Here’s a situation most physicians are probably familiar with: You’re entering patient information into your electronic health record (EHR), and a pop-up window appears on your screen—the same window you’ve seen 10 times already that day. What’s your reaction?

Bombarded by alerts

Clinical decision support technology, whether integrated into EHRs or as add-on software, is intended to increase quality of care, enhance health outcomes, help avoid errors and adverse events, and improve efficiency, according to the Centers for Medicare & Medicaid Services. Although clinical decision support is not limited to pop-up windows, many physicians associate it with the alerts that appear on their screens as they attempt to move through a patient’s record, offering prescription reminders, patient care information and more.

But the hidden dangers in these pop-ups can bring the threat of medical liability, two experts explained during a session last week at the 2015 annual meeting of the Healthcare Information and Management Systems Society in Chicago.

“Are we bombarding our providers with so much information in disparate areas of the medical record that they don’t have time to get through their day, so they bypass that information?” said Sheryl Bushman, DO, chief medical information officer at Optimum Healthcare IT. “Are we teaching them to pay attention to these alerts or teaching them [that] it’s okay to bypass this alert because you’ve seen it 50 times?”

Clicks and bypasses tracked

Data suggest that systems likely are cultivating this bypass behavior. A 2014 study in Applied Clinical Informatics found 95.1 percent of drug-drug alerts were overridden by physicians in a large teaching hospital system. A 2013 review of clinical decision support alert effectiveness in The Ochsner Journal showed alert overrides occur for 49-96 percent of alerts.

An EHR tracks everything, Dr. Bushman said—not only what you click but also what you don’t click. It can even record how long you spend on a particular page. Combine this ability to log a physician’s every action with potential alert fatigue, and there may be an open door for medical liability cases, she said.

For example, as a physician, are you liable if you bypass an order set? If you print out a patient education sheet, as prompted by the EHR, are you sure that the information on the sheet is in alignment with what you or your nurses would tell the patient? If you get a reminder for an overdue result, how liable are you if you don’t follow up immediately?

The overarching question, Dr. Bushman said, is: If you are interfacing with clinical decision support in your EHR, “have you just opened up everything within that software to making you liable for it?”

How to avoid liability

Potentially, said Paul A. Testa, MD, chief medical information officer at New York University Langone Medical Center and a trained attorney. There haven’t yet been enough high-level medical liability court cases on topics involving clinical decision support to know what physicians could be held liable for.

However, physicians can practice general risk management when working with an EHR in two ways, Dr. Testa said: Document and communicate.

“These two actions are the best defensive practices in medicine,” he said. “Well-documented cases are not attractive.”

But this can be difficult for physicians bombarded with data and information each day, Dr. Testa acknowledged. A 2012 review in the American Journal of Medicine found that primary care physicians receive an average of 56 alerts per day, spending an estimated average of 49 minutes each day processing these alerts.

“It’s easy to blow past it—but now there’s a record,” Dr. Testa said of alerts.

The AMA is working to improve EHRs through its Physician Satisfaction and Practice Sustainability initiative, ensuring the voices of physicians are part of EHR development. Last year, the AMA released a blueprint outlining ways to improve the Medicare and Medicaid meaningful use program and a framework that details eight priorities for moving toward more usable EHR systems. The AMA is using this framework to work with physicians, vendors, policymakers, health care systems and researchers to drive EHR improvements that can advance the delivery of high-quality, affordable care.

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