Reference Scenario

Patient Eighteen is admitted to the hospital and treated with Gentamicin for a kidney infection. The patient has a signed consent directive that limits disclosure of HIV and substance abuse information except for emergency situations. The patient’s physician, a young resident named Dr. Greenhorn, orders a routine creatinine lab test in VistA/EHR. When the blood test is completed, the hospital Health Information Technology (HIT) system, publishes the result to a centralized EPS and the “Diagnostic Reports topic”. One subscriber to this topic, the CDS system, evaluates the results, determines that it is abnormal, and recognizes that the patient’s medication list contains Gentamicin, a nephrotoxic drug. It then sends an eHMP alert to the author of the order, Dr. Greenhorn, informing them of the elevated creatinine level (1.8 mg/dL) and that an unsigned order for a Gentamicin dose adjustment has been placed in VistA. When Dr. Greenhorn does not respond to the EMR based-alert within a pre-determined amount of time, the system re-routes the alert to the attending physician, Dr. Greybeard. Both providers are requested to either sign, modify, or cancel the recommended order. There is a final option, determined by alert type and content. This option, “Pharmacy Consult”, provides a mechanism for the provider to quickly ask a question of a pharmacist in a secure chat room.

Dr. Greybeard, prior to deciding on his course of action, elects to consult with the pharmacist on duty about the proposed order. He asks his question in the secure pharmacy chat room used by all hospital pharmacists. A responding pharmacist recommends an alternate antibiotic formulation. Dr. Greybeard then proceeds to modify the CDS recommended order based on his discussion with the pharmacist, selecting a new formulation from a list of orderables (catalog) presented to him. Upon filling the medication order, a pharmacy tech questions the dosage recommended by Dr. Greybread and seeks confirmation from the doctor prior to continuing with the medication dispense. The tech uses a VOIP text-to-voice messaging tool to call Dr. Greybeard’s his office phone with a brief message. When Dr. Greybeard does not answer his phone, the system escalates to an SMS message sent to his registered SMS-enabled mobile device. Upon receiving the text, Dr. Greybeard confirms that the dosage is correct by return texting “YES” and the tech proceeds to fill the order. The communication between the three providers is recorded and documented/linked to the patient’s file as a monitored conversation.

Several days later, Patient Eighteen has a positive blood culture, for an organism that is multi-drug resistant. The CDS system sends a recommendation to Dr. Greenhorn recommending an Infectious Disease consult. Dr. Greybeard accepts the advice, and while  filling out the consult request, he is presented with a variety of order (workflow) requirements. He addresses each precondition, completes all details of the order in the Computerized Physician Order Entry (CPOE) system and submits the consult request for fulfillment to the Infectious Disease department.

The Infectious Disease department, upon receiving the consult request, is advised of the “Service Level Agreements” (SLA) that the organization has in place regarding consult review and appointment wait times. Based on the organization’s policy, two previously resulted labs for patient Eighteen (an HIV blood test and a cocaine drug screening) in the patient record are treated as protected content. Given the patient’s consent policy vis-à-vis protected content, these are not visible nor accessible except under emergency conditions. The creatinine lab result and its alert, however, are not so restricted.

While the patient is awake and conscious in the hospital, the physician only sees the gentamicin alert and any non-confidential alerts.

Later, the patient develops florid urosepsis, becomes unconscious, needs mechanical ventilation / treatment for unstable hypotension. To ensure a comprehensive differential diagnosis, the physician elects to ‘break the glass’ in order to access any protected health information in the patient health record, restricted alerts and advisories that may be relevant to the care required. In this context, ‘break the glass’ overrides the patient’s consent directive, allowing the provider access to the full medical record, including restricted data and alerts.