Getting Beyond Interruptive Alerts: Reducing Unintentional Duplicate Orders using a Visual Aid

ABSTRACT Importance Electronic health records (EHRs) allow teams of clinicians to simultaneously care for patients but an unintended consequence could result in duplicate ordering of tests and medications. Objective We asked if a simple visual aid would reduce duplicate ordering of tests and medications for busy teams of clinicians in our emergency department by placing a red highlight around the checkbox of a computer-based order if previously ordered. Design We performed an interrupted time series to analyze all patient visits 1 year before and 1 year after the intervention. Significance testing was performed using a negative binomial regression with Newey-West standard errors, correcting for patient level variables and environmental variables that might be associated with duplicate orders. Setting The emergency department of an academic hospital in Boston, MA with 55,000 visits annually. Participants 184,722 consecutive emergency department patients. Exposure If an order had previously been placed during that ED visit, we cue the user by showing a red highlight around the checkbox of that order. Main Outcome Number of unintentional duplicate orders. Results After deployment of the non-interrupting nudge, the rate of unintentional duplicates for laboratory orders decreased 49% (incidence rate ratio 0.51, 95% CI 0.45-0.59) and for radiology orders decreased with an incidence rate ratio of 0.60 (0.44-0.82). There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR. Conclusions and Relevance Passive visual queues that provide just-in-time decision support are effective, not disruptive of workflow, and may decrease alert fatigue in busy clinical environments. Key Points Question Can a simple visual aid reduce duplicate ordering in an electronic health record? Findings In this interrupted time series, the rate of unintentional duplicates for laboratory orders decreased 49% and for radiology orders decreased 40%. There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR. Meaning Quality improvement often relies on changing clinician behavior. We believe guiding clinicians to a right action is better than telling the clinician they have already made an error. Our approach will help reduce alert fatigue and lessen clinician complaints about EHRs.