The massive number of injured patients from the April 2013 Boston Marathon bombings overwhelmed electronic medical records and information systems in some Boston emergency departments.

Their experiences offer an important lesson at a time when most hospitals have switched to electronic systems and providers are soon to face financial penalties for not doing so.

During mass-casualty events, paper and pen might be best, said Dr. Andrew Ulrich, executive vice chair of emergency medicine at the Boston Medical Center (BMC).

"The ability to get names into the system fast enough to order tests and establish a medical record limited us" on April 15, he noted. "There were so many patients coming through so quickly [23 at BMC right after the bombs went off] that it was difficult to know exactly who had what done and where they were going. You couldn’t leave the patient to" go to a computer, log on, get an update, and place orders, Dr. Ulrich said.

Other hospitals "had similar experiences. Communication was one of the more difficult components of this event," he said.

At Brigham and Women’s Hospital, "the first issue was our naming convention. We found that when every patient is ‘unidentified’ with a string of numbers, there’s a lot of confusion and many near misses. [Also,] if your system is inundated with multiple patients at once, it takes more time to register them so you can" go to work, said Dr. Eric Goralnick, the hospital’s medical director of emergency preparedness, who helped care for the 19 blast victims his ED received in the first half hour, and more later.

Now, at Brigham and Women’s, unknown patients are identified with a color, state, or other quickly recognized word.

Since the bombings, the EDs at Boston Medical Center and Brigham and Women’s have stocked up on old-school paper-and-pen trauma packets – an envelope with a wrist band, presigned orders, and other care documents all prestamped with a unique identifier – so that they are ready for the next mass-casualty event.

"We are much more flexible, much more adaptable if we go back to basics on this one, and that’s paper and pen. We are preparing to do that" for the next disaster, so "we can pull a bracelet out of the packet, throw it on the wrist," and start to work. It’s "much faster than getting [patients] onto the [electronic] medical record," Dr. Ulrich said.

Also from the old school department: "We [may also] have a clipboard attached to the patient’s bed, so when the patient rolls somewhere else, whoever gets them just has to look at the paperwork" to know what’s going on "instead of separating information from the patient" with the computer system, he said. "In a situation where there’s so much going on, it’s a clearer way of exchanging information."

Electronic record problems aren’t uncommon in EDs.

"There are many places where the computer system is a barrier to care. If you are trying to handle [an event] like this with a system that’s optimized for internal medicine clinics, it’s not going to work," said Dr. Larry Nathanson, who helped tend to the 22 bombing victims Beth Israel Deaconess Medical Center received in the first hour, almost half of whom were in critical condition.

Things went more smoothly at Beth Israel, where the electronic information system worked well. Part of the reason is that the hospital uses a home-grown system designed by Dr. Nathanson, a computer programmer as well as an emergency physician. The system is quick and provides patient information with few clicks. To identify unknown patients, the system uses a convention similar to the one used to name hurricanes (Annie, Bruce, Candace, etc.); the record can be easily updated once a patient’s identity is known.

The system had been tested prior to the bombings via simulation including 500 patients. "We made sure beforehand that [it] could handle the influx and quickly register large volumes of critical patients," said Dr. Nathanson, who serves as the ED’s director of emergency medical informatics.

"The reason it worked well in a disaster is because it works well every day," he said.

Based on feedback from his colleagues, he’s since added an interface that pops up when two or more mass-casualty victims are in the ED. Pressing it displays them all with a summary of their situations, so providers can home in on them.

Dr. Ulrich and Dr. Goralnick have no relevant disclosures. Dr. Nathanson owns stock in Forerun Inc., the commercialized version of the system he developed for Beth Israel.

aotto@frontlinemedcom.com

Emergency department electronic record systems fell short in Boston bombings