As a hospitalist, like most in health care, I am afflicted by the slow march of thousands of mouse clicks on the electronic health record (EHR) every day I work. But after starting a new job and learning a new EHR, I have become painfully aware of the volume of alerts that pop up when I place orders. Don’t get me wrong: I appreciate being informed that a patient has a prolonged QT interval when I am about to order an atypical antipsychotic, or if I unknowingly re-started a home ACE-inhibitor on a patient with an elevated potassium level or acute kidney injury.
However, here are some of my favorite alerts I am forced to click past on a daily basis:
1. A patient has constipation and is already on a stool softener (for example, docusate). I add a stimulant or osmotic laxative – a common thing to do. The EHR alert pops up that the patient is already on the stool softener. I click “OK,” and another pop-up box appears that makes me click my justification for adding another constipation medication. I have to select from multiple choices including “Not applicable” to “Disagree with this recommendation” to “Treatment Plan Requirement,” whatever that means.
2. A patient has a history of heart failure with preserved ejection fraction. I order metoprolol tartrate, let’s say to control the heart rate as the patient has atrial fibrillation. The EHR says to me: “According to the current guidelines, metoprolol succinate, bisoprolol, or carvedilol is recommended for patients with heart failure” – yes, thank you. These medications are used for heart failure with reduced ejection fraction. Two more clicks.
3. My favorite is when a patient has COPD or asthma and is on an inhaler in the hospital. If there is wheezing or dyspnea and I want a nebulized bronchodilator to be administered, the smart EHR tells me that my patient is already using an inhaler and makes me justify why I would want to add another medication. Last I checked, patients can receive concomitant short-acting bronchodilators and long-acting inhalers.
You may say: “What’s the big deal? It’s just two clicks.” Well, these extra clicks add up and increase the time I spend interacting with the EHR. Additionally, the more interactions I receive, the more I become numb to important ones.
I believe alerts should be carefully selected and designed to i) point out serious drug-drug interactions, or ii) to provide patient-safety related tips. For instance, recently newer notifications are asking me to justify why I am ordering haloperidol for an elderly patient. Though I usually grumble when confronted with the alert, it has made me second guess the decision several times. Also, the EHR now warns me to avoid ordering a urine culture with a urinalysis unless I am strongly suspecting a urinary tract infection, to prevent over-treatment of asymptomatic bacteriuria.
At this point, you may be thinking: “Wait a minute, you were just complaining about too many pop-ups, and now you are commending certain ones?” This begs the question, then, what are important alerts and what alerts are just slowing us down? I would agree this is a slippery slope. How can we avoid the frustration that comes with a computer questioning our clinical judgment and giving us extra clicks while simultaneously realizing we are humans and prone to diagnostic and therapeutic errors?
I think the best question to ask when these alerts are formulated is: “If the physician orders X, does it have the possibility of causing short-term harm Y”? I would argue that if I order metoprolol tartrate in a patient with heart failure instead of metoprolol succinate, I may or may not have made the correct clinical decision, but it will not cause immediate harm to the patient. If I order an albuterol nebulizer therapy on a patient with COPD who is taking a long-acting muscarinic antagonist inhaler, I am not causing any harm. But if I order lisinopril for a patient with a potassium of 5.9 or piperacillin/tazobactam in a patient with a (real) penicillin allergy, there is a higher probability of me causing harm.
So, what do you think? What are some of the EHR alerts frustrating you, and which ones are helpful?
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