Habit and Automaticity in Medical Alert Override : Cohort Study

Background: Prior literature suggests that alert dismissal could be linked to physicians’ habits and automaticity. The evidence for this perspective has been mainly observational data. This study uses log data from an electronic medical records system to empirically validate this perspective. 
Objective: We seek to quantify the association between habit and alert dismissal in physicians. 
Methods: We conducted a retrospective analysis using the log data comprising 66,049 alerts generated from hospitalized patients in a hospital from March 2017 to December 2018. We analyzed 1152 physicians exposed to a specific clinical support alert triggered in a hospital’s electronic medical record system to estimate the extent to which the physicians’ habit strength, which had been developed from habitual learning, impacted their propensity toward alert dismissal. We further examined the association between a physician’s habit strength and their subsequent incidences of alert dismissal. Additionally, we recorded the time taken by the physician to respond to the alert and collected data on other clinical and environmental factors related to the alerts as covariates for the analysis. 
Results: We found that a physician’s prior dismissal of alerts leads to their increased habit strength to dismiss alerts. Furthermore, a physician’s habit strength to dismiss alerts was found to be positively associated with incidences of subsequent alert dismissals after their initial alert dismissal. Alert dismissal due to habitual learning was also found to be pervasive across all physician ranks, from junior interns to senior attending specialists. Further, the dismissal of alerts had been observed to typically occur after a very short processing time. Our study found that 72.5% of alerts were dismissed in under 3 seconds after the alert appeared, and 13.2% of all alerts were dismissed in under 1 second after the alert appeared. We found empirical support that habitual dismissal is one of the key factors associated with alert dismissal. We also found that habitual dismissal of alerts is self-reinforcing, which suggests significant challenges in disrupting or changing alert dismissal habits once they are formed. 
Conclusions: Habitual tendencies are associated with the dismissal of alerts. This relationship is pervasive across all levels of physician rank and experience, and the effect is self-reinforcing.