When Too Many Alerts Lose Physicians’ Attention
By Karen Appold
As more medical institutions implement electronic health records (EHRs) that contain clinical decision support (CDS) systems, a new problem is emerging that could decrease the gains expected from these sophisticated tools: alert fatigue. A tool intended to aid medical providers, alerts are periodic pop-ups or notifications generated by CDS systems to call attention to important information. For example, when a provider enters a lab order, a pop-up box might alert the physician that the test is potentially redundant. Another type of alert is a notification delivered to some type of inbox in the EHR. This type of alert is often used to notify the provider of an abnormal test result.
Because providers must retain so much information today, the idea behind the alerts is to help alleviate some of the burden of remembering a lot of small details. While beneficial in some cases, excessive alerts can result in a type of fatigue whereby the provider, after receiving too many alerts, begins to ignore and/or override them (1).
In fact, a study conducted in Veterans Affairs (VA) clinics found that one in 10 alerts for abnormal lab test results went unread by providers, and a significant proportion of the patients involved did not receive timely clinical follow-up. The investigators found similar results when analyzing follow-up of alerts for abnormal imaging results. Alert fatigue is one possible explanation for these findings (2).
Hardeep Singh, MD, MPH, assistant professor of medicine and staff physician at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston, Texas, recommends a multi-faceted approach to prevent alert fatigue from occurring in clinical labs. He directs the VA Center of Inquiry to Improve Outpatient Safety through Effective Electronic Communication that addresses issues related to alerts.
Technology—An EHR system must be capable of supporting required clinical activities related to alerts and be user friendly. If hardware or software is inadequately sized, configured, or maintained, or if the computer display is not user friendly, the system will function poorly. Local EHR oversight committees are one way to help ensure proper and safe functioning of CDS systems (3).
Policies and procedures—Define policies regarding what types of results—normal, abnormal, and critical—should be communicated and how they should be conveyed, verbally or electronically. Also delineate who is responsible for reporting the results and the procedure for follow-up.
Workflow—Alerts need to fit into the workflow of providers. For instance, if providers don’t have time to process notifications in a busy clinic, then alerts won’t fit well into their workflow, especially if they receive a large number (3).
Providers—Not only should clinicians be well trained in the use of alert systems, but they should also understand how to integrate the system into their workflow and how to function when it is unavailable. Close interaction among informatics experts, clinical application coordinators, and end users is essential for safe design and use of alert systems (3).
“We are still early in the journey of finding solutions to alert fatigue,” Singh noted, adding that his institution is documenting its experiences with alert fatigue related to notifications and is in the process of exploring strategies to reduce it. “We haven’t found all of the answers yet, but our ongoing work based on the above multi-faceted approach is leading us in the right direction, so stay tuned.”
- Alert Fatigue. Available at: www.informatics-review.com/wiki/index.php/Alert_Fatigue. Accessed May 3, 2010.
- Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med 2010;123:238–244.
- Singh H, Sittig D. Eight rights of safe electronic health record use. JAMA 2009; 302:1111–1113.
Karen Appold is an editorial consultant for the clinical laboratory industry.