BackgroundAlthough alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. We tested hypotheses arising from two possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time.MethodsRetrospective cohort study using electronic health record data (both drug alerts and clinical practice reminders) from January 2010 through June 2013 from 112 ambulatory primary care clinicians. The cognitive overload hypotheses were that alert acceptance would be lower with higher workload (number of encounters, number of patients), higher work complexity (patient comorbidity, alerts per encounter), and more alerts low in informational value (repeated alerts for the same patient in the same year). The desensitization hypothesis was that, for newly deployed alerts, acceptance rates would decline after an initial peak.ResultsOn average, one-quarter of drug alerts received by a primary care clinician, and one-third of clinical reminders, were repeats for the same patient within the same year. Alert acceptance was associated with work complexity and repeated alerts, but not with the amount of work. Likelihood of reminder acceptance dropped by 30% for each additional reminder received per encounter, and by 10% for each five percentage point increase in proportion of repeated reminders. The newly deployed reminders did not show a pattern of declining response rates over time, which would have been consistent with desensitization. Interestingly, nurse practitioners were 4 times as likely to accept drug alerts as physicians.ConclusionsClinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert. Reducing within-patient repeats may be a promising target for reducing alert overrides and alert fatigue.
Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.
In the early stages of the "meaningful use" program, use of specific EHR functions was associated with higher performance on healthcare process metrics.
Background
Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload.
Objective
To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes.
Design
Quality improvement quasi-experiment, analyzed as interrupted time series.
Participants
Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers.
Intervention
In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription.
Main Measures
Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions.
Key Results
Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards.
Conclusions
Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress.
Trial Registration
www.ClinicalTrials.gov protocol 1710018646
Purpose The purpose of this pilot study was to review the implementation of symptom-triggered benzodiazepine therapy and evaluate the feasibility and outcomes as compared with a previous hospital standard of fixed-dose phenobarbital protocol for alcohol withdrawal on a family medicine service. Methods This retrospective chart review of 46 patients' medical records was performed on admissions to the family medicine service occurring between February and October of 2005 compared with February and October of 2006. Included in the study were adults who were suffering from alcohol withdrawal symptoms (AWS), who admitted to heavy daily alcohol intake, who were intoxicated on admission, and who had a history of AWS and/or history of AWS-related seizures. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) was used to evaluate the impact of individualized symptom-triggered therapy on outcome measurements utilizing symptom-triggered benzodiazepine therapy compared with the previous hospital standard using a fixed-dose phenobarbital protocol. Results One hundred percent of the patients in the phenobarbital group required drug compared with 38% in the benzodiazepine group ( P < 0.001). Fewer patients (9.5%) in the benzodiazepine group left the hospital against medical advice (AMA), while 36% of patients in the phenobarbital group left AMA ( P = 0.045). There was no significant difference in length of stay or the number of days on the protocol. Conclusion The results of the pilot study demonstrated that symptom-triggered therapy using benzodiazepines resulted in better outcomes than fixed-dosing phenobarbital. Importantly, most patients in the benzodiazepine group required no drug administration.
Background and Objectives: Cultural barriers and patient-provider language discordance exert deleterious effects on patient care. One solution has been the integration of medical interpreters into the care of patients with limited English proficiency. While medical schools and residency programs have started developing training programs on how to work with medical interpreters, no similar endeavor has been reported by student-run free clinics.
Methods: Over 1 year, 76 third-year medical students (MS3s) were enrolled in control and intervention groups, and evaluated by in-person interpreters during interpreted real-patient encounters. MS3s in the intervention group received a lesson- and reminder-based training program on how to work with in-person interpreters.
Results: MS3s who received the intervention were more likely to ask the patient one question at a time (odds ratio [OR] 3.54, P=.0079), listen to the interpreter without unnecessary interruption (OR 3.30, P=.022), and speak in short, simple sentences with pauses for interpretation (OR 3.08, P=.017).
Conclusions: Our lesson- and reminder-based training program on provider-interpreter collaboration can improve the performance of MS3s within a select skill set with minimal cost and time investment.
Following publication of the original article [1], the authors reported that the article erroneously stated that Dr. Ancker was affiliated with the Tehran University of Medical Sciences. Dr. Ancker is not affiliated with that institution.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.