The commentors on Usability: No Stupid Questions have raised the most important question of all … when is the “no stupid questions” rule an aid to improving the functional design of an EHR and when might it be used to the detriment of patients.The concern is that physicians who are resistant to CDS would equate “no stupid questions” to “no CDS.”
Does a concern about alert fatigue mean that there should be no alerts? Of course not. Physician informaticists that are daily in the throes of implementing CDS recognize the need for balance between too few alerts and too many. If physicians have formed the habit of clearing alerts without reading them, then the alerts aren’t effective.
A principle as simple as “no stupid questions” will never be the primary means of making the judgment on which alerts to support. Indeed the discussion that Dick and I had about this principle was not related to CDS. It was about how to involve the clinician when importing problems, allergies and meds from one EHR into another. Most sites and vendors that have implemented the CDD and CDR have come to recognize that this process is not an automatic one, it sometimes involves the user. The two “stupid question” rules were applied to optimize the user’s time by only asking questions when necessary and designing the system so that the necessary questions could be meaningful to the user.
It is interesting that two commentators brought up pilot check lists and Peter Basch specifically mentioned The Checklist Manifesto. Such a wonderful short read and so profound! If you ever need a way to explain to Aunt Agatha why implementing CDS puts us between an informational rock and a cultural hard place, the book is a great place to start.
In the context of “no stupid questions” the important take-away from Gawande’s book is in chapters 5 and 6, wherein he describes his initial attempt to create a checklist, which turned out to have a lot of stupid questions. Talking to Daniel Boorman, Boeing’s checklist guru, Gawande learned how to make checklist questions smart. He found that the aircraft checklists are “remarkably brief,” carefully chosen for high impact (the likelihood of avoiding an error) from the hundreds of questions that might be asked. Sixty to 90 seconds is the point where alert fatigue begins to set in.
In the context of CDS the obligation to ask no stupid questions does not equate to asking no obvious questions. Indeed the smartest questions are often the most obvious such as a reminder about a penicillin allergy. The obligations are to pick the questions carefully.
I would venture a guess that if the rest of an EHR is notably free of stupid questions, clinical users will have a slightly highly tolerance for CDS questions then if they begin ordering with “pre-CDS alert fatigue.”