Doing Alerts Right

June 24, 2011
James Feldbaum, M.D. The electronic medical alert arguably represents one of the best opportunities to improve the quality of patient care as part
James Feldbaum, M.D.
The electronic medical alert arguably represents one of the best opportunities to improve the quality of patient care as part of computer-assisted decision support. In its most common, albeit primitive form, it is the allergy alert. In its most advanced manifestation, it is the unsolicited life-saving knowledge transfer from the electronic medical record to the practitioner in real time at the point of care.

Despite its promise, medical alerts are often despised as interruptions to medical work and thought flow; they are considered superfluous and ignored, or become the genesis of what has become widely known as “alert fatigue.”

As part of their exuberance implementing electronic medical records, physicians and pharmacists often rush to create electronic medical alerts in hope of harnessing the real clinical power of the new electronic systems. Unfortunately, it is this unbridled and well-meaning enthusiasm that often leads them astray. In this commentary, I would like to outline some rules, steps, and processes that can align the desire to implement alerts with the likelihood of succeeding in the effort.

The first question is most frequently about timing. When is it best to begin thinking about and crafting alerts? Clearly, some alerts, like allergy and drug interaction checking, come with our software right out-of-the-box. Alerts which would seem innocuous are most often overly inclusive and instigate over-alerting and alert fatigue.

In an article published in the “Archives of Internal Medicine” physicians overrode 91.2 percent of drug allergy and 89.4 percent of “high-severity” drug interaction alerts. There was not a statistically significant number of adverse drug events (ADEs) between the two groups. So, for openers physicians will find themselves in need of a process and a governance to deal with all of the alerts and the perception of over-alerting.

Let's begin by defining a step-by-step thought process:

Why are we even thinking about an alert? Is there really a problem? Have we performed any metrics that clearly define this issue as a problem? The need to comply with core measures, regulatory deficiencies, or documented incidents makes a clear case for action, but more often our issues are those of perception that often fail to reach problem status in the face of closer analysis.

Will this particular alert improve care? Once we have clearly documented that a problem exists, will a well-designed alert solve it? Is an alert the best way to achieve our goal? Have other modalities of intervention (education) been tried? Have we established metrics to assess the impact of the corrective modalities that we implement?

Who should be the target for this alert? Are some medication alerts better or more efficiently screened by non-physicians or do they need to appear synchronous with ordering?

What is the urgency for this alert? Is the alert so critical that it warrants interrupting an order session?

How best do we display the warning? Many studies have documented the ineffectiveness of non-obtrusive warnings. How provocative do you want your alert display to be? A medical center in Jerusalem employed a flashing screen visible whenever an individual patient's chart or entire ward's results was accessed on any hospital computer. It was effective.

What steps must a practitioner make to comply with an alert?

Next, assuming there are significant improvements in care to be achieved, let's describe six qualities of a well-designed alert:

An alert must access only accurate high quality data. An alert based on patient weight or home medications, both notoriously unreliable, will create false alerts. Advanced alerts need to rank, calculate, and compare data in order to determine when parameters for alerting are met. It is garbage in, garbage out all over again.

It must present information to the right person at the right point in the ordering workflow. Do not underestimate the cost in time and effort for a practitioner to respond to an alert.

It must improve care or outcomes. Do not assume that an alert has had the anticipated effect. Measure it. If it doesn't work, rethink it, redesign it or trash it. Avoid alerting for the sake of alerting.

It must be based on sound and compelling science. Is it controversial? There is much national debate about the standard of what we refer to as “best practice” or “evidence-based medicine.” Define how your organization obtains consensus on clinical decision making before crafting alerts.

It should make the act of compliance simple and fast. Many programs employ “actionable-alerts” affording the provider the opportunity to take recommended action within the alert window itself. Conversely, an opportunity must be given for a practitioner to document the rationale for bypassing an alert.

It must consolidate data that either by its volume or subtlety a practitioner might miss when caring for the patient.

Personally, I like alerts conceptually and I like the thought exercise that crafting them entails. But with all of the caveats described above, how can an organization get the courage to fire one up? The answer is simple. Run them in the background. Imagine them, discuss them, research them, craft them, monitor them and refine them. Just don't alert anyone. When an electronic alert seems ready for prime time, choose carefully the target for the alert.

In an article from JAMA, medication alerts were first screened by pharmacists who then contacted physicians if needed. This was, according to this study, both a cost-effective strategy for the prevention of ADEs, and a tool to identify alerts of low sensitivity.

Alerting is most often a component of a computer-based provider order entry (CPOE) implementation. CPOE implementations are universally plagued by missteps of their own, both technical and behavioral. Alerts have the potential for making matters much worse despite the obvious advantages. Create both a strategy and governance for the alerting process early during the CPOE initiative.

Like CPOE, alerting must be a clinical initiative and leadership must come from physicians, nursing, and pharmacy. The very first question that must be asked is whether the provider culture is ready to accept the “intrusion” of alerts? If they are not, an aggressive educational process must be initiated. Consider the readiness of your staff when implementing alerts, but never allow unreasonable resistance to thwart implementation of a critical high quality alert.

It is disheartening that a lack of national standardization makes it nearly impossible to package quality alerts for distribution. Even institutions with identical software rarely find alerts directly transferable. Despite hurdles apparent in this early stage in the evolution of alerting, there have been notable successes that fuel optimism. There have also been notable misfires that provide important lessons. But there is little doubt that alerts hold the promise to access and assess limitless amounts of data and if properly designed, present to the practitioner at the correct point of care actionable knowledge that takes advantage of the information rich environment in which we now practice.

James Feldbaum is a physician consultant specializing in clinical transformation, CPOE, and interoperability. He is a consultant to hospitals, national consulting firms and software developers representing the technology needs of practicing physicians. He hosts the blog “MD meets IT.”

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