Our response to COVID-19 has been largely hindered by the lack of a coordinated national response. In addition, a major hindrance to our national response is the fact that our health care system is not a “system” at all. A system is defined as “a set of things working together as parts of a mechanism or an interconnecting network.” One basic element of a “system” that we do not have is compatibility and standardization of EMR systems.
Right now, hospitals can’t easily compare notes with each other, for example, on what treatments for COVID-19 work the best, because their EMRs can’t talk to each other. We’re too early in this pandemic — and too focused on immediate patient needs — to study the ways that COVID-19 treatment would have been optimized with a synchronous EMR system. To help us prepare for future pandemics, we must standardize our EMR systems nationally.
Congress meant to fix this problem more than a decade ago, when most hospitals were still using paper records. As part of the American Reinvestment and Recovery Act of 2009, Congress included incentives and penalties meant to encourage health care providers to implement “meaningful use” of EMRs. After that, the use of EMR systems exploded and today almost every hospital in America has one. And these are not thousands of different proprietary EMRs, but rather a very small market. More than 50% of all hospitals in America use one of two providers: Epic or Cerner. Among large hospitals (more than 500 beds), these two systems have 85% of the market.
And yet, we do not use EMRs “meaningfully,” because of one fatal flaw: Congress never required these EMRs to be mutually compatible.
I work in a large academic hospital in Boston, which is part of the largest health care network in Massachusetts. We use Epic across our entire health care network, and Epic has a built-in feature that allows us to access records from other health care systems that use Epic. Those records from hospitals do not appear in the same easily readable way as the ones from within our own network do, but they’re better than nothing.
Several other major hospitals within the city belong to other health care networks, and they don’t use Epic. Patients from these hospitals often get referred to our hospital because they need specialized care. As we’re trying to help these patients and their families, they trustingly ask us, “Do you have all my history in your computer there?” We are forced to answer, “No, I’m afraid not.”
Unless the transferring hospital prints out a large stack of health records and sends it with the patient, someone has to now call the other hospital, fax over a signed release of medical information, and then have those health records printed from their EMR and then faxed over, so these paper copies can then be scanned into our EMR. This is a waste of precious time that ought to be spent in caring for our patients.
And, besides being incompatible with each other, these EMRs are often incompatible with the hospital equipment. And that equipment is often incompatible with other equipment. In a 2014 opinion piece in the journal Anesthesiology, world-renowned expert in hospital quality and safety Dr. Peter Pronovost cites many examples of how this harms patients. He describes, for instance, a young girl who died when she stopped breathing after receiving too high a dose of IV opioids. The pump giving her the opioids could not talk to the monitor that showed that her breathing rate was slowing down, and neither one could talk to the EMR where the opioid dose had been prescribed.
In a true “system,” the EMR — which is usually programmed to catch dosing errors — would program the pump directly when the drug was ordered, preventing an overdose from ever happening. Even if an overdose did occur, the monitor could catch that her breathing rate was getting slower, and signal the pump to stop automatically.
What happens instead overwhelms the staff. Nurses have to manually program and then re-check all the infusion pumps to try to prevent dosing errors. Dr. Pronovost describes that across all the patients in a single 20-bed ICU, it takes about 8 to 10 nursing hours every single day to do this. That’s the same as hiring another full-time nurse.
And that does not even include the amount of hours spent manually re-entering the data from monitors and other equipment into the EMR, rather than the equipment uploading that data directly. And that is just for one ICU in one hospital. We could literally hire thousands more nurses across the country with the hours we waste simply on the fact that our equipment and EMRs don’t talk to each other.
When Dr. Pronovost spoke at a meeting of the Society of Critical Care Medicine that year, he said that if our health care system built a jetliner, it would have a lever to drop the landing gear, and then the pilot would have to roll down the window to check if the landing gear was truly down rather than having an indicator light. The next word out of his mouth captured our “system” perfectly: “Ridiculous!”
Standardization is the norm in other industries so it doesn't make sense that we lack it in medicine when patients’ health and lives hang in the balance. Cars in America must be built with the steering wheel on the left side. Electronic devices operate with standard battery sizes. Text messages sent from phones of one manufacturer are received by phones from another manufacturer. And yet EMRs, the backbone of a system to protect human health in America, each operate within their own self-contained vacuums.
And we already have experience with integrated EMR in America. The largest health care provider in the country is the Veteran Affairs (VA) Medical System, which currently uses a single proprietary Windows 95-based system across its entire system. Despite being antiquated, this system is highly rated, because it is easy to use and, most of all, because it’s portable. Any health care provider in any VA hospital anywhere in the country can see the health records from any other VA hospital anywhere else in the country. The VA is currently in the middle of upgrading this system.
Our patients Google their symptoms all the time. We should be able to do the same type of search on our patients’ records across medical systems. In 2020, we still rely on fax and paper which The New York Times called a “chokepoint” for COVID-19. I can play music stored on my Apple iPhone through my Amazon Alexa, but my heart monitor doesn’t record directly into my EMR and my infusion pump can’t be automatically programmed from the order I put into the EMR. None of this makes sense and may be partially why we cannot get a grip on this health crisis.
The way this much-needed change will happen is if our systems actually talk to each other. We can only achieve modernization through standardization.
Standardization can be done with relative ease. The simplest solution for the U.S. government would be to require all EMR software to be compatible with the upgraded VA health record system. After that, they would be free to add whatever bells and whistles they would like to on top of that platform. This would not limit innovation in EMRs any more than requiring a left-sided steering wheel limits innovation in cars, but it would provide a commonality for EMRs to work through.
Our health care system needs drastic change, and the question of who pays for it is only one part of that change. Only through standardization will we be able to begin to form a true health care “system,” ready to respond to the next pandemic, rather than the disjointed chaotic response of a health care conglomeration-of-fiefdoms.
Hemal N. Sampat, M.D. is a hospitalist at Massachusetts General Hospital. He is dually board-certified in internal Medicine and pediatrics. He is also a Public Voices Fellow with The Op-Ed Project.