The Antidote to Alert Fatigue

1. The Antidote to Alert Fatigue May 26, 2010 Best Ever Medical Center Best City, IL MMI – 406: Decision Support Systems and Healthcare Suzi Birz, Nicki Cliffer, Kyle Johnson, Debbie Michaelson

2. Agenda • Welcome and Introductions • We Hear You – You have Alert Fatigue • The Antidote (the process) • Stop-The-Noise • Evaluation • Become a Participating Physician

3. Welcome and Introductions

4. Meeting Participants • Champions • Welcome to our physicians and pharmacists • Welcome to other stakeholders • Lori, our Chief Nursing Officer • Beth from the Office of Legal Affairs • Jeff from Performance Management • Krista from Patient Safety • Thank the CPOE Team

5. We hear you have Alert Fatigue

6. Problem Statement • Alert fatigue is the most common complaint by physicians about CPOE systems. • Alerts are overridden 49 – 96% of the time. • Contributing factors to our high alert rate: • Doses larger than the alert threshold are often warranted due to our patient severity mix • Some of our drugs are entered by package not by dose • Some order changes generate an unwarranted duplicate order alert

7. Not All Alerts Are Noise • “GOOD ALERT” Prescription for Amphotericin 5 mg/kg generates a “maximum dose exceeded” alert • “NOISE ALERT” Prescription for potassium-sparing diuretic warns that patient is receiving potassium

8. Clinical Objectives • Turn off non-meaningful overridden alerts • Display alerts in order of salience • Reduce number of clicks in the ordering process • Reduce overall time it takes to place medication orders • Improve ordering patterns • Reduce adverse drug events

9. The Antidote

10. Process

11. Scenario A 68-year old female, Mrs. Mary MacIntosh, is admitted to Best Ever Medical Center with an admitting diagnosis of acute myocardial infarction. Medication reconciliation performed by the ED pharmacist shows her current medication list as: • Aspirin 81 mg PO daily • Cardizem CD 180 mg PO daily • Simvastatin 40 mg PO daily • Synthroid 100 mcg PO daily Dr. Steve Jobs, her attending physician, examines Mrs. MacIntosh and orders laboratory tests. Dr. Jobs makes some changes to the medication regimen. The changes prescribed are: • D/C aspirin • Plavix 300 mg PO STAT, followed by 75 mg PO daily • Nitroglycerin IV 5 mcg/min • Metoprolol 25 mg PO Q6H • Morphine 2 mg IV Q2Hprn pain • Docusate 100 mg PO BID • Acetaminophen 650 mg PO Q6Hprn t

12. Stop-The-Noise

13. System Design

14. The App

15. Analysis and Decision

16. Evaluation

17. Evaluation Elements • Alert CDS verification and validation • Verification: Level 1 – Establishing Order-Alert sensitivity and specificity • Validation: Level 2 – Utilizing Order-Alert-Response sensitivity and specificity to revise alert firing rules and thresholds • Alert database validation and verification • Verification methods • Validation requirements • Alert Decision Support Customer Satisfaction Survey • Physician Super User observations • Evaluation of performance against target clinical objectives • Suggested logs and report formats • Communication recommendations

18. Process Steps • Sensitivity, specificity, percent of false positives, and the percent of false negatives occurring at a given threshold level will be assessed. • Threshold levels will be fine-tuned, additional data will be gathered, and will be evaluated after a three-month period. • Threshold levels will continue to be fine-tuned until the balance between specificity and sensitivity is such that the level of false negatives is as low as is reasonable.

19. Sensitivity and Specificity: Accepted

20. Sensitivity and Specificity: Override

21. Sample Calculations

22. Feedback Loop • Our promises to you • Notification of alerts analyzed and decisions • Routine meetings for open discussion of alerts • Multiple communication avenues including e-mail, SharePoint site, meetings • Reports / Queries available to you • Alerts analyzed and decisions • Literature review • Analysis documentation • Your iPhone responses

23. Become a Participating Physician

24. Alerts have you pushing the override button on every patient? Tell us … why We’ll send you a message with the clinical details, you select one choice, and we’ll use that data to improve our alerts.

25. Sign Up • Sign Up Today • Contact CMIO for more details Debbie@bestevermedicalcenter.edu 312.555.5555