Why Providers Must Heed EHR Decision Support Alerts

Physicians and nurses might be overlooking clinical decision support (CDS) provided by EHRs, and patients could be at risk, according to a report.

A study, published in the BMJ, found that clinicians are six times as likely to override alerts advising intense care unit patients of possible adverse drug alerts. Overall, clinicians are overriding about 80% of CDS alerts, though most were deemed medically appropriate.

The study measured six intense care units for nearly a year, tallying 2,448 overdriven alerts from 712 unique patient encounters. The study’s authors suggest that more importance needs to be given to evaluating the appropriateness of overridden alerts, in efforts to ensure that vulnerable patients aren’t sent home with unsafe drug combinations.

“CDS alerts, specifically medication-related ones in this study, are important because they serve as a reminder of a potential problem,” says Adrian Wong, division of general internal medicine and primary care at Brigham and Women’s Hospital, and lead researcher on the study. “The initial studies on this technology found a significant reduction in preventable adverse drug events, which led to reduced patient morbidity and mortality. Based on the premise that comprehensive knowledge of all situations is impossible to obtain, these alerts may serve as important reminders to providers, if they are created appropriately.”

Wong says that many clinicians suffer from “alert fatigue,” where he or she is desensitized to EHR alerts because there are so many.

“This occurs because alerts are constantly added due to new medications or literature supporting new alerts. However, alerts may not be evaluated for who they may be clinically relevant in and whether they should be presented at all,” Wong says. “This can result in clinically relevant alerts being overridden.”

Many alerts also lack clinical relevance to the patient, Wong says.

“A drug-drug interaction alert of the absorption of a medication and an antacid-this alert is never relevant because the absorption of the intravenous form of the medication is not affected by an oral antacid,” Wong says.

Though a large amount of CDS alerts are being overridden, Wong says that many of those decisions are based on the clinician’s interactions with patients and information provided in EHRs.

“For example, in an alert for renal dosing of an alert, alerts likely do not account for the type of renal replacement therapy the patient is on, such as continuous renal replacement therapy,” Wong says. “Therefore, despite the lab value of serum creatinine that is often included in the alert logic, that value is not reflective of a patient’s true clinical picture.”

Ultimately, Wong says that CDS alerts need to be improved to ensure that the relevant ones that can impact patients receive attention from clinicians.

Wong suggests these methods to improve clinician interactions with these alerts:

• Incorporate of providers and front-line clinicians in designing alerts to improve buy-in and design.
• Determine which alerts are most important or should be presented to providers.
• Let clinicians know that CDS alerts are continuously being evaluated for performance metrics by a multidisciplinary group that evaluates these alerts.
• Work with commercial EHR vendors to make institution-specific changes to alerts.
• Incorporate human factors to determine how to best present CDS alerts.