A Lesson In Clinical Decision Support: We Cannot Defeat Human Nature

      Our UCSF Clinical Informatics group met a few months ago with several representatives from a major Health IT vendor. The vendor, we’ll call them RxLabs, is a provider of pharmaceutical related knowledge in many domains, including decision support tools for the EHR. Our conversation centered around how to better customize medication alerts. We talked about the popular topic of “alert fatigue,” and how to improve EHR decision support tools to improve their impact, rather than just being white noise annoying clinicians.
      The vendor was walking us through a slide-deck about their hypotheses and data about EHR medication alerts and we were having a vibrant discussion about how to improve provider adherence with decision support. We saw slide after slide about how to make pop-ups smarter and about trying to get more buy-in from providers with paying attention to alerts. After all, why would a provider trying to take care of her patient ignore an alert that is trying to help provide an important message? It must be sloppiness or laziness on the part of providers!
      Ten minutes in to this conversation about drug alerts, up pops the following:
Windows 7 Display Alert
      I’ll give you a second to guess what happened next.
      Without a moment’s hesitation or thought, the presenter clicked the little X in the upper right corner. Our conversation went on. More slides. More data about medication alerts in the EHR. Ten minutes later, guess what happened?
      Up came the same pop-up Windows alert. The presenter again, hastily, without paying attention, and perhaps giving a small huff of displeasure, clicked the little X in the upper right corner. More slides, ten more minutes, same thing. You get the idea.
      This happened three times, with each passing pop-up, the presenter becoming slightly more annoyed. The fourth time the pop-up appeared, my colleague Russ Cucina, the Associate CMIO at UCSF, paused the presenter to have us all read the pop-up alert message. We took ten seconds together to learn that selecting any of the three choices rather than clicking the “x” would have satisfied the alert and kept it from coming back.
      The room broke out into laughter. We all understood our own hypocrisy. We cannot defeat human nature.

OneTouch Verio IQ meter

I won’t review this meter, since I haven’t tested one, and there is a very thorough review already here at DiabetesMine.  I do want to draw attention to it, however.  The draw of this meter is that it purports to find patterns in a user’s glucose data and to then give the user feedback and recommendations about how to make changes based on those patterns.  In theory, this sounds wonderful.  Give feedback to a patient during a “teachable moment,” ie at the moment when the feedback is relevant and someone is most likely to learn from it.  Unfortunately, according to the DiabetesMine review, the actionable recommendations are actually contained in a separate paper book that you have to request.  This would significantly detract from the usefulness of the feedback given by the meter.

There is significant medical literature about decision support and how to make it successful.  One BMJ systematic review from Kawamoto et al in 2005 noted that four key features are that “(a) decision support provided automatically as part of clinician workflow, (b) decision support delivered at the time and location of decision making, (c) actionable recommendations provided, and (d) computer based.”  It sounds like the Verio IQ meter tries to achieve these goals but still falls short…

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