Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review

Abstract

Objective Alert fatigue limits the effectiveness of medication safety alerts, a type of computerized clinical decision support (CDS). Researchers have suggested alternative interactive designs, as well as tailoring alerts to clinical roles. As examples, alerts may be tiered to convey risk, and certain alerts may be sent to pharmacists. We aimed to evaluate which variants elicit less alert fatigue. Materials and Methods We searched for articles published between 2007 and 2017 using the PubMed, Embase, CINAHL, and Cochrane databases. We included articles documenting peer-reviewed empirical research that described the interactive design of a CDS system, to which clinical role it was presented, and how often prescribers accepted the resultant advice. Next, we compared the acceptance rates of conventional CDS—presenting prescribers with interruptive modal dialogs (ie, “pop-ups”)—with alternative designs, such as role-tailored alerts. Results Of 1011 articles returned by the search, we included 39. We found different methods for measuring acceptance rates; these produced incomparable results. The most common type of CDS—in which modals interrupted prescribers—was accepted the least often. Tiering by risk, providing shortcuts for common corrections, requiring a reason to override, and tailoring CDS to match the roles of pharmacists and prescribers were the most common alternatives. Only 1 alternative appeared to increase prescriber acceptance: role tailoring. Possible reasons include the importance of etiquette in delivering advice, the cognitive benefits of delegation, and the difficulties of computing “relevance.” Conclusions Alert fatigue may be mitigated by redesigning the interactive behavior of CDS and tailoring CDS to clinical roles. Further research is needed to develop alternative designs, and to standardize measurement methods to enable meta-analyses.

Clinical Decision Support and Implications for the Clinician Burnout Crisis

“…They also proposed tiering of alerts to improve acceptance and consideration of human factors in CDS design [20] The analytic reviews analyzed the features of previously implemented CDS tools. Several reviews examined alert use, generally finding acceptance rates to be low [21] and override rates to be high [22][23][24]. Hussain et al delved into why alerts are so commonly overridden and found that although interruptive alerts are the most common design, they are also the least accepted.…”

“…Hussain et al delved into why alerts are so commonly overridden and found that although interruptive alerts are the most common design, they are also the least accepted. The authors also found that role-tailoring alerts to pharmacists instead of physicians had improved acceptance [21]. Carli et al undertook a systematic review of positive predictive values (PPVs) of CDS alerts as a proxy for clinical relevance, finding massive PPV variations from 0% to 97%, with most in the 20%-40% range.…”

How the presentation of patient information and decision-support advisories influences opioid prescribing behavior: A simulation study

“…Modal dialogs are relatively easy to implement, and there seems to be a perception that modal dialogs-because of their interruptive nature-are an effective means of obtaining clinicians' attention, leading to a higher likelihood of actions. However, there has been an extensive body of literature suggesting that alerts delivered through modal dialogs are frequently overridden, 22,45 much like in our study, in which participants overrode 96% of modal dialogs. Further, modal dialogs are a significant contributing factor to clinician frustration, 46 burnout, 47 and potentially unsafe prescribing practices.…”

Experience in Developing an FHIR Medical Data Management Platform to Provide Clinical Decision Support

“…This approach is commonly referred to as microservice architecture [25].Specifying standard interfaces, CDS Hooks (https://cds-hooks.org), provides a hook-based pattern for automatically invoking CDSS functions within routine clinical workflows [26]. This specification natively supports HL7 FHIR R4 to simplify the data flow, enabling easy integration of HISs and CDSS services.The experience shows that most of the CDSSs are standalone implementations focused on one clinical condition or workflow [27][28][29]. However, the implementation of sophisticated clinical decision support platforms that are capable of providing a full spectrum of clinical decision support functionality to various medical information systems is still missing.…”

“…The experience shows that most of the CDSSs are standalone implementations focused on one clinical condition or workflow [27][28][29]. However, the implementation of sophisticated clinical decision support platforms that are capable of providing a full spectrum of clinical decision support functionality to various medical information systems is still missing.…”