Last week, I wrote about some of the things your healthcare IT folks are working on with respect to the novel coronavirus (aka SARS-CoV-2 or 2019-nCoV) and the disease that it causes (COVID-19). To summarize, we’re creating and loading the proper diagnosis codes so we can accurately report and create clinical decision support (CDS) tools. We’re building the new lab tests so once they’re available, our physicians will be able to order them in the EHR. We’re updating order sets and inserting the new tests as appropriate. We’re modifying the patient portal to ensure patients who are at high risk of disease aren’t exposed to other patients or clinicians who aren’t properly protected. I mentioned last week that travel screen is a bit passé at this point because we are well into community spread now (meaning it really doesn’t matter so much if you’ve traveled internationally or not).
So, what now?
Now we’re preparing for patients — lots and lots of patients. Hospitals are trying to figure out how to see large number of patients in a safe and effective way. Patients with COVID-19 symptoms (fever, dry cough, and shortness of breath) must be immediately separated from other patients to prevent cross infection. We know that most people who get COVID-19 will have mild disease, but the elderly and those with chronic medical problems are at higher risk. Potential COVID-19 patients need to be triaged so that attention can be directed to the sickest people. Typically, a nurse or physician will sit at a desk as patients approach the emergency room. He or she will obtain a very quick clinical history, check vital signs, and do a brief physical exam. Based on this evaluation, the patient is categorized from the most severe (critical condition) to least severe (“worried well”).
Triage will likely now take place in new areas of the hospital to accommodate an influx of patients. Maybe additional spaces will be opened; maybe tents will be set up outside. Either way, your IT colleagues are working to ensure clinicians have access to the EHR. New “rooms” and beds must be created in the system so patients can be tracked as they move through the hospital. Wi-Fi and Internet access must be set up and supported. New technologies might be employed to help deal with these evaluations. There are emergency medicine physicians who are in home quarantine because they’ve been exposed to COVID-19, yet they feel fine. These doctors can do initial screening of many patients from the comfort of their bedroom if they have an iPhone, a laptop, and Internet access. It may not be pretty, but it can get the job done.
Your CMIO and CHIO colleagues are working to incorporate external lab results into our EHRs via new interfaces to reference labs or, more likely, create the ability for a nurse, doctor, or clerk to enter COVID-19 results discretely while scanning paper that is received from governmental or other third-party laboratories. Remember that just scanning a piece of paper into the EHR doesn’t magically allow the result to become useful for trending, alerting, or CDS. The computer needs discrete results: yes, no, inconclusive, etc. With these kinds of data points, those of us in the HIT world can configure the EHR to be more helpful and less of a hindrance.
For our primary care physicians (PCPs), we’re looking to ramp up telehealth programs as quickly as possible. PCPs are on the front line, as patients seek help from the doctor they see for annual physicals and routine problems. Since most COVID-19 patients don’t require any specific treatment besides isolation, time to recuperate, and symptomatic treatment like fever and pain reducers, they can be evaluated in their homes with a doctor or nurse sitting in the clinic and documenting in the EHR. This happens all over the country regularly, but we’ll be aggressively moving to get this option into more hands during this pandemic.
As I close, I’d like to get on my soapbox for a bit and, at the risk of feeling the wrath of some compliance, legal, and regulatory professionals, I’d like to remind all of us that sometimes rules are there to be broken. I hope that the dire predictions of many epidemiologists are wrong. I hope that for some crazy reason, the United States will be spared the misery that other countries are enduring. Yet, hope is not a plan. If push comes to shove, if we really do get inundated with patients who need to be triaged, admitted, and treated with life-saving therapies like ventilators and IV medications, then we need to do what we need to do. Maybe we need to use paper for specific documentation and ordering workflows. Maybe we need to let clinicians use personal devices to call patients and do basic triaging. Maybe we have to relax our fastidious privacy policies to share information with close relatives even without signed consent.
Don’t get me wrong; I don’t want to do any of these things. We should not have to do any of these things. But I think if we’re in the middle of a true emergency, we need to do what’s right by the patient, by the doctor, by the nurse, and by society as a whole. If we do that in good faith, I’m comfortable with dealing with the repercussions after the fact.
Craig Joseph, MD, is a pediatrician and physician informaticist with experience in both clinical practice and the use of the EHR to improve patient care and physician efficiency. He currently serves as Interim CMIO at El Camino Hospital in Mountain View, California, and is also the Chief Medical Officer for Avaap, an EHR and ERP consulting firm. This piece was originally posted on Avaap’s blog page.