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Best Practices to Mitigate EHR Clinical Decision Alert Fatigue

Healthcare organizations across the country are finding creative ways to reduce EHR clinical decision alert fatigue through optimization and teamwork.

EHR alerts serve a significant purpose, but they can also result in EHR clinical decision alert fatigue, clinician burnout, or even frustration.

EHR alerts permit clinicians to access real-time patient data, ideally resulting in enhanced patient safety and medication accuracy. Alerts can also notify clinicians about potential adverse drug interactions.

According to Stanford University health IT professionals, EHR alerts are a vital part of EHRs that are “not merely the use of technology; it is using technology to find meaningful information to make clinical decisions and provide the best possible patient care.”

Although a clinician’s first instinct might be to close the alert to limit frustration, healthcare organizations attempt to limit alert quantity and improve alert quality to boost clinician satisfaction.

Optimizing or Eradicating Low-Value Alerts

Clinician burnout and EHR fatigue caused by alerts have been an issue for clinicians struggling with EHR usability overload.

Although EHR alerts can offer providers practical suggestions and updates, EHR alert fatigue has been an issue for clinicians already struggling with EHR usability problems. Low-value EHR alerts can disrupt patient care and contribute to clinician burnout.

At Brigham and Women’s Hospital, clinicians were getting roughly one alert for every two medication orders, and clinicians were overriding an astounding 98 percent of the alerts.

“One of the big issues is that many of the clinical systems that are in routine use today, alert too frequently,” David Bates, MD, chief of the Division of General Internal Medicine at Brigham and Women’s Hospital, said in an interview with EHRIntelligence. “When clinicians are overriding that high a proportion of alerts, clinicians get very used to closing the alert, and sometimes they aren’t fully processing what the alerts are saying and they tend to stop paying attention to the important alerts.”

Unsatisfied with how their EHR vendor fired off alerts, Bates and his health IT team tapped Seegnal eHealth to leverage its EHR alert solution and conduct an EHR alert study at the hospital. 

The study compared Brigham’s current EHR alerts from inpatient and outpatient settings to the vendor’s alerts from a de-identified data set from the two environments. The platform also presented the alert so that the clinician could see how critical the signal are and what the next step should be in the clinical process.  

“The way myself and other leaders in the alert space think about it is, EHR alerts should fire when the clinician needs to be shown something,” Bates said. “Having the clinician change what they do at least a third and ideally a half the time. If I'm going to show you something and there's less than a one in three chance that you're going to change what you do, it's probably not worth interrupting you.”

A similar practice occurred at Vanderbilt University Medical Center (VUMC), when Vanderbilt Clinical Informatics Center (VCLIC) launched the Clickbusters program to minimize the number of EHR alerts.

The program’s goal was not only to reduce the number of alerts, but also to boost alert quality. The program audited alert utilization. While the program deleted some warnings, it optimized others to address burnout.

“We believe in alerts,” Adam Wright, PhD, professor of Biomedical Informatics, said at the time. “There should be a lot of good alerts in the system that are accepted a lot of the time and that people find to be useful.”

“Currently, BPAs are acted upon 8% of the time at VUMC. The Clickbusters goal is 30%,” Wright continued.

For example, a CDS alert urged a clinician to recommend a patient to lose weight, but it also fired off for an anesthesiologist working in the operating room.

“BPAs are always well meant, the motivation being to guard clinical safety and quality or reduce unnecessary costs,” said Neal Patel, MD, chief informatics officer with VUMC. “However, alert fatigue seems to have somewhere along the line became practically endemic in health care.”

Garnering Clinician Feedback

Communication between a health organization and its clinicians is vital to minimize EHR alert fatigue.

According to a study published in the Yearbook of Medical Informatics, gathering clinician feedback and engineering communication between the healthcare organization and clinicians can improve both EHR alert fatigue and mitigate clinician burnout. 

As a result of a literature review of 89 articles, researchers put together several factors that developers should concentrate on when designing CDS and implementing it into the EHR to reduce the chances of clinician burnout.

First, providers should customize EHR alerts with specific patient data to lessen the number of notifications.

Next, researchers learned the end-user should be directly involved in EHR alert design, testing, and implementation.

The researchers also said the clinician should have access to customize alerts to reduce clinician alert burden and enhance alert relevance.

Following implementation, EHR alert efficiency and effectiveness should be measured to see its impact on workflow, override rates, clinician burnout, and patient outcomes. A lack of alert utilization should result in optimization or even deletion to improve its result.

As is with EHRs and other forms of health IT, EHR alerts require ongoing optimization and updates to adhere to current medical standards.

Study authors noted the vast number of EHR alert user experiences as a positive of the study. However, only one individual reviewed the articles, which could be a limitation.

At Rush University Medical Center, a hospital-wide survey led leaders to implement a team of health IT and EHR professionals to work one-on-one with its clinicians, called the Provider Optimization and Experience Team (POET).

“In the past, the clinician would either ask a colleague that had spent some dedicated time and was willing to help them personalize their experience, or they would try to work with an analyst or a health IT specialist to explain to them their specialty or their clinical background to see if they could help them,” Jordan Dale, MD, acting CMIO of Rush, said in an interview with EHRIntelligence.

Sometimes that scheme was successful if there was a subject matter expert in that practice, Dale explained. However, if there was a knowledge gap or if Rush did not have a health IT expert or a clinician with experience working beside the clinician, the clinician experienced frustration and burden.

POET includes seven total individuals who hold a clinical license to fully understand clinical language or have extensive experience or training at the clinical level, such as five to ten years of go-live and optimization support, Dale explained. POET members aim to go beyond initial training and focus more on optimization and support, he added.

After implementing POET in 2017, Rush deployed a second survey and the hospital saw excellent results and Rush clinician EHR satisfaction scores significantly improved.

EHR alerts aim to be helpful, but alerts can also lead to severe clinician burnout and fatigue. However, healthcare organizations are becoming more mindful of boosting clinician satisfaction.

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