Working 22.6 hours a day: Alert fatigue, guidelines and “left of boom” opportunities in health care

Where do alerts fit in a physician’s 22.6 hour day?

When I’m travelling around the country interacting with healthcare leaders and health systems, I mostly see valiant efforts to improve outcomes through improved management of diseases. While improving disease management through guideline adherence is certainly a good thing, this is a problematic strategy given the current reality of our tools, the design of our workflow and our ability to recognize and address the multiple non-disease factors that weigh heavily on outcomes.

I have written before about the profound impact non-clinical factors have on clinical outcomes. Here, I will address how guideline adherence drives a large volume of alerts and how that volume may act as an unintended negative influence on the healthcare work force and outcomes.

Ostbye and colleagues calculated that the average primary care physician (PCP) needs 10.6 hours per day to address guideline recommendations for the top 10 conditions for their patient population.ⁱ Add to this the average of 7.4 hours per day required to address the prevention needs of their populationⁱⁱ plus the 4.6 hours per day required to address acute problems,ⁱⁱⁱ and we have the typical 22.6 hour work day of the average PCP.

The work exceeds the capacity of even the most dedicated provider and, as acute needs takes precedence for most people, we should not be surprised that around 55 percent of people receive their recommended care.^iv

A recent article on cyber security in The New York Times noted similar findings:

“The average organization receives 16,937 alerts a week. Only 19 percent of them are deemed 'reliable,' and only 4 percent are investigated.”

The cyber security startup’s approach is to “get left of boom”—a military term meaning the moment before a bomb explodes. In the military, it means figuring out where the bomb-makers obtained supplies, and how they made and deployed their weapons.

The cyber security innovators are working to separate meaningful alerts from the noise. In health care, we don’t want to lose the small signals of “gaps in care” but we must get our technology to automate and simplify these tasks so that we can also attend to the bigger signals, the “left of boom” alerts.

People who self-identify as having significant, bothersome pain or emotions, who think their medicines are making them ill or who lack confidence are significantly more likely than others to end up in the emergency department or hospital.^v Health risk assessment data can help us identify these issues^vi and layer that knowledge on top of claims and EMR data.

The promise of technology is its ability to sift through vast databases, perform automated tasks, help us find the signal in the noise and focus on important issues—all while making our work less complicated. Sending out an increasing volume of alerts runs into the overwhelmed reality of most of primary care in the U.S. In addition to moving away from volume-driven payment, let’s attend to the volume-driven work through smarter technology.

L. Gordon Moore, MD, is senior medical director for populations and payment solutions at 3M Health Information Systems.

Documentation compliance tools. Applied to helping physicians focus on what's important: patient care.

ⁱ Østbye, Truls, Kimberly S. H. Yarnall, et al.. “Is There Time for Management of Patients with Chronic Diseases in Primary Care?” Annals of Family Medicine 3, no. 3 (June 2005): 209–14. doi:10.1370/afm.310.

ⁱⁱ Yarnall, Kimberly S. H., Kathryn I. Pollak, et al.“Primary Care: Is There Enough Time for Prevention?” American Journal of Public Health 93, no. 4 (April 2003): 635–41.

ⁱⁱⁱ Stange, K. C., S. J. Zyzanski, C. R. Jaén, , et al. “Illuminating the ‘Black Box’. A Description of 4454 Patient Visits to 138 Family Physicians.” The Journal of Family Practice 46, no. 5 (May 1998): 377–89.

^iv McGlynn, Elizabeth A., Steven M. Asch, John Adams, et al.. “The Quality of Health Care Delivered to Adults in the United States.” New England Journal of Medicine 348, no. 26 (June 26, 2003): 2635–45. doi:10.1056/NEJMsa022615.

^v Wasson, John H, Deborah J Johnson, and Todd Mackenzie. “The Impact of Primary Care Patients’ Pain and Emotional Problems on Their Confidence with Self-Management.” The Journal of Ambulatory Care Management 31, no. 2 (June 2008): 120–27. doi:10.1097/01.JAC.0000314702.57665.a0.

^vi Wherry, Laura R., Marguerite E. Burns, and Lindsey Jeanne Leininger. “Using Self-Reported Health Measures to Predict High-Need Cases among Medicaid-Eligible Adults.” Health Services Research 49, no. S2 (December 2014): 2147–72. doi:10.1111/1475-6773.12222.