title: Clinical reminders designed and implemented using cognitive and organizational science principles decrease reminder fatigue.
abstract: BACKGROUND
  Response rates to point-of-care clinical reminders typically decrease over time. We hypothesized that this "reminder fatigue" could be prevented by (1) applying sound human factors engineering and cognitive science principles in designing the reminder system, and (2) implementing the reminders with rigorous attention to organizational science principles.
  
  
  METHODS
  This was a retrospective cohort enumeration from January 1, 2006, through July 31, 2012, in a set of 5 academically affiliated family medicine practices. We modeled the odds ratio of clinician action in response to a reminder according to the number of reminders issued during the encounter, the number of problems on the patient's problem list, patient age, and time (number of months since launch) using logistic regression with clustering by encounter.
  
  
  RESULTS
  There were issued 988,149 reminders at 453,537 encounters during the sampling frame. Action was taken in response to 60.1% of reminders, and discussion or consideration was documented in another 26.8%. The odds ratios for action in response to reminders over time, by number of prompts during the encounter, and by number of problems were 1.01, 1.18, and 1.02, respectively. Key design features included issuing reminders only when a service was due, allowing clinicians to attend to reminders when doing so fit their workflow (vs forcing attention at a specific time), keeping reminders very short and simple (action item only, no explicative material), and a team meeting and buy-in process before each new reminder was implemented.
  
  
  CONCLUSIONS
  Reminder fatigue over time, with increasing numbers of reminders and with increasing complexity of patients, is not inevitable. A reminder system designed and implemented in accordance with the principles of cognitive science and human factors engineering can prevent reminder fatigue.
authors.affiliation: From the Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada (LAG); the Department of Family Medicine, University of Colorado-Denver, Aurora (DN); and the Department of Family Medicine, University of Michigan, Ann Arbor (MSK). lagreen@ualberta.ca.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Green
authors.affiliation: From the Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada (LAG); the Department of Family Medicine, University of Colorado-Denver, Aurora (DN); and the Department of Family Medicine, University of Michigan, Ann Arbor (MSK).
authors.forename: Donald
authors.initials: D
authors.lastname: Nease
authors.affiliation: From the Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada (LAG); the Department of Family Medicine, University of Colorado-Denver, Aurora (DN); and the Department of Family Medicine, University of Michigan, Ann Arbor (MSK).
authors.forename: Michael S
authors.initials: MS
authors.lastname: Klinkman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003071:Cognition; D006804:Ergonomics; D005194:Family Practice / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D005222:Mental Fatigue / Q000209:etiology / Q000517:prevention & control*; D008875:Middle Aged; D019095:Point-of-Care Systems / Q000592:standards; D058996:Quality Improvement; D017010:Reminder Systems / Q000592:standards; D012189:Retrospective Studies; D057188:Workflow; D055815:Young Adult
keywords: Clinical Decision Support Systems; Primary Health Care; Quality Improvement; Reminder Systems; User–Computer Interface