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June 4, 2020 Readers Write 2 Comments

Hospital Vital Signs: The EHR Doesn’t Know Everything
By Keith Boone

Keith “Motorcycle Guy” Boone is informatics adept and SANER Project leader for Audacious Inquiry of Baltimore, MD.

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In the fight against COVID-19, it is imperative to understand and monitor the vital signs of our healthcare system – the hospitals and health systems that are playing a critical role –  to ensure that we can provide patients with unfettered care as this global pandemic plays out.

To this end, numerous agencies at the local, state, and federal levels are attempting to monitor the pulse, EKG, respiration rate, and chemical balance of hospitals across the country for a better assessment of whether the hospitals we rely on to keep people safe are themselves up to the task. This information is needed to rapidly identify the hospitals that need supportive care as they face COVID-19 head to head.

Today’s data collection efforts are focused on extracting data from the EHR, which focuses on data elements such as bed numbers and bed types, ventilator use, and death rates. While this is a great place to start, the EHR is just one critical information system within a hospital.

Similar to how the body has many flows — or as these were once explained, humors — a hospital also has a network of systems that manage its overall wellbeing and operations.

  • Asset tracking solutions monitor the physical inventory in a facility, and asset management systems can both pinpoint the location of a ventilator or anesthesia system and report its present operational status.
  • Bed management solutions help a hospital streamline patient flow, ensuring that patients are getting into beds as fast as possible. They identify if beds that need cleaning are being turned around quickly and whether patients are being discharged efficiently.
  • ICU and central monitoring solutions keep track of patient telemetry inside the ICU, bringing signals from the monitors and medical devices at the patient’s bedside to the central nursing station, possibly long before the information is available in the EHR.
  • Inventory management solutions keep track of consumable medical supplies – simple service parts such as ventilator tubing,  medicines, lab test reagents, personal protective equipment, and the cleaning and disinfectant supplies that a hospital goes through faster than your most germophobic relative.
  • Workforce management solutions track the flow of staff and are often linked with identity management solutions that grant privileges, identify credentials, and monitor access points.
  • Some hospitals have command centers into which many essential data elements flow. These have compelling visual displays, dashboards, and teams of staff who manage hospital capacity, but they are rare outside of larger academic medical centers, and even the most advanced command centers may not be able to readily share data outside their own system. 

The list goes on and on. These systems collectively determine the pulse or heart rate of a hospital.

While a hospital’s EHR system may be considered the brain of an organization by many who think about hospital information systems – and that’s probably not a bad analogy – a critical failure in any one of these other systems can be debilitating to hospital operations. Though EHRs may be the highest level as the most business-critical decision-making element of a hospital, they cannot track all the functions of an organization that are essential for efficient and prolonged patient surge operations.

To truly understand the health of a hospital and its level of readiness for taking in a surge of critically ill patients requires tracking more than just what is going on in its brain. In our analogy, the heart, the lungs, and liver represent a hospital’s staff, supplies, and equipment. All of these are tracked by other systems.

Some of these systems connect to the EHR, and extracting data via the EHR rather than from the system directly is possible. However, in these instances, speed and clarity may be sacrificed for simplicity. The originating systems often know something well before it is shared with the EHR, just as your stomach responds to food without your brain having to decide how to handle it. Some of these data sources may have no direct connection to the EHR at all, yet their importance to the overall vitality of the system remains undiminished.

As we experience our 100-year pandemic event, the healthcare industry is learning that it didn’t think of everything that hospital leaders might need to know considering equipment or critical supply or staffing shortages. The magnitude of this response has drawn national attention to the critical infrastructure deficiencies in our healthcare, public health capacity, and surveillance systems.

But a silver lining in this endeavor is the rapid progress that is being made by passionate and committed individuals and organizations coming together to solve these complex data sharing and interoperability challenges. HL7 International is doing a tremendous job supporting their members by enabling the secure and rapid transfer of information about hospital bed capacity and availability of critical resources during public health emergencies. From May 13-15, they held a virtual connectathon to demonstrate projects in development. It is promising to see such rapid progress being made through data standardization using FHIR-based APIs.

As an industry, we need to support standards across the many information systems inside a hospital. We need to expose the critical vital signs these systems have to hospital leaders so they can work with public health and emergency response agencies to ensure that appropriate measures are being taken to address this pandemic. While we don’t yet have a consistent approach to sharing data from disparate sources within the healthcare system, it can be achieved.



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Currently there are "2 comments" on this Article:

  1. Great Article as always Keith. Based on my background I would always advocate to include Enterprise Content Management(ECM) systems for the unstructured data as well.

  2. Keith,

    You are absolutely correct, both in the fact that the EHR is not the only solution with data and that we can use the entire ecosystem to understand the state of a hospital or clinic. However, in order for that to occur there is a need to engage in Master Data Management across the solutions. Anytime you hook to subsystems together you can expect that there will be a degradation of the data quality.

    Telemetry feeding into an EHR may not hold the same scope and types as the receiving system — meaning there must be a translation — meaning there is degradation. Labs returned with notes can certainly be read, but they will not provide intelligence on the labs. I have never seen a successful supply interface into an EHR. And, population health solutions seem to extract the data from the source, sometimes in multiple stages, leading to significant distortion.

    We can and should do better. Keep up the fight







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