Hurricanes Harvey and Irma Draw the Line - Time for the US to Embrace Open Source Emergency and Disaster Response

Roger A. MaduroVast areas of the Caribbean and the United States are still reeling from the impact of two major hurricanes, Harvey and Irma. In some cases the devastation has been almost total such as in Barbuda and Saint Marteen, as well as Puerto Rico, some parts of Cuba, large areas of Texas as well as South Western Florida. Millions have been displaced, and in Florida over 5 million customers (medical facilities, residences, and businesses) are still without power. Providing relief to the victims, and areas impacted by the hurricanes, require immediate, coordinated relief and recovery efforts.

For nearly 20 years now the global open source community and applications have been a keystone to disaster relief efforts around the world. The enormous number of disaster relief applications and knowledge that has been developed through all these years, should, and needs to be leveraged in the current crisis. For that reason Open Health News is starting a series of articles to highlight some of the most important solutions. A substantial portion the open source applications for emergency and disaster response that exist are actually already in the news website in the form of articles and resource pages. This article presents some of the open source resources for major disaster and emergency situations, there are many more. We will be working with the community to organize and present the potential solutions that can be immediately applied to the current crisis.

There needs to be immediate action on the part of Federal, State, and local agencies in the US to embrace the open source collaborative approach as well as applications. This is the approach that is working and has worked in other major disasters. Harvey and Irma are disasters of a magnitude greater than any other disaster that the US has faced in recent times and pose multi-dimensional threats to the health and well being of the immediate victims of the hurricanes and the nation as a whole.

Which have been the great health IT success stories?

Health IT and emergency response applications and actions that have succeeded in the current crisis are the very same type of applications and approach that has succeeded in dozens and dozens of major disasters that have taken over the past twenty years: open source apps, collaboration, community, local response backed by national and international aid.

Hurricane Harvey as it makes landfall in Texas on August 24Open Health News has posted hundreds of articles on how open source solutions have been used in disaster response and recovery, from hurricanes, to tsunamis, floods, earthquakes, and to infectious disease outbreaks such as the ebola outbreak in West Africa. These are now very mature and capable applications that surpass the capabilities of the tools being used by first responders in the US including the Federal Emergency Management Administration (FEMA).

That said, there seems to be major barriers to the adoption of these tools in the US. Barriers include Federal government procurement policies, but also the lack of knowledge and knowhow on the part of open health projects and organizations to present these solutions to the right agencies. Hopefully the disconnect between open source emergency and disaster response tools and emergency response agencies and organizations in the US will be fixed soon.

There are some extraordinary success stories from Harvey. Here are some:

Let’s examine some in detail.

The Stephen F. Austin Community Health Network and OpenEMR Plus

There is proof-of-concept of a homegrown open source emergency response solution in Houston. Article below is about how the Stephen F. Austin Community Health Network (SFA) responded to the crisis by leveraging their open source EHR, OpenEMR Plus, to reach out to their patients and victims of the hurricane in areas of Texas that are virtually inaccessible. The Health Network, a Federally Qualified Health Center (FQHC) is located in one of the areas hardest hit by Hurricane Harvey and currently recovering. The story is told in an aritcle titled: Community Health Network in Houston Leverages Open Source Tech to Help Victims of Hurricane Harvey.

Since Harvey SFA and the OpenEMR Plus developers at William Medical Technology have been working really hard to add capabilities in response to the medical needs of the victims of the hurricane (such as intake questions regarding exposure to floodwaters which can have far reaching health implications). In addition, with Irma coming up to Florida, they streamlined the workflow of OpenEMR Plus so that it can be used in the field by first responders in Florida with minimal training. It can be used as an AWS hosted application in laptops and tablets, or if there is no internet access, it can be used as a stand-alone app in a laptop. That particular capability is one of the reasons that the Peace Corps selected OpenEMR as the electronic health record (EHR) for their staff and volunteers. The Peace Corps has deployed OpenEMR in 77 countries.

As demonstrated in Houston, OpenEMR Plus allows first responders to connect to other resources and specialists from outside of the impacted area though the embedded telemedicine capabilities. These resources could help first responders diagnose and make triage decisions on the spot. This represents huge “force multiplier” capabilities and potentially an enormous savings in overstressed local resources. Using telemedicine as an integral part of the emergency response EHR can provide much needed relief to local medical personnel.

OpenEMR Plus can leverage CCD-A messaging to send patient information to local hospital emergency rooms, rescue units, and health information exchanges. This can be bi-directional. The current challenge with this approach is not an OpenEMR Plus issue but that that that this capability is mostly not leveraged by proprietary EHR vendors (they rely on old data silos). OpenEMR Plus is ready to be deployed in Florida or anywhere it is needed.

Astronaut VistA - Shows the power of modernized VistA on the cloud

There is another major open source success story in Houston. Astronaut VistA is a regional Electronic Health Record that remained operational before, during and after Hurricane Harvey with no down time. This is an open source version of VistA for community health centers and mental health facilities developed by Ignacio Valdes, MD, MS and his team. Dr. Valdes has spent over a decade improving and enhancing VistA for the private sector.  Astronaut VistA has a deep feature set,  is fully capable for inpatient and outpatient, mature and cloud-based. As with the Stephen F. Austin Community Health Centers, a substantial number of the medical facilities using Astronaut VistA were at ground zero. As with OpenEMR Plus, there was no downtime at all for anyone, and all patients had full access to their medical record. Their providers were able to track them and even change pharmacies on the fly as so many were flooded.

What Kind of Worked but Not Really?

From the standpoint of health information technology the key factor in an emergency situations like Harvey and Irma is whether the victims rescuers/medical providers have full access to their medical records following the storm. This is a critical recurring issue. Back to 2005 the Katrina hurricane destroyed the medical records of more than one million victims (and most also lost their medications). In sharp contrast, all the medical records of Veterans under the care of the VA had full access to their medical records.

A VIIRS satellite image of Hurricane Irma on September 3There certainly has been some improvement Harvey and Irma in comparison to Katrina. Some of the major medical systems that remained in operation during Harvey and Irma have been able to provide full access to their patient’s medical records. But those systems that had to shut down were not able to do so, and those victims that did not have access to their providers, were also not able to have access to their medical records. Wired magazine has an article that reports on problems faced by Harvey evacuees in accessing their medical records. In Florida the situation was even more problematic for patient records, as 35 hospitals had to evacuate their patients to other hospitals or locations

Writing in Politico, Darius Tahir quotes former ONC chief Dr. David Brailler on the implications of not having access to medical records. Tahir writes:

The next big test of the region’s EHRs, meanwhile, is to see whether they have enough interoperability to make sure patients scattered by the storm — and their new doctors — can access their records. Brailer is pessimistic. “It’s no easier to put together a database for emergency response now than it was then,” he said. Identifying high-risk patients requires good data, and ensuring that that data gets to the right persons requires easy transfer. Both tasks have proved challenging. “My prediction is that there will be a bump in non-disaster deaths that arise from discontinuity of care,” he said. “God forbid that will happen, but it’s happened every time we’ve had a disaster. Many people have missed a treatment.”

In addition, a federal agency within the Department of Health and Human Services (HHS) has just issued a draft guidance document to help healthcare facilities with disaster planning and recovery for major hurricanes. The Office of the Assistant Secretary for Preparedness and Response document provides an overview of the “potential significant public health and medical response and recovery needs facing hurricane- and severe storm-affected areas.” Health information management is one of the topics covered.

Some key points:

  • “During a disaster, patients may be separated from their ‘medical home’ and medical records,”
  • “Information technology systems may be damaged in the event, and access to the systems may be limited by physical barriers, access issues, power disruptions or other impacts.”
  • “Patients being evacuated or moved from one healthcare facility to another need complete medical records transferred with them, but that is not always possible if the facility has experienced significant damage, and paper records are damaged or missing and electronic records are not accessible”
  • “Redundant IT systems and back-up paper records with the critical information are ways to mitigate this issue.”

Based on reports from the ground and the outline of key issues raised by ASPR TRACIE working draft, here is an initial rough scorecard for the EHR response to the hurricanes:

  • Hospital systems with EHRs that remained open and had backup systems fared well and were able to provide access to the full medical record for their patients. That said, in most cases they were not able to access the medical records of victims that came for care who were not already patients. SCORE = PASS
  • [Update 9/20] We have received email reports, as well as an article in Politico, that the Greater Houston Health Connect (GHH) was able to provide medical records through phone calls and through computer access at several major shelters. GHH is a regional HIE that remotely stores health information for over 4 million patients from the Houston/Beaumont/Port Arthur region in southeast Texas. Although access to GHH medical records was limited, it demonstrated the capability of a regional HIE in emergency situations. SCORE = PASS
  • Patients of medical centers with working EHRs who had to evacuate and have no direct access to their medical home EHR systems are in most cases unable to obtain access to the medical records. SCORE = FAIL
  • Individuals who had to evacuate or has been displaced, in almost all cases do not have access to their medical records. This is the case even if they go to medical centers with working EHRs (those EHRs are unable to pull the data in from other hospital/medical systems). SCORE = FAIL
  • Individuals who were under the care of medical facilities using OpenEMR Plus, Astronaut VistA and the VA medical system’s open source VistA EHR have full access to their medical records regardless of condition (as long as they have access to phone service or the Internet). SCORE = SUCCESS

The last point is very important. Although there is no specific article that talks about Veterans under the care of the VA medical system that have been affected by the hurricanes, a large number of articles point out that Veterans are able to obtain medical care from any VA medical facility. Those who have evacuated or been displaced but no access to VA facilities, still have access to their medical records. This is a repeat of the one great medical success story that took place in the aftermath of the Katrina hurricane in 2005. Over 60,000 Veterans were affected by hurricane Katrina. Yet, no matter where the Veterans found refuge in the US, they had full access to their medical record thanks to the open source VistA EHR.

The performance of the VA during and after Katrina was so extraordinary in comparison to the private sector hospitals, that President Bush’s entire cabinet went on a tour of the VA’s Washington medical center. And the very success of the VA during that hurricane in many ways lays out some of key principles today. Two good articles on the success of the VA, and VistA are Preparedness Pays Off, and Use of Electronic Health Records in Disaster Response: The Experience of Department of Veterans Affairs After Hurricane Katrina.

This is a large-scale success story that needs to be studied by Congress and the administration of President Donald Trump. Two key factors. First, VistA is a world-class open source EHR whose capabilities are unmatched by any proprietary EHR system. Second, the VA is a single payer system. Its focus is full access to medical care and for that care to be coordinated.

After more than $38 billion in Meaningful Use payments, over $80 billion in health IT expenditures by federal government agencies, and over two trillion dollars spent by medical systems in the United States to implement proprietary EHRs, the HITECH Act has failed in its key purpose. Victims of a hurricane, first responders, emergency medical personnel, do not have Meaningful Access to the medical records of victims and evacuees in a life threatening emergency.

The failure of the HITECH Act has now risen to the level of a civil defense, national defense, and national security issue. And there is a simple solution. On September 15, 2008, Congressman Pete Stark (D-CA) introduced H.R. 6898 in the 110th Congress. The Stark bill called for the establishment of a federal open source Health IT system that would leverage federal funding for open source health IT solutions so the investment could benefit all Americans. There are links below to two articles by Dr. Bruce Wilder that discuss the superiority of the Stark bill to the HITECH Act.

Useful articles to read.

OpenMRS as an Integrated clinical and public health disaster management platform

There are dozens of mature open source applications that can be immediately leveraged for disaster response in the Caribbean and the US. We will have a series of articles in Open Health News on these solutions. That said, right now the single most important one may be OpenMRS. In context, Texas is already dealing with all kinds of diseases as a result of Harvey, and facing a massive mosquito outbreak that will bring West Nile virus, Zika, Yellow Fever, Dengue fever, and Encephalitis; victims that were exposed to toxic chemical and biological compounds in the water are already showing horrific infections, including flesh eating bacteria; massive amounts of sewage and superbug-loaded contaminants from factory feedlots are expected to lead dangerous diseases including cholera and typhoid fever for starters.

This is where OpenMRS comes in.

OpenMRS has become the standard platform for emergency and disaster relief in developing countries. Dozens of major open source applications, and platforms in their own right such as DHIS2, have interfaces with the open APIs that are a part of  OpenMRS. OpenMRS has a large number of full time  volunteer developers and contributors and over 200 part time contributors around the world. More than 30 countries are currently in the process of implementing, or evaluating OpenMRS for use as a national health IT platform (see here and here). All these resources can be leveraged in short order.

OpenMRS has the ability to track patients, identify patients within the cohort builder functionality, and quickly integrate standard terminology and new coding if and when needed. The development of additional functionality  within OpenMRS is determined by the community and the needs of the end users--ensuring that appropriate user needs exist within the system and can be augmented based on people’s needs.  The OpenMRS Leadership Team is  partially composed of scientists from the Regenstrief Institute in Indianapolis, Indiana. Regenstrief has an incredible team behind it, including Dr. Paul Biondich and Dr. Theresa Cullen, who was the former CIO of the Indian Health Service and former Chief Medical Informatics Officer of the Veterans Health Administration.

Case in point is the role of OpenMRS in helping stop the Ebola epidemic in Africa.

Some articles:

OpenMRS is currently seeking funding to take their OpenMRS platform to a higher level and turn it into a universal integrated clinical and public health disaster management platform. Someone in the Federal government needs to step up to the plate and immediately fund this effort. But there is no need to wait until then to leverage OpenMRS for the current crisis. It has strong capabilities that have been developed to track and monitor infectious disease outbreaks and provide case tracking, community tracking, supply management, logistical support, etc.

Beyond OpenMRS there are dozens of other open source applications that can be quickly leveraged in the areas that have been devastated by the hurricanes. Everything from apps that track concentrations of mosquito vectors effectively used in Latin America and Africa to deal with malaria and yellow fever outbreaks to disaster and infectious disease outbreak mapping using openstreet maps. Open Health News will be providing additional information as time and resources permit. In the meantime, we hope that Federal, state, and local emergency response agencies will finally embrace the rich ecosystem of open source disaster response tools and practices.

[Update 9/20] Added information received after post publication on the role of the Greater Houston Health Connect (GHH) HIE in providing access to the medical records of some of the victims of Harvey through phone calls and direct computer access as some of the large shelters.