Ebola cases put focus on health IT needs
The Ebola cases in the United States, despite their limited numbers, have generated considerable discussion and anxiety. The discussion has included health IT because of the initial assertion that the Dallas hospital electronic health record led to the first U.S. Ebola case being sent home. The assertion was subsequently refuted, but it initiated conversation about whether the EHR was really to blame and, eventually, how EHRs might lean forward and help in such circumstances.
Unfortunately, either way, the focus on EHRs in these Ebola discussions does not recognize more prominent outbreak health IT needs nor the ways we have yet to meet most of these needs with incentives and infrastructure.
[See also: Ebola case highlights lack of planning]
Outbreak health IT and case reporting need attention too
The general outbreak anxiety is distressing and sometimes misplaced, but it does play an important role in motivating action. It is an unfortunate truth that emergency preparedness only gets attention during and shortly after emergency events. Work like health IT which requires sustained attention, incentives, standards, certification, and information exchange particularly suffers under these dynamics. An EHR did not cause the initial Ebola illnesses in the US, but health IT is also not yet aligned to substantially help with outbreaks either. Without adding to the anxiety, we should recognize the needs now and address them as soon as we can.
The health IT requirements for outbreak management and other public health emergencies are known (a list of such requirements is at the end of this article) and they are mostly not about EHRs. They do include health information exchange with EHRs but even this exchange, also known as "case reporting," has not been addressed in HITECH incentive funds or meaningful use. And unlike clinical "continuity of care" health information exchange, there are no incentives in health reform to eventually accomplish it either. This is not health information exchange or interoperability that will be addressed by market forces.
As unfortunate as the situation is then, perhaps Ebola can break these dynamics, focus appropriate attention on some of these non-EHR aspects of health IT, and bring population health capabilities that can support outbreak management to the fore. These capabilities are needed for routine population heath purposes as well.
[See also: EHR still in play with US Ebola case]
For now, EHRs should provide information and communication – not conclusions
The one possible role for EHRs right now is screening for additional cases now that an “index case” has already been identified in the US. This screening is important, but there are challenges to EHRs being effective in automating this use. There is also a large potential downside risk that next time an EHR would be appropriately blamed for a clinical misstep.
The effectiveness of EHRs for screening must be considered in the context of the level of provider awareness and changing guidelines. When provider awareness of the need to screen patients was low, EHRs could easily help raise awareness through casting a "wide net" and flagging patients for subsequent attention (high sensitivity). But now that provider awareness is high, the EHR “ask” looks more like the definitive adjudication of whether a patient should be a suspect case (high specificity). Unfortunately, among other issues, the recording and structure of travel history data is not strong in EHRs. The exposures of concern also continue to grow and change – first certain countries, then more countries, then exposure to health care workers who were exposed, then people on planes, ships and an expanding target.
All the while, the guidance that the Centers for Disease Control and Prevention are sharing is changing. This is not uncommon in outbreaks. There are legitimate reasons that guidance needs to be dynamic. But how do we know EHRs will represent the current state? Even when guidelines are stable, there are subtle issues in interpretation and implementation. What if the EHR gets it wrong? We know that clinical personnel at times ascribe definitive interpretation to guidance they get from computers. All of these factors suggest that EHRs right now should be used to provide information and facilitate communication and not to present "judgment."
Outbreak management needs are much more than an EHR interfaces
More broadly, the focus on this EHR screening role also distracts from the broader heath IT needs for outbreak management. Unfortunately, as in the Ebola discussion, the national health IT agenda continues to focus on EHRs. The Ebola events come into harsh contrast with the most current health IT focus on interfaces with EHRs (also called APIs – application programming interfaces).
EHR APIs were by no means the only suggestion of the recent JASON review and report, but they are what seems to be an almost singular focus of the response. Outbreak management, connecting lab results and case data, contact tracing and other functions have requirements that don’t relate to EHR APIs. Health IT architecture in the US must consider broader needs too.
Much of what needs to be done for outbreak management health IT will not be done in the immediate months of this Ebola crisis. It is critically important, though, that we note the broad needs now and commit to addressing them as soon as we can. Hopefully Ebola will not fully demonstrate their importance, but already Ebola has shown some of these needs.