CDS Alert Fatigue Runs Rampant in Ambulatory Clinics

Ambulatory clinics are facing significant clinical decision support (CDS) barriers related to health IT resources and user satisfaction, which is resulting in CDS alert fatigue among clinicians, according to a study published in the Journal of the American Medical Informatics Association (JAMIA).

Research suggested health systems should provide further assistance to improve CDS alerts at affiliated ambulatory clinics. In particular, rural clinics may need additional resources for CDS training.

Researchers analyzed CDS data from 821 healthcare clinics at 117 health systems in Minnesota.

Researchers identified seven common CDS barriers, which related to resources, user acceptance, and technology:

• Lack of resources to build and integrate CDS
• Lack of staff and provider training
• Redesign of EHR workflow processes
• False and disruptive alarms
• System upgrade requirement
• Software not available
• Hardware problems

Over two years, researchers examined the association between the CDS barriers and healthcare clinic characteristics, such as clinic type, location, number of physicians, number of clinics in a health system, and health system affiliation.

Fifty-seven percent of respondents offered at least some specialty care, 86 percent had 19 or fewer physicians, 58 percent were in medical groups with 21 or more clinics, and 82 percent were situated in urban areas.

Research revealed 98 percent of clinics utilized alerts and electronic medication guides, but only 61 percent leveraged high-tech diagnostic imaging.

“The limited use of high-tech diagnostic imaging in both groups was not surprising, as its cost-effectiveness has been increasingly questioned,” explained the study authors. “However, the relatively low use of automated reminders and chronic disease care plans by clinics not affiliated with health systems is concerning, as these 2 CDS functions may be effective in improving patient outcomes.”

Twenty-four percent more of health system clinics leveraged CDS tools than clinics not in health systems. However, 26 percent more clinics in health systems faced more barriers connected to resources and user acceptance.

Two major barriers, workflow redesign and false alarms or disruptions, increased significantly over the two-year sample size, something that is consistent with previous literature on clinician burnout, the study authors wrote.

Workflow-related barriers also increased in health system-based clinics. Furthermore, rural clinics reported training barriers.

“Finally, clinics in health systems showed a much higher level of using alerts, reminders, and chronic disease care plans, which also seemed to have led to more frequent reporting of false alarms and disruptions,” wrote the study authors. 

While health systems help affiliated clinics with CDS adoption, barriers increased. As a result, health systems should allocate specific resources to enhance CDS implementation and training to mitigate alert fatigue.

“Our findings also echo the advocacy to establish federal leadership in advancing CDS standards and creating a national CDS repository, which can potentially facilitate and coordinate CDS implementation, training, and workflow redesign across the board,” concluded the study authors. “For clinics outside health systems, there may need to be policies to further incentivize the expansion of CDS use.”

CDS alerts intend to flag an adverse drug event or a medication error for clinicians. However, if alerts cannot fire effectively, then patient safety is in danger.

While EHR optimization has increased in recent years, CDS alerts still fail to detect up to 33 percent of medication errors, according to a separate study published in JAMA Network Open.

Using simulated medical records, researchers from University of Utah Health, Harvard University, and Brigham and Women’s Hospital found that EHR systems continue to put patients in unfavorable and potentially deadly situations, due to the inability to consistently detect errors.

“Although EHRs are now widely used, their safety performance continues to vary from hospital to hospital,” said David W. Bates, MD, a study co-author and chief of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital. “Hospitals decide what drug-related decision supports to turn on within their systems. They have a great deal of latitude around this.”