health IT Workforce Curriculum Version 2.0/Spring 2011

Advanced Drug Alerts Drug-Lab alertsDrug-Condition interactionsDrug-Disease Contraindication alertsDrug-condition alerts aimed at appropriate prescribing Component 12/ Unit 69 Health IT Workforce Curriculum Version 2.0/Spring 2011

Advanced Drug Alerts Drug-age alerts Drug-formulary alerts Dosing guidelines Complex prescribing alerts Component 12/ Unit 610 Health IT Workforce Curriculum Version 2.0/Spring 2011

Evidence to Support Drug Alerts Systematic review examined 20 studies that evaluated the impact of efficacy of computerized drug alerts and prompts –23 of 27 alert types identified demonstrated benefit Improving prescribing behavior Reducing error rates –Greatest potential for affecting prescribing Drug-drug interaction alerts Drug-disease contraindication alerts Dosing guidelines based on age Component 12/ Unit 611 Health IT Workforce Curriculum Version 2.0/Spring 2011

Improving Adoption of Drug Alerts Shah & colleagues studied improving clinician acceptance of drug alerts in ambulatory care –Designed a selective set of drug alerts for the ambulatory care setting using a criticality leveling system –Minimized workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow Alert levels: –1: clinician could not proceed with the prescription without eliminating the contraindication; –2: clinicians could proceed if provided an over-ride reason –3: alert displayed at top of screen in red; did not hinder workflow Component 12/ Unit 612 Health IT Workforce Curriculum Version 2.0/Spring 2011

Basic Laboratory Alerts Drug-laboratory alertsDuplicate laboratory testing alert Basic laboratory test order guidancePublic health situational awareness Component 12/ Unit 613 Health IT Workforce Curriculum Version 2.0/Spring 2011

Evidence to Support Lab Alerts Research examined the impact of a CDDS that generated reminders of previous lab test results Found that the proportion of unnecessarily repeated tests dropped significantly Features of the Alert –Alert was automatically prompted and was part of the clinician workflow –User could not deactivate the alert output –Most recent laboratory result for viral serology test an its date was automatically retrieved from the patient’s EHR –Alert was displayed at the time and location of decision making (before the user ordered an unnecessarily repeated test Component 12/ Unit 614 Health IT Workforce Curriculum Version 2.0/Spring 2011

Practice Reminders Provides recommended treatment Guiding Checks prescriptions against clinical practice guidelines Critiquing Helps provider follow the patient Monitoring Component 12/ Unit 615 Health IT Workforce Curriculum Version 2.0/Spring 2011

Practice Reminders Challenges Incorrect guidelinesToo generic guidelinePatient data inconsistencyInappropriate actionPotential Risk Component 12/ Unit 616 Health IT Workforce Curriculum Version 2.0/Spring 2011

Administrative Reminders Guides prescribers to document to support appropriate medical coding Medical Coding Guides the collection of QI indicator data Quality Improvement Component 12/ Unit 617 Health IT Workforce Curriculum Version 2.0/Spring 2011

Success Factors: Alerts Specificity Alert clinically important for the patient Sensitivity Alert generated in all dangerous cases Component 12/ Unit 618 Health IT Workforce Curriculum Version 2.0/Spring 2011 van der Sijs, et. al., 2006

Success Factors: Alerts Information Content Clear, concise, unambiguous Justification noted Further information accessible Alternative actions presented Component 12/ Unit 619 Health IT Workforce Curriculum Version 2.0/Spring 2011 van der Sijs, et. al., 2006

Success Factors: Alerts Workflow Directed to right person at right time Specialty-specific; Knowledge-specific Avoid repetition Safe, efficient handling High threshold Reasons for non-compliance Promotes action Speed; Screen design; minimize work Component 12/ Unit 620 Health IT Workforce Curriculum Version 2.0/Spring 2011 van der Sijs, et. al., 2006

Summary Alerts/reminders have the potential to improve patient safety Types include: drug and lab test alerts, practice reminders, and administrative reminders Nuisance alerts provide little perceived benefit to the prescriber at the time of the alert, causing clinician frustration and alert fatigue Successful alerts are specific, sensitive, clear, concise and support clinical workflow, allowing for safe, efficient responses. Component 12/ Unit 621 Health IT Workforce Curriculum Version 2.0/Spring 2011