The Ebola situation in Dallas—with one patient death, two nurse exposures, dozens under quarantine, and talk last week of declaring a state of emergency in the city—has thrown into stark relief the gaps between public health and frontline clinical care. But those gaps also present opportunities to make public health data work harder and to change how doctors approach clinical care in times when events and information are changing at Internet speed.
It comes down to making electronic health records (EHRs) work more flexibly, in ways that help promote situational awareness among clinicians during times of crisis and flag instances when a patient’s condition may require more attention than usual.
Increasing situational awareness
“The EHR did exactly what it was supposed to in Dallas,” says Mandl, who chairs biomedical informatics and population health in Boston Children’s Informatics Program. “But EHRs are designed to work in the context of the average patient. For the average patient, travel history is not particularly relevant, but in this case, travel history was the whole story.”
But bringing greater situational awareness to the point of care requires the data to be available. Public health authorities like the CDC are constantly releasing new data and recommendations, but none of that information is available in a format that can be plugged directly into an emergency room’s clinical workflow.
“Public health is locked out of the point of care,” Mandl says. “But it has a lot to say, a lot of data that could provide clinical context for how to approach individual patients.”
App-ropriately bringing public health to the clinic
The answer, he says, is to provide systems that make it easy to connect the dots—ideally EHR-connected app platforms like the SMART platform he co-developed. These systems would flag patient characteristics that might not be important most of the time but that become critically important in emerging situations.
As a clinical example, Mandl points to a study he published in 2013 showing that adding public health data into decision-making algorithms for strep throat could eliminate hundreds of thousands of unnecessary antibiotics courses per year.
“Imagine if the CDC or World Health Organization developed an app that changes the clinical workflow of an EHR, for instance highlighting travel history as an important field,” he muses. “Or that can calculate, based on geography, a patient’s risk for exposure. That single app could flag patients for closer inspection and heightened caution.”
The technological obstacles to implementing such a system are low, Mandl adds. It largely takes manpower and willingness—and the latter has been lacking. “There’s been a prolonged socioadministrative-regulatory inertia in to improving how EHRs work,” he says. “And if not now, when? We need to instrument the health care system to interface with public health in order to protect patients and health care workers.”
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