Some people receive constant reminders on their personal smartphones: birthdays, anniversaries, doctor’s appointments, social engagements. At work, their computers prompt them to meet deadlines, attend meetings and have lunch with the boss. Prodding here and pinging there, these pop-up interruptions can turn into noise to be ignored instead of helpful nudges.
Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard. The electronic patient records that the federal government has been pushing — in an effort to coordinate health care and reduce mistakes — come with a host of bells and whistles that may be doing the opposite in some cases.
What’s the problem? It’s called alert fatigue.
Electronic health records (EHRs) increasingly include automated alert systems pegged to patients’ health information. One alert might signal that a drug being prescribed could interact badly with other medications. Another might advise the pharmacist about a patient’s drug allergy. But they could also simply note each time that a patient is prescribed painkillers — useful to detect addiction but irrelevant if, say, someone had a major surgery and is expected to need such meds. Or they may highlight a potential health consequence relevant to an elderly woman, although the patient at hand is a 20-something man.
The number of these pop-up messages has become unmanageable, doctors and IT experts say, reflecting what many experts call excessive caution, and now they are overwhelming practitioners.
Clinicians ignore safety notifications between 49 percent and 96 percent of the time, said Shobha Phansalkar, an assistant professor of medicine at Harvard Medical School.
“When providers are bombarded with warnings, they will predictably miss important things,” said David Bates, senior vice president at Brigham and Women’s Hospital in Boston.
Now, doctors, health information technologists and software vendors are trying to fix the problem.
Research on this human-computer interaction is starting to explore the degree of risk posed by excessive alerting versus the benefits the alerts produce. The companies selling electronic health records say advances are moving their systems toward more targeted, relevant warnings, instead of broad-brush signaling.
“This is an issue that everyone’s going to have to wrestle with eventually,” said Bill Marella, executive director of patient safety operations and analytics at ECRI Institute, a nonprofit organization that studies health care safety and quality issues. In April, the institute ranked design and implementation of new health IT systems as its top safety concern for 2016.
Some hospitals and health systems are already paving the way.
Take Children’s Hospital of Philadelphia. In 2012, the inpatient facility switched over to a new electronic health record, said Eric Shelov, a physician and the hospital’s associate chief medical information officer. Immediately, he said, practitioners began seeing far more alerts, to the point that doctors were overriding almost all of them. The problem, Shelov said, is that “if you see enough nonsense, you’re going to start ignoring it.”
That has consequences. In one instance at Children’s, doctors ignored relevant information about how a patient might respond to a drug, Shelov said, because it appeared alongside heaps of other superfluous notifications — warnings, for instance, about drugs that posed minimal risk of interfering with each other. Consequently, the patient received medication that induced a potentially lethal reaction.
The hospital caught the mistake in time, but the incident spurred a series of changes. A team of pharmacists, doctors and other clinicians have sorted through what triggered alerts in their system, turning off the ones they decided weren’t actually relevant or necessary. That has helped. But it’s still an ongoing battle, Shelov said. “It’s a little bit of trying to turn off the firehose.”
Systems such as Cleveland-based MetroHealth, the University of Vermont Medical Center and Group Health Collaborative of Southern Wisconsin have undertaken similar projects. Still others, like Brigham and Women’s, are working on it.
But figuring out what merits a computer warning takes time, manpower, expertise and money. Not all hospitals have those resources, Bates said. It’s inherently subjective. Some stakeholder groups have put out recommendations, and hospitals like Children’s have presented on ways to combat alert fatigue. But individual hospital task forces often end up deciding for themselves what’s risky enough to warrant an alert.
Patients, meanwhile, aren’t standing beside their doctors as they scroll through their medical records, noted Helen Haskell, a patient safety advocate. Patients can request access to their records, but that’s a static page they’ll see only after getting care. That means that, while this hyper-alerting poses a danger, there’s no way for consumers to know if, say, they got worse care because the doctor missed a warning.
“It’s very rare that patients are granted that perspective,” she said.
Software vendors say they’re trying to make their systems smarter.
Epic Systems, outside Madison, Wisconsin, for example, has been hearing feedback for years from doctors about redundant or irrelevant alerts, said Bret Shillingstad, a physician who works on Epic’s clinical informatics team. They’ve added in functionality for hospitals to turn those alerts off. They’re working now to develop software that might target alerts based on things like a patient’s health condition or recommend medications that better match someone’s overall profile. Then there are simpler adjustments, like changing a system so that if a patient needs a vaccine, reminders just go to the primary care doctor, not the orthopedist, too.
In the long term, system designers are trying to better consider the nuances of a patient’s medical needs so that they can use fewer warnings and send them only when they matter, said Terry Fairbanks, an emergency physician and director of MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. For instance, people with advanced cancer often need doses of morphine that might be unsuitable for other patients. A smarter system would warn doctors about that morphine order for patients who don’t have cancer but would treat it as normal for someone in the disease’s late stages.
Such a change could limit distractions so that physicians act upon pressing reminders — like notifications highlighting if a patient is at risk for sepsis, which can be deadly if it’s not noticed early.
But there’s still debate. Haskell said she would argue doctors should always be warned about certain medications and drug interactions.
“All of these alerts have really reduced medication interactions. It’s a service,” she said. “It just needs to be refined.”
But there’s clearly a cultural shift underfoot, added Phansalkar, who also works as director of informatics and clinical innovation at Wolters Kluwer Health, which supplies drug information to electronic health record systems. Alert fatigue is no longer “just something providers complain about,” she said. In health care, people are trying to devise more effective, nuanced ways for electronic systems to improve care.
“Because it’s so easy to put an alert to address a problem, that’s people’s natural, knee-jerk reaction,” said Douglas Gentile, medical director of clinical information systems at the University of Vermont Medical Center. But “as you add those, it creates additional problems. And you get collateral damage.”
Owen had been living outside for many years. He suffered an injury to his back and neck about 20 years ago. He wasn’t able to work and support himself after that. He was proud of how he cared for his campsite and liked living outdoors. But there were two big problems: The city was shutting down the camp and his physical health was deteriorating. He didn’t know if he could survive another Iowa winter outside, especially if he had to move.
Fortunately, he connected with a local hospital and a trusting relationship was built. He was enrolled in health insurance and qualified for disability benefits under Social Security. Despite early apprehension, he started showing up to medical appointments and received consistent care.
The hospital also helped him find an apartment, set up a bank account and get a phone. Now Owen’s life is stabilizing, he enjoys making meals in his apartment and is optimistic about his future.
Robert was staying at the local shelter when he was referred to the hospital. In the years prior, he had lost his job and gone through a bad divorce. As a result, he had no stable place to live and no money. He was very depressed.
The hospital assisted Robert in finding an apartment and secured rent support for him. Once Robert obtained stable housing, the hospital referred him to Goodwill’s supportive employment services. Robert was interested in their janitorial training program and he excelled right away.
About the time Robert completed the janitorial program, Goodwill moved to a new building. He was hired as a fulltime overnight janitor. He shared the good news with the people at the hospital who had helped him. He said he couldn’t remember the last time he felt so happy.
These are two true stories about Iowans in need and how a hospital intervened and served them, not with groundbreaking research, intricate surgery or amazing technology, but with those things that hospitals and the people who work for them have been bringing to the table for centuries: compassion, dedication, hope, resourcefulness. Such are the roots of community-based health care, but it is also where health care is headed.
Every day brings greater understanding about how an individual’s world affects their health. Not only the world where they live today, but the one where they grew up, went to school and where they work now and before. Health by definition is the absence of disease or injury, but that is just a fleeting snapshot, an ever-changing sum of a hundred different inputs.
The provision of “health care” is a relatively small determinant of overall health – perhaps 10 percent, most experts agree. To truly meet the Triple Aim, hospitals and other providers must participate and lead in the other 90 percent. Those opportunities are found in shelters for the homeless and abused. In daycares, schools, neighborhoods, parks and recreation centers. In VFW halls and senior centers. In factories, offices and farm fields. In courtrooms and the places of government.
These are the places where health and lives, like Owen’s and Robert’s, will be lost or saved. And to truly make a difference, hospitals must be there too.
That is the legacy of community-based health care – and its future.
Mercy Medical Center-Sioux City partners with the Sioux City Community School District to sponsor KidShape 2.0, a fun-filled, eight-week program that helps children and their families live a healthier lifestyle.
The goal of the program is to reverse the obesity epidemic. KidShape 2.0 is geared toward children who are overweight or obese, but is family-based, so the children attends classes along with their parents or guardians, helping the entire family is engage in making healthier choices. The children and their families attend a weekly two-hour class.
The class curriculum covers topics such as:
- Nutrition: a registered dietitian teaches well-balanced eating habits for a healthier lifestyle.
- Physical activity: kids participate in 30 minutes of fun, aerobic exercise. Ten minutes of family fun is promoted each week.
- Supportive activity: adults and kids learn how to support each other in how to change old habits and adopt healthy lifestyle changes.
KidShape has made a huge impact on the families participating. One 10-year-old student who has autism learned a great deal while in the program. As the KidShape team worked with her, she opened up and became very engaged. At the end of her eight-week program, she was asked how she would make an unhealthy meal healthier. She chose hotdogs as an example of a meal to improve on. She brought a whole wheat bun with a banana to replace the hot dog, and peanut butter for the topping, which is a much healthier option.
Besides healthy food choices, children and their families are encouraged to adopt a variety of other healthy habits. The children are taught fun indoor activities that will keep them active year-round. They are also encouraged to keep time spent in front of the television, computer and hand-held electronics to a minimum. Families are asked to commit to eating dinner together at least four nights a week.
Jerry Hernandez, Mercy Medical Center’s KidShape liaison, explained, “The main goal is to transform lives which will make a healthy impact for the future. We don’t gauge success by weight loss, although our students do lose weight. We see success when we change habits concerning eating and physical activity.”
To help the families achieve success in maintaining their healthier lifestyles, they receive vouchers for fruits and vegetables at the local grocery stores, tickets for admission to the local ice skating rink and a variety of other giveaways that encourage activity and good health.
Education is the key to Kidshape 2.0. The KidShape team consists of a dietitian, physical education instructor, mental health coach and a translator since the Siouxland community is culturally diverse. These experts work with the entire family to teach new behaviors that will help the entire all members feel good.
There is no cost to the students and families who participate in KidShape 2.0, which is funded with grant money. Because of this, any child and family who want to participate can do so.
IHA’s Iowa Hospital Education and Research Foundation (IHERF) has awarded $115,500 in scholarships to 33 college students from all parts of Iowa. The students, who are all studying in health care fields, will each receive $3,500 (an increase from $3,000 awarded in previous years) for the upcoming academic year and each student is eligible for an additional $3,500 award. Five of the students are repeat recipients from 2015.
IHA established the IHERF Health Care Careers Scholarship Program in 2004 to help address the ongoing shortage of health care professionals and encourage young Iowans to establish or continue their careers with Iowa hospitals. The first scholarships were awarded in 2005 and now more than 300 students have benefited from the program.
Iowa hospitals also benefit from the scholarship program. In exchange for financial support, scholarship-receiving students agree to work one year in an Iowa hospital for each year they receive an award. Today, more than 200 past scholarship recipients are working in hospitals across the state.
Including these latest awards, the scholarship program has now provided more than $1 million in direct support to students since its inception.
IHA staff, the IHERF Board, hospital leaders and IHA Auxilian/Volunteer Board members from throughout the state evaluated scholarship applications from more nearly 150 students, who were judged on grade-point average, a written personal statement, letters of reference and extracurricular, community and health care-related activities. The students, who are in both undergraduate and graduate programs, will be recognized this summer at IHA’s “Swinging for Scholars” event, which is the primary fundraiser for the scholarship.
This year’s scholarship recipients are listed below:
|A||Kayla Bakker||Rock Valley||Nursing – ADN|
|A||Marissa Morenz||Sioux City||Nursing – BSN|
|A||Amanda Richard||Estherville||Nursing – MSN|
|A||Sara Roth||Wall Lake||Nursing – BSN|
|B||Abbey Devers||Rutland||Nursing – MSN|
|B||Lynne McKenna||Algona||Nursing – ADN|
|B||Yuridia McVey||Belmond||Radiology Technology|
|B||Lacey Verink||Ankeny||Nursing – BSN|
|B||Deena Zadow||Kanawha||Nursing – BSN|
|C||Pam Brahn||Nashua||Nursing – MSN|
|C||Holly Eastman||Waverly||Nursing – MSN|
|C||Allison J Flaucher||Jesup||Nursing – BSN|
|C||Valerie Henson||Jesup||Ultrasound Technician|
|D||Megan Kalene King||Corning||Dietician|
|D||Kyle Kreger||Council Bluffs||Nursing – MSN|
|D||Paige Machacek||Bellevue||Nursing – BSN|
|D||Brennan McNitt||Iowa City||Physical Therapy|
|E||Adrian Accurso||Des Moines||Medical Technology|
|E||Brenda Kay Barfels||Iowa Falls||Nursing – ADN|
|E||Sheena Marie Bauer||West Des Moines||Nursing – MSN|
|E||Sarah Copple||Norwalk||Nursing – MSN|
|E||Laura Coyle||Des Moines||Nursing – DNP|
|E||Shannon Dailey||Charles City||Nursing – BSN|
|F||Carmen Ertz||Mediapolis||Physical Therapy|
|F||Jensen Rylee McCarty||Keokuk||Nursing – ADN|
|F||Patricia Meserole||Washington||Nursing – ADN|
|F||Summer West||Ottumwa||Nursing – BSN|
|G||Melissa Bitner||Clinton||Nursing – MSN|
|G||Heidi Haugland||Solon||Nursing – BSN|
|G||Kyle Kroymann||Pella||Physician Assistant|
|G||Lydia Molitor||Marion||Nursing – BSN|
|G||Amanda Paulson||North Liberty||Physical Therapy|
|G||Nicole Shatek||Stockton||Occupational Therapy|
Eric Burge of Davenport is no stranger to the world of organ transplantation. In fact, Eric’s brother, John, received a kidney transplant just a few years prior to Eric discovering he needed a transplant as well. Eric and John have an inherited disorder called polycystic kidney disease. It is the most common hereditary disease in the U.S., affecting more than 700,000 people each year. Many cases require an organ transplant due to the formation of cyst clusters in the kidneys that destroy healthy tissue.
Alan Reed, M.D., director of the Organ Transplant Center at University of Iowa Hospitals and Clinics, says many individuals with polycystic kidney disease need a transplant need a transplant but tend to have a very favorable prognosis. Luckily, when Eric started having health issues, his lifelong friend, Mary Beth Murray, had a special connection with organ donation and was willing to help. Mary Beth, who also lives in Davenport, decided to become an organ donor because of her father’s kidney issues when she was younger. Although she desperately wanted to help, Mary Beth was not a compatible match and unable to donate to her father.
When Mary Beth’s older sister faced the same kidney issues years later, Mary Beth once again was not a compatible match and unable to donate to her sister. Unwilling to give up, Mary Beth was determined to help Eric when she discovered he needed a kidney transplant. This time around, Mary Beth was a perfect match for her friend in need.
On January 3, 2013, the day of the surgery, Mary Beth remembers feeling excited and unsure what to expect, but determined to have a successful procedure. Reed performed Eric’s kidney transplant surgery with great success.
Since his transplant, Eric’s care has been managed by UI Post Kidney and Pancreas Transplant Coordinator Lou Ann Reynolds, RN. Eric describes Lou Ann’s support and calming influence as “immeasurable.”
Reynolds stresses the importance of becoming an organ donor. “Whether it’s for a friend, a workmate, or a total stranger, I would tell people they have the ability to change another person’s life,” Reynold says.
To Eric, a kidney transplant meant a second chance at life; “As a recipient, there’s no way to thank [my donor] to that magnitude.”
Both Eric and Mary Beth will participate in the 2016 Transplant Games, set for June 10-15 in Cleveland. They look at the games as a celebration of life and an opportunity to be together with family and friends. They will be competing together in the donor/recipient bowling event. Eric will also participate in the track and field events and swimming relay.
“I’m incredibly proud of these athletes and so pleased that they have taken this opportunity to do such great things,” Dr. Reed says.
To learn more about organ and tissue donation and the Iowa Donor Registry, click here.