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In the aftermath of the 2013 Boston Marathon attack, Brigham and Women's Hospital reviewed its information systems (IS) and discovered some processes needed improvement.

On April 15, 2013, the hospital's emergency department (ED) received 19 patients within 30 minutes. Overall, it treated 40 patients from the marathon site, recalled Dr. Eric Goralnick, medical director for emergency preparedness at Brigham and Women's Hospital. After the mass casualty incident (MCI), the hospital determined it had to enhance IS in three key areas: unidentified-patient naming conventions, situational awareness, and patient documentation.

Dr. Goralnick and Dr. Adam Landman, the hospital's chief medical information officer for health information innovation and integration, will discuss their findings during a keynote presentation Tuesday, April 29, at Medical Informatics World in Boston.

"We really, to this day, continue to analyze the lessons from this event," said Dr. Goralnick, who this year ran the Boston Marathon for the first time. "We knew we had a clear deadline to fix and prioritize these lessons learned, and information systems was at the top of the heap."

Brigham and Women's Hospital partially activates its emergency plans for all special events in Boston. After the bombing, it looked toward the fast-approaching July 4 festivities. With that target date in mind, a team quickly began looking for ways to address unidentified-patient naming conventions.

Many marathon bombing patients were unidentified when they arrived at the ED. Names are vital to start treatment, and the hospital identified unnamed patients with a unique code consisting primarily of numbers. But the staff could not easily tell patients apart, because the codes looked so similar, said Dr. Goralnick. When one or two unnamed patients arrived at the ED in a typical day, this was not a problem, but with many people simultaneously coming into the emergency room -- and the fear that more might be on their way -- the risk of error heightened.

In the new system, implemented prior to the July 4 deadline, the ED uses a mix of commonsense data to separate unidentified patients, said Dr. Landman.

"It specifies a patient's gender, because that can be important for blood transfusions, and then we included a unique string of characters that was intuitive for clinicians to remember. We actually started with colors. We're able to incorporate that color into an unidentified patient's name," he said. "We figure, once we exhaust colors, we'll go to different categories, such as states or lakes. You want to be able to call your patient something. You don't want to say Room 10. You can say Mr. Blue."

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The hospital incorporated the amended process into its electronic health records (EHR) system. The staff preferred the more human-oriented, less numerical coding, said Dr. Landman.

Seldom if ever a concern during regular ED operation, situational awareness did not function optimally on the day of the marathon bombing. When the staff moved a patient -- to the operating theater, a room, or radiology, for example -- a nurse or technician manually moved the patient's icon on a tracking board, so other staff members could find them. In the post-bombing chaos, the staff did not always move tiles in a timely manner, so they did not always know exactly where patients were located, said Dr. Goralnick. "We revised our emergency operations plan, specifying our chain of command."

To improve how it handles patient documentation during an MCI, Brigham and Women's Hospital returned to paper, said Dr. Goralnick. The new system is modeled on how hospitals in Tel Aviv, Israel, cope with a sudden influx in emergency patients. The Boston hospital now has packets of information prepared for patients as they come through the door, he said. An employee later scans paper documents into the EHR, so the patient's record is complete.

Brigham and Women's Hospital continues to refine the process, looking for more ways to automate the system and make it part of employees' daily work processes.

"Disasters or mass casualties don't occur every day. Ideally, we can build solutions that are in everyday use of the systems," Dr. Landman said. "Then, when the MCI happens, it will work in the MCI, and our staff knows how to use it. There are lots of solutions we can come up with for mass casualty incidents, but staff won't be familiar with them."

The hospital also wants to investigate technologies like RFID for tracking patients, Dr. Landman said. It's also open to discovering whether there's a technological replacement for scribes (nurses or off-duty healthcare professionals who volunteered after the bombing) that could take doctors' notes during an MCI and automatically and directly feed them into the EHR, he said.

More immediately, however, Brigham and Women's Hospital is seeking a replacement EHR, an enterprise-wide solution, instead of its current departmental approach. Ideally, the system will provide the ED with more automated, user-friendly, and intuitive MCI capabilities that will only need to be used for drills.

In the five years before the marathon bombing, Brigham and Women's Hospital conducted 78 drills replicating events such as chemical attacks, aircraft collisions, and a school shooting, said Dr. Goralnick. "These drills taught us about trust, about collaboration, and these drills saved lives on April 15, 2013."

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