title: Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
abstract: Although 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.
  
  
  
  Retrospective 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.
  
  
  
  On 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.
  
  
  
  Clinicians 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.
authors.affiliation: Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medical College, New York, NY, USA. jsa7002@med.cornell.edu.|Health Information Technology Evaluation Collaborative (HITEC), 425 E. 61st Street, Suite 301, New York, NY, 10065, USA. jsa7002@med.cornell.edu.|Tehran Heart Center, Tehran University of Medical Sciences, New York, NY, USA. jsa7002@med.cornell.edu.
authors.forename: Jessica S
authors.initials: JS
authors.lastname: Ancker
authors.affiliation: Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medical College, New York, NY, USA.|Health Information Technology Evaluation Collaborative (HITEC), 425 E. 61st Street, Suite 301, New York, NY, 10065, USA.
authors.forename: Alison
authors.initials: A
authors.lastname: Edwards
authors.affiliation: Department of Family Medicine, Mount Sinai Icahn School of Medicine, New York, NY, USA.|Institute for Family Health, New York, NY, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Nosal
authors.affiliation: Department of Family Medicine, Mount Sinai Icahn School of Medicine, New York, NY, USA.
authors.forename: Diane
authors.initials: D
authors.lastname: Hauser
authors.affiliation: Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Mauer
authors.affiliation: Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medical College, New York, NY, USA.|Health Information Technology Evaluation Collaborative (HITEC), 425 E. 61st Street, Suite 301, New York, NY, 10065, USA.
authors.forename: Rainu
authors.initials: R
authors.lastname: Kaushal
mesh_terms: D000328:Adult; D000071064:Alert Fatigue, Health Personnel; D020000:Decision Support Systems, Clinical / Q000592:standards* / Q000706:statistics & numerical data; D057286:Electronic Health Records / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D009722:Nurse Practitioners / Q000592:standards* / Q000706:statistics & numerical data; D058007:Physicians, Primary Care / Q000592:standards* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016526:Workload / Q000592:standards* / Q000706:statistics & numerical data
keywords: Alert fatigue; Clinical decision support; Electronic health records