Guest authors Peter Groen and Jaime Nasuti aiming to promote use of EHR systems through fictional drama

Shepherdstown 23 September 2007Guest authors Peter Groen and Jaime Nasuti are presenting here a dramatic short story about the use of Electronic Health Record (EHR) systems. This story and all characters in it are purely fictional. The intention of the authors is to support and enhance the goal of improving health care using IT systems by means of fictional drama to make their statement. Virtual Medical Worlds Magazine is publishing the story in its unchanged form.

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A Case of Murder and Electronic Health Records (EHR)

Explicative note by Peter Groen and Jaime Nasuti

In the U.S., even though the President has mandated the use of electronic health record (EHR) systems nationwide by 2014 and many politicians support this stance, progress is painfully slow. A recent Health Industry Insights national survey shows most Americans are unaware of the U.S. government's initiative to make Electronic Health Records (EHRs) available to citizens within 8 years. To date, only 9% of physician offices and approximately 25% of hospitals have implemented comprehensive EHR systems. Less than 1% of the population is using computerized Personal Health Records (PHR) systems. It is our contention that progress would improve significantly if the popular entertainment media were to bring the issue before people's eyes in the form of a movie drama, TV show, and entertaining short stories. The following short story is one such initial attempt.

"Presidential hopeful Congressman Stan Martin has dedicated his political career to trying to prevent similar instances as what the U.S. saw in the aftermath of Hurricane Katrina. With no national healthcare in place and major resistance by the American Medical Association (AMA) and the pharmaceutical and insurance industry, Congressman Martin has focused his presidential campaign on national healthcare, with an emphasis on the nation-wide implementation of electronic health records (EHR)." - Reuters News Article

Stan could never forget the circumstances surrounding his wife's death. The constant stream of news articles brought the memories. Surely one of the most reputable hospitals in the nation should have been able to handle her situation, even if there was a hurricane raging. She shouldn't have died. The memory was still painful, even after all this time.

They had spent most of their married life in New Orleans, just outside the French Quarter. Even with the imminent threat of Hurricane Katrina looming over the area, Stan never considered relocating the family inland. After all, they had lived through the threat of other hurricanes over the years and had successfully weathered those storms. The decision to stay was also based on his wife's medical condition. She had to stay on track with her chemotherapy if they expected to beat it this time. After being reassured by the physicians at the LSU Medical Center that they would be able to continue her treatments uninterrupted, Stan had made the fateful decision not to evacuate, but to remain in their home and brave the storm.

Hurricane Katrina hit New Orleans with tremendous force. Windows were blown out and flying glass and debris filled their Victorian house. With no storm cellar or basement in which to seek refuge, Stan, Kitty, and their kids huddled in the antique cast-iron tub in the guest bathroom in the center of their home. It was at the height of the storm that a branch from the kids' favorite climbing tree came crashing through the roof, and as the bathroom wall began to crumble, it was too late to move. Kitty took the brunt of the impact as she shielded the kids from the wall's debris.

As the winds began to die down, the cries from the children filled the destroyed room. Blood began to make a small pool in the tub, which caused the kids to panic and start screaming for help. From under the debris, Stan struggled to move the remains of the bathroom wall covering them in the tub. But a large tree branch weighed down debris from the wall, slowing his progress. He finally managed to shift the tree branch, lift a section of the wall, and clamber out of the tub. The kids' panic heightened when there was a loud crackling and they heard their mother yell out in pain. Stan began working like a madman in the dying rain, applying all his strength to move the tree branch and debris from the fallen wall. Kitty's pain filled yells reverberated off the walls and drove him onward.

Stan finally managed to make a hole big enough for the kids to climb to safety. As they grabbed a hold of his neck and climbed out of the opening, blood smeared all over Stan's clothes. He checked them over quickly to see if they were okay, making sure none of the blood was coming from them. Aside from a few scrapes and bruises they seemed fine, so Stan turned his attention immediately back to his wife. She had not cried out in pain during the last few minutes and Stan hoped she was quietly waiting for him to rescue her.

Kitty was a petite woman, and 4 months of chemotherapy had caused her to lose quite a bit of weight. It should have made it easy for Stan to drag her through the hole in the wall. But as he stuck his head through the opening he had made to determine her condition, he could see she was bleeding badly and he didn't know where it was coming from. He tried to get her to talk to him, tell him where she was hurt, but she had passed out from the pain. Stan gently placed his hands under her armpits in order to pull her out and could feel that her left arm was in bad shape. As he pulled her up and dragged her body through the hole, she made a whimpering sound, which gave him hope. He just knew she was going to be okay, but he had to get her to a hospital. As the winds began dying down, he carried his wife out to the car, which had miraculously survived the storm. The kids sat quietly in the back of the car as Stan carefully drove through the carnage that was everywhere.

Hurricane Katrina had wreaked havoc at every turn. The local hospital was beyond recognition. Stan knew Kitty was in desperate need of medical care, besides her arm he was certain she had suffered other injuries he had overlooked. The hospital had no electrical power. The emergency power from backup diesel generators was being used to provide lighting and power to the emergency rooms, surgical suite, and selected medical equipment. Ceiling tiles, glass, and other debris littered the once spotless patient waiting rooms and halls. The skeleton crew of physicians, nurses, and technicians were struggling not to be overwhelmed by the disastrous situation they faced.

When the medical staff finally turned their attention to Kitty, they tried to do their best. Her physical condition related to her cancer treatment complicated the picture. Her chemotherapy for a rare form of cancer involved the use of some very powerful drugs. Unfortunately, her medical records were not available to the clinical staff. Her entire medical record, along with those of almost all other residents of New Orleans's, had been destroyed during the storm. The medical record rooms, containing paper charts on hundreds of thousands of patients, were located in the basement of the hospital. Initial flood damage to these rooms by the storm was further compounded when the dikes broke. At that point, virtually all the medical records in hospitals, clinics, and doctor's offices across the city were totally obliterated. Given the crush of patients, the need for immediate treatment, and the lack of information about the patient's medical history, the doctors proceeded to treat her external wounds. As the nurse administered a pain medication through an IV, Kitty began to shake uncontrollable. The doctors tried desperately to resuscitate her when she stopped breathing, even as the nurses forcefully dragged Stan back to the waiting room to wait with his kids.

A short while later a doctor came out to give Stan the devastating news of her death. The doctor, accompanied by a nurse, tried to console Stan and the kids, but Stan rushed into the emergency room not wanting to believe it. But she was already gone. They never got a chance to say good-bye. All Stan could think about was, "How could this have happened?"

* * * * * * * * * *

In the aftermath of Hurricane Katrina, Congressman Stan Martin listened to a seemingly endless series of horror stories presented at the Congressional hearings. Many of these stories were very similar to his own. Stories of citizens seeking care both in New Orleans and elsewhere across the country. Tens of thousands of evacuees learned first hand how unprepared the U.S. was to deal with this kind of natural disaster. With all the technological advances we have made in healthcare, it became clear the healthcare system as a whole was inadequate. The loss of the paper charts of thousands of New Orleans residents seemed to be the cause of most of the medical disasters. It became obvious to Congressman Martin that our country was not fully embracing the IT advances - medical facilities were still running on paper!

However, one surprising story emerged from the hearings - a success story from a most unlikely place, the veterans' healthcare system. The Congressman found it hard to believe, but the U.S. Department of Veterans Affairs (VA) was the only healthcare system to continue to provide uninterrupted care to its patients no matter where they showed up after the storm. Because all VA patient records were computerized and backup copies were kept at a remote location hundreds of miles away, no records were lost due to the storm or the flooding that followed. As patients showed up in Baton Rouge, Houston, Washington D.C., and other VA medical centers across the country, doctors were able to pull up copies of their electronic health records and effectively care for the evacuees.

Congressman Martin was a military veteran, having enlisted right out of high school as a way to see the world and pay for college. When his military service ended, he took advantage of the GI Bill benefits package for veterans. The GI Bill paid for his undergraduate and most of his graduate school expenses. Because he was not wounded during his tour of duty in Vietnam, he had never gone to the VA for medical care. Having seen movies like "Born on the Fourth of July", like many others he had come to believe the stereotypes associated with the VA healthcare system - the care was sub-standard and admission to a VA medical center was to be avoided at all costs. So how could the VA be the most notable major success story to come out of the Hurricane Katrina disaster? Stan vowed to look closely into the phenomenon.

* * * * * * * * * *

Presidential hopeful, Congressman Stan Martin, sat at ease waiting for the questions to begin once again. In his tailored pinstriped suit that Kitty had bought for his birthday last year, he felt confident and in no doubt of his decision to run for office. He knew the pressure interviews like this would cause in normal circumstances, but when you believe whole-heartedly in what you stand for it is "no sweat". Shifting ever so slightly to get more comfortable, the interviewer turned to Stan and asked him if he needed anything before they started the next segment.

Stan knew what was coming and was prepared. He shook off the offer for a drink of water and sat patiently for the cameras to start rolling.

"Welcome back to ABC's Nightly News Special Report - Presidential hopeful Congressman Stan Martin from Louisiana speaks out on his controversial platform calling for the creation of a national healthcare system and electronic health records (EHR) for every citizen. Congressman Martin, thank you again for joining us this evening."

"Now let's get down to this key issue of your campaign. Let's talk about your stance on healthcare reform. We've been hearing a lot about an 'electronic health record' throughout your campaign. Help me to understand exactly what an 'electronic health record' is and why it is so pivotal in improving our nation's healthcare system."

Stan knew he needed to let people know what he believed and try to win them over to his side. But his response was a carefully crafted presentation of facts which he planned to voice in such a way that every American would listen and understand that he knew what he was talking about. He didn't want listeners to tune him out because he spouted off too much 'data'.

"Let me give you a few simple facts about our healthcare system. Last year, the U.S. spent over $1.8 trillion on healthcare, which is over 16% of our country's Gross National Product. That's a lot of money. Yet the richest country in the world, the United States, ranks at or near the bottom of all industrialized countries in terms of vital health statistics. Of 13 developed countries, the United States ranked 13th in infant mortality; 13th for years of potential life lost; and 10th for age-adjusted mortality."

"Depending on which major studies you read, at least 44,000 people, and perhaps as many as 200,000 people, die as inpatients in hospitals each year as a result of medical errors that could have been prevented. It has also been estimated that there were 199,000 deaths from medical errors in outpatient care. This makes our healthcare system itself, one of the leading causes of death in the U.S. In addition to the cost in terms of human lives, medical errors have been estimated to result in total costs between $17 and $29 billion per year to hospitals nationwide."

"To put this into perspective, this is the equivalent of a World Trade Center disaster every week for over a year and a half, or the crash of two fully loaded 747 aircrafts every day of a year."

"We have to do something now!"

"One thing we can do that will make a huge difference is to ensure all healthcare providers in this country start using electronic health record (EHR) systems as soon as possible. The Department of Health & Human Services (HHS) estimates that use of health information technology and EHR systems in the U.S. could save approximately $140 billion per year, not to mention saving countless lives."

The interviewer wanted to appear balanced and fair minded in this interview. With obvious shock in his voice he continued with the questions on the queue cards.

"That sounds like a far-fetched fantasy of a highly critical healthcare professional. However, your background is in Public Administration, not healthcare. Can you explain further how you came to your position on the need for a national healthcare system and use of electronic health records? Why do you feel the U.S. needs such dramatic healthcare reform?"

Stan responded with sincerity and passion to the questions.

"We all know of the sufferings of the residents in my home state of Louisiana, and our neighboring state of Mississippi. Hurricane Katrina was a wake-up call to me and to our country. As you know, I have a very personal interest in making sure we are better prepared next time. My wife was one of the many victims who died as a result of the storm. As you may know, she went into shock due to an allergic reaction to one of the medications she was given. Because her medical record was unavailable, the doctors didn't know about her previous allergic reactions. Because the doctors didn't have that one tiny bit of crucial information, their uninformed actions proved fatal. I don't want that to happen again to others. We need to move towards a national health care system and the availability of life long 'electronic health records' for everyone."

* * * * * * * * * *

As his Presidential campaign progressed over the coming months, Congressman Martin began to feel the mental and physical strain on his body. Recounting stories of the victims of Hurricane Katrina, along with his personal tragedy, Stan tried to keep his detractors at bay. His push for national healthcare hit roadblocks at every turn from lobbyists of the American Medical Association (AMA) and the pharmaceutical and insurance industries. If he could only convince the American people of the overwhelming benefits of electronic health records, he might just win this race.

His conservative opponent was putting up a good fight. They seemed to agree on most political issues except healthcare, and the Congressman was seeing how the lack of financial backing from the healthcare industries was hurting his campaign. But Stan believed so much in the need for a better national healthcare solution and the use of electronic health records, he had to persevere. It was while speaking at an outdoor rally at Shepherd University in Shepherdstown, West Virginia, that Congressman Martin began to feel the ill effects of the summer heat and humidity. He visibly struggled to complete his speech and then quickly headed for his limousine. He felt overheated and like he was having a heart attack. As he climbed into his limo, he told his campaign manager and head of security he needed to get to a hospital. The closest hospital emergency room was at the nearby VA Medical Center in Martinsburg.

Concerned for his charge, the head of his Secret Service security detail called ahead and asked to speak to the Director of the VA Medical Center.

* * * * * * * * * *

The Director, Chief of Staff, and Dr. Douglas, the head of Cardiology, were there to meet the Congressman when the limousine pulled up at the entrance to the Emergency Department. Dr. Douglas immediately noticed the flushed appearance and perspiration on Congressman Martin's brow as he emerged from the limo. His grip, when they shook hands, was weak. He immediately ushered the Congressman into a small examination room, asking the security detail and other bystanders to remain outside.

During the brief physical exam, Dr. Douglas noticed other troubling symptoms. He had a slight fever, but that could have been from the summer heat. He also had elevated blood pressure and complained of an extreme headache. Dr. Douglas also noticed a slight slurring for his words that began to concern him greatly. Because the Congressman had undergone a physical check-up during a recent visit to the VA Medical Center at Washington D.C., Dr. Douglas was able to bring up a copy of his electronic medical record on the computer terminal. The doctor also noticed that there was a flashing button on the screen indicating additional information was available from the military's Walter Reed Medical Center where he had also been previously treated. In just minutes, the doctor had a fairly good medical history on his new patient.

It became immediately apparent that Congressman Martin needed to be hospitalized and further tests run. Something serious was afoot. The doctor called for a nurse and they used the computer to quickly admit the patient and find and reserve a bed and room in the Cardiac Care Unit. Dr. Douglas also entered orders for an x-ray, lab work, and a CT scan of the congressman's head into the hospital's computer system. Stan was impressed by the speed, professionalism, and quality of the care he was receiving. In particular, it was the use of the computerized patient record system that really caught his attention.

* * * * * * * * * *

Dr. Rosen was a relatively new physician on the medical staff of the hospital. Upon hearing of the Presidential hopeful's admittance to the hospital, Dr. Rosen decided to take a quick look at the medical record of the Congressman. It was not that he had any need to look at the record, but he was disturbed by this upstart politician's liberal position on healthcare and just wanted to know more about this man he strongly disagreed with on so many levels.

If he could be the one to keep Stan Martin from continuing on his quest for the presidency, he would be held up as a hero by some of his peers. He might also just get that position he had been dreaming about at the highly prestigious Johns Hopkins medical center. He decided to use the VA's electronic health record (EHR) system to learn more about the patient. How ironic, he thought, to use the very type of system Congressman Martin was promoting to bring about his downfall. If the system could be used to harm the Congressman, that would prove his plans for a national health care system and the use of EHR systems was wrong and just might just cause him to lose the election. Dr Rosen reasoned with himself that he was doing this for the betterment of the citizens of this country.

Logging into a nearby computer console, Dr. Rosen pulled up Stan Martin's electronic chart. With adrenaline pumping, he felt a deep urge to do something to keep this candidate off his feet. The longer he was not on the campaign trail, the better it would be for his opponents. He knew, and agreed, with his colleagues and his mentor, that this candidate for president was bad news for the healthcare and private industry. Seeing no one around, Dr. Rosen quickly placed a pharmacy order, logged off the computer, and walked away.

* * * * * * * * * *

The warning message began flashing on Dirk's computer screen, a somewhat rare occurrence. Not too many high-profile public officials tend to be admitted to the VA Medical Center in Martinsburg, West Virginia, for treatment. Especially not a Presidential candidate.

"I better check this out right now", he thought.

As the VA's information security officer (ISO) for the Martinsburg VA Medical Center, it was one of Dirk's jobs to keep an eye on suspicious activity within the VA health IT systems. Dirk opened up the warning message from the computer and quickly scanned and evaluated the information the computer had automatically gathered and forwarded to him. He saw that Dr. Douglas had ordered a series of tests for Congressman Martin. He called the Chief of Staff to confirm that Dr. Douglas was the physician officially assigned to care for the Congressman. This was confirmed and Dirk hung up the phone relieved.

Politicians never sat well with Dirk. With the upcoming election looming, Dirk made it a point to watch the numerous debates just so he could speak intelligently about why he hated all the candidates. However, a recent interview had caught his attention when a candidate began talking about the VA's electronic medical record. No one ever seemed to give the VA any recognition for its technological advances in the field of medicine or the high quality of care it provided, as confirmed by the Joint Commission on Hospital Accreditation. But it still didn't matter to Dirk. He still wasn't going to take the time to go down to his local precinct to cast a vote on Election Day.

Just as he hung up, another security alert appeared on his computer screen. Dirk opened the computer generated warning and noted that another physician, Dr. Rosen had apparently logged on to the hospital's computer system, accessed Congressman Martin's chart, and had placed an inpatient pharmacy order. This was odd, especially since the Chief of Staff had just told him Dr. Douglas had been assigned as the Congressman's primary treating physician. It was not an unusual occurrence for doctors to open the chart of a patient being treated by someone else, since they often worked in teams or were asked to consult on a case. However it was unusual for a doctor to order a prescription for another doctor's patient. The computer was also indicating that the prescription could result in a deadly drug-to-drug interaction. Something definitely seemed out of place.

Dirk immediately called the Chief of Staff's office again. He gave the secretary a rather curt response as to why he was calling to speak to the Chief of Staff again. She could tell this was an urgent matter and quickly connected him. Once the Chief of Staff got on the phone Dirk quickly explained what he had discovered. The Chief of Staff was silent for a moment and then said he needed to call and get the Hospital Director involved. He then said, "Make sure! Double-check the computer's audit trail and let me know everyone that accessed the Congressman's record and what they did. I will personally put a hold on anything in Martin's record and verify nothing adverse has been given to him. I hope this turns out to be a non-issue, but you never know."

Hanging up, the Chief of Staff called his secretary into his office. "Get the Director on the phone. Also, find Dr. Douglas now! Get him in here and be quiet about it."

* * * * * * * * * *

Dr. Douglas, the cardiologist taking care of Congressman Martin, sat in a stupor in the Chief of Staff's office. What was going on? Dr. Rosen was not his favorite colleague but to be tampering with his patient's medical record, ordering unauthorized meds, potentially deadly ones ...

The Chief of Staff's phone rang loudly in the deadly silenced room. The Chief of Staff raised his eyebrows as he listened. The Director, who was also in the office, watched him closely. Dr. Douglas noticed the perspiration beginning to bead on the Chief of Staff's face.

"I think we better call the head of his Secret Service detail and have them meet with me and the Director here in two minutes! You better come too, Dirk, so you can brief them in detail and show them what you found in the computer system."

* * * * * * * * * *

The Secret Service suddenly had their hands full. Dr. Rosen immediately denied any wrongdoing and went on the offensive when confronted about his unauthorized access to a patient's medical record. However, Dr. Rosen had no idea there was enough security in place within the VA's hospital computer systems to pinpoint the exact time and place of a login, who's record was accessed, by whom, and what actions had been taken - keystroke by keystroke. He knew nothing of the ISO capability to monitor suspicious activity within the system, or of the automatic flags that went up when access was made without authorization. The evidence collected by the system's security software module was damning. The Secret Service arrested him and took him away.

* * * * * * * * * *

As Dr. Douglas was recovering from the unbelievable events that had unfolded just days before, he made a final detailed pass through Congressman Martin's electronic medical record as he prepared to discharge him. He wanted to make sure only his orders were entered in the electronic chart, that everything was clearly documented, and that no mistakes had been made. He carefully looked through the clinical images from the CT scan and other radiology tests he had ordered. The Radiologist had read this scan in record time, he remembered. Apparently having a high-priority Presidential candidate makes everyone move a bit faster. Congressman Martin had presented with basic symptoms of a heart attack but that was ruled out due to his normal EKG. An anxiety attack was the final diagnosis, which was no wonder considering the pressures of running for office. But the slightly slurred speech and extreme headache had forced Dr. Douglas to order the CT scan of Martin's head. Was it possible something was missed? As he double-checked the images, Dr. Douglas noticed a slight irregularity in the scan that caused him to jump up from his chair and run down the hall. They had missed something!

* * * * * * * * * *

"Welcome back to this special coverage of the Presidential election results. If you have not heard, Democratic Congressman Stan Martin has beaten his opponent in a land-slide victory."

"Some might say Congressman Martin, or I should say President Martin, was helped by the recent harrowing events that took place at the Martinsburg VA Medical Center. An attempted assassination plot that was foiled by the computer security measures embedded in the VA's electronic health record system, designed to both protect patients and their confidential medical information. Even as the hospital computer system was used to foil the murder attempt, using the same system, President Martin's doctor discovered the life-threatening brain tumor and successfully removed it within days after the assassination attempt."

"When questioned about his experience at the VA Medical Center, President Martin had this to say": "I have always stood behind the VA and its use of an electronic medical record. Ever since the tragedy of my wife's death, I have seen the need for a better healthcare system within our country. My opponents used patient privacy and computer security concerns as a way to discredit my call for a national healthcare solution and the use of electronic medical records systems similar to that used by the VA. I have seen not only the workings of the electronic medical record, but also the extensive security measures put in place to protect that record. I have also learned first-hand, how such a system could actually save my life, and the lives of many other citizens."

THE END

*** This story and all characters are purely fictional ***

Authors:

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation - see www.shepherd.edu/surc.

Mrs. Jaime Nasuti is a graduate of Shepherd University, a former English teacher, aspiring author, currently working for a national healthcare provider organization on the development of training programs and materials for EHR and other health IT systems.


Peter Groen and Jaime Nasuti

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