Coronavirus pandemic puts focus on strengths, weaknesses of EHRs
A central problem the COVID-19 pandemic has highlighted is the fact that EHR systems are large, slow monoliths that don’t quickly adapt to new, emergent demands on their design and workflow.
Future planning will also need to include routine practice run-throughs for building rapid-alternative-care sites, as many hospitals are setting up alternative patient-care sites during this pandemic. Most EHR systems, however, are very location-based.
"EHR disaster preparedness testing in the future will need to be able to simulate large volumes of patients over long periods of time," Dana Bensinger, RN-BC, informatics nurse specialist and client-solution executive with CTG, told Healthcare IT News.
"Every hospital has disaster plans that typically involve how to handle a large influx of patients during a disaster, and these plans are tested on a regular basis."
Bensinger noted, however, that organizations are not always set up to test the EHR during these exercises.
"We know how an EHR responds when we test 100 patients a day for COVID-19, but how does it respond when I test 1,000 or 2,000 or 10,000?" he asked.
Dr. Jay Anders, Chief Medical Officer of Medicomp Systems, noted the main flaw in current EHR architecture is that these systems have not been designed to store and share data between disparate and independently functioning systems.
"During a pandemic, information needs to be shared quickly and widely," he said. "This becomes a major challenge when systems do not communicate with one another and data is stored in a variety of structured and unstructured formats."
He explained that because few EHRs were architected for information sharing, clinicians will have difficulty finding the actionable information they need for decision-making, which in turn will delay patient care.
"There will be many lessons learned as a result of the COVID-19 pandemic," Anders said. "Right now, as stakeholders across the healthcare industry pull together to flatten the curve, one lesson many have already realized is that we must improve data sharing and make systems interoperable. During this pandemic, accurate and complete data is essential for efficient and effective decision-making."
Doug Cusick, CEO of TransformativeMed, also agreed that data sharing with public health system is a major issue with today’s EHR architectures. Because EHR providers and the U.S. healthcare system are driven by for-profit interests, they are highly competitive, but not highly coordinated.
"The U.S. healthcare, EHR and public health systems are not well suited to quick, consistent information sharing," he said. "This makes tracking the outbreak with electronic data – like China and South Korea did – much more difficult."
He noted that the downstream impact is that the EHR workflow process is likely going to be clunky, inefficient, not intuitive and "duct-taped" together.
"Hospital systems might make this work, but it won’t necessarily work well," Cusick said. "The people who end up bearing the burden of this failure are the frontline clinicians that are already overwhelmed with the crisis and burnt-out from the EHR."
However, there are also voices out there who acknowledge that, despite the many challenges facing better integration of EHRs into networks of healthcare organizations and professionals, they can be of great help during a health crisis.
"We should first acknowledge that EHR architecture, despite its many flaws, is actually a huge asset during a pandemic or other widespread public health emergency," Devin Soelberg, vice president of business development and partnerships at Redox, told HealthcareITNews. "Organizations are able to track and report abnormal conditions much faster and with much higher fidelity than a paper-based system."
He said during a pandemic, recommended protocols evolve very quickly, and EHR architecture enables organizations to implement changes to protocols far more uniformly.
While EHRs are highly optimized for high-volume routine workflows, they tend to be inflexible and unaccommodating to on-to-the-fly adaptation by providers and staff.
"Pandemics often force healthcare professionals to adapt from their normal routine in order to respond to the crisis," Soelberg said.
These could include floating shifts across departments, on-call or agency (contractor) staff, and the opening and closing of care locations like field triage in the parking lot, within the hospital.
"For a triage nurse in a busy Emergency Department during a pandemic, the volume of data becomes less important to the ability to quickly consume the key health metrics of a patient," he noted. "It requires skilled clinical informaticists at each healthcare organization to customize the data visualization for each role and workflow, which can lag behind during a public health emergency."
Not surprisingly, cybercriminals take advantage of the panic and fear during a public health crisis like COVID-19 to target medical data of organizations and individuals.
As the virus spreads, social distancing forces people to conduct more of their lives online, increasing the risk of a phishing attack. As critical hospital IT staff are quarantined, it makes it harder to maintain the same level of rigor around security patches and updates.
"EHRs are data repositories that must be kept secure from unauthorized access, while balancing the need for more data exchange with new authorized parties that are working together to battle the pandemic," Soelberg said.
The final interoperability ruling released on March 9 mandates standards-based exchange of health information through application programming interfaces, or APIs.
"If this capability currently existed across all EHRs, the ability for health systems to securely share information in a public health emergency, like we are facing now, would be vastly improved," he said.
Many EHRs were developed under the assumption that the patient was going to receive care from a provider in a physical office or care-delivery setting. As such, most health care organizations have built their strategies around patient engagement, clinical documentation, data governance, and medical billing around those same assumptions.
"Pandemics like COVID-19 cause a paradigm shift for patients that expect, and in some cases are forced, to receive care outside a physical office," Soelberg said. "Telehealth, mobile engagement with a provider, home delivery of medical supplies, including medications, are rapidly accelerating trends that are forcing health care organizations, and the developers of their EHRs, to reevaluate their strategic assumptions."