The New York Times reported recently on the death of an emergency department patient at NYU Langone Medical Center who was discharged before abnormal lab results were received. The patient was told they were suffering from a typical stomach bug, and never told that a lab order was placed. The primary care physician was never made aware of the lab results either.

My objective is to analyze how health IT might have played a role to help in this tragic event. With the formation of HIEs and ACOs along with adherence to Meaningful Use criteria, the goal is that all patients will receive better quality and more efficient healthcare. 
 
Could available health IT standards prevented what happened at NYU? I will attempt to recreate the workflow of healthcare data using the latest standards and communication frameworks available in healthcare.
 

Health IT Standards Now Available

CCDContinuity of Care Document (CCD) The HL7 CCD is the result of a collaborative effort between the Health Level Seven and American Society for Testing Materials (ASTM) to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR)... More Document: CCD, or Continuity of Care Document, summarizes the patient health information required for the continuing care of the patient. It includes 17 sections of information, including such things as labs, meds, vitals, etc. Some hospitals will automatically forward a CCD to the local HIEHealth Information Exchange (HIE) focuses on the mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate health... More upon patient discharge.

HIE: An HIE, or Health Information Exchange, orchestrates the exchange of patient health information electronically across organizations within a region or community. HIEs can be established and governed by a private entity, such as a large health system, or by the government.

IHEIntegrating the Healthcare Enterprise (IHE) is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. Visit the IHE website. Synonyms: Integrating the Healthcare Enterprise: IHE, Integrating the Healthcare Enterprise, establishes profiles for transferring patient health data among providers and/or HIEs. IHE simplifies the process of sending CCD documents by ensuring all providers are exchanging them the same way. Once a provider is set up to exchange CCD documents with one organization, they do not have to recreate the wheel to exchange with additional facilities. All communications in the next section would be based on IHE standards.

The Workflow of Health Information

Using the health IT standards discussed above, the following six steps could have been utilized to more efficiently process the patient health information in the NYU scenario:

Step 1 – CCD on Discharge: When the patient was discharged from NYU, a CCD summarizing the care received could have been forwarded to the local HIE. Since lab results were not yet received, the lab results would show as pending.

 

Step 2 – CCD forwarded by HIE to intended recipients: Upon receiving the CCD, the HIE would store the CCD in its repository and also forward the CCD to all parties listed in the intended recipient list within the CCD document. Both the primary care physician and ER physician would be intended recipients, and would receive copies of the CCD document.

Step 3 – NYU receives completed lab results: NYU received the abnormal lab results after the patient left the hospital. These lab results are added to the patient’s electronic medical record (EMRElectronic Medical Record (EMR), as defined in Defining Key Health Information Technology Terms (The National Alliance for Health Information Technology, April 28, 2008): An electronic record of health-related information on an individual that can be... More).

Step 4 – EMR at NYU raises alert for abnormal lab result: Electronic medical records have clinical decision support capabilities to alert on urgent matters. In this case, an alert could have been raised that an abnormal lab result was received. That alert should remain active until someone at the hospital manually acknowledges that they are aware of the situation.

Step 5 – Status of lab results in CCD changed to complete: Since the lab results were not available when the CCD was created, the CCD will automatically be updated with the completed lab results.

Step 6 – Revised CCD forwarded to HIE: A revised CCD document with new version number will be forwarded to the HIE. The labs will be marked as complete and they will show the abnormal results.

Step 7 – Revised CCD forwarded by HIE to intended recipients: As in Step 2, the CCD will be forwarded to the intended recipients including the primary care physician and the ER physician. All physicians involved with this patient will have been alerted to the abnormal results.

The above steps are a simple example of how health IT standards can be used to improve the quality of care. While health IT cannot solve all problems, it can certainly be a factor in providing more efficient and timely information to all involved. It can also be extremely useful in automatically raising flags.

Would health IT have changed the outcome in this case? I don’t know. But it could have helped in getting the appropriate care to the patient when they needed it.

 

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