Eyeworld

September 2017 • Ophthalmology Business 7 a certain screening or lab test, the alert is sent to everyone system-wide, whether it's relevant to them or not. "The impact that has on a primary care doctor who may see 10 patients in a half day is very different from the impact on the ophthalmol- ogist who may see 20 to 25 patients in a half day. Even though it's just one alert, we get twice as many in a smaller period of time when we're trying to be more efficient and focus on one organ system," Dr. Areaux said. Naveen Rao, MD, assistant professor of ophthalmology, Tufts University School of Medicine, Bos- ton, described the two most com- mon examples of alerts he sees on a regular basis. "(1) When I am scheduling a patient for a follow-up appointment, I see a warning that they already have an outstanding follow-up order previously entered with someone in our department. This could be useful to prevent duplicate appointments, but the warning does not let me easily see when the appointment is and who it is with. I don't care if a patient has an appointment with a glaucoma or retina specialist in our practice if I want them to see me for a cornea follow-up. I often click away these messages without reading, although they may be useful," he said. "(2) Medication-related advisory messages are the worst offenders for causing alert fatigue. If I'm entering orders for an antibiotic eye drop for a patient with a corneal ulcer, and if I want the drops to be used every hour, I always get an alert saying this exceeds the recommended dosing Hundreds of papers have been published on the topic of alert fatigue. A 2009 report looked at medication safety alerts—also called decision support systems—generated on an electronic prescription system by 2,872 physicians between Jan. 1, 2006 and Sept. 30, 2006. 1 More than 3 million prescriptions were electron- ically written during this time period, 6.6% of which generated an alert. The researchers found clinicians overrode most high severity drug interaction and allergy alerts, with 9.2% and 23% alert acceptance rates, respectively. Other research has found "cli- nicians became less likely to accept alerts as they received more of them, particularly more repeated alerts." 2 Yet another study reported more than half of drug allergy alerts (more than 600,000 collected from two Boston academic centers from 2004–2013) were overrode due to irrelevance; this research also showed providers were more likely to override repeat alerts. 3 Impact on ophthalmologists The idea of clinical alert pop-ups for electronic health record systems goes back many years with the thinking that it would make care better and safer, said Michael Boland, MD, associate professor, and director of in- formation technology, Health Science Informatics, Wilmer Eye Institute, Baltimore. Dr. Areaux said that while ophthalmologists might be "shield- ed" from alerts more than general practice physicians, electronic health records are often shared among spe- cialties. When a healthcare institu- tion decides to roll out an alert for A patient needs an eye drop medication. You hop onto your electronic health record system and order the medication, click "sign," and—pop—up comes an alert in the middle of your screen. The alert pro- vides a long list of alternate medica- tions, medications in that category, potential side effects, any medication conflicts or allergies specific to the patient, and more. Sound familiar? Alerts and alarms occur dozens of times a day when it comes to prescriptions, procedures, diagnoses, and other situations. Physicians, however, often find the information clinically inapplicable or irrelevant, and have become prone to glossing over the alerts or ignoring alarms in some- thing called "alert fatigue." This situation can become a patient safety issue, however, when an important piece of information gets lost among all the other noise. "The more you pay attention to something and continually find it to be a nuisance and waste of your time, the more you tend to start, subconsciously, ignoring it," said Ray Areaux, MD, clinical informaticist and assistant professor of pediatric ophthalmology and strabismus, University of Minnesota, Minneapo- lis, and medical director, Minnesota Lions Children's Eye Clinic. "That's the concept of alert fatigue: that buried in the noise of all the alerts will be something significant, and there's a potentiation of the end user, the physician or provider, to click past it quickly because they've never seen a significant alert. That's the real problem." continued on page 8

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