Interoperability During Disasters: Lessons from Tragedy

More than 600 people were rushed to Las Vegas hospitals after the shooting rampage at a country music festival on October 1, some of them arriving in the backs of pickup trucks. “It was like we were in a war zone,” a trauma surgeon at University Medical Center of Southern Nevada told the Las Vegas Review-Journal. The injured were shot, trampled, or hurt jumping over fences at the late-night event, attended by many people from out of state. These patients, of course, were hardly in a position to supply the health records that can be vital for emergency treatment.

Interoperability is perhaps most essential, and in some respects most inadequate, in emergency departments, especially under the pressure of large-scale disasters. The shooting in Las Vegas, the fires in Northern California, and the hurricanes in Houston, Puerto Rico, and throughout the Southeast underscore how crucial it is for emergency personnel to be able to access electronic health records and identify relevant information—namely medication history and chronic conditions—immediately. In the 10 days after Hurricane Harvey hit, Dave Fuhrmann, vice president of interoperability at Epic Systems, observed a 75% increase in the exchange of records between Houston and Dallas, to which many victims had been evacuated.

Hospitals nationwide should take note: These events highlight the necessity for preparing information-sharing systems for disasters before they strike. They also contextualize the appeal of an emergency record-sharing tool that was employed for the first time this fall in California.

Evacuations across state lines and transfers to new providers pose additional challenges during these sorts of crises. Jitin Asnaani, executive director of CommonWell Health Alliance, a national group that offers cross-vendor interoperability service, described how the accessibility of health records “can make all the difference in saving a life or providing the appropriate care in a timely manner.

“When people are displaced or away from their home,” he explained in an e-mail, “there is less of a chance their records will be available to the new providers they are seeing due to lack of nationwide interoperability between providers and health IT systems.”

Electronic record sharing can also help families identify missing persons amid the pandemonium of a tragedy. That’s possible only if a hospital can identify a patient, however; one story out of Las Vegas described a 32-year-old from Los Angeles named Michelle Vo, who befriended a man at the concert hours before being shot in the chest and rushed in the bed of someone’s truck to a hospital, her phone and ID left behind in a purse. The recent acquaintance and Vo’s relatives spent hours calling every hospital they could find in the city trying to locate Vo, as the Washington Post reported, finally confirming that she had been receiving treatment at Sunrise Hospital, where she later died.

Asked about Sunrise’s ability to access records for the 214 patients treated on that nightmarish night, Fran Jacques, the hospital’s vice president of marketing, said the urgency to provide lifesaving care was too great—and the scene too chaotic—to have worried about pulling up medical histories.

About a week after the shooting, more than a dozen wildfires broke out across Northern California’s wine country and caused unprecedented devastation to the state. Two hospitals were evacuated, residents of nursing homes were relocated, and some patients affected by the fires were sent 50-plus miles to hospitals in Davis and Sacramento.

Kaiser Permanente, an Epic member, safely evacuated 130 patients from its Santa Rosa Medical Center, while its other hospitals in the region remained operational. In a statement to Healthcare Analytics News^™, the Permanente Federation’s chief information officer, Patricia Conolly, MD, praised a feature Epic integrated last year called Happy Together, which consolidates a patient’s history at Epic and, in certain cases, non-Epic providers onto a single interface. That efficiency is especially useful for emergency departments receiving someone for the first time. Last month, Epic planned to release Share Everywhere, which will allow patients to log on to a portal and instantly share their health records with doctors.

Back in 2005, floods from Hurricane Katrina destroyed hundreds of thousands of medical records that were stored in basement filing cabinets. Lee Stevens, with the Office of the National Coordinator for Health Information Technology, says the transition to electronic record keeping prevented any such destruction from natural disasters over the past few months.

Use of electronic records in emergency departments increased 84% from 2006-2011, according to the CDC. But by 2015, 72% of respondents to a Black Book survey said they were dissatisfied with the interoperability of their department’s system. “Eighty-nine percent of emergency department leaders believe their hospitals rushed to purchase new electronic health records and ED systems between 2010 and 2013 for meaningful use dollars”—which were part of the Health Information Technology for Economic and Clinical Health Act’s interoperability incentives—“just to see productivity fall, liability rise, and connectivity stall,” Black Book reported.

During a crisis, the secretary of health and human services can suspend certain Health Insurance Portability and Accountability Act regulations on electronic record sharing, and 72-hour waivers were granted to states in the Southeast after the hurricanes and to California during the fires. Stevens has not heard of any dramatic problems with record sharing for victims of the fires or hurricanes, partly because of where those crises occurred. “California is the most progressive state I’ve worked with on preparing for disasters,” he said. “Florida is also incredible. They don’t miss a beat when it comes to interoperability for storms.”

Still, a variety of difficulties remain, which is why Stevens is enthusiastic about the progress of a government-funded technology called Patient Unified Lookup System for Emergencies (PULSE). “What is missing is the integration of emergency medical services to the health information exchange infrastructure,” explains Richard Cothren, the executive director of the California Association of Health Information Exchanges (CAHIE). With $3 million in grants over 3 years, CAHIE and other developers created a portal for disaster workers, mainly at field hospitals, to view a summary of a patient’s medical history aggregated from different interoperable systems. PULSE would activate after an emergency is declared and provide immediate, mobile access to this potentially lifesaving information.

This summer, California simulated how PULSE would perform after a massive earthquake in the northern part of the state, and participants in the drill were largely successful at retrieving available records using the type of limited information that would be available to identify patients. “That’s a huge success,” Stevens said. “This is a design that we hope to see on a national scale. It meets the exact needs of every single one of the events we’ve just had.” In fact, PULSE was employed for the first time at emergency camps for victims of the fires in Napa Valley, and the system was activated on a limited basis but without problem, according to Cothren.

Participants in the PULSE drill said the system could better simplify the information that medical personnel have to sort through with little time to spare. Cothren echoed that advice for hospital administrators, who can do more to prepare their systems to distill patient histories down to “the minimum necessary data” for emergency departments under the duress of a disaster.

“A lot of what is going on today with EHRs and [health information exchange] systems is targeted at interoperability for the purposes of care coordination,” Cothren explained. “What we’re learning is that the needs during a disaster are different than during normal conditions. What we’re finding is that people who were rushed from their homes may just need their medication.”

“There’s a lot of interest in these things when there’s a disaster,” Stevens cautioned, “but 2 weeks after the disaster, people go back to their lives.” Improving interoperability during emergencies, in other words, will require more preemptive engagement.