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Abstract
Background: Electronic medical record (EMR) alerts may inform point of care decisions, including the decision to prescribe potentially inappropriate medications (PIM) identified in the Beers criteria. EMR alerts may not be considered relevant or informative in the clinician context, leading to a phenomenon colloquially known as “alert fatigue.”
Objective: To assess the frequency of clinical interaction with EMR alerts and associated deprescribing behaviors in ambulatory settings.
Methods: This is a retrospective observational study in two ambulatory clinics (the Kaye Edmonton Clinic Senior’s Clinic and the Lynnwood Family Practice Clinic) in Edmonton over an observational period of 30 months. Statistical analysis was done using descriptive statistics, chi-square and regression analysis.
Results: The reminder performance for interactions with the alert was 17.2% across the two clinics. The Number Needed to Remind (NNR) or mean number of alerts shown on clinician screens prior to a single interaction of any kind with the alert was 5.8. When actions were defined as a deprescribing (ie discontinuation) event that was related to the alert and that particular interaction in the EMR, the reminder performance was 1.2%, for an NNR of 82.8.
Conclusion: The configuration of alerts in the EMR was not associated with a clinically detectable increase in the uptake of the Beers criteria for high hazard medications.
Acknowledgments
This study was funded by Alberta Health Services eCLINICIAN Innovation Grant.
What is already known on this topic
Clinical decision support (CDS) has the potential to influence clinician behavior at the point of care, including the decision to prescribe or continue orders for potentially inappropriate medications (PIMs).
Different barriers exist to effective CDS, including alert fatigue.
Some measures of CDS effectiveness have been initially defined including Number Needed to Remind (NNR).
What this study adds to our knowledge
Effective measurement of CDS performance should include informative process measures of clinician behavior, including interaction with alerts and documented decisions to deprescribe PIMs.
Future valid CDS performance measures such as the Number Needed to Deprescribe would be supported by e-prescribing systems and effective clinician use.
Glossary
Polypharmacy – total of five or more concurrently prescribed medications.
PIM – Potentially Inappropriate Medications – medications prescribed without a valid indication or with a contraindication, where risks outweigh the benefits where there is an increased risk of adverse drug reactions, or when a safer alternative is available.
EMR – Electronic Medical Record – the digital version of the patient medical record.
Computerized Physician Order Entry – an application that enables providers to enter medical orders into a computer system.
BPA – Best Practice Advisory – an EMR alert presented to health care professionals that provides patient-specific information, intelligently filtered, triggered for pre-determined situations to help improve the delivery of care.
CDS – Clinical Decision Support – a health information technology that analyzes data to help health care professionals make decisions and improve patient care.
Navigator – A series of sections in an electronic medical record meant to follow a particular workflow such as an office visit or medication reconciliation.
Orders management – a computer system that provides entry and storage of orders for prescriptions, tests and other services in order to enhance legibility, reduce duplication and improve the speed with which orders are executed.
Reminder performance – the result of the numbers of alert interactions recorded with an alert (ie the BPA) divided by the total number of alert presentations.
Number Needed to Remind (NNR) – the mean number of alert presentations specific to a medication and patient presented to a health professional user before there was an interaction with the alert or a deprescribing event.
Number Needed to Deprescribe (NND) – the mean number of alert presentations specific to a medication and patient presented to a health professional user before there was a deprescribing event.
Alerting burden – the frequency of alert presentations.
Alert presentation – a previously designed patient-specific electronic message that is inserted based on pre-set triggers into the workflow of a health care professional in the context of patient care.
Alert interaction – Any electronic response by the health care professional to an alert presentation in the context of patient care.
Electronic Medical Record (EMR) Alerts – an alert presentation in an EMR.
Deprescribing event – evidence of complete discontinuation of a medication within the same class as the alert as found in the ordering section of the correct patient chart on the day the alert was presented.
Alert Fatigue – a phenomenon in which health professionals who are busy or see the same patient frequently may become desensitized to automated alerts and consequently ignore or fail to respond appropriately to such warnings.
Disclosure
Dr Allen Ausford reports consulting fees for clinical development work on the province of Alberta HIE(netcare)and CIS(eCLINICIAN- the ambulatory program that was used in this study) from Alberta Health Services, during the conduct of the study. Dr Jacques Romney received grants from University of Alberta eClinician EMR Innovation Grant, during the conduct of the study. The authors report no other conflicts of interest in this work.