Arraya Insights | October 9, 2014
Electronic health records (EHRs) are supposed to improve communication, but a flaw in one hospital’s system may be partially to blame for the Ebola scare that’s been dominating headlines recently and which has up to 100 people being monitored in Texas.
Thomas Eric Duncan, the man identified as the first person to be diagnosed with and die from Ebola on American soil, went to the emergency room at Texas Health Presbyterian Hospital in Dallas a few weeks back complaining of a fever and abdominal pain. He told staff that he’d just been to Liberia, a country dealing with a severe Ebola crisis, but he was still sent home. Three days later he returned to the hospital and was diagnosed with Ebola. He died a little over a week later.
So what went wrong?
According to Texas Health, its team followed all the necessary protocols while they were treating Mr. Duncan. He was released because his symptoms weren’t Ebola-specific or thought to be severe. His stay in Liberia should have been a red flag, however a fault in Texas Health’s EHR system allowed this vital information to slip through the cracks.
Its EHR system features separate workflows for doctors and nurses. Some elements of a patient’s history are shared between the two systems, but at the time Mr. Duncan was first admitted, travel history was not one of those shared items.
The system was designed this way, according to a statement released by Texas Health, “to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order.” As a result, doctors weren’t made fully aware of Mr. Duncan’s travel history, including his time in Liberia, and so the link was never made between his symptoms and the early stages of Ebola.
This is a case where doctors and nurses did everything correctly, but they were let down by a fault in how their EHR system had been configured. The hospital’s EHR system seemed to have been designed to help staff get ahead of one problem – influenza – but instead let a potentially more serious issue get through.
Once this issue was discovered, Texas Health relocated the travel history documentation so that it was shared between doctors’ and nurses’ EHR workflows. In addition, it’s also been mended to specifically call-out parts of Africa which have been struck by the Ebola epidemic.
Sure, it’s easy with the benefit of hindsight to say what the hospital should have done differently to prevent this situation. However, it seems like this gap could have been uncovered by a role-playing training session where staff went through a contagious disease scenario using their EHR system. A test run could’ve given IT teams and healthcare professionals an early warning about possible holes in their systems.