For those of us who live in the corporate world email has been both a boon and a curse.

Before email, we composed interoffice memos and placed them in a magical envelope which routed itself through an arcane hidden system.  Days or weeks later we received a response. For more urgent issues we picked up the phone and called the other party.

Today, corporate users are flooded with email and messaging services.  It’s not uncommon to receive several hundred emails per day, and the acceptable response time is now measured in minutes.

Email has shaped us.  It interrupts our daily activities, shortens our attention span, and takes away from our ability to complete complex tasks.  Without significant effort it is easy to become Pavlov’s dog waiting for the proverbial chime.

Applying the notification methodology of the office to physicians requires extreme care.

There’s a fine line between the concept of notification and alerting that is not understood by most IT systems.  A notification is a discretionary message that is intended to draw your attention to an event that may be of interest.  An alert requires immediate processing in real time.

Bob Wachter has written extensively about alerts, and in particular, about how their indiscriminate use can be detrimental to patient care.  If everything requires immediate processing, then nothing requires immediate processing, and alerts become part of normal operations.  In time this tends to lead to alerts that are ignored.

The problem with notifications is more subtle.  By its definition a notification is discretionary.  If a patient is being discharged from the hospital a notification may be sent.  Does this require your attention?  Perhaps, depending on the nature of the patient’s condition.

Most of the systems on the market try to handle notifications by defining filtering rules that resemble those you might find in Outlook or Gmail.  The rules take the form of a production, if “this” then “that”.  When the “if” clauses is true, the “that” action fires.

It’s not enough to put simple filters in place.  Saying “notify me of all lab tests for all patients” is almost never a good idea. Asking for updates related to blood work for patients with lupus may be more useful.

Likewise, systems that send messages on each admit, discharge, and transfer event may distract.  Do MD’s really need to know the patient has gone in for routine surgery today, especially if they’re the one who referred him for that surgery?  Probably not, but they are interested in patients who are presenting at the emergency department with an exacerbation of chronic condition or a new acute problem.

One way to improve notifications is to provide an excellent suppression mechanism. Physicians should be able to turn off most of the notifications about a hospitalization event for a given patient with a single click. More important events should not be “suppressible” and perhaps should bubble up into alerts.

To conclude, notification systems that parallel corporate email are probably minimally useful, and are likely to result in additional physician distraction. The key is clinical relevance and a light touch that results in the right notifications being sent to the physician – right when they need them.

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