Why this presentation?

1. Allina Guiding Principles for Alerting Health Care Providers and Caregivers Across the Continuum of Care

2. Why this presentation? • Many have expressed fear and belief that we are approaching alert fatigue. • To share all of the types of alerts that users are experiencing. • Talk about the BPA guidelines in relationship to upgrades and build policy decisions.

3. Alert Fatigue Or User Desensitization • Is Defined as …. “When clinicians either consciously or unconsciously, begin to systematically bypass CDS alerts without regard to their importance, enabling the possibility that a clinically important alert is missed,”

4. Reasons for Desensitization • Poor signal to noise ratio • Irrelevant – consequence of non compliance is low • False positives • Repeat too often • Alerts too long and difficult to interpret/understand • Lack of consistency with other knowledge sources • Importance of the therapy –need if even cause problems • Clinician faith in their own knowledge • Lack of time for processing the alert

5. Medication Alerts Override Rates/Adverse Consequence • Overdose warnings 25% (ADE 2.3%) • Interactions 35% (ADE 2.6%) • Contraindications 43% (ADE 6%)

6. The Epic Context • Alerts and reminders come from multiple sources • Different types of alerts are within Allina’s control to varying degrees. • Although Allina has done some custom coding in the past, every effort is being made to move back to and stay within model product when possible.

7. From the End User Perspective Reminder/Warning Mechanisms • Popup/Dialogue box • Interrupts the end user workflow. • Requires the end user to interact with it before proceeding with the task they were performing. • Allina has very limited control of the look and function of pop-ups. • Navigator Section • An activity within a workflow that presents and processes advisories generated from the processing of the patient’s information against a standard. • Allina does not control the look or functioning of the navigator section.

8. Reminder/Warning Mechanisms (con’t) • Print group – Two types . • Best Practice Advisory . • Displays all active or unsatisfied BPAs. • Whether or not the print group appears on a report is controlled by the design of the report. • Allina cannot control the look and functioning of the print group. • “Banner” . • A colored ribbon with a message on it. • Whether or not it appears on a report is controlled by the design of the report and by a rule which determines if certain conditions are met within the patient’s record. • Allina controls the rule, the color of the ribbon and the message printed on it.

9. Non BPA Reminder/Warning Mechanisms Occur During • Navigation – pop-ups • Are you sue you want to exit, etc. • Order Entry – pop-ups • Failure to provide required information • Failure to provide suggested information • Duplicate orders • Enter diagnosis for some orders • Reminder that this order will overwrite previous order • Conflicts between data such as priority and frequency • Medication Order Entry – pop-ups • Contraindication level drug alerts

10. Non BPA Reminder/Warning Mechanisms Occur During (con’t) • Bar Code Medication Administration – pop-ups • Wrong patient/wrong drug • No order • Can’t read bar code • Flowsheets – pop-ups • Data entry errors • Change in value concerns • MAR – pop-ups • Documentation for pain • Health Maintenance – activity/report • Annual mammogram due • Immunization due

11. Best Practice Advisories • Pop-ups • Suggest orderset to use • Sponge/Sharps Count • Workflow assists for adding care plans templates • Workflow assists for placing follow-up orders • Medication/problem list conflicts • Print group • Risk assessment documentation • Immunization administration reminders

12. BPAs also • Manage which sites have access to which ordersets • Dynamically control which order sections appear in an orderset • Dynamically control which activities appear on a navigator • Manage the Banners BPAs do not

13. General BPA Alerting Policy October 2010 • Alerts may be used to streamline workflow, notify of a potential harm or treatment situation, and to address very specific problems. • Ease of Use should drive workflow design/alerting solutions. • Allow users more than one way to do something. Do not rely on adherence to a defined workflow. • Avoid redundancy: all workflows should result in the same outcome (output). • In deciding to use an alert, sponsors must always be aware of the potential for alert fatigue • The care giver should always be given the chance to do the right thing. • Efforts to gain attention should escalate. • Start with background reminders. • Use “hard stops” when softer reminders are ineffective.

14. BPA Process Guidelines – October 2010 • When being used to address a problem, completion of a root cause analysis and determination that an alert is the best solution for dealing with that root cause is a prerequisite. • When an alert is chosen as the means to address an issue in a given population, the sponsors must consider the same issue in other populations and design the alert to support best care around that issue for all populations. • The people who will receive the alert must participate in its design. • An alert should always be implemented with a well planned, complete and documented change management plan. • Alerts designed to resolve problems should be piloted to ensure that it is reaching the right person at the right time, is clear and understandable and that it is effective in resolving the issue as intended. This requires collection and sharing of pre and post data with use of a control group whenever possible, • Alerts designed to streamline workflow may be piloted to ensure their accuracy.

15. BPA Design/Build Guidelines August 2011 • Removed - Pop-up's Workflow should not be interrupt unnecessarily. Pop-ups should be used sparingly. • Timing and targeted recipient should be very specific. • Removed – They should always include a remind me later button. • Removed - The dashboard design showing tasks that must be completed eminently should be used for placing alerts on reports. • Replaced - All advisories should be actionable. Tasks should be completed directly from the notification or from a link that goes directly to where the task is to be performed. • Removed - Links should always be in underlined blue font. • Remove - All alert messages should be very brief and clear as to what the recipient is to do. • Terms used should be consistent with terms known to the end user. • Add- When functionality permits, BPA numbers should not show. • Links to supporting documents should be used for added detail and rationale Add- rather than including the information in the display text.

16. BPA Design/Build Guidelines August 2011 • Workflow should not be interrupt unnecessarily. Pop-ups should be used sparingly. • Timing and targeted recipient should be very specific. • Advisories should be actionable. Tasks should be completed directly from the notification or from a link that goes directly to where the task is to be performed. • Messages should be very brief and clear as to what the recipient is to do. • Terms used should be consistent with terms known to the end user. • When functionality permits, BPA numbers should not show. • Links to supporting documents should be used for added detail and rationale rather than including the information in the display text.

17. Next Steps • Create recommendation for when to use which tools • Review existing alerts and modify if necessary to fit recommendations.

18. Overview of Best Practice Advisories

19. Overview of Best Practice Advisories

20. Overview of Best Practice Advisories