Officials at Texas Health Presbyterian Hospital in Dallas effectively retracted an earlier statement claiming that a flaw in the hospital's electronic health record system had led to the initial discharge of the first patient diagnosed with Ebola in the U.S., Modern Healthcare reports (Modern Healthcare, 10/4).

Background on the 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.

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 where he was diagnosed with Ebola and placed in isolation.

Conflicting EHR Statement Details

According to the hospital, Duncan told a nurse during his initial hospital visit about his recent travels to Liberia, and the nurse correctly entered his travel history information into the hospital's EHR system (iHealthBeat, 10/3).

On Thursday, Texas Health Resources, the hospital's parent company, released a statement saying although the nurse had included the information about Duncan's travel history in the EHR, a flaw in the system had prevented his physicians from seeing the note (Modern Healthcare, 10/4).

"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."

In response to the incident, the hospital said it had moved the travel history into the workflow for both physicians and nurses. It also said the EHR system had been modified to specially highlight regions of West Africa struggling with the Ebola outbreak (iHealthBeat, 10/3).

However, late Friday night the hospital released a "clarification," explaining that "the patient's travel history was documented and available to the full care team in the [EHR], including within the physician's workflow." The hospital noted that "there was no flaw in the way the physician and nursing portions interacted related to this event" (Goedert, Health Data Management, 10/3). The hospital uses EHR software developed by Epic Systems.

In an email to Politico, an Epic spokesperson said the events at the hospital were not related to a software issue. The spokesperson also suggested said dismissed suggestions that Epic was not involved in pressured the hospital's to reverse its statement because of a contract gag clause -- which is common in many Epic EHR contracts --  reversal, noting that such a suggestion speculation is "overestimating [the vendor's] their power" (Gold, "Morning eHealth," Politico, 10/6).

Questions Raised

Despite the hospital's revised statement, it still remains unclear why the patient was originally discharged from the hospital, the New York Times reports (Fernandez et al., New York Times, 10/3).

Some physicians who have experience working with EHRs say the reported events suggest that an error occurred with the way hospital staff interacted with the EHR system. According to Politico, some EHRs are easier to use than others, and some have added safeguards and alerts for such high risk events (Allen, Politico, 10/5).

Meanwhile, some experts say the issue has less to do with the transition to EHRs and more to do with persisting hospital culture, in which doctors ignore notes made by nurses.

Dean Sittig, of the University of Texas Health School of Biomedical Informatics, said, "The culture you're seeing here is, in general, doctors tend to ignore nursing notes; they ignored them when they were on paper, and now they ignore them on the computer" (Frieden, MedPage Today, 10/4).

Implications for EHR Vendors    

Some EHR vendors, such as Athenahealth, took immediate action following the original news. On Friday, Athenahealth announced that it updated its Web-based EHR system to include specific questions related to Ebola (Modern Healthcare, 10/4).

Jonathan Weiner, director of the Center for Population Health Information Technology at Johns Hopkins University, in an email to MedPage Today, said he expects the latest events will prompt other vendors of EHRs and computerized clinical workflow systems nationwide to issue quick system updates (MedPage Today, 10/4).