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Sandra L. Kane-Gill, PharmD, MSc, FCCM,
The idea of clinical decision support (CDS) may generate some mixed feelings in clinicians. CDS has been used in many ways, such as for medication error reduction and as an early warning disease tool.1,2 Overall, CDS has demonstrated modest improvements in patient outcomes.2,3 Quality improvement efforts often focus on fixing problems with the aid of technology, including CDS; unfortunately, no follow-up assessment of CDS effectiveness has been conducted. The “set it and forget it” mentality results in numerous alerts, which are often sensitive but lack specificity. Oversensitivity results in nonactionable alerts.
In the context of medication-related CDS, 80% of alerts are appropriately overridden; however, overriding alerts is still a cause of concern because it is associated with an increased risk of adverse drug events (ADEs).4,5 This immunity in clinicians’ response to alerts and concern for missing an actionable alert is referred to as alert fatigue (see Table 1 for definitions).6-11 It is important to note that alert fatigue extends beyond the number of alerts received to more complex metrics involving appropriate responses, inappropriate alerts, number of overridden alerts, desensitization, and resulting harm.9 More rigorous studies of these detailed metrics, extending beyond quantity, are needed since quantity reduction alone has not consistently resulted in better clinician responsiveness.12
Some institutions are now devoting their efforts to improving the performance of alert systems to contend with user dissatisfaction and potential burnout.13-16 The development of an effective alert requires multiple iterations using advanced underlying knowledge and programming. Also needed is an active quality improvement plan to meet the intended outcome of alert development. Examples of possible alert modifications are shown in
Table 2. The overarching problem is that institutions make independent efforts to improve alert performance without sharing results, which is evident by the lack of studies on effective approaches to managing alert fatigue in critically ill patients.9 More institutions committed to improving the performance characteristics of alerts and a united public format for sharing results are needed.
Another area for improvement in alerts is to move away from detection and toward prevention.17 This is occurring in the case of early warning alerts for sepsis and acute kidney injury.2 However, some medication-related alerts, such as those for antidotes, are focused on the detection of an ADE after the injury has occurred rather than at the point of a drug-related hazardous condition, when there is still an opportunity for intervention.18 A preventive approach would be better. In the example of hyperkalemia, a preventive approach would mean generating an alert when the patient is receiving a drug that can cause hyperkalemia and the potassium level is 5.6 mEq/L without the patient having any ECG changes, rather than generating a detection alert for the administration of sodium polystyrene sulfonate. While detection alerts have a role, they are unlikely to have a major impact on averting ADEs and improving patient outcomes.
This call to action for effective alert development and alert fatigue reduction comes with substantial effort and cost. Unfortunately, obtaining funding for such research can be challenging because CDS advancement alone does not bring with it high marks for novelty. The key may be incorporating CDS advancement ideas with other innovative technologies or novel therapies for improvement of patient outcomes. Still, federal funding can be sought through organizations such as the Agency for Healthcare Research and Quality, which announces programs for developing new CDS to disseminate and implement evidence-based research findings and health information technology to improve healthcare quality and outcomes. The U.S. National Library of Medicine has funded projects on machine learning that can be incorporated into the enhancement of better-performing predictive alerts.19,20
Effective alert development is an area of much-needed research to allow the enhancement of patient safety by using health information technology for better surveillance in resource-conscious environments without burdening the clinician. Some day, it would be amazing to say that clinicians are 100% responsive to alerts because they know with confidence that the alerts they receive are 100% actionable and, as a result, patient safety has been extraordinarily improved.