**Field Note: Supporting Clinical Judgment in the Age of Digital Alerts** 16 April 2025 Moses Hng --- **Why This Matters** As digital alert systems and messaging platforms become increasingly embedded in healthcare workflows, frontline clinicians are navigating new kinds of responsibility. These tools promise timely insights and better continuity of care, but they also create real emotional and cognitive strain — especially when signals are unclear or protocols are lacking. This note offers a framework that trusts clinicians, clarifies accountability, and helps organisations manage this shift with care. It bridges a gap that many healthcare teams are feeling but have yet to name: how to work safely and sustainably with digital signals without falling into blame, burnout, or overreaction. **Executive Summary** The increasing integration of digital alert systems into healthcare delivery presents both opportunities and risks. These tools can enhance patient monitoring and early intervention, but they also introduce uncertainty around accountability, clinical decision-making, and information overload. This note proposes a shared responsibility framework that clarifies expectations, protects staff, and promotes ethical, sustainable use of digital communication and alert technologies in healthcare settings. Based on implementation experience and ground-up feedback from clinical staff, this framework outlines practical recommendations for: - Responding to alerts in a way that balances safety with clinical autonomy - Managing digital communication (e.g., WhatsApp, Microsoft Teams, SMS) - Aligning organisational culture with a learning-oriented, no-blame approach The goal is not to eliminate risk, but to create clarity and trust in environments where digital information is abundant, but time and attention are limited. --- **1. Context and Rationale** Digital alert systems and asynchronous messaging tools are rapidly becoming embedded in modern healthcare. While promising to improve care continuity, these technologies have also created new pressures: - Clinicians feel anxiety over missing or misjudging alerts - Communication via chat platforms creates ambiguity around ownership and urgency - Patients and caregivers may develop unrealistic expectations about response times and responsibilities This note addresses these issues by proposing a clear, scalable framework that honours clinical expertise while embracing technological tools as supportive (not directive) inputs. --- **2. Core Principle: Alerts Are Supportive, Not Directive** Alerts should be treated as prompts for reflection, not automatic triggers for action. In the "Managing Care" scale of clinical knowledge, there is a spectrum: - At one end are conditions with **clear, measurable thresholds** and well-established responses (e.g., blood pressure readings, blood glucose levels). In these cases, interventions can be standardised and protocolised. - At the other end are **ambiguous or evolving digital signals** where context and relational history matter more than any single data point. Here, alerts should serve as **supportive cues** rather than prescriptive commands. Digital alerts currently fall in the middle of this scale. They offer useful input, but lack the maturity and validation to override professional judgment. Until long-term data validates specific alert thresholds as predictive and actionable, clinicians should prioritise clinical reasoning informed by context, and treat alerts as one of many inputs into decision-making. Staff are not expected to act on every alert. Instead, they are encouraged to: - Integrate alerts with clinical knowledge, history, and patient trajectory - Use professional discretion - Document rationale clearly when choosing not to act They offer an additional stream of behavioural or digital signal data, which must be interpreted in context — not in isolation. Staff are not expected to act on every alert. Instead, they are encouraged to: - Integrate alerts with clinical knowledge, history, and patient trajectory - Use professional discretion - Document rationale clearly when choosing not to act Until long-term evaluation data is available to support predictive reliability, clinicians should be supported in prioritising clinical judgment over algorithmic signals. --- **3. Minimum Contact & Triage Expectations** A practical threshold for minimum contact should be defined. For example: - If no contact has occurred in the past 30 days and an alert is triggered, a check-in is recommended. - If the patient is unreachable after two documented attempts, teams should revert to their service’s standard protocol. Contact is defined as a two-way clinical interaction, including phone, video, in-person, or secure digital exchange. Triage principles: - **Low-priority alerts**: Monitor only - **Moderate-priority alerts**: Consider outreach if other indicators suggest change **High-priority alerts**: Review carefully, and check in if recent contact is lacking or if clinical concern is triggered **3A. No-Blame Principle for Alert Decisions** This framework recommends that organisations adopt a no-blame stance when it comes to alert review and response decisions, provided that staff apply clinical reasoning and document their decisions appropriately. - Staff should not be penalised for choosing not to act on an alert if that decision was made in good faith and supported by professional judgment. - Alerts are tools to guide reflection — not systems of enforcement. They cannot account for the full clinical picture or patient history. - Adverse events should be examined with a systems lens, recognising that digital signals are only one piece of the care puzzle. At the same time, clinical teams are encouraged to continue engaging in professional development, supervision, and reflective practice. Judgment must be nurtured, not replaced. Technology can support insight, but it cannot substitute for ongoing learning, mentorship, and situational awareness — all of which remain core to safe and effective care. Creating this culture of psychological safety is essential to sustain the emotional labour involved in digital monitoring. --- **4. Documentation Standards** A consistent documentation approach supports transparency and protects staff. Suggested fields include: - Alert type and level - Last meaningful contact date - Summary of rationale for action or inaction - Whether supervision or peer discussion was sought Routine alerts not associated with clinical concern (e.g., missing data) do not require documentation unless judged relevant. --- **5. Communication Boundaries for Messaging Platforms** With the use of tools like Microsoft Teams, WhatsApp, and SMS: - Messages should be considered asynchronous unless otherwise agreed - Time-sensitive matters must be escalated via direct calls or live handover - Message senders must not assume responsibility has been transferred unless acknowledged After-hours messaging is not monitored unless team-specific crisis protocols apply. Staff are not expected to respond outside working hours unless rostered. Clinically significant conversations via chat should be summarised in clinical notes. --- **6. Shared Responsibility Across the System** This framework mirrors shared responsibility models used in financial cybersecurity. In healthcare: - **Technology providers** ensure reliable systems with auditable outputs - **Organisations** provide training, staffing, and clear expectations - **Clinicians** apply judgment and document decisions - **Patients and caregivers** are informed that messaging tools are not substitutes for emergency services Clear onboarding and disclaimers should be part of all digital tool rollouts. --- **7. Addressing the Cognitive Load** This framework recognises the emotional and cognitive strain clinicians face when deciding whether or not to respond to an alert. Especially when judgment and system signals differ, staff may carry the burden of potential risk and retrospective scrutiny. This white paper proposes: - Normalising supervisory consultation - Creating space for reflective discussion - Promoting documentation as a sign of care, not defensiveness Digital transformation must not erode the human foundation of care. Systems must be built with space for discretion, discussion, and dignity. As digital tools grow in complexity, clinical training must evolve alongside them. The goal is not to defer to algorithms, but to develop clinicians who can interpret, question, and guide technology with insight and care. AI should augment, not diminish, the thinking capacity of professionals entrusted with patient lives. --- **Appendix: Sample SOP Excerpt** - Alerts are clinical prompts, not commands - Minimum expected contact: one meaningful check-in every 30 days - If alert level is high and patient has not been contacted in >30 days, initiate outreach or document rationale - Document decisions when alert is reviewed but not actioned - Do not assume digital messages are acknowledged without reply - Escalate urgent matters verbally; do not rely on chat tools alone ---