Health Management Technology

Is there anyone who doesn’t remember Hurricane Katrina and the heart-wrenching TV images of traumatized New Orleans residents being herded onto busses and then disbursed and displaced into Utah, Texas, Arkansas and Georgia? More than any political speech or legislative initiative, Hurricane Katrina drove home the hardest of healthcare lessons: The time to prepare for disaster is before it strikes.

In New England, a small but mighty collaboration of medical, IT and volunteer personnel has heeded the warning. New Hampshire-based Dartmouth-Hitchcock Medical Center, IT supplier athenahealth Inc. of Watertown, Mass. and dozens of New Hampshire volunteers, with support from the Department of Homeland Security’s Northern New England Metropolitan Medical Response System (NNE MMRS), staged a 1-day medical emergency simulation on Nov. 15, 2006, to test an emergency response model using the Web-based athenaNet platform.

The objective was simple: Simulate a disaster and test the creation of a Web-based electronic medical record (EMR) that could service all affected patients regardless of location. The planning and execution, however, weren’t simple. They required elbow grease.

Track, Treat and Record
During any mass casualty episode, be it a terrorist attack, pandemic event or a natural disaster, “We have an enormous problem keeping track of what we do to and with patients,” says Dartmouth-Hitchcock Medical Center’s Medical Director for Emergency Response, Robert Gougelet, M.D., who also serves as program director for the NNE MMRS. He says that during events such as Hurricane Katrina or the SARS emergency, “We need to keep track of patients, of how we treat them, when and where we treat them, what medications they receive, what procedures are done, which facilities they visit and for how long they remain under our care. Those are the basics we should be doing. In the past, we have seriously struggled with these because we have been forced to do them manually,” and with no continuity of record keeping.

The NNE MMRS/athenahealth pilot, if expanded, would erase the manual portion of that equation and would offer extensive potential for continuity of data.

The NNE MMRS/athenahealth team utilized 50 high school student volunteers acting as patients impacted by an emergency, who were then “treated” in area facilities for a wide range of medical conditions. The demonstration utilized athenaNet, a Web-based platform that functions as the backbone of athenahealth’s practice management system, supplying the foundation for billing rules, electronic eligibility checking, scheduling, claims submission and reporting. The system runs with as little as a PC, a browser and an Internet connection. During the simulation, healthcare providers were able to create individual EMRs for every patient seen via athenaClinicals, a Web-based EMR service hosted on athenaNet.

“The objective,” says Gougelet “was to track each patient from the point that he or she entered the healthcare system during an emergency and then be able to create and build a usable EMR for that patient, regardless of entry point. We know that during emergencies, patients don’t come equipped with their medical records. At best, some may have two or three photocopied documents about medications or medical histories. Even if hospitals do use EMRs or electronic charting, they may be unable to access their data during an emergency, and they certainly can’t exchange data with other providers in a disaster-struck region. With the athenahealth EMR, we were able to create a record for each patient. A record that every provider involved in treating that patient could access and augment.”

Gougelet says this is critical in a crisis. Many patients will have one healthcare encounter, and they’re done. But in most emergency situations, some patients will experience two or three episodes of treatment by different providers at different types of facilities, possibly in different locales, or over a prolonged period of time. The demonstration proved that patients could be transported and moved among facilities in different locations without detrimental impact on any provider’s ability to access patient data or to add to it.

What’s the Big Picture?
Pilots and demos are one thing. Real metropolitan or regional emergencies are another. But Gougelet and his teams, both at Dartmouth-Hitchcock and at the NNE MMRS, are experts. They talk routinely in terms of disaster-site triage, triage tags, resource mobilization, medical strike teams, surge capacity and “distributing” patients to alternate care facilities, terms well outside the norm of typical healthcare lingo.

Theirs is an unusual challenge in terms of preparing for disaster. NNE MMRS is the first Metropolitan Medical Response System in the nation to develop a multistate project. Together, Maine, Vermont and New Hampshire constitute a condensed geographical area, largely rural in nature, and yet one that includes an international border, an Atlantic seacoast and multiple, potential urban targets to the south in Boston, Hartford and even New York City. It is a perfect place to launch an emergency simulation.

“We have a system here that could be developed and adopted as a national system, says Gougelet. “We anticipated this before the pilot and are convinced of it now. The system creates a unique EMR with a unique numerical identifier for each patient. We can create such a record from triage tags from the field, even if we lack the patient’s name. If the tag has a bar code and location, we can bring data into the athenahealth system where the EMR starts and then can create a data collection that can be accessed by any provider treating the patient, even in another community or another state. All along the way, data can be added to the patient’s record. We can even follow patients for 15 or 20 years with these records. This is what lends accountability to providing healthcare. True accountability of this nature doesn’t exist today.”

Nevertheless, Gougelet stipulates that such success is the tip of the iceberg and that much work remains. Interfacing with field tracking and resource sharing software, such as HC Standard, and the development of templates and front-end pages are primary examples. He estimates that up to 25 different kinds of emergency situations exist for which dozens of templates can and should be built, so that communities are ready for almost any crisis. “Anthrax, for example,” he says. “We know the symptoms and treatments. We can build templates into the system for Anthrax-related disaster, combine them with user-friendly, pull-down menus and then tie the software back to an interface that is friendly and fast. Templates like this also can be designed on the fly, because the system is centralized.”

Anyone for Reimbursement?
In a true emergency, providers probably don’t think much about coding, claims and reimbursement. “When we started the project,” says Gougelet, “reimbursement was of absolutely no concern to me. That wasn’t how I thought about disasters. But as we moved further into planning and held briefings, the issue became clearer. Hospitals and communities can’t support all this emergency medical care on their own. There should be a mechanism open for data collection and billing, in the event that the care is reimbursable.”

Indeed, there is a mechanism. The athenahealth system tracks and records everything in the background; that includes the provider, the facility, patient by numerical identifier or name, symptoms, diagnosis, treatment rendered, medications distributed, procedures performed and subsequent referral. According to athenahealth Director of Revenue Cycle Product Management Bob Gatewood, the system operates like this behind the scenes because, “Dr. Gougelet is right. Physicians, triage nurses and EMTs don’t want to think about having to collect and store data in the midst of an emergency, when hundreds or even thousands of people need help.”

The most that can be expected of medical personnel in a real crisis, he says, is that they can electronically document how and when they encounter and treat each patient. “So, we designed the system to keep track of everything for them, but in the background. If there is reimbursement out there that can compensate for emergency medical services, this system will apply codes to the captured data so reimbursement can be sought as soon as it is feasible.”

As the athenahealth system evolves toward servicing communities and regions in crisis situations, it works in ways geared to best support emergency medical needs. According to Gatewood, “We can put huge volumes of data into the system in advance. We can load in facility, trauma center and treatment capability information, plus data about all providers in a region—physicians, nurses, EMTs—and their locations and skill levels. Literally, we can create a database for a community. Then, if an emergency strikes, we can show up with a laptop and make use of all the data via an Internet connection. We can prevent the confusion that was experienced so vividly by patients and medical personnel during Hurricane Katrina.”

Forecast for the Future
The system provides another advantage that both providers and first responders will appreciate. The continual data capture can be used for more than creating claims and seeking reimbursement; it also can be used for modeling and forecasting. While some people think the spitting out of reports is boring—and sometimes it is—the spitting out of reports that can extrapolate and predict for community leaders and first responders what they can expect in pandemic or emergency situations can prove invaluable.

How fast will a disease spread in a given population and where will it spread first? What ratio of patients coming to a hospital will need only minimal services, compared to those who will need maximum-level services? Which patients will arrive first? How fast will a current supply of medications be consumed? A community or region that could answer those questions in advance would be light years ahead of others in terms of disaster preparedness.

The very term “disaster preparedness” means preparing in advance for the future, and that’s a concept Gougelet et al currently embrace. The next step, he says, after data from the November emergency exercise is shared with and analyzed by surrounding states, is to identify funding sources and pursue future funding for project expansion. “In New Hampshire alone, we have 26 hospitals. We can query each: What kind of EMR do you have? What would you do if you lost patient records? We can begin to customize how we use the athenahealth system so that it meets a variety of medical needs throughout New Hampshire, and then Vermont and Maine as well.”

While Gougelet talks confidently of identifying funding sources, seeking funding, expanding the pilot, analyzing more data, looking at reports, gathering and considering opinions, in the end, he remains a man of few words. He feels strongly, however, that this is a critical step forward in our national preparedness efforts.

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