In hospitals and clinics, automated alerts and reminders from electronic health record (EHR) systems are sometimes perceived by busy members of the clinical team as unhelpful or a nuisance. To the extent that such perceptions become more common and so-called alert fatigue sets in among users, everyone loses.
On April 1, the Vanderbilt Clinical Informatics Center (VCLIC), in coordination with Health IT, launched a grassroots program called Clickbusters to stem alert fatigue at Vanderbilt University Medical Center.
In eStar, the EHR system used at VUMC, automated alerts and reminders are called best practice advisories, or BPAs. To date, Clickbusters has reduced BPAs by 49,000 per week, or about 10% of the approximately 488,000 BPAs that fire in a typical week as VUMC users interact with the system.
Some BPAs have been eliminated outright by Clickbusters, others have been altered in ways that affect when they do and don’t fire, and for which users.
According to the director of VCLIC, Adam Wright, PhD, the Clickbusters goal is better BPAs, not sheer reduction in numbers.
“We believe in alerts. There should be a lot of good alerts in the system that are accepted a lot of the time and that people find to be useful,” said Wright, professor of Biomedical Informatics.
VUMC can audit which BPAs are disregarded by users and which are acted upon.
“Currently, BPAs are acted upon 8% of the time at VUMC. The Clickbusters goal is 30%,” Wright said.
eStar has 142 distinct groups of BPAs. Some were developed by VUMC and others came from the vendor for eStar, Epic Systems Corp. Some oddities were found in the initial round of Clickbusters, which concluded June 1. One BPA, urging the clinician to counsel the patient to lose weight, was firing for anesthesiologists working with anesthetized patients in the OR. Another was prompting users to refer patients to a discontinued clinical outcome risk reduction program.
“BPAs are always well meant, the motivation being to guard clinical safety and quality or reduce unnecessary costs,” said Neal Patel, MD, MPH, chief informatics officer with Health IT. “However, alert fatigue seems to have somewhere along the line became practically endemic in health care. At VUMC, Clickbusters is helping us clean house one BPA at a time.”
Round two of the program launched on June 29, with a fresh list of BPAs deemed eligible for busting. Clickbusters volunteers — physicians, nurses, pharmacists — sign up to review a given BPA in detail using a 10-step process that involves everything from the clinical logic that gave rise to the advisory, to how often the advisory is disregarded in practice. If a BPA is found completely sound it’s left unchanged, but otherwise it may be altered or shut down for some or all users. Recommended changes are adjudicated by the program sponsors or forwarded to relevant clinical governance committees for a decision.
Helping to engage people’s sporting instincts, Clickbusters is gamified, with scoring (and prizes) based on a volunteer’s overall impact on the system.
In a related system update from VCLIC, BPAs now come with emoticons — a smiley face, a sad face (and an in-between face): clicking on one lodges the user’s general level of satisfaction with the BPA and opens a dialogue box for optional comments. This input is used to direct improvements, and according to Wright, Epic has taken notice of this VUMC feedback mechanism and is adding it to their product.
Wright said efforts are also underway to improve the user experience with other forms of eStar clinical decision support, such as order sets.
Wright credits Allison McCoy, PhD, MS, assistant professor of Biomedical Informatics, with helping to foster Clickbusters. For more information visit the program webpage at VCLIC.