"Alert fatigue" is a major concern for hospitals implementing computerized physician order entry systems. Executives worry that if too many alerts are trigged when physicians order tests or medications, doctors will begin to ignore virtually all alerts. That's why George Reynolds, M.D., is using business intelligence software to monitor how physicians respond to alerts and then fine-tune them or eliminate them, as appropriate. Reynolds, a pediatric intensivist, is chief medical informatics officer at Children's Hospital and Medical Center in Omaha, Neb. Reynolds' long-term goal is to make most alerts virtually unnecessary. "I don't want alerts to fire at all. I want the order sets to be written well enough that they steer doctors to the right choices." To move toward the goal of avoiding alert fatigue by triggering only the alerts that matter most, Reynolds is using QlikView software from QlikTech International, a Swedish firm, to keep a close eye on how physicians interact with the CPOE system, from Eclipsys Corp., Atlanta. The 142-bed hospital's 590 physicians input 86% of all orders using CPOE. And they were closely involved in creating and refining 300 order sets.

Using the business intelligence software, Reynolds can watch each type of alert category and drill down to make inquiries, such as "show me the most common drug dose range alerts triggered in May." He then shares the results with a physicians' informatics group of about 30 to 40 volunteers. One alert that physicians were ignoring, he says, warned doctors that they should not order Albuterol more than once every four hours. In subsequent meetings with the physicians group, he determined doctors frequently want to order the drug for hourly use for severe asthma cases. They recommended he eliminate the alert. In another instance, he noticed that, in certain cases, doctors were overriding an alert advising against over-prescribing potassium chloride, which can be fatal at excessive doses. But physicians said they wanted to keep the alert because it offered a good reminder. "So we don't just look at how many times alerts fire or how many times doctors turn it off." Sometimes, the BI software helps Reynolds to fine-tune an alert so it fires only under certain circumstances. For example, in monitoring an alert for the use of antibiotics given before and after surgery, Reynolds noticed some surgeons were ordering a post-surgical dose sooner than the alerts said they should, making adjustments for the length of the surgery. Reynolds and the surgeons determined that the alert should be eliminated. But physicians also determined that if a clinician on a patient floor orders an antibiotic to be administered to a post-surgical patient every four hours and the guideline is every six hours, the alert should still fire. Today, only 6.6% of orders submitted using CPOE trigger an alert, down substantially since using business intelligence to fine-tune the system, Reynolds says. Of those, 22% result in a physician changing their behavior, Reynolds says. "As you use CPOE, you come up with ways to make sure alerts don't fire," Reynolds says. For example, once they get accustomed to using order sets, doctors get into the routine of checking records to making sure they're not ordering duplicate medications or lab tests. In that way, the alert against ordering duplicates is never triggered. Reynolds calls CPOE "a very expensive enterprise that's complicated to implement." That's why he stresses that it's so important to use business intelligence to help fine-tune the system and make sure physicians use it properly. "CPOE has to be much more than a very expensive typewriter that produces orders that are easier to read," he says. Winning physician support for CPOE requires data, such as the information BI reveals, Reynolds stresses. "To me, data is the key to influencing physicians' behavior and convincing them that what we're doing with CPOE is right." Without the data, he says, some physicians might remain skeptical of CPOE, viewing it as a "challenge to their autonomy or the flavor of the month." Reynolds also advises hospitals implementing CPOE to:

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