Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review

Powers, Emily; Shiffman, Richard N.; Melnick, Edward R.; Hickner, Andy; Sharifi, Mona

doi:10.1093/jamia/ocy112

Cited by 92 publications

(71 citation statements)

References 55 publications

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“…Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated. [20,24,97] -Role tailoring of alerts [21,82] -Tiering of alerts [20,80] -Iterative design [25] Harmful -Interruptive or hard stop alerts [21,25,80] -Lack of "right information" [18] -Lack of relevance [80,97,108] -Lack of integration [78]…”

Section: Resultsmentioning

confidence: 99%

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Clinical Decision Support and Implications for the Clinician Burnout Crisis

Janković

Chen

2020

Yearb Med Inform

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Objectives: This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout. Methods: We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria. Results: Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS. Conclusions: CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.

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Section: Resultsmentioning

confidence: 99%

“…In evaluating the user experience, the authors found that CDS for which the end users were involved in design and iteration were the most acceptable. Hard stops for documentation purposes were poorly received [25].…”

Section: The Big Picture -Review Articlesmentioning

confidence: 99%

Clinical Decision Support and Implications for the Clinician Burnout Crisis

Janković

Chen

2020

Yearb Med Inform

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“…Restriction of choice [39] The removal of an order option ultimately resulted in fewer laboratory tests and reduced healthcare expenditure in all studies. [14,28,31] Finally, we identi ed two different types of implemented hard-stops: [40] an interruptive alert [30] and a restrictive hard-stop [14]. An interruptive alert requires a clicking response from the physician before being able to move forward.…”

Section: Resultsmentioning

confidence: 99%

Economic impact of clinical decision support interventions based on electronic health records

Lewkowicz

Wohlbrandt

Boettinger

2020

Preprint

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Background Unnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR).Methods We searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools. Results and discussion Twenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems. Conclusion Current research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.

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“…First, as our goal was to understand how prescribers acting of their own free will responded to different interventions, we excluded "hard stops," which impose heavy time penalties to override, and which therefore materially restrict the prescriber's range of action. Readers interested in an analysis of hard stops should refer to a 2018 systematic review by Powers et al 6 Second, we excluded articles that did not describe the interactive design in enough detail to produce a description. Third, we excluded articles in which researchers made global changes to an alerting system, but only reported acceptance rates for those alerts intended to convey the most urgency, for certain drug categories, or for a selected subset of users exposed to the alert; some of these authors may have chosen to report only the most palatable results.…”

Section: Eligibility Criteriamentioning

confidence: 99%

“…For example, in some instances, "hard stops" have prevented patients from receiving potentially life-saving treatment in time. 6 The information technology infrastructures that organizations must install to integrate CDS into the medicationordering process-often accompanied by changes in workflow and communication patterns-can disrupt work during "roll-out," as well as in long-term use. 7 These disruptions can increase instances of ADEs, which can, in turn, increase patient mortality.…”

Section: Introductionmentioning

confidence: 99%

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review

Hussain

Reynolds

Zheng

2019

Journal of the American Medical Informatics Association

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Objective Alert fatigue limits the effectiveness of medication safety alerts, a type of computerized clinical decision support (CDS). Researchers have suggested alternative interactive designs, as well as tailoring alerts to clinical roles. As examples, alerts may be tiered to convey risk, and certain alerts may be sent to pharmacists. We aimed to evaluate which variants elicit less alert fatigue. Materials and Methods We searched for articles published between 2007 and 2017 using the PubMed, Embase, CINAHL, and Cochrane databases. We included articles documenting peer-reviewed empirical research that described the interactive design of a CDS system, to which clinical role it was presented, and how often prescribers accepted the resultant advice. Next, we compared the acceptance rates of conventional CDS—presenting prescribers with interruptive modal dialogs (ie, “pop-ups”)—with alternative designs, such as role-tailored alerts. Results Of 1011 articles returned by the search, we included 39. We found different methods for measuring acceptance rates; these produced incomparable results. The most common type of CDS—in which modals interrupted prescribers—was accepted the least often. Tiering by risk, providing shortcuts for common corrections, requiring a reason to override, and tailoring CDS to match the roles of pharmacists and prescribers were the most common alternatives. Only 1 alternative appeared to increase prescriber acceptance: role tailoring. Possible reasons include the importance of etiquette in delivering advice, the cognitive benefits of delegation, and the difficulties of computing “relevance.” Conclusions Alert fatigue may be mitigated by redesigning the interactive behavior of CDS and tailoring CDS to clinical roles. Further research is needed to develop alternative designs, and to standardize measurement methods to enable meta-analyses.

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Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review

Cited by 92 publications

References 55 publications

Clinical Decision Support and Implications for the Clinician Burnout Crisis

Clinical Decision Support and Implications for the Clinician Burnout Crisis

Economic impact of clinical decision support interventions based on electronic health records

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review

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