As the healthcare industry moves from paper-based records to Electronic Health Records (EHR’s), Clinical Decision Support Systems (CDSS) and Clinical Physician Order Entry points (CPOE), the proliferation of alarms has produced a cacophony of sound. Hospitals in particular were never particularly quiet places…anyone who has visited one has heard the conversations of visitors with hospital patients, phone calls to various areas of the hospital, the whooshing sound of ventilators breathing for severely ill patients and the beeps and bings of various tones coming from all kinds of machines and monitors. Anything from the gentle, rhythmic beeping of a heart monitor to the shrill, fast-paced pulsing of that same monitor when the patient’s heard enters a danger zone of either too low or too high. Medicine-inspired shows like ER, Scrubs, Grey’s Anatomy and House all used these infamous tones to instantly up the drama in the scene, as viewers would immediately pay attention to the show and feel their own hearts racing as doctors and nurses worked frantically to save the patient.
As hospitals and pharmacies have installed CPOE, CDSS and Electronic Medication systems, staff are not only bombarded by audible alerts, they are also surrounded by visual alerts. All of these systems are designed to help prevent medical errors by comparing the orders a physician gives for a patient to the patient’s medical history and current medications list to make sure that what the doctor ordered is in line with standard recommendations for treatment and that therapies are not contraindicated. The software excels at this particular type of task; if a physician orders twice the recommended dose of Prednisone for a patient based on the patient’s weight, the system will alert the physician that the recommended dosage has been exceeded and have the physician verify the dose. Or if a patient is allergic to a certain class of medications and a doctor unfamiliar with the patient prescribes it, the system will alert the physician to the allergy so that another prescription can be made.
But now that these systems have been in place at facilities for several years, a dangerous side effect of these actions has been identified: Alert Fatigue. What is Alert Fatigue? Essentially, it’s when healthcare providers become desensitized to, or start outright ignoring, warning alerts that are being issued by their systems. Think back to the early days of the internet, before pop-up blockers and privacy settings in your browser allowed you to cruise the web without seeing many pop-up ads. Do you remember the days when you screen would look something like this every time you clicked on a page? Oh yes…those were the days! Now do you remember how you might look at the first pop up or two that came up during a visit to a website, but that by the 5th or 6th you were closing them down without even glancing at them? That is alert fatigue…and in the healthcare field it’s a serious concern.
What causes alert fatigue? One of the major causes is software systems that are too good at their jobs. Behind the scenes, EHR’s, CPOE’s and CDSS systems are checking every piece of data entered against all of the standards/best practices/patient data that exists in the system. Any time there is a value entered that doesn’t match a given parameter, an alert is triggered. Sometimes these are serious alerts, for things like a patient being allergic to a certain drug. But sometimes the alerts are for trivial things, like reminding a physician to check the patient’s weight before picking a dose of medication. If you start to see too many of these “inconsequential” alerts, they become like the annoying pop-up ads above. They are just visual noise and you ignore them. The problem with that, of course, is that not all alerts are inconsequential, and if you ignore them all you might miss the important ones.
Healthcare IT News recently ran a story profiling the University of Vermont Medical Center and it’s response to this serious issue within healthcare technology. Essentially, they recognized that in order to fight alert fatigue you have to reduce the overall number of alerts a particular system is giving off, turning off the less serious informational or reminder type alerts while keeping the severe alerts and warnings in place. That way, the alert maintains its true purpose (warning of a potentially fatal mistake) without becoming so pervasive that staff begin to ignore it. They attempted to do this within their EHR system created by Epic, but they were still faced with thousands of alerts which they considered to be more informational in nature but were characterized in Epic as severe, and thus they could not be eliminated.
UVMC decided to go the third-party route and added a product called AlertSpace to their systems. AlertSpace essentially acts as a second filtering program, allowing a particular facility to customize the alerts they do and don’t want to see in certain circumstances and applying those changes to their EHR’s, CPOE’s and CDSS’s. Alerts that can bypass the filters built into the software program cannot bypass the filters set up by AlertSpace. UVMC stated that its alerts per prescription order dropped from .77 to .5 with the use of this program.
In the future, I hope that software programs built for the industry begin to add more robust tools for their alerts, so that third party applications wouldn’t be necessary. But until that day comes, this is a good tool to help fight the dangers of alert fatigue.