The recent spate of infectious diseases identified in the US-whether Ebola, enterovirus D68 or just the beginning of the plain old flu season, healthcare has become increasing complex. It involves more players in terms of patients, providers, administration, insurance , governmental bodies and now CDC screeners at airports. This leaves more risk for miscommunications and patient error as we have seen in the death of Eric Thomas Duncan who was sent home from a hospital with a temperature of 103 degrees, an obvious breakdown in the flow of critical data among medical professionals.
This crucial data was never automatically escalated, and apparently never sent to the right people at the right time. More of these errors will continue and push the number of deaths from medical errors past the 1,000 patients killed daily as noted by the CDC and other organizations. This can all be changed and perhaps Duncan's life saved if hospitals began addressing the issue of EMR interoperability and implementing connectivity solutions available today.
This changing environment must be carefully reviewed by CMOs, CIOs, CEOs and other hospital executives as these changes can have huge ramifications for the way hospitals now need to operate. Considerations now need to be made for everything from the traditional role of EHRs to the way health professionals communicate with each other, patients and other outside organizations.
In medicine, patients present with a set of symptoms, clinical signs, and test results. A not very well connected story at the beginning, but evolves as data is uncovered, ultimately leading to a diagnosis and a treatment plan. The art of medicine encompasses this process where physicians and other healthcare providers uncover meaningful information from the disparate pieces of data that patients present. However, if the EMR data is static and does not offer "smart" analysis, it becomes more challenging for healthcare providers to identify an appropriate course of treatment.
Current EMR Systems Not Keeping Up with Increasingly Complex Healthcare Delivery
Unfortunately, this delivery of healthcare has become more complex, making the process challenging and not always leading to successful outcomes as in the case of patient Duncan. Another hospital patient Bill White almost lost his life because of a potassium level that became elevated to life threatening due to a critical report left at a nursing station. If the hospital had used an EMR system that escalated data to the right medical staff at the right time, this could not happen.
The system of medicine is no longer centralized, but distributed over many care providers. Duncan's case drives home the life and death attention to an issue with communication, miscommunication and omission of vital information between healthcare providers, something the EHR is expected to catch , but doesn't. When critical patient data is missed by the care team, delays in treatment and death can result.
EHRs Migrating to Central Communication Hubs
Communication lies at the root of medicine and can take many forms. EHR's have not only replaced their paper predecessor for narrative documentation, but they are becoming the central hub for all clinical, administrative and quality aspects of healthcare. Although EHR's were not designed as a communication tool, the EHR is encroaching on this role as well. When looked at from this perspective, we must be careful of the unintended consequences this may lead to.
The ability to communicate concerns, open action items that need following up, the interpretation of labs and tests, disease management , interventions and now admissions data are becoming components of EHR's. This data is used by many to try and produce a complete and accurate picture of the care provided. The data is easy to collect, store and transmit, but it is the meaning that stems from this data, coupled with the current clinical context of the patient that is important for timely and accurate care to be delivered.
Data Scavenger Hunt
EHR's are just databases capable of storing any type of data and at any level of complexity. The storage of data is not the utility of an EHR; the utility comes from use of the data where meaning is applied to the data collected. Physicians and other providers depend on the information to make management decisions. Given the many possible places any piece of healthcare data can be stored in the EHR makes caregivers often go on a data scavenger hunt.
The problem occurs when a physician does not search in the area where the data is recorded or a critical piece of information, such as recent travel history in the Texas Ebola case, was not readily available in the standard workflow of the physician. So from the data storage level, one could argue the system was designed in an adequate fashion, but if looked at from a presentation level, the information was not usable in at least one context.
Although the recent Ebola issues have many on edge, this same clinical scenario is present with all types of patient data. Collection of a blood glucose value in a diabetic can easily be hidden from another providers' view when it is recorded in a location within the EHR that is not part of that providers' standard workflow.
Adopting this mode of searching for all relevant pieces of data also has issues as well. When information is searched for and not found, one concludes it does not exist. This leads to the problem with duplication of tests or additional time tracking down who entered the data and where which can lead to a patient's death.
As the EHR expands its role is as a central repository for all types of healthcare data, providers are collectively using the data to manage patients, all from a different vantage point. Face to face communication will always exist in healthcare, but given the current limitations of EHR technology, we must look for different solutions to this communication issue.
Most of the EHR platforms have a comprehensive data model to incorporate the vast amounts of information generated on a daily basis so there is no need, at least at this point, to scrap this functionality. We need instead to expand the capabilities of the EHR so that the data contained in the record can be utilized in a more dynamic, actionable way. Looking at the communication problem from this angle, we have the ability to use existing systems and available technology to address the issues that arose in the Ebola case.
"Push" Communications Platform Tied to Subscription Model
What is needed in healthcare is not another data storage application, but instead a dynamic, real-time communication platform that sits on top of the implemented databases. We need to proactively use the data when it becomes available. A system using push technology coupled to a subscription model for patient care where all members of the team are subscribed to a patient that they have some impact into the care being delivered.
This subscription can be as short as a shift or remain with the patient as they transition through different phases of care. Not everyone on the team needs to be responsible for ever piece of data generated in the course of care, but this aspect can also be managed so that data and information is communicated to those who are responsible for certain aspects of care. Although abstract, this model can be applied to any patient situation, be it as an ambulatory office visit or a hospital admission.
Understanding the issues that arise, such as a missed travel history, fever symptoms, or any other critical piece of health data illustrates the immediate need to implement connectivity software across all EHRs. A nurses' section of the system needs to also be available to doctors and open to all to view simultaneously whether in the U.S. or the nation's of West Africa.
This can be achieved today with push technology and middleware software. We can even tackle expanded uses of EMRs through open APIs that enable medical record app developers to easily create new solutions that can address the increasing need for EHR communication.
Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University. A board-certified anesthesiologist, researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.