%% Text written by Jon Doyle and Zak Kohane about alerts for AMRMC
%% BAA.


Modern automated monitoring, testing, and communications systems now
have the capacity to provide almost continuous flows of alerts to
physicians. Such large flows of information have little value,
however, if the frequency and reasons for interruptions force
physicians to ignore the alerts simply to be able to think. For
example, ICU attendants sometimes turn off distracting monitors rather
than suffer their constant and ordinarily trivial interruptions, and
clinicians at a major hospital disparaged a new textual-pager system
for noisily delivering a stream of uninteresting laboratory reports
(even after protests had finally led the implementors to reprogram the
system so that clinicians only received reports for their own past and
present patients, rather than the reports for all patients).  

Even when busy physicians do not tune out the flow of ``junk'' alerts,
alerting them to abnormal clinical data or trends too late or too soon
can waste their time and impair their ability to treat the patient in
question.  In general, the conditions under which it is appropriate to
alert a physician can vary with the patient, clinical condition, the
physician, the clinical setting, and even the recent clinical
history. In particular, an abnormal clinical datum or trend will have
a specificity and sensitivity with regard to a particular pathological
state and a corresponding cost or disutility of ignoring the datum or
trend in further investigation of the hypothesized pathological state,
as well as costs or disutilities associated with generating an alert
too long before or too close to the time of the hypothesized
pathological state.  For example, if hematocrit trends down but is in
normal range, an alert might be appropriate 6 months before hematocrit
crosses the lower limits of normal in pediatric cases treatable by
dietary supplements, but might be appropriate much earlier in trauma
cases.

We propose to avoid these difficulties, and so enhance the efficiency
and effectiveness of patient care, by developing and testing automated
alerting agents employing methods based on decision-theoretic
preferences to direct alerts to the appropriate physicians by the
appropriate means at the appropriate time, where appropriateness is
judged both by general criteria and by individual preferences
modifiable by recipient physicians to suit their own clinical needs,
either in advance, or in response to experience, with clinicians
modifying the partial preference information regarding alerts directed
towards them (e.g., ``I was alerted too soon for patients this age; I
prefer later alerts for patients over 18 years old.'').  We believe
that enabling physicians to modify the alerting strategy in this way
increases physician satisfaction and acceptance of the alerting
system, and also increases the appropriateness and timing
appropriateness of testing and treatment.  We propose to investigate
these methods by implementing a clinical event monitoring system
producing alerts for a small number of routinely ordered laboratory
studies (e.g., hematocrit, arterial blood gas, creatinine and BUN)
with the alerting strategy guided by easily-modifiable personal
preferences for each clinician using the system.
