Alerts in Clinical Information Systems: Building Frameworks and Prototypes Project presented by Rolf...

Alerts in Clinical Information Systems:Building Frameworks and Prototypes

Project presented byRolf Wipfli

Project team:Rolf WipfliProf. Christian Lovis

2©2010 University Hospitals of Geneva

Content of presentation

• Framework with different views on alert systemsFramework with different views on alert systems• Possible implementation of alerts in a Clinical Possible implementation of alerts in a Clinical

Information SystemInformation System• Ongoing researchOngoing research• PhD thesis (Psychology)PhD thesis (Psychology)


Why medical alerts are important?

• Provides decision support for handling the ever Provides decision support for handling the ever growing quantity of medical data and knowledgegrowing quantity of medical data and knowledge

• Studies show positive effect on prescribing Studies show positive effect on prescribing behavior (e.g., more efficient) or reduced error behavior (e.g., more efficient) or reduced error ratesrates

Schedlbauer et al. (2009), Weingart et al. (2009), Koppel et al. (2005),Schedlbauer et al. (2009), Weingart et al. (2009), Koppel et al. (2005),Raschke et al. (1998)Raschke et al. (1998)


Problems identified

High number of alert overrides due to:High number of alert overrides due to:• Unspecific or non applicable alertsUnspecific or non applicable alerts• Alert fatigue caused by irrelevant and repeating Alert fatigue caused by irrelevant and repeating

alertsalerts• Usability issues: misunderstood or unnoticed Usability issues: misunderstood or unnoticed

alerts, interruption of work processesalerts, interruption of work processes• Problem of system acceptanceProblem of system acceptance

Van der Sijs et al. (2006), Hsieh et al. (2004), Shah et al. (2006)Van der Sijs et al. (2006), Hsieh et al. (2004), Shah et al. (2006)


Open issues

• How to make alerts more context depended?How to make alerts more context depended?• How to integrate alerts in CIS? When and how How to integrate alerts in CIS? When and how

should they be displayed in order to be best should they be displayed in order to be best adapted to physician's work processes?adapted to physician's work processes?

• How can physicians best give feedback to How can physicians best give feedback to improve the alert system?improve the alert system?


System-centric view


User-centeric view

Norman (2002)


Evaluation: Levels of decision making

Rasmussen (1986)Rasmussen (1986)


Organization-centric view

Kuuti (1996), Carayon et al. (2007)


Requirements

• System needs to hold alert information System needs to hold alert information seamlessly in information cycle, providing seamlessly in information cycle, providing feedback functionality [system-centric view]feedback functionality [system-centric view]

• The interface should use unified processes for The interface should use unified processes for alert interaction [user-centric view]alert interaction [user-centric view]

• Alerts support medical decision making, hence it Alerts support medical decision making, hence it should correspond to theories of human decision should correspond to theories of human decision making [levels of decision making]making [levels of decision making]

• Alert system should implement the whole context Alert system should implement the whole context (collaboration with other care providers, etc.) (collaboration with other care providers, etc.) [organizational view][organizational view]


Mockup skill-based alert screen


Mockup rule-based alert screen


Mockup knowledge-based alert screen


Next steps

• Further development of frameworkFurther development of framework• Interviews with physicians, work observationsInterviews with physicians, work observations• Build scenario-based prototypeBuild scenario-based prototype• Experimentally test prototypeExperimentally test prototype

• Population: physicians of different departments at Population: physicians of different departments at University Hospitals of GenevaUniversity Hospitals of Geneva

• Method: Scenario-based usability testMethod: Scenario-based usability test


Bibliography

• Hsieh, T. C., Kuperman, G. J., Jaggi, T., Hojnowski-Diaz, P., Hsieh, T. C., Kuperman, G. J., Jaggi, T., Hojnowski-Diaz, P., Fiskio, J., Williams, D. H., et al. (2004). Characteristics and Fiskio, J., Williams, D. H., et al. (2004). Characteristics and consequences of drug allergy alert overrides in a consequences of drug allergy alert overrides in a computerized physician order entry system. Journal of the computerized physician order entry system. Journal of the American Medical Informatics Association : JAMIA, 11(6), American Medical Informatics Association : JAMIA, 11(6), 482-91. doi: 10.1197/jamia.M1556.482-91. doi: 10.1197/jamia.M1556.

• Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., et al. (2005). Role of computerized R., Kimmel, S. E., et al. (2005). Role of computerized physician order entry systems in facilitating medication physician order entry systems in facilitating medication errors. JAMA : the journal of the American Medical errors. JAMA : the journal of the American Medical Association, 293(10), 1197-203. doi: Association, 293(10), 1197-203. doi: 10.1001/jama.293.10.1197.10.1001/jama.293.10.1197.

• Kuuti, K. (1996). Activity Theory as a Potential Framwork for Kuuti, K. (1996). Activity Theory as a Potential Framwork for Human-Computer Interaction Research. In B. A. Nardi, Human-Computer Interaction Research. In B. A. Nardi, Context and Consciousness: Activity Theory and Human-Context and Consciousness: Activity Theory and Human-Computer Interaction (pp. 17-44). MIT Press.Computer Interaction (pp. 17-44). MIT Press.


Bibliography

• Norman, D. A. (2002). The design of everyday Norman, D. A. (2002). The design of everyday things. New York NY: Basic Books.things. New York NY: Basic Books.

• Raschke, R. A., Collihare, B., Wunderlich, T. A., Raschke, R. A., Collihare, B., Wunderlich, T. A., Guidry, J. R., Leibowitz, A. I., Peirce, J. C., et al. Guidry, J. R., Leibowitz, A. I., Peirce, J. C., et al. (1998). A Computer Alert System to Prevent Injury (1998). A Computer Alert System to Prevent Injury From Adverse Drug Events: Development and From Adverse Drug Events: Development and Evaluation in a Community Teaching Hospital. JAMA: Evaluation in a Community Teaching Hospital. JAMA: The Journal of the American Medical Association, The Journal of the American Medical Association, 280(15), 1317-1320. doi: 280(15), 1317-1320. doi: 10.1001/jama.280.15.1317.10.1001/jama.280.15.1317.

• Rasmussen, J. (1986). Information processing and Rasmussen, J. (1986). Information processing and human-machine interaction. (A. P. Sage). human-machine interaction. (A. P. Sage). Amsterdam, The Netherlands: Elsevier Science Amsterdam, The Netherlands: Elsevier Science Publishers.Publishers.


Bibliography

• Shah, N. R., Seger, A. C., Seger, D. L., Fiskio, J. M., Shah, N. R., Seger, A. C., Seger, D. L., Fiskio, J. M., Kuperman, G. J., Blumenfeld, B., et al. (2006). Kuperman, G. J., Blumenfeld, B., et al. (2006). Improving acceptance of computerized Improving acceptance of computerized prescribing alerts in ambulatory care. Journal of prescribing alerts in ambulatory care. Journal of the American Medical Informatics Association : the American Medical Informatics Association : JAMIA, 13(1), 5-11. doi: 10.1197/jamia.M1868.JAMIA, 13(1), 5-11. doi: 10.1197/jamia.M1868.

• Schedlbauer, A., Prasad, V., Mulvaney, C., Schedlbauer, A., Prasad, V., Mulvaney, C., Phansalkar, S., Stanton, W., Bates, D. W., et al. Phansalkar, S., Stanton, W., Bates, D. W., et al. (2009). What evidence supports the use of (2009). What evidence supports the use of computerized alerts and prompts to improve computerized alerts and prompts to improve clinicians' prescribing behavior? Journal of the clinicians' prescribing behavior? Journal of the American Medical Informatics Association : JAMIA, American Medical Informatics Association : JAMIA, 16(4), 531-8. doi: 10.1197/jamia.M2910.16(4), 531-8. doi: 10.1197/jamia.M2910.


Bibliography

• van der Sijs, H., Aarts, J., Vulto, A., & Berg, M. van der Sijs, H., Aarts, J., Vulto, A., & Berg, M. (2006). Overriding of drug safety alerts in (2006). Overriding of drug safety alerts in computerized physician order entry. Journal of the computerized physician order entry. Journal of the American Medical Informatics Association : JAMIA, American Medical Informatics Association : JAMIA, 13(2), 138-47. doi: 10.1197/jamia.M1809.13(2), 138-47. doi: 10.1197/jamia.M1809.

• Weingart, S. N., Simchowitz, B., Padolsky, H., Weingart, S. N., Simchowitz, B., Padolsky, H., Isaac, T., Seger, A. C., Massagli, M., et al. (2009). Isaac, T., Seger, A. C., Massagli, M., et al. (2009). An empirical model to estimate the potential An empirical model to estimate the potential impact of medication safety alerts on patient impact of medication safety alerts on patient safety, health care utilization, and cost in safety, health care utilization, and cost in ambulatory care. Archives of internal medicine, ambulatory care. Archives of internal medicine, 169(16), 1465-73. doi: 169(16), 1465-73. doi: 10.1001/archinternmed.2009.252.10.1001/archinternmed.2009.252.

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