Perspective: Alert fatigue – a pitfall of the EMR

Padgett MD, professional headshotBy Ryan G. Padgett MD FACEP
September, 2014

[Editor’s Note: This month’s “Perspective” is contributed by my colleague, Dr. Ryan Padgett, who provides services as a Consulting Expert with / CP]

Mention the word “EMR” (Electronic Medical Record, aka EHR for Electronic Health Record) to a health professional and you can expect a strong opinion to be immediately expressed. Overwhelmingly the response is negative. While there’s no going back to paper, longings for the old days will be the consistent theme. Sure, an EMR has become a great repository of data and chart notes, readily available and legible for all to read. But dissatisfaction with inefficient data entry, insertion of a screen between caregiver and patient, and voluminous notes that rarely convey a helpful picture of the situation still predominate. But most practitioners bemoan the EMR for the wrong reasons.

They really should be worried about the medical malpractice pitfalls that lurk within.

Previous “Perspective” articles published in the “Malpractice Bulletin” have pointed out some of the drawbacks.  [See: Template Charts: The good, the bad and the uglyThe chart is my witness, and EMRs: Can we trust them?]

  • Chart cloning, also known as copying and pasting, can speed data entry but risk perpetuating incorrect information and implies less engagement by the practitioner in the current visit.
  • Fraudulently upcoding becomes all too easy and passively encouraged with check boxes and macros, premade sentences that contain, for example, a 10 point physical exam.
  • Lack of documented medical decision-making cheats us of a window into the true thinking about a case.  Computer generated prose lack the texture and color of a caregiver-patient interaction that could give an accessible feel for what the caregiver truly saw.

As experience with EMRs increases, new challenges are discovered. One of the most critical is “alert fatigue,” an unintended consequence of seemingly infinite information and computer algorithms. The promise of electronic systems is that they can use technology to alert a caregiver to abnormal lab results, drug-drug interaction, drug allergies or changes in patient clinical status. However, alert fatigue occurs when an EMR or other systems such as patient monitors give prompts, alerts and alarms resulting in an overwhelmed and unresponsive caregiver. Unfortunately, humans lack infinite capacity to respond appropriately to every alert, so the overwhelmed caregiver begins to ignore them.

Having served as both a user of more than one EMR and as a “superuser” for one hospital’s EMR implementation, I have watched as alert fatigue affects others. I have also experienced it firsthand. Alert fatigue works like this: Initially one responds as intended. When a patient is allergic to penicillin and a physician prescribes cephalexin, a drug allergy alert might point out that there is the possibility of cross-reactivity and potential danger in this. However, the physician, knowing that the patient has previously tolerated cephalexin, will enter (usually by manually typing) the full rationale for the choice of antibiotic then override the alert. After multiple experiences with this alert, perhaps 1o, maybe more, at some point the physician will seek a work-around, like clicking a box stating “Physician Choice.” If this happens with dozens of other alerts, the overly confident physician will begin to believe that alerts are more of a problem than they are worth and begin to override them as a habit. Ignoring the software’s ability and intent to prevent a mistake becomes a matter of efficiency and eventually wins out.

Recognizing this challenge, vendors have been forced to  design better tools to strike a balance between a) the number and quality of alerts and b) the ability of caregivers to respond to them. Many EMRs now have scalable alert levels. This helps filter out less important alerts and allow only the most important to get through. “Hard stops” for critical situations when the alert must be acknowledged are becoming fewer. But at what cost?

One driver of this may even be found in physician employment contracts and payor audits, where meeting standards of efficiency, productivity, and certain other core measures is tracked.  While a provider is expected to provide a high level of customer service to produce satisfied patients, he or she is also expected to see more patients in a shorter period of time. Because it’s hard to do both, this leads to a temptation to cut corners.  Companies like Press-Gainey and HealthGrades track this and score doctors on such things as door to doctor time, door to door time for discharged patients, and door to decision time and door to floor time for admitted patients. Customization of the EMR with things like check boxes is commonly employed to speed documentation, but at great risk of both over- and under-documenting. And while it seems that should add to productivity and efficiency, this has been proven to be difficult. A recent survey, published in Medical Economics, shows that the EMR costs physicians an extra 48 minutes per day.

Technology offers an as yet unfulfilled promise, and the AMA is calling for continued significant improvements. In the quest for efficiency, work-arounds and shortcuts are pervasive and can bypass built-in safety features, thereby negating a system’s strengths. While practitioners would like to blame EMR vendors to make them legally liable for the failures of their safety systems, the vendors seem to be well-insulated from responsibility. The physician remains fully responsible for the integrity of the medical chart.

For now, EMRs are proving to be great repositories of information but are a huge disappointment in terms of communication – which is the real purpose of a medical record. Because the EMR is so prone to providing misleading, excessive, erroneous and/or irrelevant information, and very little communication, it appears to have done nothing to reduce the incidence of malpractice suits, and may be the plaintiff attorney’s best friend. But it is here to stay. Hopefully, as our experience and knowledge grows, the promise of the EMR to improve patient safety and reduce medical malpractice exposure will be fulfilled.

What began as a way to avoid mistakes has now become a source of them.

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