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      Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review

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          <div class="section"> <a class="named-anchor" id="s1"> <!-- named anchor --> </a> <h5 class="section-title" id="d1173938e181">Objective</h5> <p id="d1173938e183">Clinical decision support (CDS) hard-stop alerts—those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party—are increasingly common but can be problematic. To understand their appropriate application, we asked 3 key questions: (1) To what extent are hard-stop alerts effective in improving patient health and healthcare delivery outcomes? (2) What are the adverse events and unintended consequences of hard-stop alerts? (3) How do hard-stop alerts compare to soft-stop alerts? </p> </div><div class="section"> <a class="named-anchor" id="s2"> <!-- named anchor --> </a> <h5 class="section-title" id="d1173938e186">Methods and Materials</h5> <p id="d1173938e188">Studies evaluating computerized hard-stop alerts in healthcare settings were identified from biomedical and computer science databases, gray literature sites, reference lists, and reviews. Articles were extracted for process outcomes, health outcomes, unintended consequences, user experience, and technical details. </p> </div><div class="section"> <a class="named-anchor" id="s3"> <!-- named anchor --> </a> <h5 class="section-title" id="d1173938e191">Results</h5> <p id="d1173938e193">Of 32 studies, 15 evaluated health outcomes, 16 process outcomes only, 10 user experience, and 4 compared hard and soft stops. Seventy-nine percent showed improvement in health outcomes and 88% in process outcomes. Studies reporting good user experience cited heavy user involvement and iterative design. Eleven studies reported on unintended consequences including avoidance of hard-stopped workflow, increased alert frequency, and delay to care. Hard stops were superior to soft stops in 3 of 4 studies. </p> </div><div class="section"> <a class="named-anchor" id="s4"> <!-- named anchor --> </a> <h5 class="section-title" id="d1173938e196">Conclusions</h5> <p id="d1173938e198">Hard stops can be effective and powerful tools in the CDS armamentarium, but they must be implemented judiciously with continuous user feedback informing rapid, iterative design. Investigators must report on associated health outcomes and unintended consequences when implementing IT solutions to clinical problems. </p> </div>

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          Author and article information

          Journal of the American Medical Informatics Association
          Oxford University Press (OUP)
          November 2018
          November 01 2018
          September 18 2018
          November 2018
          November 01 2018
          September 18 2018
          : 25
          : 11
          : 1556-1566
          [1 ]Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
          [2 ]Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
          [3 ]Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
          [4 ]Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
          © 2018


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