Healthcare // Clinical Information Systems
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4/26/2014
08:35 AM
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Marathon Bombing Lessons: Boston Hospital Revamps Information Systems

Brigham & Women's emergency department leaders describe how they corrected system deficiencies revealed by the 2013 crisis.

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In the aftermath of the 2013 Boston Marathon attack, Brigham and Women's Hospital reviewed its information systems (IS) and discovered some processes needed improvement.

On April 15, 2013, the hospital's emergency department (ED) received 19 patients within 30 minutes. Overall, it treated 40 patients from the marathon site, recalled Dr. Eric Goralnick, medical director for emergency preparedness at Brigham and Women's Hospital. After the mass casualty incident (MCI), the hospital determined it had to enhance IS in three key areas: unidentified-patient naming conventions, situational awareness, and patient documentation.

Dr. Goralnick and Dr. Adam Landman, the hospital's chief medical information officer for health information innovation and integration, will discuss their findings during a keynote presentation Tuesday, April 29, at Medical Informatics World in Boston.

"We really, to this day, continue to analyze the lessons from this event," said Dr. Goralnick, who this year ran the Boston Marathon for the first time. "We knew we had a clear deadline to fix and prioritize these lessons learned, and information systems was at the top of the heap."

Brigham and Women's Hospital partially activates its emergency plans for all special events in Boston. After the bombing, it looked toward the fast-approaching July 4 festivities. With that target date in mind, a team quickly began looking for ways to address unidentified-patient naming conventions.

After two bombs exploded, ambulances lined up to take the injured to local hospitals, including Brigham and Women's.(Source: Rebecca Hildreth/Flickr)
After two bombs exploded, ambulances lined up to take the injured to local hospitals, including Brigham and Women's.
(Source: Rebecca Hildreth/Flickr)

Many marathon bombing patients were unidentified when they arrived at the ED. Names are vital to start treatment, and the hospital identified unnamed patients with a unique code consisting primarily of numbers. But the staff could not easily tell patients apart, because the codes looked so similar, said Dr. Goralnick. When one or two unnamed patients arrived at the ED in a typical day, this was not a problem, but with many people simultaneously coming into the emergency room -- and the fear that more might be on their way -- the risk of error heightened.

In the new system, implemented prior to the July 4 deadline, the ED uses a mix of commonsense data to separate unidentified patients, said Dr. Landman.

"It specifies a patient's gender, because that can be important for blood transfusions, and then we included a unique string of characters that was intuitive for clinicians to remember. We actually started with colors. We're able to incorporate that color into an unidentified patient's name," he said. "We figure, once we exhaust colors, we'll go to different categories, such as states or lakes. You want to be able to call your patient something. You don't want to say Room 10. You can say Mr. Blue."

[Electronic health records fuel a hot new job category. See EHR Jobs Boom: 8 Hot Health IT Roles.]

The hospital incorporated the amended process into its electronic health records (EHR) system. The staff preferred the more human-oriented, less numerical coding, said Dr. Landman.

Seldom if ever a concern during regular ED operation, situational awareness did not function optimally on the day of the marathon bombing. When the staff moved a patient -- to the operating theater, a room, or radiology, for example -- a nurse or technician manually moved the patient's icon on a tracking board, so other staff members could find them. In the post-bombing chaos, the staff did not always move tiles in a timely manner, so they did not always know exactly where patients were located, said Dr. Goralnick. "We revised our emergency operations plan, specifying our chain of command."

To improve how it handles patient documentation during an MCI, Brigham and Women's Hospital returned to paper, said Dr. Goralnick. The new system is modeled on how hospitals in Tel Aviv, Israel, cope with a sudden influx in emergency patients. The Boston hospital now has packets of information prepared for patients as they come through the door, he said. An employee later scans paper documents into the EHR, so the patient's record is complete.

Brigham and Women's Hospital continues to refine the process, looking for more ways to automate the system and make it part of employees' daily work processes.

"Disasters or mass casualties don't occur every day. Ideally, we can build solutions that are in everyday use of the systems," Dr. Landman said. "Then, when the MCI happens, it will work in the MCI, and our staff knows how to use it. There are lots of solutions we can come up with for mass casualty incidents, but staff won't be familiar with them."

The hospital also wants to investigate technologies like RFID for tracking patients, Dr. Landman said. It's also open to discovering whether there's a technological replacement for scribes (nurses or off-duty healthcare professionals who volunteered after the bombing) that could take doctors' notes during an MCI and automatically and directly feed them into the EHR, he said.

More immediately, however, Brigham and Women's Hospital is seeking a replacement EHR, an enterprise-wide solution, instead of its current departmental approach. Ideally, the system will provide the ED with more automated, user-friendly, and intuitive MCI capabilities that will only need to be used for drills.

In the five years before the marathon bombing, Brigham and Women's Hospital conducted 78 drills replicating events such as chemical attacks, aircraft collisions, and a school shooting, said Dr. Goralnick. "These drills taught us about trust, about collaboration, and these drills saved lives on April 15, 2013."

NIST's cyber-security framework gives critical-infrastructure operators a new tool to assess readiness. But will operators put this voluntary framework to work? Read the Protecting Critical Infrastructure issue of InformationWeek Government today.

Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio

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Alison_Diana
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Alison_Diana,
User Rank: Author
4/28/2014 | 12:00:39 PM
Re: Thank goodness that the number of casualties were relatively low
As both doctors stressed, all hospitals around the country have events that typically attract large crowds of visitors -- a county fair, July 4, New Year's Eve, race day... -- and those scheduled events are days that hospitals can prepare to potentially encounter mass casualties. But it's the regular days turned tragic, like September 11, that really demonstrate just how well hospitals (among other facilities) handle emergencies.

That's why Brigham and Women's holds so many drills of such variety throughout the year. And it's one reason they really dug deeply into what worked well, what worked okay, and what created bottlenecks after the Boston Marathon bombings. Recognizing that all problems resided in information systems -- and knowing the best way to improve them was to incorporate systems they could use every day -- they moved fast so they'd be ready by the next potential scheduled mass casualty incident day, July 4. Thankfully, they didn't have to test their systems then. But testing and retesting and drills are something all hospitals do (and if they're not, they darn well better start).
PaulS681
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PaulS681,
User Rank: Ninja
4/27/2014 | 6:18:07 PM
Re: Thank goodness that the number of casualties were relatively low

Good question Gary... I think all the systems for these types of catastrophes that are in place today stem from that fateful day on 9/11. I like the way Brigham & Woman's is using IT to help in these situations. Sadly they will be needed again. It's not a question of if... it's a question of when.

Gary_EL
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Gary_EL,
User Rank: Ninja
4/27/2014 | 4:24:39 PM
Thank goodness that the number of casualties were relatively low
The tragedy on that day was traumatic and undeniable. But, the sad truth is that could have been much, much worse. I wonder what kind of system for this sort of catastrophe they have in place in New York, given their horrific experience on that terrible day in 2001?
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