The judicious use of hard stops in EHR workflows and clinical decision support systems can improve performance on process measures and lead to better care.
Clinical decision support systems that use hard stops, in which a response is required before a user can move forward with a task, are associated with higher performance on both process and outcomes measures, according to a new study published in JAMIA.
The literature review of 32 articles found that well-designed CDS workflows with hard stops improved performance on process measures in 79 percent of studies, while outcomes improved in 88 percent of the articles included in the sample.
Hard stops were also found to be more effective than soft stops, during which the user can easily override the suggestion, in three out of four studies.
The authors are quick to note, however, that performance improvements were only achieved in organizations that embraced user feedback and leveraged iterative design to create intuitive and streamlined workflows.
“An alert—an automatic warning message meant to communicate essential information to the clinician using an EHR—is now generated for 6 percent to 8 percent of all orders entered into an EHR by providers,” explained the team of researchers from Yale University.
“Each of these alerts represents an intention to provide useful information to the clinician, shape clinician behavior, and positively impact patient safety and outcomes.”
However, EHR alerts have also produced serious unintended consequences: alarm fatigue and physician burnout.
Previous studies have shown that EHR users receive dozens of notifications during the course of a typical day, many of which are low-value or not relevant to the task at hand. Providers may spend up to an hour a day simply sorting through these alerts, which produces a highly frustrating user experience.
The high number of notifications that add little value to the clinical decision-making process leads to desensitization.
Users are more apt to ignore important alerts when they are overwhelmed with pointless data. With clinicians immediately dismissing up to 95 percent of all alerts, noted the Yale team, vital information is easy to miss.
To combat desensitization and fatigue, EHR developers and clinical decision support designers have created three tiers of alerts: hard stops, soft stops, and passive alerts.
“We define hard-stop alerts as those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party,” said the team. “The most common alert trigger was order placement for the medication or test that was the CDS target.”
In the studies included in the review, hard stops were programmed into workflows as interruptive pop-up notifications or less intrusive inline requirements to fill out specific data elements before being allowed to continue to another task.
“Soft-stop alerts are those in which the user is allowed to proceed against the recommendations presented in the alert as long as an active acknowledgement reason is entered,” the study continued.
Passive alerts present information to the user, but do not require any action and do not interrupt the workflow.
The key to creating a workflow that meets the needs of the user while preventing potential harm to patients is carefully balancing hard stops with other methods of communication.
Most of the implementations included in the review managed to achieve this goal well enough to improve the delivery of care, the researchers said.
Of the 15 studies that evaluated delivery outcomes, 11 showed improvement in the target metric. Half of the studies focusing on patient health outcomes also showed positive results from hard stops in CDS tools.
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