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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 ( 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.

Patients Message Providers More When Providers Reach Out

Posted on April 26, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new study has concluded that patients use secure electronic messaging more when their primary care providers initiate and respond to secure messages.

To conduct the study, the research team worked a large database stocked with information on health care transactions and secure messaging records on 81,645 US Army soldiers. The data also included information from almost 3,000 clinicians with access to a patient portal system. The dataset encompassed the 4-year period between January 2011 and November 2014.

The data, which appears in a paper published in the Journal of Medical Internet Research, suggests that current provider-patient exchanges via secure messaging aren’t that common. For example, during the study period just 7 percent of patients initiated a secure message during a given month. Meanwhile, Providers initiated an average of 0.007 messages per patient each month, while responding to 0.09 messages per patient during a month.

That being said, when physicians got more engaged with the messaging process, patients responded dramatically.

Patients who knew their providers were responsive initiated a whopping 334 percent more secure messages than their baseline. Even among patients whose providers responded infrequently to their messages, the level at which they initiated messages to their clinicians was 254 percent higher than with PCPs who weren’t responding. (Oddly, when PCP response rates were at the “medium” level, patients increased messaging by 167 percent.)

In fact, when clinicians communicated more, there seemed to be spillover effects. Specifically, the researchers found that patients messaged PCPs more if that provider was very responsive to other patients, suggesting that there’s a network effect in play here.

Meanwhile, when PCPs were the ones prone to initiating messages, patients were 60 percent more likely to send a secure message. In other words, patients were more energized by PCP responses than clinician-initiated messages.

Of course, for secure messaging to have any real impact on care quality and outcomes, a critical mass of patients need to use messaging tools. Historically, though, providers have struggled to get patients to use their portal, with usage levels hovering between 10 percent and 32 percent.

Usage rates for portals have stayed stubbornly low even when doctors work hard to get their patients interested. Even patients who have signed up to use the portal often don’t follow through, research suggests. And of course, patients who don’t touch the portal aren’t exchanging care-enhancing messages with their provider.

If we’re going to get patients to participate in messaging with their doctor, we’re going to have to admit that the features offered by basic portals simply aren’t that valuable. While most offer patients access to some details of their medical records and test results, and sometimes allow them to schedule appointments, many don’t provide much more.

Meanwhile, a surprising number of providers haven’t even enabled a secure messaging function on their portal, which confines it to being a sterile data receptacle. I’d argue that without offering this feature, portals do almost nothing to engage their typical patient.

Of course, physicians fear being overwhelmed by patient messages, and reasonably fear that they won’t have time to respond adequately. Even though many organizations including the research of Dr. CT Lin has shown this just isn’t the case. That being said, if they want to increase patient engagement – and improve their overall health – secure messaging is one of the simplest tools for making that happen. So even if it means redesigning their workflow or tasking advanced practice nurse with responding to routine queries, it’s worth doing.

5 Tips When Implementing a Secure Text Messaging Solution

Posted on December 20, 2016 I Written By

The following is a guest blog post by Matthew Werder, CTO, Hennepin County Medical Center. Thanks to Justin Campbell from Galen Healthcare Solutions for facilitating this guest post for us.

Now twelve months into our secure messaging implementation, and it’s safe to say our transition to a secure-messaging application with the aspiration to eliminate pagers has been quite a journey.  Recently, I answered a couple of reference calls on the selection process from some of my healthcare colleagues and determined it was time to share 5 (of many) tips for implementing a secure messaging solution.  Like most healthcare technologies, what may appear to be simple isn’t and even with the best of the best implementation plans, project manager, and leadership support – the road to implementing a secure messaging solution contains many challenges.

To start, here are five tips that have left me with scars & memories:

#1 – Define Your Strategy.  Are you just adding another technology, enhancing an existing, or just buying into the hype of secure text messaging applications?  In his post dated January 26, 2016, Mobility Solutions Consultant, Jason Stanaland from Spok stated, “secure text messaging should be implemented as a workflow solution, and not simply a messaging product.”  Before putting ink to paper, ensure that your goals are aligned, providers are supportive, and a measureable outcome has been identified.  Just because you can implement a technology doesn’t mean you should.

#2 – Beware of the Pager Culture.  In the words of Peter Drucker, “culture eats strategy for lunch,” and the same can be said for the pager culture.  This was impressed on me last summer when a physician stopped me in the hallway and had questions about the new text messaging solution we were implementing.  She was very excited and encouraged to hear that we were taking communication, mobility, and security seriously.   What I wasn’t prepared for was her question, “What is your plan to address the 4, 5, and 9-digit callback needs?”

In many institutions, a pager Morse code exists.  Telemediq’s Derek Bolen wrote in December last year that the, “Pager culture’ is real, and extremely persistent, in healthcare.” Judy Mottl, of Fierce Mobile Healthcare, talks about “Why the pager remains a viable and trusted tool for providers.” She wrote that the pager has been a resilient tool and in order for new technologies to replace it, they must overcome the benefits of such a simple mobile device – the pager!  Don’t underestimate #PAGERPOWER!

#3 – Text Administration and Etiquette Policy.  If your goal is to replace your paging system or add a secure text messaging solution in addition to pagers, your paging and messaging policy will need to be archived and a new text messaging/secure messaging policy will need to be authored.  Who authors the policy will be a collaborative effort between the medical staff, legal, IT, nursing, compliance, and operations.  Gentle reminders as written by Dana Holmes, Family Lifestyle Expert of the Huffington Post, in her 2013 blog, “A Much-Needed Guide to Text Etiquette”, highlights the necessary rules and guidelines of texting. Many of these are well known, yet good reminders in the adoption of secure text messaging in healthcare.

#4 – Think Beyond Text Messaging.  Regardless of your strategy, text messaging alone will provide minimal value.  Organizations implementing secure text-messaging solutions should think beyond the implementation and think in terms of “Connection Point” or “Communications Hub” opportunities with the patient/customer in mind.  On August 19, 2015, Brad Brooks, TigerText Co-Founder and Chief Executive Officer, stated that secure texting not only fosters a collaborative environment, but it also enables users to quickly communicate and coordinate with other colleagues while eradicating the need for multiple devices and tedious communication channels. Unlike emails, secure texting is instantaneous and avoids outside threats or hackers. Secure texting encompasses everything we love about mobile messaging, but with built-in features and tools to help one work faster and more easily with his or her team.  Does the vendor have a roadmap to take you where you want? Intersect it with patients, and make for texting amongst patients and provider. Include the patient, how can they take advantage of the texting platform?  Turn it into an engagement tool.  Drive collaboration and improve the patient experience and family experience.

#5 – Enjoy and Have Fun.  I am amazed at times when technologists don’t embrace the adoption of a new technology that could have a significant impact on their organization.  The secure text messaging industry is rich and deep right now with countless options and innovative solutions at every corner.  You run into unforeseen obstacles and workflows, and despite the promise of a short implementation multiple it by two.  We all know that change in healthcare is challenging and exhausting so enjoy the ride!

Of course there are many more. At last count, about 37 additional lessons and tips should be considered when implementing your new secure-messaging solution, so feel free to comment and share your experiences.

About Matthew Werder
Matthew Werder brings over 20 years of healthcare experience in his position as Chief Technology Officer at Hennepin County Medical Center, a 477-bed Level 1 Trauma Center and Academic Medical Center in Minneapolis. In his role, he is responsible for advancing HCMC’s technology vision and strategy to enable the organization to achieve its critical priorities.  Currently, Matthew is leading the development of an enterprise telemedicine strategy, migration to a new data center, and leading the execution of the organization’s technology strategy.

Prior to his role as CTO, Matthew was the Director of Supply Chain at HCMC, where over the course of 4 years achieved over $12M in cost savings while transforming the supply chain organization whom received recognition by Supply & Demand Chain Executive as Pros to Know.  He also worked as a Supply Chain Manager for Medtronic, Inc. at their Physiological Research Laboratories and in the Global Strategic Sourcing group. Matthew is a certified Master Lean instructor and previously worked as a Lean Consultant with Operational Excellence, Inc. 

Matthew holds a Master’s Degree in Health and Human Services Administration from Saint Mary’s University and graduated from Concordia University with a degree in natural science.  He has presented and been published on several topics focusing on operational excellence, cost management, technology and the patient experience, and strategic sourcing for services in healthcare.

Barcodes, Integrating Bedside TVs, EHR, and Nurse Messaging Into Pain Management Workflow

Posted on February 7, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As I look across the healthcare IT landscape, I believe we’re just at the beginning of a real integrated solutions that leverage everything that technology can offer. However, I see it starting to happen. A good example of this was this case study I found on “Automated Workflow for Pain Management.”

The case study goes into the details of the time savings and other benefits of proper pain management in the hospital. However, I was really intrigued by their integration of bedside TVs together with barcodes, EHR software, and nurse messaging (sadly they used a pager, but that could have easily been replaced with secure messaging). What a beautiful integration and workflow across so many different technologies from different companies and this is just the start.

One major challenge to these workflows is making these external applications work with the EHR software. Hopefully things like the blog post I wrote yesterday will help solve that problem. Case studies like the one above illustrate really well the value of outside software applications being able to integrate with EHR software.

What I also loved about the above solution is that it doesn’t cause any more work for the hospital staff. In fact, in many ways it can save them time. The nurse can have much higher quality data about who needs them and when.

This implementation is also a preview of what Kyle Samani talked about in his post “Unlocking the Power of Data Science in Healthcare.” While Kyle wrote about it from the perspective of patients and getting them the right information in the right context, the same applies to healthcare providers. The case study above is an example of this shift. No doubt there will be some resistance to these technologies in healthcare, but once they get refined we’ll wonder how we lived without them.