Alert Fatigue: Searching For A Cure

Telemedicine Tools That Are Transforming Healthcare

Clinicians and IT system designers at a veterans' hospital in Indianapolis are testing new models of electronic medication alerts as they look to combat alert fatigue, a condition that causes prescribers to tune out critical warnings.

"Prescribers are overwhelmed by the number of alerts, and studies suggest that alert designs do not fully support prescriber decision-making," says an article published in the April issue of the International Journal of Medical Informatics, the official journal of the European Federation of Medical Informatics. That study, conducted by the Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis and the Regenstrief Institute, is said to be the first in-depth examination of how clinicians react to medication alerts generated by electronic health records (EHR) systems.

"This was one of the first studies to directly observe prescribers … as they react to medication alerts," Alissa Russ, a research scientist with the U.S. Department of Veterans Affairs, told InformationWeek Healthcare. "We observed them in real time."

[ For more background on e-prescribing tools, see 6 E-Prescribing Vendors To Watch. ]

Russ now is leading a team at Roudebush to test out experimental designs for alerts based on findings in the study. The investigation discovered that there are 44 themes of electronic medication alerts that influence prescribers, falling into nine main categories: alert system logic; alert system redundancy; alert content; alert display; cognitive factors; pharmaceutical knowledge; medication management; clinician workflow; and alert system reliability.

"Addressing alert fatigue is a high priority, but, at the same time, attention needs to be paid to how information is presented to clinicians," said Russ, who works at the Center of Excellence on Implementing Evidence-Based Practice at the Roudebush VA Medical Center, and also is an adjunct assistant professor of pharmacy practice at Purdue University.

"Alerts are very tricky to design," she added. Even small changes could alter how alerts appear on the screen, what information is presented to clinicians, and how clinicians react.

VA and Regenstrief researchers observed 30 physicians, nurse practitioners, and pharmacists entering and processing a total of 320 outpatient prescription orders. They found that prescribing clinicians often were confused about why the EHR delivered alerts and determined that the electronic warnings tended to be oriented more toward pharmacists than toward those who write prescriptions.

"The alert system checked against medications prescribed at other VAMCs, but prescribers wanted additional, external cross-checks for medications filled by other pharmacies," the study said.

The researchers also found that prescribers spent too much time retrieving data in response to an alert, suggesting that EHR systems should automatically deliver relevant information from patient records, such as test results and documentation about adverse reactions to certain medications. "Prescribers wanted more patient-specific alerts, and were particularly appreciative of alerts triggered by a patient's laboratory values," said the article.

On the positive side, physicians often are taking advantage of prescribing alerts to educate patients about their options and the benefits and risks of each medical decision, according to Russ. "Alerts sometimes lead to important conversations between providers and patients," she said.

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