What Joplin teaches hospitals about disaster recovery planning

Last month's tornado in Missouri left one hospital destroyed and others scrambling to treat patients. A new EHR system, fast vendor support and operational WAN all helped.

The Joplin, Mo. tornado took a harsh human toll -- it was the deadliest in the United States since 1947. It also dealt a direct blow to the health care infrastructure in the city of 50,000, leveling St. John's Regional Medical Center and leaving its health care providers, administrators and IT staffers with a difficult road to disaster recovery.

"Pictures do not do the area justice," said Sandi Godfrey, birthing unit nurse manager at McCune-Brooks Regional Hospital in nearby Carthage. "It's devastating to look at….it's like a war zone where bombs went off, repetitively. It's a miracle we don't have thousands dead."

Seeing the pictures of the Joplin devastation and considering how such an event would impact their own facilities probably has inspired hospital leaders across the country to redouble their own disaster recovery planning efforts as they pertain to both operations and information technology. The key lesson from Joplin is that IT and operations intersect at many points.

Thanks to St. John's electronic health record system, a working connection to its parent system's data center and a clearly defined disaster response plan from its EHR vendor, patient care continues in the midst of the ruins of St. John's as the injured patients recover and the hospital rebuilds. St. John’s has established a 60-bed mobile field hospital while reconstructing the main facility.

Access to clinical data allows treatment to continue, not restart

Just three weeks before the tornado hit, St. John's switched on a brand new integrated EHR system, which included digital scans of legacy paper records. While the twister scattered X-ray films, birth certificates and other non-electronic records as far as 70 miles away, electronic patient records remained functional thanks to live, offsite servers administered by St. John's parent company, Sisters of Mercy Health System, which operates 400 clinics and hospitals throughout the Midwest and South.

The EHR system aided the handoff of patients to Freeman Hospital in Joplin, to McCune-Brooks and to an improvised clinic set up at Missouri Southern State University's Joplin campus. While interoperability issues prevented the electronic flow of records among all systems, providers were at least able to access records and print charts. This aided disaster recovery planning, Godfrey said, as it let her unit pick up where St. John's obstetrics staff had left off by caring for several patients who transferred in the wake of the evacuation.

In many cases, the printouts were the only information that health care providers received during the tornado response, said Pam Barlet, McCune-Brooks community relations and program development manager. With phone and power out, a few people at the various facilities were able to exchange brief cell phone text messages, but that was it.

McCune-Brooks saw 300 patients affected by the tornado. That amounted to a massive surge for the 25-bed critical access hospital, which invoked disaster recovery planning that enabled the facility to treat all but the most serious, or Level I, trauma patients.

While St. John's sent seven official patient transfers, four of them to the obstetrics unit, McCune-Brooks may very well have seen more patients that were either evacuated from St. John's or otherwise would have gone there had it not been hit by the twister. McCune-Brooks had no way of knowing for sure which other patients had been seen by St. John's triage units or showed up on their own. Some patients, Barlet said -- including expectant moms -- weren't injured during the storm but needed typical pregnancy care.

This presented an electronic clinical data dilemma. "A lot of the patients in the Joplin area started becoming a little anxious because the phone lines were down," Barlet said. "They weren't sure if their doctor has lost their office or were still practicing…they started coming to us because they weren't sure."

One St. John's patient, an expectant mother, had been due to be induced within a week. The tornado hit, and she ended up at McCune-Brooks. Because of the anxiety surrounding the storm, her blood pressure spiked. Physicians induced her delivery early -- and successfully. Such procedures are risky when caregivers can't survey a particular pregnancy's back-story and understand the implications of inducing labor. In this case, the patient history present in the EHR system saved the day, Godfrey said.

"In the birthing unit, the ability to get a hold of those records and see what medications those ladies were on -- or their history -- allowed them to continue their treatment instead of starting all over," Barlet said.

Professional org offers aid

In the wake of the Joplin disaster, the American Healthcare Information Management Association (AHIMA) Foundation announced the creation of the Health Information Relief Operation (HIRO) Fund to offer technology support and clothing for hospitals in need. While the foundation had assisted in relief for hurricanes and other disasters in previous years with one-off fund drives, Bill Rudman, AHIMA vice president of education and workforce development, said the Joplin tornado crystallized his organization's idea for a permanent fund.

Now that EHR adoption is rising across the U.S. health care system, the major needs for health information managers and their IT coworkers during disasters are clothing, smartphones and computers -- the latter of which are properly configured to access system backups.


Disaster recovery planning must outline patient, clinical workflows

Advanced preparation makes emergency response go smoothest, said Dr. Michael Ward, a researcher in the University of Cincinnati Department of Emergency Medicine who recently received a $150,000 grant to investigate EHR implementations in emergency departments (EDs).

As Ward theorized, and the McCune-Brooks responders attested, the main problem during a patient surge is keeping track of everyone -- that is, assigning numbers and documenting care in a fast-paced environment. As the surge subsides, the issues becomes linking patient history -- allergies, medications and the like -- to the information gathered on admission.

Ward's research will incorporate computer simulations of how different EHR implementations affect ED workflows. For effective disaster recovery planning, he said hospital IT leaders should figure out what's going to happen if the EHR system goes down, and what the ED will do for a backup. That includes figuring out how caregivers will access patient data, track and document current patient care and, later, how the information generated while computers are offline will be integrated back into the EHR system.

"When you're paper-based, you can check a couple boxes, and you can do it anywhere you want, whereas with an [EHR] you have to go to a physically working computer that is networked, and spend more time documenting than you would [with] the more archaic system. In a sense," Ward said, trying to use an EHR system in a disaster "kind of takes you away from the patient care."

In disaster recovery planning, determining clinical data workflow is the first step. The next step, Ward said, is figuring out how a disaster will change patient care workflow and planning for how the EHR system will work differently during a large patient surge. (Emergency physicians, he noted, are pretty comfortable cycling through and tracking the progress of roughly 15 patient records per shift.)

When an emergency occurs and physicians get more patients, they tend to go "by rote" and won't always have the luxury of paging through electronic records for those 15 patients. Figuring out the number of patients is the "trigger point" that alters care workflow -- and planning for that change -- will give a benchmark for dealing with the problems that occur in patient surge scenarios.

More disaster recovery planning resources for health care organizations

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Hardwiring EHR vendor support into software contracts

One key factor in disaster recovery planning for hospitals is the help they receive from their EHR vendor getting back online. Ultimately, it really depends on which EHR systems are in use, and what's been put into the software purchase agreement. Sometimes, benevolence will come in to play and the EHR vendor will volunteer some of its resources beyond what's written into the agreement.

"Different vendors have different approaches of how to treat their customers," said Bill Rudman, vice president of education and workforce development for the American Healthcare Information Management Association (AHIMA). "Some vendors have a heart for not just their customers, but the people in the area [affected by a disaster]."

If you negotiate a disaster-recovery component into your software agreement with an EHR vendor, University of Cincinnati’s Ward said, be sure to include agreed-upon timeframes for the vendor to get your system up and running. Having a workable IT response plan for the in-between time is key. If they can get you back up in 72 hours, that's great, he said. "But what are you going to do for 72 hours?"

Assisting in disaster scenarios was part of McCune-Brooks' software service agreement with General Electric Co. (GE) for its Centricity Perinatal EHR. The company, however, provided more computer hardware and software licenses than the contract strictly obligated -- enough to add five exam rooms to the obstetric unit's four existing. GE also responded within 24 hours, Barlet said.

In disaster recovery planning, determining clinical data workflow is the first step. The next step is figuring out how a disaster will change patient care workflow.

While disaster recovery is written into customer contracts, GE Healthcare will also search for customers in an area where disaster has struck and assist in getting systems back up and running, said Tamara Grassle, general manager for Centricity Perinatal. In cases where hospitals such as McCune-Brooks had a patient surge, the vendor will help hospitals quickly expand operations, she added.

WAN assists disaster recovery planning; HIE could, too

As luck would have it, both St. John's and McCune-Brooks used GE EHR systems. This allowed the vendor to enable health information exchange (HIE) between the facilities. Moreover, because Mercy, St. John's parent system, uses a wide area network (WAN), GE was able to verify that crucial data such as fetal monitor feeds was secure and accessible even though phone lines were down and the vendor couldn't get in contact with anyone at St. John's, Grassle said.

If, on the other hand, McCune-Brooks and St. John's had been on the same WAN, Grassle said handoff from one facility to the other would have been fairly seamless. Instead, McCune-Brooks had to access St. John's patient records via printable files. Nationwide HIE, as federal health IT leaders envision it, would greatly aid disaster recovery planning by allowing all EHR systems to share patient data, she added.

Ward agreed. While he is typically skeptical of new "panacea" technologies or systems that will solve a big problem -- he said "the devil's in the details" of EHR implementation -- Ward feels that working, nationwide HIE will help emergency departments provide better, more efficient care in disaster scenarios.

He cited the example of the interconnected Veterans Health Administration. If, for any reason, one of the hospitals gets knocked "off the grid," no patient data is lost, and veterans can simply resume care at another facility, Ward said.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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