Evolving Message Systems Learn To Filter And Route Alerts For Health Care Providers

Posted on December 11, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Because health care is a collaborative endeavor, patients can suffer if caretakers don’t get timely notifications. At the same time, the caretakers suffer when they are overloaded with alerts. Threading one’s way through this minefield (“Communications are complicated,” Vocera CMIO, Dr. Benjamin Kanter told me) was the theme of November’s Healthcare Messaging Conference and Exhibition at the Harvard Medical School. Like HIMSS, the major conference in health IT, something of a disconnect existed here between the conference and the exhibition. The speakers in the sessions implicitly criticized what the vendors were offering, information overload being the basic accusation.

Conference speakers told story after story of well-meaning installations of messaging systems that almost literally assaulted the staff with dozens of messages an hour. Kenny Schiff of CareSight reported seeing boxes full of expensive devices stuffed into closets in many hospitals. Dr. Trey Dobson reported research suggesting that 85% of standard hospital alarms require no intervention at all. He speculated that messaging has similar wasteful effects. In his facility, the Southwestern Vermont Medical Center at Dartmouth, they determined which lab results need to be delivered to the physician immediately and which could wait. They greatly reduced the number of messages sent about labs, which in turn decreased delivery time for important messages from an average of 50 minutes to only 7 minutes. These stories show both the benefits and drawbacks of current messaging systems.

State of the science
We all remember the first generations of pagers. Modern messaging systems, as represented by the vendors at the Healthcare Messaging Exhibition, offer a much sleeker experience, including:

  • Knowledge about who is responsible for a patient. No longer should messages be delivered to the nurse who left his shift an hour ago. The technical mechanism for tracking the role played by each clinician is group membership, familiar from the world of security. All clinicians who share a responsibility–such as working on a particular ward or caring for a particular patient–are assigned to a group. The status of each clinician is updated as he or she logs into the system, so that the message is delivered to the doctor or nurse currently on duty. A clinician dealing with one urgent situation should also not be interrupted by messages about another situation.

  • Full tracking of a message throughout its lifetime. The system records not only when a message was sent, but whether and when it was read. A message that goes ignored after a certain period of time can be escalated to the next level, and be sent to more and more people until someone addresses it.

  • Flexibility in delivery medium: mobile device, pager, computer, WiFi link, cellular network.

  • Sophisticated auditing. If a hospital needs to prove that a message was read (or that it was never read), the logs have to support that. This is important for both quality control and responses to legal or regulatory actions.

  • Integration with electronic health record systems, which allows systems to include information about the patient in messages.

  • HIPAA compliance. This essentially requires just garden-variety modern encryption, but it’s disturbing to learn how many physicians are breaking the law and risking their patients’ confidentiality by resorting casually to non-compliant messaging services instead of the ones offered at this exhibtion, which are designed specifically for health care use.

  • Cloud services. Instead of keeping information on devices, which can lead to it becoming lost or unavailable, it is stored on the vendor’s servers. This allows more flexible delivery options.

Although some of these advances generate more informative and useful messages, none of them reduce the number of messages. In fact, they encourage a vast expansion of the number of messsages sent. But some companies do offer enhancements over the common traits just cited.

  • Vocera has been connecting health care staff for many years. The company formed the subject of my first article on health IT in 2003, and of course its technology has evolved tremendously since then. Their services extend beyond the hospital to the primary care physician, skilled nursing facilities, and patients themselves. Dr. Kanter told me that they conceive of their service not simply as messaging, but as a form of clinical decision support. Their acquisition of Extension Healthcare in 2016 allowed them to add a new dimension of intelligence to the generation of messages. For instance, the patient’s health record can be consulted to determine the degree of risk presented by an event such as getting out of bed: if the patient has a low risk of falling, only the patient’s nurse may be alerted. Location information can also be incorporated into the logic, so that for instance a nurse who is already in the patient’s room will not receive an alert for that patient. Vocera has a rules engine and works with hospitals to develop customized rules.

  • HipLink has a particularly broad range of both input and delivery devices. In addition to all the common devices used by clinicians, HipLink can convert text to voice to call a plain telephone with a message. CEO Pamela LaPine told me it also accepts input not only from medical sensors, but from sensors embedded in fire alarms, doors, and other common props of medical environments.

  • OnPage helps coordinate secure communications through the use of schedules, individual and group messaging, and message tracking. For instance, the end of an operation may generate a message to the nursing staff to prepare for the arrival of a post-op patient. A message to the cleaning staff might be generated in order to prepare a room. All the necessary messages are presented to a dispatcher on a console.

  • 1Call, which provides a suite of innovative and integrated scheduling and communication applications, includes prompts to call center staff, a service they call Intuitive Call Flow Navigation. For a given situation, the service can help the staff give the information needed at the right point in each call. The same logic applies to the automated processes carried out with 1Call’s integration engine and automated notification software, which can also consolidate messaging based on rules, be customized to each organization’s needs, and improve efficiency throughout the organization.

Michael Detjen, Chief Strategy Officer of Mobile Heartbeat, laid out the pressures on messaging companies to evolve and become more like other cutting-edge high-tech companies. As messaging become universal through a health care institution, workflows come to depend on it, and thus, patient lives depend on it too. Taking the system down for an upgrade–or even worse, having it fail–is not acceptable, even at 2:00 in the morning. Both delivery and successful logging must be guaranteed, both for quality purposes and for compliance. To achieve this kind of reliability, developers must adopt the advanced development techniques popular among the most savvy software companies, such as DevOps and continuous testing and integration.

Looking toward the future
In his presentation, Schiff described some of the physical and logistical requirements for messaging devices. Clinicians should be able to switch devices quickly in case one is lost. They should be able simply to run their ID card through a reader, pick up a new device, and have it recognize them along with their message history (which means storing the messages securely in the cloud). Login requirements should be minimized, and one-hand operation should be possible. Schiff also looks forware to biometric identification of users.

Shahid Shah pointed out that the burden current messaging places on caregivers amounts to a form of uncompensated care. If messages are sent just to reassure patients, doctors and nurses will treat them as annoyances to be avoided. However, if the messages improve productivity, staff will accept them. And if they improve patient outcomes, so much the better–as long as fee-for-value reimbursements allow the health care provider to profit from improved outcomes.

To introduce the intelligence that would make messaging beneficial, Shah suggests more workflow analysis and the automation of common responses. A number of questions regarding patients could be answered automatically by bots, leaving only the more difficult ones for human clinicians.

The message regarding messaging was fairly consistent at the Healthcare Messaging Conference. Messaging has only begun to reap the benefits it can provide, and requires more analytics, more workflow analysis, and more integration with health care sites to become a boon to health care staff. The topic was a rather narrow one for a two-day conference, perhaps the reason it did not attract a large audience in its first iteration. But perhaps the conference will help drive messaging to new levels of sophistication, and become true life-savers while reducing burdens on clinicians.

Healthcare messaging and communication is also one of the focuses of our conference Health IT Expo happening May 30-June 1, 2018 in New Orleans. If you’re in charge of your hospital messaging systems, join us in New Orleans for an in depth look at best practices, hacks, and strategies for hospital messaging and communication.

This article is also available in a Portuguese translation by homeyou.