Electronic alert overload

The Washington Post: “Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard… It’s called alert fatigue… Electronic health records increasingly include automated alert systems pegged to patients’ health information… The number of these pop-up messages has become unmanageable, doctors and IT experts say, because of reflecting what many experts call excessive caution, and now they are overwhelming practitioners.”


I had to laugh when I read The Washington Post article quoted above. Pharmacists have been dealing with this for years. We’ve been getting hammered with unnecessary alerts since electronic order entry became a thing. I don’t know exactly when it started, but it’s been an integral part of my career for the past 20 years.

It’s a problem to be sure. A vast majority of alerts, conservatively 90%, have absolutely no bearing on the job clinicians are asked to perform. The article mentions receiving alerts for pain meds when it’s obvious that the patient needs them, such as in a post-op situation. Even more ridiculous is getting an alert for a duplicate fluid, or my favorite, lactation warnings for an 80-year-old female.

It’s difficult to say what the impact of these alerts is on patient care, but I think it’s safe to say that they cause more harm than good. They pop up so often that most simply get ignored. I know that I’ve clicked through my fair share of alerts without more than a glance.

And here’s the thing, physicians see only a fraction of the alerts seen by pharmacists. Many hospitals minimize alerts so as not to irritate physicians. We wouldn’t want to irritate physicians now, would we?

With all that said, things have improved in the past few years. Usability is on the radar of hospitals and healthcare systems. We can thank consumers for that. Healthcare workers are consumers first and their experience with software and hardware in their day-to-day lives has spilled over into healthcare. Today’s software is much better than it was a decade ago, even in the Bizzaro World of healthcare.

I can recall my experience with pharmacy information systems during the early years of my career. They were terrible, and I do mean terrible. The things were barely usable. They were often functionally rich and usably poor. It wasn’t until quite recently that pharmacy systems became more user-friendly, in part because of the introduction of EHRs.

Physicians wield a disproportionate amount of power within healthcare systems, so when they are forced to use EHRs with poorly designed user interfaces and ridiculous alerts, the vendors hear about it. The result of all that complaining has been improvements in usability. As the pharmacy system is an integral part of many EHRs, pharmacists have benefited.

I dare say that we are nowhere near the user experience of consumer products, but the improvements are nonetheless welcome. Given time, and enough physician whining, we may live to see the day when alerts are useful rather than annoying. Until then, I say to my physician brothers and sisters, welcome to my world.

Saturday morning coffee [August 2 2014]

“A journey of a thousand miles begins with a single step.” – Lao-tzu, Chinese philosopher (604 BC – 531 BC)

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The coffee mug below is relatively new. I picked it up in Las Vegas at M&M World during one of my daughter’s volleyball tournaments earlier this year.

Yellow M&M Mug
Continue reading Saturday morning coffee [August 2 2014]

Fresh application of older healthcare technology

I came across an interesting article in the July issue of Pharmacy Practice News. The article describes some of the posters presented at the 2013 ASHP Summer Meeting in Minneapolis. The technology covered is relatively old, and a little antiquated when you look at much of the technology floating around the world these days. Nonetheless, this technology still represents opportunity in healthcare.
Continue reading Fresh application of older healthcare technology

Saturday morning coffee [June 15 2013]: The Purge, Nanopatch, NSA, Adherence, Smartphones, CPOE

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The coffee mug below is from the Netherlands. Just in case you’ve forgotten, I stopped in Amsterdam back in November 2011 on my way to Germany for work. Amsterdam is the largest city in the Netherlands and serves as the regions capital. It’s also a dirty city with a weird vibe to it. Didn’t care for it. I would return to Germany in a heartbeat, but wouldn’t choose to spend any personal time in Amsterdam. I can’t really say much about the rest of the Netherlands.

Continue reading Saturday morning coffee [June 15 2013]: The Purge, Nanopatch, NSA, Adherence, Smartphones, CPOE

Saturday morning coffee [March 16 2013]

MUG_ASHPSM2011So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The coffee mug to the right was presented to me as a gift from ASHP for winning the 2011 ASHP Summer Meeting Twitter Contest. Not to be confused with the one I put up last August for the 2010 ASHP Midyear Twitter contest. The mug was accompanied by a $50 Best Buy gift card; very nice. The meeting was held in Denver, CO and was the first ASHP Summer Meeting I ever attended. The Summer Meeting is quite a bit different from the Midyear Meeting held in December each year. Midyear is much larger and has a much wider variety of educational sessions. Midyear also has a bigger exhibitor area. With all that said I found the Summer Meeting quite enjoyable as it had several informatics related sessions that I was able to attend. It was the last pharmacy conference that I was able to enjoy as an attendee.
Continue reading Saturday morning coffee [March 16 2013]

CPOE reduces likelihood of error by nearly 50% [article]? I’m skeptical

There’s quite a bit of talk floating around the internet about a recent article in JAMIA that looks at reduction of medication errors in hospitals secondary to CPOE adoption (J Am Med Inform Assoc doi:10.1136/amiajnl-2012-001241). The article is available for free so I read through it last weekend. By the end I was looking at something that wasn’t all that impressive. The authors use a lot of sleight of hand, i.e. statistical models to tell a story about how CPOE “decreases the likelihood of error on that order by 48%”, which ultimately could potentially lead to a reduction in medication errors by approximately 12.5%”. That would be great, except that the entire thing is based on statistical models, assumptions, survey data and a great big meta-analysis.

Continue reading CPOE reduces likelihood of error by nearly 50% [article]? I’m skeptical

Forcing re-entry of patient ID cuts wrong-patient errors

You know how websites make you double enter your email address and password when you sign up for a service? Well, apparently that’s not a bad system for making sure you have the right patient during order entry. You’d think we would have figured that out a while back, but then again this is healthcare we’re talking about; equation for healthcare technology “innovation” is ([today’s technology] -10 years).

The study found that requiring clinicians to re-enter patient IDs resulted in a 41% reduction in wrong-patient orders. Single-click confirmation of patient ID reduced wrong-patient orders by 16%. It’s not all peaches and cream though. The study found that double entry increased order entry by 6.6 seconds. Oh no!

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial (J Am Med Inform Assoc. 2012 Jun 29 )
Objective: To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. Materials and methodsIn phase 1, from May to August 2010, the effectiveness of a ‘retract-and-reorder’ measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an ‘ID-verify alert’, and an ‘ID-reentry function’.
Results: The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71).
Discussion and conclusion: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

CPOE failure modes and effects analysis brings up some good questions

A Failure modes and effects analysis (FMEA) is basically a methodology for predicting potential pitfalls in a project and preemptively finding solutions. This is in contrast to a root cause analysis (RCA) in which case you figure out what went wrong after the fact. Kind of like asking “what could make a plane crash and how to prevent it?” (=FMEA) versus “what made the plane crash and how do we prevent it from happening again?” (=RCA).

My current position is the first in which I’ve been involved in an FMEA, and I’ve personally found them to be powerful tools. We did an FMEA prior to implementation of our BCMA system and came up with what I thought was a pretty good list of things to look out for. Of course what the administration chooses to do with that information is a different story, but at least it’s available if needed.
Continue reading CPOE failure modes and effects analysis brings up some good questions

Impressive offerings in the new edition of ACI eJournal

The third issue of the eJournal Applied Clinical Informatics (ACI) is available online and it’s packed with some pretty interesting stuff. Even though CPOE and CDS have been topics for discussion for quite sometime, they’ve somehow managed to fly under the radar for the most part.

Here’s some stuff on CPOE and CDS in the third edition of ACI that caught my eye:

Update: Siemens Innovations 2010 final day

Today is my final Day at Innovations and I’ve managed to pick up quite a bit of good, useful information that has the potential to improve our operations back at the hospital. I’ve been in my current position as an IT pharmacist for about 2 1/2 years now and this is my third Innovations conference. I finally have enough experience under my belt to start putting the pieces together in a manner that allows me to gather information in a more strategic fashion, rather than just running around trying to gather enough information to put out fires.

This years Innovations conference was heavy with sessions on ARRA, meaningful use and CPOE. I’m not surprised as this is where all the money will be for vendors involved in HIT over the next several years.

Anyway, I feel there are a couple of presentations I attended yesterday that are worth mentioning.
Continue reading Update: Siemens Innovations 2010 final day