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Clinical Decision Support
General
Clinical decision support may be divided into two main categories:
- Checking built into the software such as drug/allergy checking
- Guidance built into the orders such as a line of text with the suggested lock-out interval for patient controlled anesthesia (PCA
Some software can also be used to create and display complex custom rules.
Alert Fatigue
(from Inpatient Computerized Provider Order Entry (CPOE): Findings from AHRQ Portfolio)
“Alert fatigue,” commonly experienced after a CPOE goes live, is caused by a combination of critical medical alerts and a high volume of marginally medically consequential alerts. Alerts are also triggered when patients with multiple diseases (comorbidities) are taking several drugs that may interact with one another. Alert fatigue can lower adoption among physicians due to physician annoyance with the superfluous pop-ups and warnings for common interactions that cause little to no harm to patients. Redundant alerts also can reduce clinicians’ sensitivity to the alerts, increasing the opportunity for patient safety error.
One way to minimize alert fatigue is to turn off alerts when risks are minimal. For example, a grantee reported that its behavioral health department turned off alerts for antianxiety drug interactions with common over-the-counter sleep aids, since the providers were fully aware of the minimal risks these combinations pose. Another grantee assigned a staff member to round with providers so that complaints about alerts could be identified promptly. Complaints were shared with a clinical oversight committee that had the authority to turn off minimal risk alerts.
Drug-allergy alerts that are triggered by a low threshold for defining a clinically meaningful adverse reaction can result in extraneous alerts being activated. One grantee discovered that multiple drug-allergy alerts were being dismissed quickly by the providers. When asked, the providers raised concerns regarding how allergies were being associated with patients. Some providers felt that a minor adverse reaction to a medication, such as nausea or a headache, did not mean the patient was allergic to that medication. The hospital worked to answer the question, “What is an allergy?” and revised how patient allergies were entered into the EHR and CPOE systems. The hospital also revised its processes for capturing and recording patient allergies. Drug-allergy alerts were revised, resulting in a lower number and severity of alerts. Clinicians viewed the dialogue and discussions around the drug-allergy alerts as a positive process for their medical community.
The organization will need to strike a balance between displaying so many alerts that clinical care is slowed and turning off alerts that could improve patient safety.
Resources
HIMSS CDS Wiki
This Wiki has valuable information for implementing CDS tools within your EHR.
National Quality Forum (NQF)'s report Driving Quality and Performance Measurement—A Foundation for Clinical Decision Support
