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Where Process and Technology Intersect: Low-Hanging Fruit...?

September 29, 2009
by Mark Hagland
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A fascinating new study was published in yesterday’s Archives of Internal Medicine. Hardeep Singh, M.D., MPH, of the MichaelE.DeBakeyVeteransAffairsMedicalCenter and Baylor College of Medicine in Houston, and colleagues, looked at processes around automated alert systems designed to let physicians know about significant abnormal findings in imaging studies.

And what Dr. Singh and his colleagues found, after studying 1,198 critical imaging notifications sent within an integrated EMR system, was this: even when physicians read and acknowledged electronic alerts about results of critical imaging studies, they sometimes failed to follow up in a timely way. And, perhaps counter-intuitively, having the system alert more than one physician only seemed to increase the chance that the alert would be ignored. As a result, 7.2 percent of alerts resulted in no follow-up for at least one month—that’s right, one month. And these alerts were all for critical (abnormal) imaging report results.

The EMR used by all Veterans Affairs hospitals relies on a notification system, which uses a tool called a “view alert” window, to alert clinicians about critical imaging test results. What’s more, that system is the only method for notifying physicians within the system about abnormal test results, unless radiologists personally pick up the phone and call referring physicians to relay life-threatening findings. What’s more, because reports of abnormal findings are added to patients’ records, it is possible for a physician to read the findings of a report without opening the corresponding notification within the “view alert” window.

Dr. Singh’s study found that 217 alerts were not opened for up to 28 days after being posted, and no evidence of documented follow-up action was recorded for 131 of those alerts. Study authors identified 111 cases among those 131 that were worthy of timely follow-up. Ultimately, 92 alerts were identified as lacking timely follow-up four weeks after posting. The most ignored type of abnormal findings involved non-specific density on a chest x-ray.

So, here’s the kicker: dual-alert notification, designed within that system as a safeguard, and to protect against lack of follow-up, ended up having the exact opposite effect, with Singh and his colleagues concluding that it resulted in numerous cases in physicians believing that the responsibility for follow-up belonged to someone else. Singh and his colleagues offered a series of recommendations, some procedural and some technological, for solving the problem.

What I find interesting in this study is this: however “smart” we believe IT enhancements can make our patient care processes, there is no substitute for carefully analyzing the impact and results of all such enhancements, and for using the results of such analysis to further improve processes. This is exactly what all the hospital organizations that I interviewed for my two books on care quality and efficiency, Transformative Quality: The Emerging Revolution in Health Care Performance, and Paradox and Imperatives in Health Care, have been doing. In short, the work of improving patient safety and patient care quality is difficult and complex, and no one should believe that IT enhancements alone, as vital as they are to improvement, can shoulder the entire burden of process improvement.

What’s more, the Singh study demonstrates the universal law of unintended consequences. So as hospital organizations move forward on EMR, CPOE, eMAR, advanced pharmacy, and other clinical applications, it will be ever more important to make sure that the technological enhancements being plugged into those systems are regularly evaluated for effectiveness. Of course, that means more work for the CIO and the IT team, and especially for the growing cadres of clinical informaticists in forward-thinking hospitals; but after all, that’s what this is all about, isn’t it? Really using information technology to improve care, not simply to automate it or speed it up. And health care IT professionals can really make heroes of themselves (yes, perhaps unsung some of the time, but heroes nonetheless!) by going that extra mile and evaluating and improving the enhancements they’re making to patient care delivery processes. If not, we can expect to see a multiplication of unintended consequences across health care.

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