2. The Antidote to Alert Fatigue May 26, 2010 Best Ever Medical Center Best City, IL MMI – 406: Decision Support Systems and Healthcare Suzi Birz, Nicki Cliffer, Kyle Johnson, Debbie Michaelson

3. Best Ever Hospital Best City, IL Agenda May 26, 20102 Welcome and Introductions We Hear You – You have Alert Fatigue The Antidote (the process) Stop-The-Noise Evaluation Become a Participating Physician

4. Best Ever Hospital Best City, IL Welcome and Introductions May 26, 20103

5. Best Ever Hospital Best City, IL Meeting Participants Champions Welcome to our physicians and pharmacists Welcome to other stakeholders – Lori, our Chief Nursing Officer – Beth from the Office of Legal Affairs – Jeff from Performance Management – Krista from Patient Safety Thank the CPOE Team May 26, 20104

6. Best Ever Hospital Best City, IL May 26, 20105 We hear you have Alert Fatigue

7. Best Ever Hospital Best City, IL Problem Statement Alert fatigue is the most common complaint by physicians about CPOE systems. Alerts are overridden 49 – 96% of the time. Contributing factors to our high alert rate: – Doses larger than the alert threshold are often warranted due to our patient severity mix – Some of our drugs are entered by package not by dose – Some order changes generate an unwarranted duplicate order alert May 26, 20106

8. Best Ever Hospital Best City, IL Not All Alerts Are Noise “GOOD ALERT” Prescription for Amphotericin 5 mg/kg generates a “maximum dose exceeded” alert “NOISE ALERT” Prescription for potassium-sparing diuretic warns that patient is receiving potassium May 26, 20107

9. Best Ever Hospital Best City, IL Clinical Objectives Turn off non-meaningful overridden alerts Display alerts in order of salience Reduce number of clicks in the ordering process Reduce overall time it takes to place medication orders Improve ordering patterns Reduce adverse drug events May 26, 20108

10. Best Ever Hospital Best City, IL The Antidote May 26, 20109

11. Best Ever Hospital Best City, IL Process May 26, 201010

12. Best Ever Hospital Best City, IL Scenario A 68-year old female, Mrs. Mary MacIntosh, is admitted to Best Ever Medical Center with an admitting diagnosis of acute myocardial infarction. Medication reconciliation performed by the ED pharmacist shows her current medication list as: – Aspirin 81 mg PO daily – Cardizem CD 180 mg PO daily – Simvastatin 40 mg PO daily – Synthroid 100 mcg PO daily Dr. Steve Jobs, her attending physician, examines Mrs. MacIntosh and orders laboratory tests. Dr. Jobs makes some changes to the medication regimen. The changes prescribed are: – D/C aspirin – Plavix 300 mg PO STAT, followed by 75 mg PO daily – Nitroglycerin IV 5 mcg/min – Metoprolol 25 mg PO Q6H – Morphine 2 mg IV Q2H prn pain – Docusate 100 mg PO BID – Acetaminophen 650 mg PO Q6H prn t May 26, 201011

13. Best Ever Hospital Best City, IL Stop-The-Noise May 26, 201012

14. Best Ever Hospital Best City, IL System Design May 26, 201013

15. Best Ever Hospital Best City, IL The App May 26, 201014

16. Best Ever Hospital Best City, IL Analysis and Decision May 26, 201015

17. Best Ever Hospital Best City, IL Evaluation May 26, 201016

18. Best Ever Hospital Best City, IL Evaluation Elements Alert CDS verification and validation – Verification: Level 1 – Establishing Order-Alert sensitivity and specificity – Validation: Level 2 – Utilizing Order-Alert-Response sensitivity and specificity to revise alert firing rules and thresholds Alert database validation and verification – Verification methods – Validation requirements Alert Decision Support Customer Satisfaction Survey Physician Super User observations Evaluation of performance against target clinical objectives Suggested logs and report formats Communication recommendations May 26, 201017

19. Best Ever Hospital Best City, IL Process Steps Sensitivity, specificity, percent of false positives, and the percent of false negatives occurring at a given threshold level will be assessed. Threshold levels will be fine-tuned, additional data will be gathered, and will be evaluated after a three-month period. Threshold levels will continue to be fine-tuned until the balance between specificity and sensitivity is such that the level of false negatives is as low as is reasonable. May 26, 201018

20. Best Ever Hospital Best City, IL Sensitivity and Specificity: Accepted May 26, 201019

21. Best Ever Hospital Best City, IL Sensitivity and Specificity: Override May 26, 201020

22. Best Ever Hospital Best City, IL Sample Calculations May 26, 201021

23. Best Ever Hospital Best City, IL Feedback Loop Our promises to you – Notification of alerts analyzed and decisions – Routine meetings for open discussion of alerts – Multiple communication avenues including e-mail, SharePoint site, meetings Reports / Queries available to you – Alerts analyzed and decisions – Literature review – Analysis documentation – Your iPhone responses May 26, 201022

24. Best Ever Hospital Best City, IL Become a Participating Physician May 26, 201023

25. Best Ever Hospital Best City, IL Alerts have you pushing the override button on every patient? Tell us … why We’ll send you a message with the clinical details, you select one choice, and we’ll use that data to improve our alerts.

26. Best Ever Hospital Best City, IL Sign Up Sign Up Today Contact CMIO for more details Debbie@bestevermedicalcenter.edu 312.555.5555 May 26, 201025