Within the walls of emergency rooms and intensive care units in New York City, providers are scrambling to provide the best care to COVID-19 patients. Much of that care depends on the efficiency of electronic health records (EHR), which catalogue the health details of each patient and serve as the first information a provider sees when caring for a new patient. As the chief medical information officer of NYC Health + Hospitals, Michael Bouton ’16 oversees the EHR systems of the country’s largest public healthcare system, putting him at the high-pressure nucleus of the COVID-19 crisis. He’s also a practicing emergency medicine physician, who sees hospital infrastructure challenges firsthand. Armed with an MD and MBA, he is tasked with understanding the needs of hospitals from both a provider standpoint and a business one—a challenging feat, especially now. Bouton describes how the city’s public hospitals have coped with the pandemic and the permanent healthcare changes that could come from this crisis.
NYC Health + Hospitals recently rolled out Epic, a $1 billion EHR program—how has this enabled hospitals to cope with this crisis?
We moved from having 11 different instances of our previous electronic medical records to a single unified database, which is an incredible improvement. If patient Michael Bouton shows up to Harlem Hospital and then leaves and goes to get care at Bellevue Hospital or any other institution, we were previously unable to see that or track it. Now we can, and we have all that information and data shared.
When patients are admitted to the hospital, providers use something called an order set that groups together the lab tests, radiology procedures, nursing orders, and treatments that providers need to request for patients based on a presumed diagnosis. This means for COVID-19, when things are changing so quickly, we are able to directly edit the order sets to include new tests and the most evidence-based interventions. If one night we realize that a certain test result can be predictive of a COVID-19 diagnosis, we can add that test into the COVID-19 order set so that providers coming in to work the next morning are alerted to the update immediately. I work with clinical leaders from emergency medicine to internal medicine to surgery to make updates to the order sets. This way, it is a consensus-driven way of making changes so that we can deliver evidence-based care to our patients.
In the current crisis there has been an immediate push for healthcare to be virtual—how has NYC Health + Hospitals adjusted to this?
We already had a telemedicine program in place before the pandemic, but we’ve added video capabilities so that patients can more easily interact with our staff. In addition to those services, we’ve added the 3-1-1 call line. This allows patients to call in and either tell the operator that they are a current patient of NYC H + H or that they do not currently have a provider, and either way they will be routed to us. Once they get through the call tree, they are connected with one of our providers who will talk to them about their symptoms and discuss whether they need to immediately visit the hospital or not. The provider can also offer guidance right on the spot or can set up a future appointment time for a telehealth visit over the phone.
What permanent changes will come from this crisis regarding data and electronic records?
When this crisis started, I got on the phone with my counterparts at the other major New York City medical institutions and planned how to best share information between us. We rapidly liberalized our ability to share information at the point of care: not for financial purposes, not for billing or operations purposes, but for the doctor taking care of a patient at Mount Sinai who needs to be able to look at our records at H + H. In the world of compliance and regulation, we’ve moved at record speed. NYC Health + Hospitals, Mount Sinai, Columbia, Cornell, Hackensack, Yale, and a number of other major players in medicine, have all agreed to changes in our information sharing to relieve the burden on the front-end point of care. This is a change I think will endure past this time and will be a very positive thing.
To give an example of what these means in real life: During my last shift I cared for a nursing home patient who, upon arrival to the emergency department, was gravely ill with COVID-19, but about whom I knew very little else. Emergency physicians are used to making critical decisions based on limited information, but when these decisions are around end-of-life care, the stakes are particularly high. My patient had never been seen within the NYC Health and Hospitals system before, but now I was able to see their records from multiple other NYC health systems without paperwork. I was able to see the patient's long list of comorbidities, including a form of dementia that had robbed them of their ability to speak. I was also able to find documentation that made clear their goals of care in such a circumstance. My patient died a few hours later, and I spent that time focusing on their comfort instead of invasive procedures. The patient received the appropriate care, I was relieved of the psychological toll around declaring medical futility, and during my conversation with the family they got to speak with a doctor who knew their loved one's full medical history.
Increased capacity as a system—the bed space that we found and quickly transitioned—will allow us to very rapidly scale to this level again in the future if it’s needed. The streamlining of our documentation has been accelerated by this and we’ve gotten down to what is absolutely necessary to get it done quickly to free up our providers. Physicians were previously spending a large amount of their time documenting, which was highly burdensome. But now, it is impossible. At this moment, we need physicians taking of our patients, not bogged down in documentation. And that's kind of where physicians always wanted to be at, but this has forced that along. Part of my job is to weigh the burden of documentation against the value of discrete data and figure out how to strike that balance. What we’ve done is make more things automatically pulled in as discrete data, which leaves the physician to only document what they think is important.
What’s the role of data analysis in the hospitals right now? How is New York using our information to inform other states that have not yet been as affected?
We’re one of the first places within the United States to experience the virus on this scale, but we're not one of the first places in the world. We definitely learned from countries that had a big influx of COVID-19 before us. There were publications both from China and then from the University of Washington in Seattle that we borrowed heavily from early on. Some of our first order sets were based on data that we saw out of the University of Washington. As time goes by, we're learning from our own data. We’ve set up registries that record all patients that either have or are suspected to have COVID-19. We've aggregated their lab results, their vital signs, the medications they're on, and we're constantly analyzing that to see which labs are predictive of good or bad outcomes or prognostics. We’ve also started drug trials to see which treatments may or may not work.
What has New York City done well in the handling of this crisis? What could it have done better?
What I think we've done well is that we rapidly increased our bed capacity to deal with the surge of patients. We redeployed our resources to meet the demands and continue to increase our capacity to meet demand. Increasing capacity of any one hospital was not going to be successful, we needed to increase the capacity of every single one of our hospitals and then level the load between them. We match capacity to bed demand on an enterprise, rather than hospital, level. Elmhurst is one of our hardest hit hospitals, so what we've been doing daily is transferring many patients out of there, and out of other hard-hit hospitals, and sending them to other institutions that are either larger and can take more volume or are in neighborhoods that are not as inundated with patients. Our view is that the care of our patients should be the same no matter which one of our facilities you are at.
As far as what the city could have done better, I'd hope that the next time something like this happens, we would be prepared with the ability to do testing and case tracking early on in the crisis. Good, rapid testing would have been very impactful with COVID-19. We have now brought testing online and get same-day test results, but that was not available a month ago. This is not really a hospital, system, city, or even a state problem, it is a national problem that we are still trying to solve.