One of the biggest draws of e-Prescribing is increasing safety by providing alerts for adverse reactions.  E-Prescribing systems can show warnings to prescribers for drug-drug, drug-allergy, drug-condition, and many other potential interactions.  However, these alerts actually become a problem if they are shown too often.  Prescribers start to have what is known as Alert Fatigue and completely ignore some or all of these warnings.  If messages are constantly popping up, a prescriber is likely to pay less attention to them and simply override them to continue with their workflow.  Studies have even shown as much as 95 percent of drug interaction alerts and 77 percent of drug allergy alerts are disregarded by doctors. 

This would not be such a huge issue if prescribers were only overriding low priority alerts.  However, they are overriding high priority alerts as well.  The problem comes from too many low priority and irrelevant alerts being shown.  Imagine a doctor first receiving a low priority alert, then an alert irrelevant to the patient, then another lower priority alert, and so on.  Doctors become so overwhelmed with alerts that they simply override all of them without taking notice of what they are, including those with the potential to prevent serious harm to patients.  A recent study published in the Journal of the American Medical Informatics Association looked at the appropriateness of overridden alerts.  Appropriate was defined as having the potential to prevent serious harm.  The study found that 53% of all overridden alerts were appropriate¹. 

Reducing Alert Fatigue

It seems like a simple concept: To reduce alert fatigue, the number of alerts needs to be minimized. With so much alert information available, the challenge comes from deciding which alerts should be shown and which are less important.  E-Prescribing vendors are also faced with solving how to display the important alerts in a manner that doesn’t diminish work-flow. 

Drug-drug and drug-allergy interaction checking is a criterion in both Meaningful Use Stage 1 and Stage 2.  The 2014 Meaningful Use HIT Certification Program, approved by the Office of the National Coordinator for Health Information Technology (ONC), defines that drug-drug and drug-allergy alerts must both be automatically shown at the point of prescribing.  The drug-drug alerts shown must also be adjustable by severity level².   

This means that certified products should, at a minimum, be including the ability to minimalize minor drug-drug interaction alerts.   This, however, does not cover severity level per drug-condition or drug-allergy alerts.  A minor intolerance allergy alert should be treated different than a major interaction that can cause serious harm or even death. 

The ONC has also created a list of the most critical drug-drug interactions (separate from the Meaningful Use program).  It has recommended that this list of 15 interactions be included in all prescribing systems and always generate an alert that cannot be turned off.  Some have suggested that these alerts should also require more to override them then the standard alerts, such as a required written reason.  It was also suggested that including these 15 alerts be a criterion for Meaningful Use of drug-drug interaction alerting.  However, this list is said to only be responsible for less than 1 percent of drug interaction alerts in some systems.  What about the rest of the alerts? 

Taking it a step further - Eliminating Alert Fatigue

In order to maximize patient safety and prescriber workflow, e-Prescribing systems need to go above and beyond the Meaningful Use Criteria.  There are 3 main points that need to be addressed to work towards the ultimate goal of eliminating alert fatigue:

      1. Selecting the Important Alerts

The importance of alert types varies from specialty to specialty and even from doctor to doctor.  This is why it is important for e-Prescribing vendors to have the ability to allow each prescriber to set their own customizable alert levels.  Each prescriber should be able to select for each alert type (not just drug-drug) whether they want to see all of the available alerts, only the highest alerts, or somewhere in between in order to maximize the effectiveness of the alerts. 

       2.  Displaying Alerts Without Causing “Fatigue”  

It is important to categorize all alerts by their severity level and display this information in a clear and easy to understand format.  If a prescriber has selected to see all alerts, it is still significant for them to know which are the highest alerts.  Color-coding alerts so that for example, red is the highest, is a good way to make each alert level clear to the user.  Alert fatigue can also be reduced by including all alerts for a given prescribing event together.  Instead of having several individual alerts popup one after another, all alerts should be displayed in one window with the highest level alert displayed at the top.   Review, overriding, or re-evaluation should never involve more than one or two clicks to continue with prescribing workflow.

3.  Creating Smarter Alerts 

A lot of e-Prescribing systems categorize each alert by level of risk per one drug interacting with another drug, but what about interaction concerns per age, weight, or condition that increase the risk?  At MDToolbox, we have taken it a step further and allow prescribers to create decision support interventions at the point of prescribing that can take into account other factors (like age, weight) when determining alert display.  We also include optional dosing references, alerts and calculators to further aid in “smart alerts”. 

Instead of being viewed as a hindrance in the prescribing workflow, alerts should be viewed as an important safety aid.  We hope that by reducing alert fatigue, the true effectiveness of prescribing medications with an alert system will be realized. 

1. Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in outpatientsJ Am Med Inform Assoc Published Online First: 28 October 2013. doi:10.1136/amiajnl-2013-001813
2. Office of the National Coordinator for Health Information Technology (ONC) - Test Procedure for §170.314 (a)(2) Drug-drug, drug-allergy interaction checks:   14  December, 2012.  http://www.healthit.gov/sites/default/files/170.314a2drug_interaction_checks_2014_tp_approvedv1.2.pdf