EHR Flaw Led to Ebola Patient's Initial Discharge, Hospital Says
A flaw in Texas Health Presbyterian Hospital's electronic health record system prevented an Ebola patient's doctor from seeing his travel history, leading to his discharge, according to hospital officials, Modern Healthcare reports (Frank, Modern Healthcare, 10/3).
Background on the Ebola Case
On Tuesday evening, CDC officials confirmed the first case of Ebola diagnosed in the U.S. after an infected Liberian man flew on a passenger plane from Liberia to Dallas, Texas, where he is now being treated at Texas Health Presbyterian Hospital (CDC release, 9/30).
Thomas Eric Duncan arrived in the U.S. on Sept. 20 and was sent home from the hospital after seeking help for a fever, stomach pain and sharp headache on Sept. 25. Duncan returned to the hospital on Sept. 28 and was diagnosed with Ebola and placed in isolation (Bever, Washington Post, 10/2).
This year's Ebola outbreak is the largest and longest ever recorded for the disease, affecting individuals in Guinea, Sierra Leone, Liberia and Nigeria. According to the World Health Organization, more than 6,500 individuals have been infected with the disease since the outbreak began, resulting in more than 3,000 deaths (iHealthBeat, 9/29).
EHR Flaw Details
According to the hospital, during the Duncan's initial hospital visit he told a nurse that he recently had been in Liberia and the nurse correctly entered his travel history information into the hospitals EHR system.
However, a flaw in the EHR system prevented his physicians from ever seeing the note.
In a statement, the hospital said that its EHR system uses separate workflows for nurses and physicians.
"The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order," according to the statement. It added that as a result, "the travel history would not automatically appear in the physician's standard workflow" (Clark, HealthLeaders Media, 10/3).
The hospital uses EHR software developed by Epic Systems, according to Bloomberg. A spokesperson for Epic was not immediately available for comment via phone or email (Gilblom/Chen, Bloomberg, 10/3).
In response to the incident, the hospital said it has moved the travel history into the workflow for both physicians and nurses. It also has modified the EHR system to specially highlight regions of West Africa struggling with the Ebola outbreak (Modern Healthcare, 10/3).
The hospital said, "We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola" (Washington Post, 10/2).
The Usability People work with you on improving the Usability of Healthcare IT.
For expert 2015 ONC Safety-enhanced Design (aka Usability) evaluation of your EHR: contact The Usability People
Together we may save a life! #SafeHealthIT