For years, we’ve mostly heard about how electronic health records systems have made clinicians’ lives a nightmare. But recently, innovators have found ways to tap their potential to save time and costs and improve quality. One example is a tool that New England Donor Services developed to streamline the time it takes to screen whether a patient who is near death or has just died is a potential organ donor.
In the last decade, the dark side of electronic health records (EHR) systems has received the most attention: how their complexity and time-consuming demands have added to physicians’ and nurses’ workloads, contributing to burnout. But in recent years, we have begun to see more and more provider organizations harness the EHR’s potential to improve care and reduce its time and costs. An initiative conducted by New England Donor Services (NEDS) and Yale New Haven Health to streamline the process for identifying potential organ donors for patients needing transplants is one of the latest examples. It offers practical insights for other organizations that are seeking to tap the power of EHRs to perform other functions and, if they are having to contend with multiple EHRs that aren’t completely compatible, how to address that challenge.
For decades, the nation’s organ donation process has relied on care providers at individual hospitals picking up the phone and calling their designated organ procurement organization (OPO) when a patient dies or is near death so that the OPO and hospital can conduct an initial medical screen together to determine if the patient can be an organ donor and then commence the time-critical process. This call takes about 15 minutes, on average. Because of the strict clinical criteria to ensure safe organ transplant, only 6% of these calls results in the identification of potential organ donors.
While 15 minutes may not seem like much time, the calls collectively can consume an enormous amount of the time of hospital and OPO staffs. For instance, a large health system can generate up to 5,000 referral phone calls per year. For its part, NEDS, the regional OPO in the northeastern United States, receives 50,000 calls from some 200 hospitals a year about patients, approximately 47,000 of whom turn out to be ineligible.
Recognizing the opportunity for innovation, NEDS used new non-proprietary technology to replace this phone call with a nearly instant computer-generated message. This is hugely important for the people in need of an organ transplant. There are more than 106,000 of them in the United States, and 20 people a day die waiting for an organ. Time matters.
Yale New Haven Health then tested this technology for eight weeks in 2020 at its flagship academic medical center, Yale New Haven Hospital. After proving it worked, Yale New Haven Health then rolled it out that same year to its four other hospitals in Greenwich, Bridgeport, and New London, Connecticut, and Westerly, Rhode Island. Since then, two other major health systems in New England — Lahey Health and Cambridge Health hospitals Alliance — have adopted it in six hospitals.
A Simple Overview of a Complex Process
The transplantation of organs is a time-sensitive process that relies on the coordination of inter-dependent stakeholders (donor hospitals, organ procurement organizations, transplant programs, regulatory agencies), expensive assets such as aircraft and organ pumps, and multidisciplinary teams of transplant surgeons and donation professionals. OPOs, which are regulated by the Centers for Medicare & Medicaid Services (CMS), coordinate the entire process — from screening and testing potential organ donors and obtaining consent for donation to surgically removing donated organs, allocating organs to the right transplant recipients, and ensuring delivery within the critically short time frame to ensure the viability of the organ. (A heart must be transplanted within four hours after its removal from a donor and a kidney within 24 hours.)
CMS regulations mandate that hospitals make a timely referral of all inpatient deaths and imminent deaths (defined with certain clinical triggers) to their designated OPO to quickly identify all potential organ donation opportunities. Most frequently this means an ICU nurse calls the OPO to review the basic medical information of the referred patient with a donation expert. While this call averages 15 minutes, it can take anywhere from six to over 20 minutes, depending on the complexity of the patient’s medical history. Nurses at Yale New Haven Health spend a total of about 1,365 hours on these donor referral calls each year. (After this initial call, a thorough medical evaluation — e.g., liver function tests, echocardiograms, tests to measure creatine levels, serology screenings for infectious diseases — are conducted before the donation procedure.)
The Pilot
NEDS invested in developing non-proprietary technology that would integrate its electronic system with an EHR and gave it for free to Yale New Haven Health to test. Automating organ donor referrals via electronic messages uses the HL7 information-exchange protocol, a proven and ubiquitous technology that has been used in health care for decades. In addition to sending an electronic message to NEDS referring a potential donor with the basic information required for the initial screen (such as age and cause of death), an additional message is sent back to the hospital, which notifies it whether the referred patient has the potential to donate organs. The messages are created via standard configuration tools for all EHRs.
An initial pilot, which involved three critical care floors at the Yale New Haven Hospital York Street Campus, began in March 2020, just before the first wave of the Covid-19 pandemic reached its zenith in the Northeast. The original plan was to deploy the technology over six to 12 months at the hospital’s York Street Campus and then gradually roll it out across the rest of that academic medical center as well as the other four hospitals in the Yale New Haven Health system in the following years.
However, the time savings in the first three months of the test were so dramatic and crucial given the huge demands that the surge of Covid-19 patients was making on the nursing staff that it was then immediately deployed systemwide. In 2020, Yale New Haven Health sent 5,418 electronic organ donor referrals to NEDS. By automating the process, the tool saved the health system 470 hours of nurses’ time that year. It saved NEDS’s staff at least as much time.
Keys to Success
There were the four factors critical to the initiative’s success that can be applied to joint efforts of different providers and individual health systems to develop and deploy other technologies aimed at tapping the potential of EHRs to improve the quality of care and reduce its time and cost.
1. Partner with a health system that’s an innovator and willing to take a risk. The first independent OPO in the nation, NEDS has been an innovator in its field. For example, it coordinated the first organ donation under a new federal law to enable HIV-positive organs to be donated for transplant into HIV-positive recipients and led the country in Vascular Composite Allograft donation.
Recognizing the need for operational innovation and systemwide improvement in organ donor referrals, NEDS consciously picked a partner — Yale New Haven Health — with a similar reputation. Both understood the need for both continuous improvement and innovations that make possible leaps forward. Significantly, the two had collaborated for decades, which produced the trust needed to test an unproven idea and the ability to have one of us (Mathew Moss) embedded in the Yale New Haven teams as the technology was developed and tested.
2. Articulate the value proposition. Provider institutions like Yale New Haven Hospital are inundated with proposals for new technology initiatives and consultants’ pitches for ways to make themselves more efficient or effective. To break through the clutter, it’s vital that you articulate a clear, compelling value proposition upfront. NEDS’s value proposition emphasized that its innovation would be a major improvement that would both help save lives by making the organ-donation process more efficient and save the hospital staff time.
3. Avoid proprietary technology. The NEDS technology is nonproprietary, configurable, and doesn’t require custom modifications to an EHR’s standard code, regardless of the EHRs vendor. Given the different EHRs being used by health systems, this is crucial to persuade as many systems as possible to adopt the technology and to enable them to implement it quickly.
4. Make it simple and part of the workflow. Even before the pandemic, clinician staff time was already at a premium in health care systems. During the pandemic, staff was stretched much more, which meant that there was no way to deploy a new EHR function that required a large-scale effort to train thousands of ICU nurses. Every hospital — and sometimes each unit in a hospital — has its own rhythm and flow; who contacts the OPO, where notes are kept in the EHR, the sequence of screens on an EHR, and even roles on a care team in an ICU can differ. Understanding this, NEDS placed the clinical trigger to send the referral message in a location within the EHR that created a generic operational process that could be easily tailored to a given hospital’s or health system’s existing workflow without requiring specialized training. The Yale New Haven Hospital’s IT staff observed and learned how the clinical staff worked and placed the clinical referral triggers in a location in the EHR that worked for the care team.
The potential of EHR systems is enormous. But tapping it depends on making new functions easy to adopt. Designing non-propriety technology, giving it to trusted partners to test, and planning the deployment collaboratively with those at the frontline of care can achieve that goal. And by doing so, we can reduce the clinicians’ burden, allow them to spend more time at patients’ bedside, improve the quality and reduce the cost of care, and, most importantly, save lives.