Clinical Alerts – Why Good Intentions Must Start as Good Ideas

As the heated debate continues about ways to decrease the costs of our healthcare system while simultaneously improving its quality, it is critical to consider the most appropriate place to start – which depends on who you are. Much has been made about the advantages of clinical alerts especially with their use in areas high on the national radar like quality of care, medication use and allergic reactions, and adverse events.   Common sense, though, says walk before you run; in this case its crawl before you run. 

Clinical alerts are most often electronic messages sent via email, text, page, and even automated voice to notify a clinician or group of clinicians to conduct a course of action related to their patient care based on data retrieved in a Clinical Decision Support System (CDSS) designed for optimal outcomes. The rules engine that generates alerts is created specifically for various areas of patient safety and quality like administering vaccines to children, core measure compliance, and preventing complications like venous thromboembolism (VTE) (also a core measure). The benefits of using clinical alerts in various care settings are obvious if the right people, processes, and systems are in place to consume and manage the alerts appropriately. Numerous studies have been done highlighting the right and wrong ways of implementing and utilizing alerts. The best criteria I’ve seen used consider 5 major themes when designing alerts: Efficiency, Usefulness, Information Content, User Interface, and Workflow (I’ve personally confirmed each of these from numerous discussions with clinicians ranging from ED nurses to Anesthesiologists in the OR to hospitalists on the floors). And don’t forget one huge piece of the alerting discussion that often gets overlooked…….the patient! While some of these may be obvious, all must be considered as the design and implementation phases of the alerts progress.

OK, Now Back to Reality

A discussion about how clinical alerting can improve the quality of care is one limited to the very few provider organizations that already have the infrastructure setup and resources to implement such an initiative. This means that if you are seriously considering such a task, you should already have:

• an Enterprise Data Strategy and Roadmap that tells you how alerts tie into the broader mission;
• Data Governance  to assign ownership and accountability for the quality of your data and implement standards (especially when it comes to clinical documentation and data entry);
• standardized process flows that identify points for consistent, discrete data collection;
• surgeon, physician, anesthesiology, nursing, researcher, and hospitalist champions to gather support from various constituencies and facilitate education and buy-in; and
•  oh yeah, the technology and skilled staff to support a multi-system, highly integrated, complex rules-based environment that will likely change over time and be more scrutinized………

◊◊Or a strong relationship with an experienced consulting partner capable of handling all of these requirements and transferring the necessary knowledge along the way.◊◊

I must emphasize the second bullet for just a moment; data governance is critical to ensure that the quality of the data being collected passes the highest level of scrutiny, from doctors to administrators. This is of the utmost importance because the data is what forms the basis of the information that decision makers act on. The quickest way to lose momentum and buy in to any project is by putting bad data in front of a group of doctors and clinicians; trust me when I say it is infinitely more difficult to win their trust back once you’ve made that mistake. On the other hand, if they trust the data and understand the value of it in near real time across their spectrum of care, you turn them quickly into leaders willing to champion your efforts. And now you have a solid foundation for any healthcare analytics program.    

If you are like the majority of healthcare organizations in this country, you may have some pieces to this puzzle in various stages of design, development, deployment or implementation. In all likelihood, though, you are at the early stages of the Clinical Alerts Maturity Model

 

and with all things considered, should have alerting functionality in the later years of your strategic roadmap. Though, there are many  projects with low cost, fast implementations, quick ROIs, and ample examples to glean lessons learned from like, Computerized Physician Order Entry (CPOE), electronic nursing and physician documentation, Picture Archiving System (PACS), and a clinical data repository (CDR) to use alerting as a prototype or proof of concept to demonstrate the broader value proposition. Clinical alerting, to start, should be incorporated alongside projects that have proven impact across the Clinical Alerts Maturity Model before they are rolled out as stand-alone initiatives.

Ten Ways to Ensure Project Failure

Sometime ago I read an article about the top ten ways to destroy the earth. Although it is a bit morbid to even think about such a topic let alone compile a top ten list, it certainly is an interesting scientific problem. Blowing planet earth to bits is not as simple as it may seem. It takes considerable amount of energy to blow up six sextillion tons of rock and metal. However, there are some exotic ways to get the job done. From creating a micro black-hole on the surface of the earth to creating an anti-matter bomb with 2.5 trillion tons of anti-matter to creating perfect Von Neumann machines (self-replicating), they are all pretty futuristic and not part of our everyday experience. Some may say- “why even think about such an absurd subject?”, but it does have few practical applications. If nothing else, it helps us think about possible dangers to the only known planet capable of supporting life.

While blowing up earth may for now be out of our grasp and may require giant leaps in technology, blowing up an IT project is quite easy. I can say that with authority, because I have seen many projects self-destruct right in front of my eyes and at times I may have contributed to some of them. So here are the ten ways of blowing up an IT project:

1. The Missing Matter—Requirements: Lack of business and functional requirements or requirements lacking appropriate level of detail.
2. Progress Black Hole: Lack of mechanisms to measure progress, milestones, and deadlines.
3. Caught in the Gravitational Pull of Technology: Focus on technology itself rather than achieving business objectives through technology.
4. Supernova – Out of Resources: Unrealistic expectations and deadlines – trying to achieve too much in too little time and with too few resources.
5. Consumed by Nebulous Clouds: Constantly changing requirements and feature creep. Inability to give the project and product a solid shape and direction. Lack of proper change control process.
6. Bombarded by Asteroids: Loss of focus and progress due to multi-tasking on unnecessary side projects and other distractions.
7. Lost in Space: Lack of a well defined project plan with appropriate level of details, milestones, and resource allocations.
8. Too many WIMPS (Weakly Interacting Massive Particles): Lack of interaction with the business users, lack of sufficient number of check points, lack of business user involvement during the planning, build, and deployment phases.
9. Journey to the Edge of the Universe: Attempting to run a project with bleeding edge technology, inexperienced project team, and poorly understood business objectives.
10. Starless Solar System: Lack of clear and convincing business case and mapping of how the project will help to achieve the business objectives.

From Free Text Clinical Documentation to Data-rich Actionable Information

Hey healthcare providers! Yeah you the “little guy”, the rural community hospital; or you the “average Joe”, the few-hundred bed hub hospital with outpatient clinics, an ED, and some sub-specialties; or you the “behemoth”, the one with the health plan, physician group, outpatient, inpatient, and multi-discipline, multi-care setting institution. Is your EMR really just an electronic filing cabinet? Do nursing and physician notes, standard lab and imaging orders, registration and other critical documents just get scanned into a central system that can’t be referenced later on to meet your analytic needs? Don’t worry, you’re not alone…

Recently, I blogged about some of the advantages of Microsoft’s new Amalga platform; I want to emphasize a capability of Amalga Life Sciences that I hope finds its way into the range of healthcare provider organizations mentioned above, and quick! That is, the ability to create a standard ontology for displaying and navigating the unstructured information collected by providers across care settings and patient visits (see my response to a comment about Amalga Life Science utilization of UMLS for a model of standardized terminology). I don’t have to make this case to the huge group of clinicians already too familiar with this process in hospitals across the country; but the argument (and likely ROI) clearly needs to be articulated for those individuals responsible for transitioning from paper to digital records at the organizations who are dragging their feet (>90%). The question I have for these individuals is, “why is this taking so long? Why haven’t you been able to identify the clear cut benefits from moving from paper-laden manual processes to automated, digital interfaces and streamlined workflows?” These folks should ask the Corporate Executives at hospitals in New Orleans after Hurricane Katrina whether they had hoped to have this debate long before their entire patient population medical records’ drowned; just one reason why “all paper” is a strategy of the past.   

Let’s take one example most provider organizations can conceptualize: a pneumonia patient flow through the Emergency Department. There are numerous points throughout this process that could be considered “data collection points”. These, collectively and over time, paint a vivid picture of the patient experience from registration to triage to physical exam and diagnostic testing to possible admission or discharge. With this data you can do things like real or near-real time clinical alerting that would improve patient outcomes and compliance with regulations like CMS Core Measures; you can identify weak points or bottlenecks in the process to allocate additional resources; you can model best practices identified over time to improve clinical and operational efficiencies. Individually, though, with this data written on a piece of paper (and remember 1 piece of paper for registration, a separate piece for the “Core Measure Checklist”, another for the physician exam, another for the lab/X-ray report, etc.) and maybe scanned into a central system, this information tells you very little. You are also, then, at the mercy of the ability to actually read a physicians handwriting and analyze scanned documents of information vs. delineated data fields that can be trended over time, summarized, visualized, drilled down to, and so on.

Vulnerabilities and Liabilities from Poor Documentation

Relying on poor documentation like illegible penmanship, incomplete charting and unapproved abbreviations burdens nurses and creates a huge liability. With all of the requirements and suggestions for the proper way to document, it’s no wonder why this area is so prone to errors. There are a variety of consequences from performing patient care based on “best guesses” when reading clinical documentation. Fortunately, improving documentation directly correlates with reduced medical errors. The value proposition for improved data collection and standardized terminology for that data makes sense operationally, financially, and clinically.   

So Let’s Get On With It, Shall We?

Advancing clinical care through the use of technology is seemingly one component of the larger healthcare debate in this country centered on “how do we improve the system?” Unfortunately, too many providers want to sprint before they can crawl. Moving off of paper helps you crawl first; it is a valuable, achievable goal across that the majority of organizations burdened with manual processes and their costs and if done properly, the ROI can be realized in a short amount of time with manageable effort. Having said this, the question quickly then becomes, “are we prepared to do what it takes to actually make the system improve?” Are you?