Controlling Care Unit Chaos - Overcoming Alert Fatigue in the Clinical Environment

On February 2^nd, I was blessed once again as my wife gave birth to the newest member of our family.  After a complication-free delivery and smooth discharge, I was left with two very memorable experiences.  First, I got to witness the miracle of life begin.  There is no more powerful moment than to see a person appear into the world.  Truly breathtaking.  Secondly, albeit a very distant second – I watched the technology and enhanced workflows I evangelize with our clients come together in a truly elegant way.  Nurse call systems and Electronic Health Record Systems integrating with WLAN phones, RFID tags standing guard to ensure infant and parent safety, wireless infusion pumps communicating with the inpatient pharmacy,  and fetal monitors offering status to clinicians of the pending miracle.  Bits and bytes, ones and zeroes, floating invisibly through the air to alert caregivers of critical events.  To the untrained eye and ear, it may not have even been noticeable – but to me, it was tremendously encouraging. 

We have come a very long way.  In the not-so-distant past, the most alerting a clinician would have had to deal with may have been two phones ringing simultaneously.  Now, there are desk phones, smart phones, nurse call systems, overhead pagers, alphanumeric pagers, PCs, RFID tags, telemetry alerts, digital signage, etc. all vying for the attention of a single clinician.  With so many events to keep tabs on, it’s no surprise to hear that an average shift in a hospital requires a nurse to walk four and a half miles (Mobile Health Alliance).  Of course, it also begs the question – have we over-adopted?  With so many beeps and pings to tend to, won’t the clinician just become desensitized or overwhelmed by it all?  After all, the Joint Commission has documented just how significant a breakdown in communication can be.  With 62% of accidental deaths and 80% of serious medical errors being attributed to communication failure, how can so many alerts possibly be good for patient outcomes?  Well, my recent experience demonstrates just how to achieve the proper balance between too few and too many of them.  Not once did a nurse or physician demonstrate signs of what is known as alert fatigue.  Rather, technology seemed to empower them to be more responsive and more attentive.  Something as ubiquitous in today’s world as a smart phone became a powerful clinical instrument.

So, how DOES a hospital achieve this balance?  To start, they must dive deep into three categories:

• Alert Management – Consider priorities, delivery assurance, clarity, and saturation points of the alerts
• Capacity Management – Determine how tight parameters are set, what staff is available to address the alerts, and the logistics involved to respond
• Policy Management – Audit assignment logistics, escalation procedures, time-to-respond intervals, and disablement requirements

With an understanding of how a care unit consumes alerts, hospitals can deliver the right data, to the right person, on the right device, at the right time, with the right context.  In order to do this, it is important to let the message drive the medium.  A clinical emergency needs to be prioritized over a simple food request, and a weather alert needs to be delivered in a matter different from, say, a patient’s discharge notice.  Additionally, regulatory issues come into play:

• HIPAA – Is Protected Health Information (PHI) secure to ensure compliance?
• HCAHPS – Is the alert management program recognizing the importance of noise reduction, responsiveness, safety and overall patient satisfaction?
• Joint Commission – Is the organization poised to address the 2014 safety goal set forth?

Needless to say, this is no easy undertaking – but with links to patient safety and cases of mortality, it is absolutely critical.  In fact, the ECRI Institute has placed “Alarm Hazards” at the top of the list of technology hazards for consecutive years.  These alerting technologies available in today’s care unit are not going away, so organizations need to understand how to use them effectively.  Care units should continually assess their environment, provide gap analysis to an ideal alert management program, and embrace efficient technologies to aggregate data, enhance workflow, improve outcomes, and increase patient satisfaction. 

Popping the Cap - Blurring the lines between patient convenience and improved outcomes

As movement toward an Electronic Health Record (EHR) continues to proliferate, enhancements of this increasingly all-encompassing technology are now beginning to pop up.  While it’s often touted (and hotly-debated) that the presence of EHR will improve patient outcomes, the concept of extracting clinical data from one source (the EHR) in order to improve workflow or add convenience is finally making an impact.  I make a habit of discussing with my clients how powerful and convenient it can be for physicians when clinical applications and unified communications systems are tightly integrated - but how about patients?  How can the same core fundamentals be used to drive patient engagement?  If we consider how and when a patient actually comes into contact with his or her patient data without a clinician serving as intermediary, the scope narrows quickly.  The most common instance is medication and prescription management.  It is quite amazing that many physicians still scribble a prescription onto a small pad, which the patient then couriers to the pharmacy for fulfillment.  Thankfully, however, a Meaningful Use requirement of the use of e-prescription has curtailed this behavior to a point where most pharmacies offer an electronic methodology of receiving and filling prescriptions.  But what happens once the medication runs out, and a refill is needed - or worse (and as common) never gets filled to begin with?  The patient is now in charge of the health process.  This presents both a challenge and opportunity for care providers.  More and more organizations are leveraging this nexus of patient, provider, and medicine to improve outcomes through technology.  By integrating on-line or call center applications with the EHR, strategies can be developed to drive medication adherence and offer counsel on drug efficacy and reactions.  

With the advent of the Accountable Care Organization (ACO), and in turn a renewed focus on outcome over encounter, providers are looking hard at the impact the pharmacy has on health.  In fact, with one third of US hospitals now managing their own in-house pharmacies, ACO team members can ensure that patients being discharged leave with their meds, and can check on adherence via data analytics platforms that interface with the EHR’s pharmacy application and call center reports.  By categorizing high-risk patients, follow-up calls utilizing the same can be performed to consult adherence, side effects, and overall efficacy.  
A recent success story of this comes from Hennepin County Medical Center helped cut admissions by 42 percent, ED visits by 37% and saved an average of $2,500 through such a program such a program.

      
      Looking toward the future, it is easy to see that something as simple as refilling a prescription over the phone can easily turn into something far greater.  Imagine what can happen next.  Perhaps it’s an ad hoc video consult between the care team pharmacist and a patient experiencing a minor side effect with their medication.  Or maybe it’s pulling up a recent prescription from an on-the-move ambulance while consulting with a Neurologist and potential stroke victim.  Regardless of the use case, the more we integrate, the more significant the impact technology can have before, during or after the point of care.  Remember, Accountable Care is about enhancing the provider/caregiver experience to improve population health.  What better way is there than to take inherently disparate interactions of a clinician interacting with a data system, and a patient interacting with a data system, and have them all integrate, nay collaborate, together?

mHealth in America

As I engage with clients across the nation, from payors to providers to health and wellness organizations, everyone in healthcare wants to talk about mHealth.  After all, it’s cool.  It’s SEXY.  But what exactly is it?

Rumor has it that Robert Istepanian, Professor of Data Communications at Kingston University London, was the first to use the term mHealth as early as the late 1990s (then “unwired e-med”) with specific mention of the term “m-Health” in 2003.  He described it as, “emerging mobile communications and network technologies for healthcare.”  While concise and to the point, Professor Istepanian’s definition lacks depth.  Granted, our world has changed significantly since he coined the phrase.  Consider that the smartphone really became pervasive in 2007 (thanks Steve). 

Like many cool and sexy things, mHealth seems to defy description – not for lack of one, however.  Try searching the internet for mHealth (who knows, maybe that’s how you found me).  mHealth is everywhere, but it’s nowhere.  It’s got thousands of definitions, but not one that’s comprehensive enough that everyone can agree on.

Originally, I sought to find clarity around the topic.  I intended to explore the vast descriptions to concisely define what mHealth REALLY encompassed.  However, I wound up in the exact place I started – staring out at the technosphere with more questions than answers.  Is mHealth delivered solely via smartphones?  Is it for patients or providers?  What about remote patient monitoring?  Is mHealth a subset of eHealth?  Or Telehealth?  Is it used in the hospital or at home?  How about public health? 

Yes.  No.  Sometimes.

With that exhausting (but enlightening) experience in my rear view mirror, I am now throwing my pursuit to define the enigmatic term of mHealth out the window.  Because, ultimately, what does it really matter?  This isn’t about neatly placing things into tidy little boxes with catchy names on them.  This is about breaking down clinical barriers.  This is about taking control of our well-being.  This is about saving lives.  But how?  What will ultimately shake out of the current frenzy (Gartner calls is the “Hype Cycle”) around these hot new tools?

For some market perspective, we don’t need to look much further than the dotcom days of the 1990s.  New ideas were popping up every day.  Some were funded by deep pockets.  Others were about to spend their last red cent in the hopes that an IPO might save them.  Consumers and businesses alike were gobbling up technology and marketing new ideas faster than they could be deployed.  It seemed like everyone was winning.  Then the unthinkable happened – the market got smart.  Venture capitalists were no longer throwing money around like drunken sailors, and consumers were developing preferences and habits.  Despite the fact that so many ideas were still undiscovered, the market was consolidating.

Similar to those booming 90s, we will ultimately be left with consolidation driven by value and viability in the mHealth space.  Here’s the difference – the internet revolution had a captive, active market.  mHealth seems to have the opposite of that.  Everyone in healthcare has heard it talked about ad nauseum, but it is hardly pervasive.  Why?   I believe there are four intertwining reasons:

-          Disinterested Consumers:  The historical sentiment around any type of healthcare in the United States has been passive.  Those that perceive themselves to be in good health rarely seek preventive medicine.  So, why would someone bother to adopt some type of healthcare technology unless the doctor ordered it?  We are experiencing a minor uptick in the use of wellness apps, but that seems to be the extent of it.  One exception to this is where we are seeing some penetration is around patient engagement.  Providers and payors are rolling out smartphone apps and portals to allow their customers to book appointments, access their medical records, pay bills, request prescription refills, and in more rare instances receive lab results.  While this is certainly a welcome improvement to a fairly archaic norm within healthcare services, its focus is more on loyalty than actual patient care.  Great stuff for the marketing folks and administrators, but little to do with outcomes.  Stage Two of CMS’s Meaningful Use Criteria includes requirements focused on this type of engagement, and long-term adoption on both the payer and provider side will lead to administrative cost reduction.  While most everyone will concur that these are good things, you may also agree that this is a fine example of where the mHealth definition becomes fuzzy at best.  Is scheduling a well-baby visit with your pediatrician really mHealth?

-          Lack of Viable Revenue/Payment Model:  While attending the recent Southern California HIMSS Chapter’s recent event, “Health IT Innovation Summit – mHealth in the Era of Affordable Care,” I was honored to listen to true thought leaders in the healthcare space.  This coincided with the Supreme Court’s ruling to uphold the Patient Protection and Affordable Care Act in its entirety.  The facility was abuzz with commentary on what it could mean for the industry, and the possibilities it would create for mHealth.  This topic of revenue and payment modeling was particularly popular.  Over the past ten years that we’ve discussed mHealth as a game-changing technology, there was never really a clear answer as to who would be responsible for the price tag.  In an overwhelmingly fee-for-service-based market, mHealth simply didn’t have a home.  The patient didn’t care, the doctor saw it as a malpractice risk, and the payer couldn’t develop a return-on-investment strategy.  However, with specific programs around Accountable Care Organizations, Patient Centered Medical Homes, and bundled payment provisions, the Affordable Care Act has revitalized this topic.  With a redirected focus on outcomes, readmission reduction and cost control, traction in this area is inevitable.  Tools such as disease management apps for smartphones and wireless medical devices, including glucometers, scales, and blood pressure cuffs will be prevalent in the self-managed disease states.  Diabetes, Congestive Heart Failure, Hyperlipidemia, and Hypertension to name just a few.  Many of these devices are already in use in trials, but I anticipate at least two years before we see general viability.

-          Lack of Clinical Evidence:  There is a phrase I hear quite often in this business – the technology is the easy part.  It’s true across all industries, but overwhelming in emerging ones like mHealth.  So much so that one must wade through idea after idea, revision after revision, just to find the tool that presents real value to the user.  In healthcare, we are nothing if not thorough.  Until something can be proven via clinical trial or pilot, it is worthless - and therefore unfunded.  A common occurrence in any emerging field is a solution in search of a problem.  Indeed, mHealth suffers from this a great deal.  Such distractions are an important part of the evolutionary process, but one must exert tremendous caution to not get hypnotized by the shiny object.  Without achieving a goal of improved outcome, enhanced workflow, or cost reduction, it is difficult to justify layering in a new technology to a healthcare environment.  This is why successful trials are crucial.  The mHealth market is currently sitting squarely in the trial phase, and it is quite exciting to see where positive impacts are realized.  The trend is to pick one thing – a workflow, disease, condition, initiative, and determine how mobile technology impacts it.  As time goes by, more and more technologies and use cases will be vetted, and we will see official programs rolled out by forward-thinking healthcare organizations.  Some interesting examples recently include remote stroke diagnosis via smartphone, wearable heart monitors, and medication adherence tools.

-       Disruptive Workflows:  “Disruptive innovations” is actually considered to be a good thing these days (albeit overused to a point), but try walking into a hospital and telling a clinician you’re going to disrupt their workflow with innovation.  You’ll be handed a discharge summary and shown the door.  For healthcare technologists, there is a very fine line between enhancing and recreating.  If you can’t gain adoption, any potential gain your technology may bring to a patient is lost.  That is why the user plays such a critical role in mHealth, and why so many trials and applications fail.  Sometimes the interface is wonky.  Other times the application requires too much bandwidth or processing.  Regardless of the issue, if you cannot improve the workflow or create a layer of convenience, your initiative will fail.  That is why we are seeing a recent shift for the positive in the involvement of physicians and nurses.  Clinicians are participating with much more enthusiasm.  They are engaged in surveys, and vocal during the interview process.  They want their voices heard.  Folks from the medical profession are even founding their own mHealth companies.  This is a very exciting turn of events, as it signifies the embracement of mHealth by a group notoriously resistant to change.  When Biz Stone, co-founder of Twitter, spoke at the 2012 HIMSS National Convention, he made a statement that resonates within the mHealth space.  “We will win if we always do the right thing for our users.”  While he was speaking from a more global perspective on technology, the point remains salient.  It will not matter how powerful your technology is if it is not embraced, adopted, and evangelized. 

I recently caught up with Todd Plesko, Chief Executive Officer of Extension, Inc., a middleware company that delivers clinical data and alerts to disparate smartphones, WLAN devices and desktops used by clinicians.  He shared his viewpoints on the state of mHealth, and offered some insight on adoption.  “We are finally starting to see the mobilization of information, and it’s empowering.  We have an opportunity to truly improve workflow, clinician satisfaction, and patient outcomes.  We must be careful, however.  If you cannot demonstrate an immediate improvement to the end user, you’ve lost the war.  It’s about putting the right information in the hands of the right person, at the right time, in the right way that will make mHealth successful.  It can be done.  The possibilities are endless.  It’s a very exciting time in US healthcare.”

If a healthcare organization can overcome these four hurdles, mHealth will become a viable tool.  It is important to note, however, this will not happen overnight.  There is much political, administrative and organizational change that must take place before patients and providers can truly leverage mHealth technology.  However, given some recent milestones in consumer sentiment, regulatory intervention, positive trial outcomes, and adoption patterns, there is hope for the proliferation of mHealth in America.  A sound plan that addresses technology, workflow, analysis, and governance is critical.   We may never agree on the definition of mHealth, but it is clear that the world is getting smaller, people more mobile, and we are at a tipping point in care delivery.  The mHealth tide is turning from neat gizmos and cocktail party chatter to powerful care delivery tools and strong financial returns.  Are you ready to ride the mHealth wave?


Where do you or your organization stand on mHealth?  Let me know!