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Actionable Public Health Alerts Sent to Physicians Via Office EMRs

Posted Feb 28 2011 12:00am

Veteran readers of Lab Soft News may recall a note posted in 2005 focusing on syndromic surveillance (see: Public Health Informatics Update ). The basic concept, which I don't think went far, was to unveil possible bioterrrorism attempts by electronically screening patients seen in Emergency Departments. The underlying idea was to screen for clusters of symptoms (e.g., nausea, vomiting) that would suddenly crop up. A project with a similar theme, albeit with a less dramatic but certainly useful goal, has now been launched (see: CDC project to test health alerts sent to docs via EHRs ). The objective is to identify episodes of food born illness by assessing symptoms recorded in EMRs and then alert physicians via these same systems. Below is an excerpt from the article:

The Centers for Disease Control and Prevention (CDC), GE Healthcare and the Alliance of Chicago Community Health Services are collaborating on a project that aims at testing the efficacy of actionable health alerts, delivered instantly to a physician's electronic medical record. Officials made the announcement at [the recent] HIMSS and said the project will begin with a six-month prospective study, seeking to determine if the alerts are triggered often enough or too often, and if doctors take the advice displayed within the alerts. As a foundation, the study will utilize GE Healthcare's densely populated Medical Quality Improvement Consortium ( MQIC ) database, which today holds more than 17 million de-identified patient records.The Alliance of Chicago Community Health Services, with participation from the Chicago Department of Public Health, has collaborated to develop and implement a use case for the pilot program since 2009...."If this is successful, and we're able to deliver instant, actionable health alerts, we can intervene more rapidly at the individual patient level and more effectively contain communicable outbreaks. This type of rapid dissemination of relevant, up-to-the-minute information to clinicians at the point of care is a model. It demonstrates how public health oriented clinical decision support could enable us to manage disease more effectively at an earlier stage. It could impact lifespan and quality of life at a global level, [said a project spokesperson]." Mark Dente, the chief medical informatics officer for GE Healthcare IT, explained how the alerts will work. "When a physician is seeing a patient, she just punches the data in as she normally would. The real work happens behind the scenes," he said. Once the data is entered, it's de-identified and transmitted to an archive where it's measured against a disease profile and, when a suitable match is found, the relevant alert is issued and appears on the doctor's EMR display without so much as an extra keystroke, Dente said. "Our first use case explores foodborne illness – and CDC estimates there are 48 million cases of it in the U.S. alone each year," explained Dente.  

From a public health perspective, I find this project interesting. However and in my opinion, the public health experts behind this initiative have teased out the challenges inherent in the approach: determining if the alerts are triggered often enough or too often, and if doctors take the advice displayed within the alerts. I suspect that most physicians don't view their EMRs as interactive systems and will tend to ignore alerts. This is commonly referred to as alert or pop-up fatigue. Here's a brief description of this phenomenon:

Alert fatigue...is a commonly perceived occurrence with the recent implementation of EMRs (electronic medical records) and specifically CDS (decision support)....Clearly, the volume of information an average ambulatory provider must remember is too much. The volume increases daily and in order to keep current a provider needs help. Decision support is one type of help that has evolved....One form of tools to aid the provider is alerts. Alerts can be in the form of "pop-ups," contact-dependent (during access of patient's record), and/or contact-independent (alert "delivered" to provider). The alerts, while found to be beneficial in some cases, can result in a type of "fatigue" whereby the provider, after receiving too many alerts, begins to ignore and/or override the alerts. Receiving too many alerts can result in slowing the provider down rendering the alert useless. A recent review stated that safety alerts are overridden by clinicians 49-96% of the time.

So, it appears that EMR alerts intended for physician users are frequently or nearly always ignored. This does not bode well for the Chicago project described above.

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