Alert Fatigue and Clinical Decision Support

Clinical Decision Support has been called out as an important part of an EMR system. You’ll get no argument from me on this. What I have been thinking a lot about is what people call “Alert Fatigue.” For those unfamiliar with the term, it basically means that a doctor gets so many alerts that they grow numb to the alerts and stop looking at them. For those that are married, it’s like your wife’s nagging. It happens so much that you stop listening (ok, that was a joke. I hope none of us do that or have reached that point. I’m just lucky to have a wife who doesn’t nag).

I think this concept of “alert fatigue” is really important and I think it will be impossible to create an EMR that strikes the perfect balance. Some EMR offer too many alerts and some probably offer too few. So, my question for you is which side should we adopt? Is it better to have too many alerts which doctors then might ignore or is it better to have too few alerts and not be alerted to something important?

There’s some real challenging issues associated with both. Liability unfortunately being a major part of each. Where do you stand on this issue?

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

6 Comments

  • I can’t think of an EMR feature that would motivate the FDA to render EMRs a medical device more than clinical decision support. You are right that poorly designed and/or implemented CDSS can and do kill and injure patients — by alert fatigue and other shortcomings. And while regulating EMRs as a medical device would improve EMR product quality and probably implementations too, the lack of regulatory oversight is not the root problem.

    Many kinds of automation at the point of care are faced with highly variable workflows that are difficult to capture in requirements and harder still to implement in an effective design. One has only to look at areas like point of care diagnostic testing or meds administration systems to see examples of partial requirements, inadequate solutions, and poorly managed systems.

    Whether EMR CDSS alert fatigue, medical device alarm fatigue or other challenging point of care applications, these are complex problems with no short time-to-market for vendors or quick implementations for customers. This is, and will remain for some time, hard work.

    John, I think your question offers a false choice. Clearly, neither alert fatigue or a scarcity of alerts that miss meaningful clinical indicators is acceptable. The only answer is doing the hard work — on both the vendor and buyer sides — to design and implement EMRs in a safe and efficacious way.

    It won’t be easy.

    As an aside, I can’t help but ask, if EMR user interfaces and workflow were better designed, could we greatly reduce our dependence on CDSS to present data that’s somehow been obscured by the EMR?

  • Decision support != alerts.

    Alerts are only the most obvious and primitive form of decision support. Other forms that are less intrusive are possible as systems develop, including automatically configuring displays so that data and order sets most likely to be needed for the next decision are integrated and made easily available, customizing workflow to patient characteristics and needs, and aggregating pertinent reference information into an easily usable and available form. If well-designed, it’s not necessary that these capabilities get in the way of clinicians to be effective.

  • I agree that decision support is not always alerts. Alert fatigue is a problem in any software it seems. (account control in Vista anyone?) Whenever I get a request for some sort of decision support to be coded into our EMR, alerts in particular, the cynic in my head always go straight to “what happened to doing your job?” Now granted, we want to be as careful as possible and improve care but as we all agree, it needs to be well reasoned and designed.

  • “As an aside, I can’t help but ask, if EMR user interfaces and workflow were better designed, could we greatly reduce our dependence on CDSS to present data that’s somehow been obscured by the EMR?”

    I agree that user interface design would solve some of the issues related to CDSS.

  • “Decision support != alerts.”

    Of course this is true. Although alerts are one facet of decision support. You say that it’s the most obvious and primitive and yet, it’s an enormous challenge to implement properly. If we can’t tackle the challenges of alerts are we ever going to be able to address the more difficult clinical decision support possibilities?

  • There is also the issue of alerts firing only to the prescriber. Medicine is a multidisciplinary function — there is no reason in a fully integrated CPOE-eMAR system that the physician should get all alerts and support on order entry. As mentioned, clinical guidance rather than alerts can decrease alert fatigue. However, sharing the workflow and information analysis may provide further benefit.
    For drug ordering, pharmacists may be the most appropriate line of defense for evaluating drug-drug, drug-disease, drug-food, drug duplication, and dose range issues. Many of these alerts, besides critical ones may be best left to a pharmacist. Similarly, nurse-driven protocols can help physicians perform their duties without micromanaging patient care.
    Creating appropriate workflows may decrease the number of nuisance alerts and improve safety compared to a wall of front-end alerts to the initial prescriber.

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