Reduced Alert Fatigue with Increased Clinician Responsiveness and Improved Outcomes Steven H. Shaha, PhD, DBA Prof, Center Public Policy & Administration Principal Outcomes Consultant, Allscripts
Disclosures & Bio Steven H. Shaha, PhD, DBA Professor, Center for Public Policy & Administration Principal Outcomes Consultant, Allscripts Former Dir. KLAS Research/Performance Insights 125+ peer-reviewed publications, 350+ peer-reviewed presentations, 3 books Advisory and consulting work for 11 govt.s in Asia, Australia, Europe and No. America Advisory and consulting to over 50 non-healthcare organisations, among them: Disney, Ritz-Carlton, Coca-Cola, New Line Cinema, IBM, AT&T, Time Warner Employment history includes: Coca-Cola, RAND Corporation, UCLA Medical Center, Intermountain HC, Gartner Education: PhD, Research Methods & Applied Statistics DBA, Business Administration (PhD) MA, MEd, BS
Prof. Steven H. . Shaha, PhD, DBA
Sample of Peer-reviewed Journals • Advance for Health Information Executives • Journal of Obstetrics and Gynecology • Advances in Patient Safety • Journal of Orthopedic Trauma • Agency for Healthcare Res & Qual (AHRQ Journal) • Journal of Pediatric Emergency Care • American Journal of Ob & Gynecology • Journal of Perinatal Medicine • American Journal of Sports Medicine • Journal of Perinatology • Applied Clinical Informatics • Journal of Shoulder and Elbow Surgery • Archives of Otolaryngology, Head & Neck Surg • Journal of the Am Acad of Ped Ophth & Strab • Breast Cancer Research and Treatment • Journal of Ultrasound in Medicine • British Medical Journal of Quality & Safety • Journal of Ultrasound in Ob & Gynecology • Epidemiology and Infection • Laryngoscope • Health Management Technology • Nurse Executive Watch • Healthcare Financial Management • Nurse Leader • Healthcare Technology Management • Nursing Economics • Intl. Journal of Medical Informatics • Pediatric Critical Care Medicine • Intl. Journal of Pediatric Otorhinolaryngology • Pediatric Emergency Care • Intl. Journal for Quality in Health Care • Pediatrics • Journal of Arthroscopic and Related Surgery • RN Magazine • Journal of Clinical Ultrasound • Spine • Journal of Emergency Nursing • Intl. Journal of Pediatric Otorhinolaryngology • Journal of Mat, Fetal & Neonatology Med • The Journal of Bone & Joint Surgery • Journal of Neurosurgery • Ultrasound in Obstetrics & Gynecology
Main Concepts • Alert Fatigue is real and harmful … … and needs to be addressed and reduced • Alerts are Important and “intentional” … … and merit/require responsiveness BUT often a short cut by non-clinicians • When Alerts are favorably impactful everyone benefits … … right?
Signal to Noise Ratio
Real-Time Outcomes Optimization Best care and best quality scores optimized while the patient is still in the bed The Power to Change Outcomes The Evolution of Health Care Information The best in advanced Clinical Decision Support Retrospective Prospective Retrospective Concurrent Automated Predictive Manual Synchronous Reporting Care Reporting Care From Clinicians Clinical Intelligence and Automated Patients Assessments From Devices Practitioners Extracted from multi-disciplinary documentation From Systems “Competitors” Improved Notify Continuous Clinical Decision Outcomes For Clinicians Support Engine Individually and collectively For Responders For Clinicians “Our” Recommended Treatments e.g. Order sets, pathways, algorithms, evidence-based medicine, To Systems For Responders inter-disciplinary documentation templates To Patients To Systems Providing the best care and achieving To “Competitors” optimal quality and performance
Safer Physician Practices 31.2% fewer alerts for Users of Intelligent Order Sets w/CDS (p<.0001) Comparative Alert Rate: CPOE vs. Non-CPOE Intelligent Order Sets vs. CPOE Alone 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% CPOE Non-CPOE Intelligent Order Sets Intelligent Order Sets CPOE Alone CPOE Alone
Safer Physician Practices 122.8% more responsive to the fewer alerts they received for Users of Intelligent Order Sets w/CDS (p<.0001) Comparative Alert Response Rate: CPOE vs. Non-CPOE Intelligent Order Sets vs. CPOE Alone 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% CPOE Non-CPOE Intelligent Order Sets CPOE Alone
Safer Physician Practices 59.2% fewer medication-related errors reached patients when managed on Intelligent Order Sets w/CDS (p<.0001) Errors "Reaching the Patient": CPOE vs. Non-CPOE Intelligent Order Sets vs. CPOE Alone Patients managed 1.20% through Intelligent 1.00% Order Sets More than double the w/CDS 0.80% error rate (p<.001) experienced 0.60% significantly fewer 0.40% errors (p<.0001) 0.20% 0.00% CPOE Non-CPOE Intelligent Order Sets CPOE Alone Estimated £ 211,000 cash released annually for PICU alone
• 31.2% fewer alerts (p<0.001) • 122.8% increased responsiveness to alerts (p<0.001) double+ versus pre-computer-computed dosing recommendations • Most importantly • 59.2% lower medication-attributed errors and incidents (p<0.001) Peds …
Signal to Noise Ratio Meaningful notifications requested versus alert fatigue … Forcing adoption versus proving value …
Improved Outcomes
Improved Outcomes • Patients arriving sicker • Less sick patients – other care pathways • Trend onerous … • What can be done?
Post Pre EPR • Constancy of 4-per-day • Impact assessment …
Improved Outcomes 3.42 Mean to 2.56 Mean Post £116,000 Annual Cash Release Pre EPR Impacts & Benefits with the EPR: Impacts & Benefits with the EPR: • • Despite increased patient severity (105.5% more, 1.67 to 3.42) Despite increased patient severity (80% more, 1.67 to 3.0) • • Controlled and decreased negative outcome Controlled and decreased negative outcome 100% lower pre month vs. recent low (3 to 0) 75.0% lower pre month vs. recent low (4 to 1) 33.3% lower pre-post year-to-year (3.0 to 2.0) 25.2% lower pre-post year-to-year (3.42 to 2.56)
Echo effect …
Improved Mortality Rates with MEWs Hosp Std Mort Ratio Post 103.7 Mean to Pre EPR 86.3 Mean Impacts & Benefits with the EPR: • Decreased negative outcome 16.7% lower pre-post year-to-year (103.7 to 86.3)
Pre EPR Post Falls • 14.1% reduced year-over-year from Pre-baseline • 13 fewer falls Falls with Injury • 45.7% reduced year-over-year from Pre-baseline • 11 fewer falls with injury
Grade 2 Avg Grade 2 PUs ppd Post Pre EPR • 50.5% reduced from Pre-baseline
Grade 3+ Zero Grade 4 Avg Grade 3+ PUs ppd Post Pre EPR • 78.9% reduced from Pre-baseline
Signal to Noise Ratio
Lessons Learnt • EMR/EPR cannot merely be “electronified paper” • Programmability and Adaptability • Rigidity vs. Openness • Local autonomy vs. dependency on vendor prioritisation • Community Connectivity and Interoperability across Settings & “HIE” • Local Innovation … Reflecting Broader Standardisation • No org or facility is identical – patient pops, layout, personnel, specialties … • Access to Clinical Data • Ad hoc, investigational, curiosity, personal/specialty improvement and optimisation • Test new implementations, verify impact and refinement as needed, continuous improvement • Routine reports formatted locally or centrally and used as needed • Outcomes-driven • Clinical • Efficiency • Cash Releasing and Cost Reducing • Stakeholder satisfaction 24
Generalizable … Clinicians collaborating with their own IT professionals
Remember the MEWs and Arrests? Why Why does does • Cl Clinician inician En Engage gagement ment and and • Lo Local cal Pr Prog ogrammability rammability Wor Work k Bet Bette ter? r? 26
Levels of Information: Needs and Perspectives • Slow change • Stable figures • Strategic perspective • Routine change • Evolving figures - Improvement • Operational perspective • Fluid change / Live figures • Real results – NOW or catastrophic • Process perspective
Levels of Information: Needs and Perspectives
Happy Ending …
Main Concepts • 31.2% fewer alerts (p<0.001) • 122.8% increased responsiveness to alerts (p<0.001): double+ versus pre-computer-computed dosing recommendations • Most importantly, 59.2% lower medication-attributed errors and incidents (p<0.001).
Signal to Noise Ratio
33
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