Abstract
BackgroundAlthough alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. We tested hypotheses arising from two possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time.MethodsRetrospective cohort study using electronic health record data (both drug alerts and clinical practice reminders) from January 2010 through June 2013 from 112 ambulatory primary care clinicians. The cognitive overload hypotheses were that alert acceptance would be lower with higher workload (number of encounters, number of patients), higher work complexity (patient comorbidity, alerts per encounter), and more alerts low in informational value (repeated alerts for the same patient in the same year). The desensitization hypothesis was that, for newly deployed alerts, acceptance rates would decline after an initial peak.ResultsOn average, one-quarter of drug alerts received by a primary care clinician, and one-third of clinical reminders, were repeats for the same patient within the same year. Alert acceptance was associated with work complexity and repeated alerts, but not with the amount of work. Likelihood of reminder acceptance dropped by 30% for each additional reminder received per encounter, and by 10% for each five percentage point increase in proportion of repeated reminders. The newly deployed reminders did not show a pattern of declining response rates over time, which would have been consistent with desensitization. Interestingly, nurse practitioners were 4 times as likely to accept drug alerts as physicians.ConclusionsClinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert. Reducing within-patient repeats may be a promising target for reducing alert overrides and alert fatigue.
Highlights
Alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined
One conceptual model, which we label cognitive overload, is that alert fatigue is caused by receipt of a large quantity of information along with insufficient time or cognitive resources to distinguish relevant from irrelevant information [7, 15]
Uninformative alerts are similar to false alarms, and it is well-established in the human factors literature that false alarms reduce responsiveness to alarms and may reduce overall performance on tasks interrupted by alarms. [16,17,18] A second conceptual model of alert fatigue is that repeated exposure to alerts leads to declining responsiveness [9, 19, 20], a phenomenon that can be called desensitization
Summary
Alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. [16,17,18] A second conceptual model of alert fatigue is that repeated exposure to alerts leads to declining responsiveness [9, 19, 20], a phenomenon that can be called desensitization. According to this model, an alert is most effective when it is first noticed, and steadily becomes less effective as the individual becomes acclimatized to it over time
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