the antidote to alert fatigue may 26, 2010 best ever medical center best city, il mmi – 406:...
TRANSCRIPT
The Antidote to Alert Fatigue
May 26, 2010
Best Ever Medical CenterBest City, IL
MMI – 406: Decision Support Systems and Healthcare
Suzi Birz, Nicki Cliffer, Kyle Johnson, Debbie Michaelson
Best Ever HospitalBest City, IL
Agenda
May 26, 2010 2
• Welcome and Introductions• We Hear You – You have Alert Fatigue • The Antidote (the process)• Stop-The-Noise• Evaluation• Become a Participating Physician
Best Ever HospitalBest City, IL
Welcome and Introductions
May 26, 2010 3
Best Ever HospitalBest City, IL
Meeting Participants
• Champions• Welcome to our physicians and pharmacists• Welcome to other stakeholders
– Lori, our Chief Nursing Officer– Beth from the Office of Legal Affairs– Jeff from Performance Management– Krista from Patient Safety
• Thank the CPOE Team
May 26, 2010 4
Best Ever HospitalBest City, IL
May 26, 2010 5
We hear you have Alert Fatigue
Best Ever HospitalBest City, IL
Problem Statement
• Alert fatigue is the most common complaint by physicians about CPOE systems.
• Alerts are overridden 49 – 96% of the time.• Contributing factors to our high alert rate:
– Doses larger than the alert threshold are often warranted due to our patient severity mix
– Some of our drugs are entered by package not by dose– Some order changes generate an unwarranted duplicate
order alert
May 26, 2010 6
Best Ever HospitalBest City, IL
Not All Alerts Are Noise
• “GOOD ALERT” Prescription for Amphotericin 5 mg/kg generates a “maximum dose exceeded” alert
• “NOISE ALERT”Prescription for potassium-sparing diuretic warns that patient is receiving potassium
May 26, 2010 7
Best Ever HospitalBest City, IL
Clinical Objectives
• Turn off non-meaningful overridden alerts• Display alerts in order of salience• Reduce number of clicks in the ordering process• Reduce overall time it takes to place medication
orders• Improve ordering patterns• Reduce adverse drug events
May 26, 2010 8
Best Ever HospitalBest City, IL
The Antidote
May 26, 2010 9
Best Ever HospitalBest City, IL
Process
May 26, 2010 10
Best Ever HospitalBest City, IL
ScenarioA 68-year old female, Mrs. Mary MacIntosh, is admitted to Best Ever Medical Center with an admitting diagnosis of acute myocardial infarction. Medication reconciliation performed by the ED pharmacist shows her current medication list as:
– Aspirin 81 mg PO daily– Cardizem CD 180 mg PO daily – Simvastatin 40 mg PO daily– Synthroid 100 mcg PO daily
Dr. Steve Jobs, her attending physician, examines Mrs. MacIntosh and orders laboratory tests. Dr. Jobs makes some changes to the medication regimen. The changes prescribed are:
– D/C aspirin– Plavix 300 mg PO STAT, followed by 75 mg
PO daily– Nitroglycerin IV 5 mcg/min– Metoprolol 25 mg PO Q6H– Morphine 2 mg IV Q2H prn pain– Docusate 100 mg PO BID– Acetaminophen 650 mg PO Q6H prn t
May 26, 2010 11
Best Ever HospitalBest City, IL
Stop-The-Noise
May 26, 2010 12
Best Ever HospitalBest City, IL
System Design
May 26, 2010 13
Best Ever HospitalBest City, IL
The App
May 26, 2010 14
Best Ever HospitalBest City, IL
Analysis and Decision
May 26, 2010 15
Best Ever HospitalBest City, IL
Evaluation
May 26, 2010 16
Best Ever HospitalBest City, IL
Evaluation Elements• Alert CDS verification and validation
– Verification: Level 1 – Establishing Order-Alert sensitivity and specificity– Validation: Level 2 – Utilizing Order-Alert-Response sensitivity and
specificity to revise alert firing rules and thresholds
• Alert database validation and verification– Verification methods– Validation requirements
• Alert Decision Support Customer Satisfaction Survey • Physician Super User observations• Evaluation of performance against target clinical objectives• Suggested logs and report formats• Communication recommendations
May 26, 2010 17
Best Ever HospitalBest City, IL
Process Steps
• Sensitivity, specificity, percent of false positives, and the percent of false negatives occurring at a given threshold level will be assessed.
• Threshold levels will be fine-tuned, additional data will be gathered, and will be evaluated after a three-month period.
• Threshold levels will continue to be fine-tuned until the balance between specificity and sensitivity is such that the level of false negatives is as low as is reasonable.
May 26, 2010 18
Best Ever HospitalBest City, IL
Sensitivity and Specificity: Accepted
May 26, 2010 19
Best Ever HospitalBest City, IL
Sensitivity and Specificity: Override
May 26, 2010 20
Best Ever HospitalBest City, IL
Sample Calculations
May 26, 2010 21
Best Ever HospitalBest City, IL
Feedback Loop
• Our promises to you– Notification of alerts analyzed and decisions– Routine meetings for open discussion of alerts– Multiple communication avenues including e-mail,
SharePoint site, meetings
• Reports / Queries available to you– Alerts analyzed and decisions– Literature review– Analysis documentation– Your iPhone responses
May 26, 2010 22
Best Ever HospitalBest City, IL
Become a Participating Physician
May 26, 2010 23
Best Ever HospitalBest City, IL
Alerts have you pushing the override button on every patient?
Tell us … why
We’ll send you a message with the clinical details, you select one choice, and we’ll use that data to improve our alerts.
Best Ever HospitalBest City, IL
Sign Up
• Sign Up Today• Contact CMIO for more details
May 26, 2010 25