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CIN: Computers, Informatics, Nursing:
doi: 10.1097/NCN.0b013e3182343e8f
Continuing Education

Reactions of Nurses to the Use of Electronic Health Record Alert Features in an Inpatient Setting

SIDEBOTTOM, ABBEY C. MPH; COLLINS, BEVERLY RN, MS; WINDEN, TAMARA J. MBA; KNUTSON, ASHA PhD; BRITT, HEATHER R. MPH, PhD

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Continued Education
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Author Information

Author Affiliations: Allina Hospitals & Clinics, Minneapolis, MN (Mss Sidebottom, Collins, and Winden and Dr Britt), and ADVANTIS Research & Consulting, St Paul, MN (Dr Knutson).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Abbey C. Sidebottom, MPH, Research Consulting Unit, Allina Hospitals & Clinics, 2925 Chicago Ave, Minneapolis, MN 55407-1321 (abbeysidebottom@allina.com).

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Abstract

While studies have been conducted to assess nurse perception of electronic health records, once electronic health record systems are up and running, there is little to guide the use of features within the electronic health record for nursing practice. Alerts are a promising tool for implementing best practice for patient care in inpatient settings. Yet the use of alerts for inpatient nursing is understudied. This study examined nurse attitudes and reactions to alerts in the inpatient setting. Focus groups were conducted at three hospitals with 50 nurses. Nurses were asked about five different alert features. For each alert, participants were asked about their feelings and reactions to the alert, how alerts help or hinder work, and suggestions for improvements. Findings include clear preferences for alert types and content. Nurses preferred a dashboard style alert with functions included to accomplish tasks directly in the alert. While nurses reported positive reactions to certain alert pages, they also reported low use of those features and occasional distrust of the data included in alerts. Findings provide guidance for future use of alerts and design of new alerts. Findings also identify the important challenge of designing and implementing alerts for integration with nursing workflow.

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BACKGROUND

Alerts within the electronic health record (EHR) are clinical decision support tools designed to improve patient outcomes, reduce medical errors, and increase compliance with standards of care. A variety of alert formats have been developed including notification banners, best practice alerts, dashboards, and pop-ups. With the ability to deploy a variety of alert formats to address many clinical disciplines, it is likely that alerts will become increasingly common EHR tools for inpatient nursing practice. While research on EHR alerts is growing, the use of alerts for nursing practice remains an understudied area.

To date, studies of EHR alerts have focused primarily on improved patient outcomes and provider behavior, with many positive findings for improved outcomes and data quality.1–7 The most widely studied types of alerts are medication safety alerts incorporated into electronic prescribing systems. Outcomes research on these alerts indicates that they can reduce the likelihood and severity of adverse drug events.8–10 However, these alerts have been found to have extremely high levels of physician overrides. Studies of physician perceptions of and attitudes towards medication safety alerts have identified the concept of “alert fatigue” related to the overwhelming number of alerts and feelings of intrusion on workflow.11 As a result, one aim of research on alerts is to improve the specificity of alerts and design alerts that will have higher user acceptance.12

The concept of alert fatigue highlights the importance of considering both the evidence for improving patient outcomes and the experience of the providers receiving the alert. In a discussion of nursing work and EHR, Robles13 indicates that “there is a fine line between including all the alerts that various disciplines want and having too many alerts hindering the user’s progress rather than helping.” Guidelines for the use of alerts for inpatient nursing practice should consider both the evidence for potential clinical outcomes and the features that will fit best into workflow and be accepted by the end users.

While there has been a large amount of research on nurse perceptions of EHRs, there is little research examining attitudes and perceptions of nurses towards EHR alerts. The purpose of this study was to explore nurses’ perceptions, attitudes, and reactions to the alerts as they are currently implemented in an inpatient EHR system. Understanding nurse attitudes about alerts and preferences for alert features will help establish guidelines for the design, introduction, and use of alerts in nursing practice.

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METHODS

Setting and Subjects

Study participants were direct patient care nurses from hospitals in the Allina Health System. Allina is a nonprofit system of hospitals, clinics, and other care services in Minnesota and Western Wisconsin. Allina facilities include 11 hospitals, more than 85 primary care and specialty clinics, 15 community pharmacy sites, and three ambulatory care centers. In 2009, Allina hospitals had 118,816 inpatient admissions; 1.2 million outpatient admissions; and 280,115 emergency care visits.

Focus groups were conducted at three hospitals: one suburban hospital with 86 beds and two urban hospitals with 449 and 633 beds. Focus group participants were recruited through existing nursing practice council meetings. At the suburban hospital, participants were from the nursing council for the medical surgical unit. At one urban hospital, participants were from the nursing practice council for the orthopedics and neurosciences departments, and at the largest hospital, members were recruited through the hospital-level nursing practice council and thus represented several departments. Focus groups were scheduled to occur within the regularly scheduled time of the council meetings and were conducted in March and April 2010. The study was approved by Allina’s institutional review board through expedited review. All participants consented to participate in research and to having the focus groups recorded.

Nurses present for the meeting were given an explanation of the focus group purpose and its voluntary nature. Additionally, any managers who were present in the meeting were asked to leave prior to the beginning of the focus group (1) to ensure that all participants were direct care providers using the EHR regularly in their care of patients, (2) to ensure that direct care nurses were comfortable talking about their experiences with the EHR and their workflow, and (3) to alleviate any concern that they might be judged by a supervisor based on what they said in the focus groups. While nurses at the council meeting were given the option to leave, all nonsupervisory nurses present opted to stay and participate in the focus groups.

After the general introduction of the focus group and consent process, participants were given an overview of the EHR alert components. Each participant was given a packet of handouts with full-page screen shots of the alerts. The name of each type of alert was reviewed to make sure the group was using the same terminology. The moderator focused on one type of alert at a time asking the same series of questions. For each alert, participants were asked questions that covered the general topics of (1) their feelings and reactions when they come across a specific alert, (2) how alerts help or hinder their work, and (3) their suggestions for improvement in the use of alerts. Specific questions asked are below (with prompts):

* When you last saw this screen, how did it make you feel? (About your work? About your practice? About the work of colleagues?)

* How does this alert help or hinder your work? (In terms of quality? In terms of efficiency?)

* To what extent does this alert give you the information you need to act? (Is it clear what you need to do? What actions do you take when you see this alert? Is any information missing?)

* How well is the information on this screen organized?

* How well does this alert fit into your workflow? (In terms of timing? In terms of appropriateness?)

* What would you like to change in this alert?

After going through the series of questions for each alert, participants were asked what advice they would give to designers of the system regarding the use of the alerts.

A total of 50 nurses participated. Participation ranged from a total of nine nurses in the suburban hospital to 16 and 25 nurses in the two urban hospitals. Focus group composition was 92% female. Participants’ average age was 38.4 years, with a range from 22 to 63 years. Participants at the suburban hospital tended to be younger (28.1 years) compared with participants at the urban hospitals (35.4 and 44.5 years). On average, participants had worked for Allina for 10.4 years. Participants’ experience with Allina’s EHR ranged from 2 to 5 years. The varying level of experience with Allina’s EHR corresponds with the EHR implementation schedule for each site.

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Electronic Health Record Alert Components

In 2005, Allina Hospitals & Clinics began the transition to Excellian, Allina’s EHR product developed by Epic Systems Corporation (Verona, WI). By May 2007, Excellian was fully implemented at 65 clinics and eight of the 11 hospitals. In early 2008, Excellian was implemented at the remaining hospital sites. Virtually all of the information needed to care for the patient is accessed through Excellian. The system informs and guides care processes by providing tools, such as evidence-based order sets, care plans, protocols, common templates for patient conditions, links to external references, and integrated ambulatory tools that allow physicians to perform documentation, orders, and patient education all from one place. Providers have access to a patient’s complete medical history at Allina, both inpatient and outpatient, at any time and from any location to make informed decisions.

Allina has incorporated several alerts for nurses into the EHR. This study examined five types of alerts. These alerts can be divided into two broad categories: banners and notifications of action required. Banners are used purely for providing information about a patient that is relevant to safe and effective care. Banners appear if information within a patient’s record meets the specified criteria. If the information changes and the patient’s situation no longer meets the criteria, the banner no longer displays. Notifications of action required inform the nurse of some action that he/she needs to take. These actions include tasks such as placing an order, adding a problem to the care plan, and completing or correcting inaccurate documentation.

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BANNERS

Nurses were asked to react to two types of banners: the Kardex Report (Figure 1) and Safety Overview Report (Figure 2). The Kardex Report banners were developed as part of a nursing quality initiative and indicate if the patient is a fall risk or at risk of developing pressure ulcers. The Safety Overview Report is a separate report that is accessed from the Kardex Report and is printable. The Safety Report banners were developed as part of an initiative to eliminate safety armbands. This banner provides an online display of information previously communicated through colored safety armbands. The banners on the Safety Report use the same color schema that was previously used in the safety armbands.

Figure 1
Figure 1
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Figure 2
Figure 2
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NOTIFICATIONS OF ACTION REQUIRED

Nurses were also asked to react to three types of notifications. The first examined is a section added to a report display in the EHR (Figure 3). This preformatted type of alert allows the organization to provide description content such as alert number and rationale for alert and what the nurse needs to do. A hyperlink can be provided to help facilitate an order if necessary. The preformatted structure does not allow the organization to prioritize or organize the appearance of alerts. Examples of such alerts include placing a pneumonia vaccine order based on screening criteria and for completing fall risk screening.

Figure 3
Figure 3
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The second notification of action alert is the dashboard (Figure 4). The particular dashboard being studied was created as part of Allina’s heart failure initiative to show all of the required nursing tasks to meet heart failure core measures. The dashboard appears only if the patient has heart failure listed as an active problem on his/her problem list. On dashboards, alert numbers and rationale are not displayed, descriptions are kept very brief, and a click on the task itself takes the nurse to the required EHR function for completing the task. Typically, dashboards consist of three colored banners with tasks listed beneath them. Completed tasks appear under the green banner. Required tasks that are not yet due appear under the yellow banner, and tasks that need to be addressed immediately appear under the red banner. The dashboard appearance, format, functioning, and content were created by Allina using vendor-provided tools. Because of previous feedback, the yellow and green tasks had been removed prior to this study, leaving only the tasks considered overdue. Nurses were asked to react to the full concept of the dashboard, as well as the removal of the green and yellow sections.

Figure 4
Figure 4
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The final alert notification method is a pop-up (Figure 5). These were introduced as part of two projects in early 2010. This category includes a series of alerts that ensure that risk assessment, skin inspection, pressure-relieving interventions, and care plan documentation are completed as outlined in the nursing standard of care for pressure ulcer prevention. A pop-up is triggered when a nurse files a flow sheet and the patient’s record is lacking specific documentation. This can happen when the nurse saves the flow sheet manually or automatically when the nurse moves from one flow sheet to another or moves to another function in the EHR. The nurse must address the pop-up before continuing on to another part of the EHR. The appearance, format, and functioning of the pop-up are provided by the EHR vendor, although content is determined by the organization. One pop-up alert used by Allina indicates that the patient’s care plan has not been updated with pressure ulcer risk, and by clicking the “Accept” button on the alert, the nurse is able to add a problem to the care plan. Some pop-ups have a “Remind Later” button, which allows the pop-up to close and delays the triggering of the alert for a specified period, giving time to perform the required task.

Figure 5
Figure 5
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Analysis

Focus groups were recorded on a digital voice recorder and transcribed. Individual transcripts from each focus group were analyzed separately by one team member (AK). Each transcript was subdivided by meaning unit, that is, key ideas or thoughts expressed in a single sentence or cluster of sentences.14 Each distinct meaning unit was coded, and content is analyzed inductively for themes. A review of themes from each focus group and further development of theme definitions was done by all authors before a second review of the transcripts was conducted. The analysis process included in-depth analysis of each individual focus group transcript, as well as analysis across groups to identify common themes. Several themes were common across hospital groups, and thus, results are presented for all groups together. Areas where distinctions were identified between hospitals are highlighted in the results.

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RESULTS

Banners on the Kardex Report

Comments indicated that nurses were aware of the banners but tended not to use them as a primary source of information about patient risks. Reasons for not using the banners included (1) distrust of data quality and criteria used to generate the alert, (2) questions regarding the relevance of the banners to their work, (3) preference for other sources of information (eg, verbal communication from other nurses), and (4) information overload on the Kardex Report. Comments included the following:

[I]t’s only based off the Hendrich Fall Scale, right? We have patients that don’t actually score as a fall risk, but we make them a fall risk because of medications or whatever.

We see it, we acknowledge it, but knowing how that banner got placed there, we ignore it because… it is not accurate.

I’m in an ICU and I have to say that I pretty much ignore it because of the way that it’s calculated for ICU patients, it ends up being not relevant. A patient that’s totally sedated and isn’t even moving in bed will still come up as a high fall risk. So for me that banner is not worth my noticing as a fall risk; it really doesn’t come into play for so many of my patients.

I work in a recovery room and people may be a high fall risk but we are not getting people up, so it is there, but it does not cause any different action [on my part].

I know Excellian pretty well, but I’m skipping a lot of those alerts in the beginning because everything goes to the top in the beginning, and I’m like, “No, I’ve got to see what’s important on my patient.”

Although in the minority, a few nurses felt that the banner causes them to reflect and take action on the alert.

It makes you ask the question if they need restraints… a few questions go through your head for the fall risk.

When I see a fall risk, it triggers me to wonder why. Why is that fall risk up there?

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Banners on the Safety Overview Report

Many nurses were unaware of the Safety Overview Report. Some nurses reported seeing it or attending a training that introduced the alert. However, even nurses who were aware of the screen indicated that they did not go to the page as part of their workflow. They attribute their lack of use to (1) having forgotten about it or not knowing how to access it, (2) viewing it as one more thing to do, (3) tending to not trust the data, and (4) relying on other sources of information that are part of their existing workflow (eg, examination report, verbal report, visual signs, for your information (FYI), first-hand information from the patient) and (5) to the fact that the topic was not covered in original EHR training.

I think I’ve seen this before. They’ve told me about it and I knew that we were supposed to go into it, but I just don’t, because it’s just another thing to click on. It’s another thing to get into… and anything that I can find in this is going to be in my exam report from my nurse that I am taking [over from], and to me that’s more reliable than looking at this. This hard-of-hearing thing might have been put in there six months ago… I don’t know how long it stays in there… sometimes, this does not get updated.

Our workflow is to check the other areas where this information is contained rather than going to this one spot.

I use the FYI click away screen.

I think if we would have learned it originally, like when we started using Excellian, it is something we would use. But because it was introduced later, it is not a habit to go and check that as often.

While many nurses reported little prior exposure to the Safety Overview Report, they gave the report a positive review based on reaction to the screen they were shown in the focus groups. Specifically, they liked that it (1) was only one click away and “not in their face,” (2) flagged important patient information that could easily be missed, (3) did not make a lot of demands on the nurse, (4) provided a quick and broad overview, and (5) could be helpful during transitions in staffing coverage. Respondents also felt that the Safety Overview Report was easier to read than the FYI and was more pleasing to the eye and they liked the bright colors.

I think it is really helpful once people build it into their workflow, because it [just] requires a nurse to click a button. It pulls in a lot of really important information… and it does not require a lot of work from the bedside nurse, which I love.

I think this would be helpful too, like for example, when we cover our partners for break. If we need to do something with this other patient, and we just needed to take a quick look, this would be good.

When asked about placement of banners related to patient safety on the Kardex Report compared with the Safety Overview Report (one click away from the Kardex), nurses preferred retaining most information on the Safety Overview Report and did not want any of the risk information on this report moved to the Kardex Report because they felt that Kardex was already overloaded. Nurses acknowledged the use of the Safety Overview Report needs to be built into their workflow because it is not currently a standard part tool in acquiring safety information about patients. When asked about improving the use of banners, nurses mostly talked about colors and organization. They wanted consistent colors and categories for orders on the Kardex and banners on the Safety Report.

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Alert Section on the Kardex Report

Nurses had mixed awareness of the alert report section on the Kardex Report, and among those who were aware of it, feedback was generally negative. Respondents felt that it (1) was too wordy, (2) was likely to be ignored because of overuse of the term best practice, (3) was not actionable in that it did not allow the nurse to complete tasks other than placing orders from the alert itself, and (4) contained irrelevant and redundant information such as the alert identification number.

One nurse described the frustration she felt at being reminded at the very beginning of her shift of tasks that she would have taken care of anyway as part of her routine.

If they did not do it in the past shift, I can’t make up their documentation, and I will take care of it in mine. Why do I see it at the beginning of my shift?

As a follow-up question, nurses were asked if they prefer the format of alert report section or dashboards for alerts. Nurses overwhelmingly preferred the dashboard type of alert. Specifically, they liked the dashboard’s ability to link to take direct action, display information, and convey priorities.

It is informational, but it is not anything that we can act on. [In the dashboard], we can click on it and take action.

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Heart Failure Dashboard

Nurses at two of the three hospitals were highly aware of and often interacted with this notification. Comments from these nurses were mixed with mostly positive feedback at one hospital (suburban) and mostly negative feedback at the second. Positive opinions about the dashboard from both indicated that it (1) drew their attention to what had been missed; (2) prompted action; (3) served as a reminder; (4) prompted reflection; (5) gave them the right amount of information; (6) fit into their workflow well; (7) prevented communication failures, especially between shifts; and (8) is helpful for informing nurses who normally do not work with cardiac patients about documentation requirements.

I felt there was something missing that I needed to get done. The red caught my eye right away and I saw that there was something that needed to be done and taken care of. So I felt it was a priority. I wrote it on my sheet right away… I wrote down “smoking”… and I went in right away and did it because it seemed like a priority to me that it was right at the top in red.

Big red banner on the top brings you right to the link. It brings you right to the spot.

It is a good reminder… because in shift-to-shift reports, things like that can get lost.

I would wonder what else is missing that has not been done yet. Sometimes I would just go to the admit flow sheet real quick and buzz through and make sure wasn’t something [missed]… Sometimes I go in there and there is only one [item filled] that is part of a core measure, but something else was not done… some other little thing.

I don’t work with heart failure patients too often. I work in mental health, and I don’t know exactly what all the core measures are… for me, it would be helpful to see what was missed and what I absolutely need to do in terms of documentation.

At one hospital, comments were generally negative towards dashboards. Several nurses said they tended to miss the actions required. Reasons include (1) skipping over the blue lettering (actions needed are worded in blue and serve as a direct hyperlink, such as “smoking status was not documented on flow sheet”), (2) not knowing that they could click on the link to take the action needed, (3) lack of communication from builders and leadership about the existence of the alerts and education on their use, (4) feeling that the task did not need to be completed right away, and (5) the length of Kardex Report coupled with nurses’ tendency to quickly scan the Kardex.

They did not notice that part [the blue lettering], they just saw “the actions required” and kept going.

I just noticed it the other day, but I did not read the blue lettering underneath. The other day, when I saw it was the first time I’d ever seen it, and I don’t remember ever getting any kind of email—I feel like things pop up all of a sudden and we are supposed to know what to do with them… Maybe I missed the memo, I don’t know.

I did not look at this as something I had to do.

So there are some things that you just kind of glaze over and… [conclude] I don’t think I have to do anything with this. So we just kind of miss things.

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Pop-Up Alerts

Because pop-up alerts are not widely used for nursing at our organization, very few respondents had seen a pop-up type alert. Some feedback given was related to the general concept of pop-up alerts without having experienced it, and some nurses gave feedback based on experience with the specific alert. In general, nurses disliked the intrusive nature of the pop-ups and felt that their use should be extremely selective.

It’s like your phone ringing all the time, constantly.

Nurses who had encountered the reminder found it irritating and disrupting of their workflow. They also mentioned that many of them did not get training and did not know how to use it correctly.

We just piloted this in our unit. Talking with a lot of the nurses, we find it pretty irritating for alerts to pop-up especially at the beginning of the shift, because these are things we have not gotten to yet, and sometimes we do not do our documentation until the end of the day, depending upon how busy we are.

I think a lot of nurses on our floor did not know how to use it properly at first because we did not really get education on it and we did not know how to make it go away.

Nurses also felt that the timing and placement of the pop-up were irritating and they ought to appear in the pertinent section of the EHR.

Nurses who had encountered the alert also mentioned certain positive aspects. They particularly liked the ability to add to the care plan and felt that it made them more efficient by saving a step. When asked about suggestions for future use of pop-ups and guidance for system designers, nurses felt that pop-ups should be used very selectively only for time-sensitive issues related to high-level importance measures. They also recommended using them only for one-time events rather than part of a nurse’s routine. For example, a pop-up alert telling the nurse that compression devices have been ordered 6 hours earlier but have not yet been applied, with a link to document application, might be appropriate. But the use of pop-ups to notify the nurse to check the compression devices regularly once they were applied would not be an appropriate use of the pop-up.

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DISCUSSION

Our focus groups revealed important information about nurse opinions of the different types of alerts used in the EHR. Nurses were somewhat distrustful of the data and criteria used to populate banners to identify patient safety concerns (either on the Kardex Report or as a separate Safety Overview Report). Nurses often preferred to get information provided in these banners elsewhere, either from other staff via the shift change report, directly from the patient, or from the original documentation in the EHR. When banners were used as a separate Safety Overview Report, nurses liked the page conceptually, having all the safety information in one location. However, most nurses were either unaware of the report or aware of it and chose not to use it. The report had never become a part of their workflow, and because their preexisting workflow involves visiting parts of the EHR that contain at least some of the same information, many saw incorporating this page into their workflow as just “one more place to click.” These findings highlight the challenges of designing and using new alert tools in ways that (1) they can be incorporated into nursing workflow, (2) are not duplicative of information already received through the current workflow, and (3) provide information in a way that nurses trust and deem accurate. Findings also demonstrate the need for improved ways to retrain staff on how to incorporate new tools into their daily work.

The dashboard alert received the most positive reactions. Positive features included the ability to take direct action through links, clear identification of what needed to be done without extra information, and easy fit into workflow. However, there were still recommendations for improving the dashboard alert by making the hyperlinks more noticeable (eg, appearing as links do on the Internet) by underlining them. Additional information needed by novice nurses should also be available through a second “information” link. Nurses also identified a need for further training on how to use the dashboard features.

Comments about the dashboard and the report section bring up clear preferences for alert content. Nurses want to see only what needs to be done now, not tasks that need to be done later or that have already been done. Most nurses indicate that they do not want alerts to contain information about why they should do something—such as the particular core measure or best practice alert number. In fact, they complained about the overuse of the term best practice, which has made them “immune” to alerts of this nature. The ability to take immediate action within the alert was extremely important. This component of the dashboard received strong support, and alerts without links (eg, report sections) were criticized for not having the ability for direct action without leaving the page.

Timing of alerts was also a major discussion point. Nurses wanted the chance to “do the right thing” during the course of their shift before being notified that it was not done. The exception to this was when the alert could be used to streamline the workflow and aid in accomplishing the task. This theme indicates that, although the alerts take several forms, they can be viewed as criticism or nagging independent of the form they take if they are not delivered at the right time in the continuum of patient care.

Conducting focus groups by specific site proved a useful tool for identifying differences at hospitals. Site differences were identified regarding awareness and use of the dashboard, pop-ups, and Safety Overview Report. Reasons for site differences may be related to the timing of rollout of EHR features by site, types of patients served, site differences in average nurse age or experience with the EHR system, or site differences in training and information sharing about alerts from management. These differences highlight the importance of assessing use of alerts (particularly passive alerts that nurses must navigate on purpose) after they are introduced.

The need for improved training is a common theme that arose throughout this study, with nurses unaware of the Safety Overview Report or unaware of how to use links within alerts. In a review of studies focused on nurses’ attitudes towards EHR systems, Sassen15 found a common theme of nurses reporting inadequate training on the EHR, as well as findings that providing adequate training fosters positive nurse attitudes towards the EHR system. The process of implementing alerts in this system followed a fairly typical pattern of technology rollout of designing and building the new tool with end users included in the process, developing guidelines for use based on current need and practice, and announcing and conducting some initial training. The findings of our focus groups indicate the need for a modification to the standard process to provide further follow-up to assess use and further need for training at the end user level once a new component has been released.

A review of nurse attitudes about EHRs15 found negative attitudes from nurses in many studies related to lack of information to help them with nursing practice. In contrast, nurses in the current study indicated that the alert features gave them all the information they needed for awareness or action. Nurses in our study did not report experiencing alert fatigue, which has been documented with drug safety alerts.11

Alerts provide a great opportunity to use the EHR system to bring attention to specific information nurses need to know for their practice. This study highlights the importance of addressing the incorporation of alerts into workflow. While nurses gave good reviews of some specific alert types, they often reported not using those same alerts because of preferences for getting information elsewhere or lack of trust of the information in the alerts. These themes speak to the challenge of incorporating alert features into workflow and work culture. This attention to incorporation into workflow can and should be addressed in the design phase, during training, as well as after an alert has been implemented in the EHR. Some possible mechanisms to better address workflow in these phases include a more integrated iterative team approach to the design of alerts that involves both designers and end users, better study of workflow prior to design, and inclusion of workflow transition in the training process as well as in additional follow-up training after implementation.

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LIMITATIONS

While this study contributes new findings to the literature about an understudied area of the use of EHR alerts for nursing, there are some limitations to be considered in the interpretation of these results. Our findings are limited in generalizability as they are based on focus groups of varying size from three Midwestern hospitals in the same health system. However, the study is strengthened by the difference in the three types of hospitals based on size and urban/regional location, with findings of many common themes identified across hospitals regardless of hospital type. While focus group analysis was done by a single rater, that rater was an objective third party outside the organization being studied. For some alert components, nurses had seen very little or knew about but had not seen in daily use (pop-ups and safety overview); therefore, comments were based on reactions in focus groups rather than actual use.

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FUTURE DIRECTIONS

Findings from this study have implications for next steps within the Allina Health System, for broader EHR development, and for future research. Following this study, the clinical decision support team modified the guidelines for using alerts at Allina to eliminate the use of the Epic static report sections and focused instead on the dashboard style for future alerts. Suggested improvements for the dashboard were incorporated, such as underlining links and adding information links for novices. Future plans in this area include pilot testing another alternative (smart navigators) for supporting documentation compliance, working with Epic on using color in a consistent manner, and exploring options for improved timing and targeting of alerts. Nurse comments about training and findings about lack of use of some features fueled the development of a new program to assess nurse proficiency with EHR functionality and educate nurses in areas where deficiencies were identified. This program will focus on the use of EHR function and the incorporation of those features into practice.

Findings are being shared with the broader EHR community through Epic user groups and health informatics conferences. Requests are also being made to the vendor (Epic) for changes in the product in ways that improve the functionality of alerts. Further research is needed to guide when certain types of alert functions should be used in inpatient nursing. Additional research is needed to understand how to design alerts with workflow incorporation in mind and how to achieve workflow incorporation in a way that benefits nursing practice and ultimately patient care. Additionally, alert designers need to evaluate the accuracy and timeliness of the data used to generate an alert as well as the criteria used to trigger it.

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Keywords:

Alerts; Electronic health record; Nursing; Nursing informatics

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