The TV show “The Pit” has received praise from viewers, critics and even emergency physicians for its depiction of the frenetic reality of the emergency department. But that action stops when doctors are faced with a simple but ominous on-screen message: “Network offline.” For most of this season, they have been serving patients without internet. In other words, they have fallen into “digital darkness” and been cut off from the electronic systems that are the mainstay of patient care.
Although Pittsburgh Trauma Medical Center (Pitt) is fictional, the dangers of a digital darkness event are devastatingly real. Defined by loss of access to electronic systems or patient information, these events can occur due to cyber or ransomware attacks, vendor outages, or natural disasters. These can cause major operational disruptions and patient safety concerns, leading to death. Such events will become more common as systems across finance, national security, and healthcare become more integrated and online, and as climate change accelerates weather-related disasters.
Because many medical devices’ key functions rely on network connectivity to transmit information, digital darkness events significantly disrupt patient care and increase the potential for new vulnerabilities that hackers can exploit. As more people receive treatment at home, a variety of digital technologies can help clinicians monitor and treat patients remotely. As networks go dark, so too do these critical elements of modern medicine.
Consider something as simple as a pit emergency room board. This is a digital interface that displays each patient’s name, room, condition, and condition. As the pits darken, doctors have to scramble to recreate them, but some patients are still overlooked or delayed in the chaos.
At its root, there are more existential questions. Do doctors still know how to practice medicine without supporting devices? I remember the days of handwritten charts and paper records (particularly in the remote areas of Africa where I practiced early in my career), but now some medical professionals have spent their entire careers, and some have spent their entire lives, operating primarily in the digital realm. The sudden transition to an analog environment, especially in the midst of a crisis, is a challenge for even the most capable and level-headed clinician.
Regardless of a clinician’s experience with analog and digital systems, digital will eventually prevail. Advances in backup systems, redundant connectivity, and digital twin technology will reduce downtime tolerance for healthcare organizations to near zero, and analog capabilities will increasingly feel like knowing how to operate a stick shift. This is a strange skill, one that is rarely needed and easily forgotten. However, healthcare organizations have a responsibility to prepare their employees and systems for the analog reality that cyberattacks, outages, and cascading infrastructure failures can occur at any time.
Hospitals and health systems need to treat dark digital events as expectations, not like outlandish TV plots. This includes developing standard operating procedures for digital darkness events, incident response plans and staff training, conducting regular downtime and disaster recovery drills, business continuity training, developing data security protocols, and creating backups of critical clinical information. Hospital and health system leaders can also partner with medical schools to ensure that the next generation of doctors is sufficiently trained to practice without the latest technology if needed.
Policymakers and regulators also have a role to play in preparing for digital darkness events. This includes ensuring timely access to state and federal resources during disaster recovery and regulating digital health products and vendors to ensure patient data is protected. This is even more important as new medical IT devices flood the market and pressure for deregulation increases. Regulators must balance fostering innovation with safety.
By the time connectivity is restored in Pitt’s fictional world, the digital darkness has wreaked havoc, causing delays in diagnosis, medication, and testing, numerous failures to trace, and ultimately, the patient’s death. A university English lecturer dies during surgery because the doctors did not know about his previously diagnosed abdominal aortic aneurysm, and one of the characters states that if the computer had worked, “they would have known”.
Their experiences are a reminder of how fragile the digital realm is. Healthcare professionals and policymakers must clearly recognize the benefits and vulnerabilities of the digital age and come together to ensure that patients are protected from threats, whether they originate from secret hackers, Mother Nature, or somewhere else entirely.
Marcus Schabacker, MD, is president and CEO of ECRI.
