Docs rarely 'game' CDS systems to reduce alerts

A vast majority of physicians entered accurate data into an imaging clinical decision support system, according to a new study that found little evidence of attempts to "game" such systems to avoid intrusive computer alerts.

The study, conducted by researchers at Brigham and Women's Hospital and Harvard Medical School, compared data entered in the emergency department for the use of CT angiography (CTA) for the evaluation of patients with suspected pulmonary embolus (PE). They chose this data because the orders can be compared directly with lab results to determine whether the tests ordered are appropriate. They also looked at downstream effects of erroneously entered information in an article recently published online in the Journal of the American Medical Informatics Association.

They found that for more than 90 percent of cases, the entered information was correct. In roughly 4 percent of cases, incorrectly entered information shielded practitioners from intrusive alerts and created potential overuse of CTA. None of the errors resulted in needed tests not being performed. The study, however, was not designed to determine whether the inaccurately entered data were intended to avoid alerts or were simply errors.

Citing other studies that found low levels of "gaming" the system, the authors said that even minor instances of such behavior need to be addressed to ensure optimal care for patients. They suggested periodic retrospective review of orders to assess accuracy of data entry and, where possible, automatic population of the CDS from the electronic health record to eliminate having to re-enter such information.

The study was conducted in busy emergency departments, where technology is particularly error-prone, the American College of Emergency Physicians warned recently. Rapid turnover, frequent transitions of care, interruptions and unfamiliar patients all play into problems such as poor communication, wrong order-wrong patient errors and alert fatigue.

A study from the Lehigh Valley Health Network found that CDS alerts helped to reduce unnecessary testing in heart failure patients. However, alert overload has been a sore point with CDS systems, though both too many and too few alerts hold the potential to complicate care and harm patients.

To learn more:
- read the article (.pdf)

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