Comparison With Prior Work
fatigue
RECRUITMENT
Clinical trials can depend on provider participation for trial recruitment [In addition to being a tool for increasing clinical trial referrals, the EHR notification encouraged providers to engage patients in ACP. The use of an embedded provider EHR notification has been demonstrated in other trials related to ACP in primary care [The number of notifications did not influence the likelihood of having an ACP note documented because of other barriers to conducting ACP in a clinic setting. A study by Tung et al [Provider experiences of the ACP notification were predominantly positive. Few comments suggested inappropriate patient identification. Despite the positive response, providers found that the notification occurred too often, was burdensome to the daily work, and was difficult to navigate. This is likely related to the increased number of clicks required to process the notification in the midst of trying to care for a patient during a busy clinical day. If the provider “dismissed” the notification, the notification would reappear during the same encounter. These recurrent notifications can contribute to alert fatigue and increase provider workload and notification desensitization [Furthermore, there are diminishing returns for providers to refer a patient to the study or conduct ACP after 5 notifications. Patients referred to the study were more likely to have less notifications because the notification would stop once the patient was referred to the study. The higher number of notifications for patients not referred to the study appears to be a marker of providers not acting upon or disregarding the notification. More concerning is that the additional notifications are less likely to achieve the original aim of the provider user. When additional notifications no longer prompt the provider action, these notifications may be setting the stage for alert fatigue, where repeated reminders may not increase ACP conversations and instead contribute to provider notification burden. Therefore, implementation of an EHR notification for ACP must be designed with the end user in mind, particularly in the context of the additional demand placed on provider’s attention and to reduce overall burden [