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When Rules Collide, Alerts Fatigue, and Disruptive Innovation may be necessary

August 6, 2008
by Joe Bormel
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In May 2008, Josh Peterson, MD, MPH, published a perspective entitled: "Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?"Â It's a beautifully balanced piece, describing the problem and prescribing proven, actionable advice.

Why This Blog? (clearing up a common misunderstanding, before we go on)

A blog is not a place to elaborately review or even summarize beyond a very high level. A blog is a perfect place to share observations worthy of discussion and have a conversation with interested, thoughtful and passionate readers.

The Challenge of Mainstream Models For Integrating CDSS

1. Portions of CDSS systems are often turned off, because of information "noise" and process [alert] "fatigue". We are all familiar with this problem and the common response, deferring and/or disabling CDDS.

2. David Classen's 2008 HIMSS presentation entitled, 'Evaluation of Implemented EHRs,' looked at this issue in detail, in the real world. Deployed EMR's were tested using the Leapfrog flight simulator. CDSS scores dropped to the 10% range (50% is passing), as a result of deferred or deliberately disabled CDDS. These systems (from many major vendors) had CDSS capable of meeting and exceeding the 50% passing grade threshold; the CDSS was turned off, reducing or eliminating the safety benefit.

The Need for Leadership

Dr. Peterson makes a few statements that speak specifically to CIO and CMIO leadership, and offers an ominous observation regarding how this is going in the USA.

- "The creation of a high-quality medication CDSS may take more time, evaluation, and refinement than initially has been envisioned." (expectation setting leadership)

- "Unfortunately, at this writing, such an infrastructure is an underfunded and distant goal in the United States, while other countries such as the United Kingdom and the Netherlands are making tremendous progress." (influence leadership)

I strongly agree. Are their pragmatic, available options? Let's kick it around.

The Current State

With or without analytic CDSS, EMRs objectively create value. They reduce and/or eliminate delays and errors in many care processes. The gains possible and proven with CDSS are much larger.

Most publicly discussed efforts to address the "turning off the CDSS alerts" problem involve a combination of
 1) adding provider-specific preferences around specific alerts and classes of alerts;Â
 2) adding more specific dose checking, dose recommending, and dosing wizards/dialogues; and
 3) adding specific screens, templates, and wrap-around systems that handle specific contexts very well.

All of those things are needed at this point. But did you notice the "adding", "adding", "adding" language? (I tried to make it easy for you.)

Does This Call for Disruptive Innovation?

I had the privilege, yesterday, to attend a presentation by Marion J Ball, Ed.D, whom most of you know, is an IBM research fellow, Hopkins Professor, Member of the IOM, Fellow of ACMI, HIMSS, CHIME, and member of HCI's Editorial Board. Â

She hit on the "adding, adding, adding" problem, in describing Disruptive Innovation in the talk. She defined DI by referencing Clayton Christensen's definition "... a technology that brings a much more affordable and accessible product or service that is simpler to use into the market." Â

Things don't get simpler by continually adding to them. And disruptive innovation is characterized not by adding or removing from the existing paradigm, but changing it and simplifying it. (e.g. Mainframe to PC, or rotary phone to iPhone, through several successive innovations.)

To frame it differently she shared the following quote which I'm sure resonates with all of us:

Perfection is achieved, not when there is nothing more to add, but when there is nothing left to take away.
    - Antoine de Saint-Exupery (1900-1944)



Summary




We have CDSS. We routinely disable it, after we deliberately selected these systems to improve safety through CDSS.




Within CDSS, we have rules and drug checking (drug-drug, drug allergy, duplication, dose, formulary, substitution, geriatric, renal, and other checking and guiding). There are other forms of CDSS.




This CDSS reasons over order intention (unsigned order scratchpads), order sets, pathways, plans, and clinical documentation, like medication reconciliation documents. Â




We're adding in more layers, as Dr Peterson and I have elaborated here. Not surprisingly, CDSS reliability is decreasing predictably and getting more complex, as the number of parts increase.




To borrow from Dr. Peterson, '

[we need a] process of discovery and refinement that ... lead to a standardized "cockpit" for knowledge management in clinical settings.

"




What do you think? Can we refine and evolve our way to more safety, or, do we need disruptive innovation, that approaches CDSS differently? What exactly is needed?







The brief word of guidance: this is a strategic dialogue, not a commercial one. Let's talk about approaches, not vendors in this setting. We all know that with time and money, anyone can do anything, if it can be reduced to an executable software algorithm. The commercial issues are best sorted out in the central marketplace, not HCI's intimate and smart blogplace.






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