The Alert System That Was Never Designed With Physicians in Mind

A Frustrating Day in the OR

I want to take you back to another frustrating day in my life as a surgeon. I was doing a fem pop bypass. Things were going really well. Spotify was playing on a speaker from my phone. I mean, it looked like the result would be really good. I should be excited, right? But the music was being continuously interrupted with alerts from my phone. Not once, not twice, but countless times throughout the case. So annoying. I mean how do you make that stop?

Well, after I finished the case, I glanced at my phone to see what I was missing. One was a refill request that could have waited until I reached the office. Another was a duplicate allergy alert that I had already acknowledged twice that week. A third was a message from our practice portal about a co pay for a patient. I have no idea why that was routed to me. Ironically, buried under all of that, was a stat potassium level on the next surgical patient in my line. That actually mattered.

Nothing about the way that information reached me told me which one was which. They all looked the same, they all sounded the same, they all demanded the same 30 seconds of my attention with the same visual weight.

That is not a physician’s problem. That is not an attention problem. That is a design problem. And it is one almost nobody built on purpose. It is one we all just inherited.

The Meaningful Use Mandate

Hello again. I am Dr. Kevin Halow, surgeon, veteran, co founder and Chief Medical Officer of ClinicianCore. Today I want to walk you through something most physicians have never been told: the origins of your alert system. Why it was built the way it was, and why the exhaustion you feel from these alerts is not a personal failing, but an engineering choice that someone else made. For a reason that had almost nothing to do with you as a physician.

Here is what most of us were never told in training, because none of us were in the actual meeting room when it happened. We were too busy taking care of patients.

In 2009, the federal government passed the HITECH Act. Buried inside it was a program called Meaningful Use. Billions of dollars in incentive payments to push physicians onto certified electronic health records. Stage one of that program, which took effect in 2011, required every certified EHR to include drug to drug and drug to allergy interaction checking, plus at least one clinical decision support rule, before a practice could collect a dime of that incentive money.

You are probably thinking, “What?” Yep, that is right. The requirement was not to build an alert system that physicians find useful. The requirement was: implement at least one rule, pass a certification, collect the incentive.

Alert Fatigue is an Engineering Choice

So the vendors built exactly what they were asked to build. As fast as they could, for as many customers as possible, to a testing standard, not a workflow standard. And when a certification body is grading whether an alert fires, not whether it fires at the right moment, for the right person, at the right threshold, the safest engineering decision every time is to make it fire more.

Because a missed alert is a liability exposure for the EHR company, and an annoying alert is just another typical Tuesday in a physician’s life.

That single design choice, optimized for legal defensibility not clinical judgment, is the ancestor of almost every alert that interrupts your day now. There is no role based logic. The same drug interaction flag that fires for a hospitalist also fires for a surgeon or for a nurse practitioner. In fact, it fires identically regardless of who is actually equipped to act on it in that moment.

There is no contextual awareness. After all, an alert does not know you have already addressed this exact flag yesterday. It does not know that you are mid encounter. It does not know that this is the fourth time this week it has told you the same thing.

More importantly, there is no differentiation in urgency. A critical potassium level and a routine refill reminder arrive wearing the same visual costume. Same color, same pop up, same font size, same interruption.

The published data on what that produces is not subtle. A systematic review in the Journal of the American Medical Informatics Association pooling 23 studies found override rates range from 46 to 96 percent depending on the alert type. Colleagues studying three years of alerts at a large academic outpatient center found physicians overrode 73 percent of medication related alerts specifically.

Those are not numbers about careless physicians. Those are numbers about a system that was never calibrated to clinical reality in the first place. You see, clinical reality was never part of the design brief. It was all about the certification. No one ever asked a physician. It was designed by engineers for corporations to meet a government metric. The physician was just thrown under the bus with the rest of the clinical healthcare team.

When every alert looks and feels the same, your brain does exactly what brains are built to do with constant undifferentiated noise. It stops treating each one as new information. It starts treating the whole category as background. That is not a discipline problem. That is a basic human neurology responding rationally to a badly designed environment.

The Joint Commission has already recognized this pattern over a decade ago. In a 2013 Sentinel Event Alert on alarm fatigue, they described exactly this dynamic: high alert volume desensitizing clinicians until true signals get missed inside the noise. The Agency for Healthcare Research and Quality still lists this issue as an active patient safety concern in their PSNet primer.

So the risk was never physicians ignoring alerts because they are lazy. The risk was always: hey, let us build a system that cries wolf enough and eventually the wolf gets through the system. We didn’t design that outcome. Nobody sat in a room and decided to bury the potassium level under three low value pings. But it is what we got because the system was engineered to satisfy an auditor, not to protect a physician’s attention.

Fixing the System with HCO Practice HQ

Now, I know where some of you go next, because I have been there too. Just turn it all off. Mute the category, get it out of my day. I just do not want those alerts in the middle of my cases anymore.

Well, unfortunately, that is the wrong fix too. I want to be straight with you about why. See, underneath the noise, some of those alerts are catching real things, a genuine interaction, a genuine critical value. Blanket suppression does not solve calibration problems. It just trades one failure mode for a worse one.

The actual fix was never fewer alerts or more alerts. It was always alerts calibrated to who you are, what you are doing right now, and how clinically significant is this specific flag. Which is precisely the kind of judgment a compliance checkbox was never built to make.

So what would it look like if physicians had been in the room when this whole system got built, instead of what it actually was, a certification deadline?

• Well, the system would know your role and would route things to you accordingly. A critical flag reaches the physician who can act on it now, not everyone with a login.
• It would know your context. It would not repeat what you have already acknowledged, and it certainly would not compete for attention mid surgical procedure the same way it competes during a Tuesday afternoon in the office.
• And it would score urgency based on clinical significance, not on whether firing the alert protects the vendor from a lawsuit.

That is not a minor user interface tweak. That is a completely different design philosophy. One built around physician judgment instead of around audit defensibility.

That is the philosophy behind HCO Practice HQ, the organizational communication module inside ClinicianCore. Intelligent, role aware routing. Urgency scoring is built around clinical significance, not compliance minimums. HIPAA compliant and built from the ground up with physicians not only in the room, but truly, truly hands on as the platform was built.

Imagine physicians as the designers of what they really need to help them practice medicine efficiently, effectively, and enjoyably. Rather than just an end user of someone else’s checklist.

A Path Forward

Here is what I want to leave with you today. The exhaustion you feel every time your EHR pings is not a discipline problem, and it is not a personality flaw. It is the direct traceable result of a system that was built to satisfy a 2011 certification requirement, not to protect your attention or your patients.

That means it is fixable. Not by willpower or resilience training or by you having a better attitude. It is fixable with better engineering. I became a physician and surgeon in order to take care of patients, not to referee a stream of undifferentiated notifications. I suspect that you did too.

I think it is worth saying plainly. The tools that were supposed to serve your judgment were, for a long time, built around something else entirely.

If you are ready to see what an alert system actually designed around a physician’s judgment is supposed to look like, then you need to experience ClinicianCore’s HCO Practice HQ. We are in soft launch now ahead of our full September release. The waitlist is open at cliniciancore.com/waitlist. Visit our website and sign up.

I am Dr. Kevin Halow, co founder and Chief Medical Officer of ClinicianCore. Let us handle the noise, so that you can enjoy practicing medicine. Thanks for listening.