Q&A

Dr. Malaz Boustani, the director of Wishard Health Services’ Healthy Aging Brain Center, thinks pop-up alerts for physicians that are part of many electronic medical record and e-prescribing systems are ineffective and need to be re-engineered. Such alerts, known as clinical decision support tools, typically warn physicians about likely drug-to-drug interactions or remind them to check for common issues in the type of patient the doctor is currently examining.

But Boustani and several fellow research scientists at the Indianapolis-based Regenstrief Institute found in a recent study of seniors with cognitive impairment at Wishard Memorial Hospital that the presence of the pop-up alerts had no noticeable impact on physician behavior. The study was published in the May issue of the Journal of General Internal Medicine.

IBJ: Why do you think the clinical decision support alerts failed to get more doctors to do such things as refer cognitive impairment patients for geriatric consultations or to discontinue potential harmful drugs?

Boustani: We heard from the physicians that they don’t trust the computer. This is much more complicated medical care than things like vaccinations. So they did not trust the computer. The prescribers are bombarded right now, with sometimes complicated conflicting decision support. So in some ways they are suffering from fatigue. The decision support system at Wishard suffers from the F8 syndrome or the Escape syndrome, where in less than 0.3 seconds, [physicians] ignore it.

IBJ: Do you think your study, even though it focused only on patients with cognitive impairment, can be extrapolated to other parts of health care too?

Boustani: I believe—and my Regenstrief colleagues will disagree with me—that any place where clinical decision support has been used for five or 10 years, these kinds of interruptive messages are not going to be as effective as we thought. My belief is to create clinical decision support on demand. The physician will ask the computer to screen all their orders to see if there’s a problem. The physicians and clinicians perceive the clinical decision support [now] as a judgment on them: “Oh, you’re a bad doctor.” So when you switch it to on-demand, then clinical decision support becomes part of the tools that the physicians have to use. Just as when you order a chest X-ray or a lab, now you can order clinical decision support.

IBJ: What was the reaction to your study?

Boustani: Some thought I went too far in my interpretation of the negative finding. But you know, I love it. This is part of the process. We just need to make clinical decision support smarter and smarter. And make it not really a judgment. You’re going to need much, much more robust decision support. It’s beautifully beneficially if we do it in the right way.