How EMR alert fatigue overwhelms physicians

As a hospitalist, like most in health care, I am afflicted by the slow march of thousands of mouse clicks on the electronic health record (EHR) every day I work.  But after starting a new job and learning a new EHR, I have become painfully aware of the volume of alerts that pop up when I place orders.  Don’t get me wrong: I appreciate being informed that a patient has a prolonged QT interval when I am about to order an atypical antipsychotic, or if I unknowingly re-started a home ACE-inhibitor on a patient with an elevated potassium level or acute kidney injury.

However, here are some of my favorite alerts I am forced to click past on a daily basis:

1. A patient has constipation and is already on a stool softener (for example, docusate). I add a stimulant or osmotic laxative – a common thing to do.  The EHR alert pops up that the patient is already on the stool softener.  I click “OK,” and another pop-up box appears that makes me click my justification for adding another constipation medication.  I have to select from multiple choices including “Not applicable” to “Disagree with this recommendation” to “Treatment Plan Requirement,” whatever that means.

2. A patient has a history of heart failure with preserved ejection fraction. I order metoprolol tartrate, let’s say to control the heart rate as the patient has atrial fibrillation.  The EHR says to me: “According to the current guidelines, metoprolol succinate, bisoprolol, or carvedilol is recommended for patients with heart failure” – yes, thank you.  These medications are used for heart failure with reduced ejection fraction.  Two more clicks.

3. My favorite is when a patient has COPD or asthma and is on an inhaler in the hospital. If there is wheezing or dyspnea and I want a nebulized bronchodilator to be administered, the smart EHR tells me that my patient is already using an inhaler and makes me justify why I would want to add another medication.  Last I checked, patients can receive concomitant short-acting bronchodilators and long-acting inhalers.

You may say: “What’s the big deal?  It’s just two clicks.”  Well, these extra clicks add up and increase the time I spend interacting with the EHR.  Additionally, the more interactions I receive, the more I become numb to important ones.

I believe alerts should be carefully selected and designed to i) point out serious drug-drug interactions, or ii) to provide patient-safety related tips.  For instance, recently newer notifications are asking me to justify why I am ordering haloperidol for an elderly patient.  Though I usually grumble when confronted with the alert, it has made me second guess the decision several times.  Also, the EHR now warns me to avoid ordering a urine culture with a urinalysis unless I am strongly suspecting a urinary tract infection, to prevent over-treatment of asymptomatic bacteriuria.

At this point, you may be thinking: “Wait a minute, you were just complaining about too many pop-ups, and now you are commending certain ones?”  This begs the question, then, what are important alerts and what alerts are just slowing us down?  I would agree this is a slippery slope.  How can we avoid the frustration that comes with a computer questioning our clinical judgment and giving us extra clicks while simultaneously realizing we are humans and prone to diagnostic and therapeutic errors?

I think the best question to ask when these alerts are formulated is: “If the physician orders X, does it have the possibility of causing short-term harm Y”?  I would argue that if I order metoprolol tartrate in a patient with heart failure instead of metoprolol succinate, I may or may not have made the correct clinical decision, but it will not cause immediate harm to the patient.  If I order an albuterol nebulizer therapy on a patient with COPD who is taking a long-acting muscarinic antagonist inhaler, I am not causing any harm.  But if I order lisinopril for a patient with a potassium of 5.9 or piperacillin/tazobactam in a patient with a (real) penicillin allergy, there is a higher probability of me causing harm.

So, what do you think?  What are some of the EHR alerts frustrating you, and which ones are helpful?

Scott Keeney is an internal medicine physician.

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