The initial misdiagnosis of the first Ebola-infected patient in the U.S. resulted from a combination of human and computer error, according to a new study published in the journal Diagnosis, Modern Healthcare reports (Conn, Modern Healthcare, 10/23).

Background on Ebola Case

Thomas Eric Duncan arrived in the U.S. on Sept. 20 and was sent home from Texas Health Presbyterian 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. He died less than two weeks later.

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 electronic health record system.

On Oct. 2, Texas Health Resources released a statement saying that although the nurse had included the information about Duncan's travel history in the EHR, a flaw in the system had prevented physicians from seeing the note.

However, on Oct. 3, officials effectively retracted the statement, 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."

The hospital uses EHR software developed by Epic Systems (iHealthBeat, 10/20).

Details of Study

According to InformationWeek, some of the study findings are speculative, as the researchers did not have access to a comprehensive collection of nurse and physician notes and could not examine the EHR system's configuration in great detail (Carr, InformationWeek, 10/23).

After analyzing an Associated Press review, the researchers found that the use of a "series of predefined symptom options" could have led to the confusion over Duncan's diagnosis. The researchers were able to determine that hospital workers used "predefined patient instructions" because of the "generic nature" of the phrases used in their notes (Modern Healthcare, 10/23).

According to the study, such templates are used to capture data, but they also can sacrifice "utility for appropriate triage and diagnosis." The researchers added that EHR systems and the meaningful use incentive program emphasize recordkeeping over care and detection of uncommon conditions (InformationWeek, 10/23).

Implications

The researchers said that the case illustrates that "EHR-based clinical workflows often fail to optimize information sharing amongst various team members, leading to lapses in recognizing specific clinical findings that could aid in rapid and accurate diagnoses" (Modern Healthcare, 10/23).

As they stand, EHRs "lack the innovations needed to prevent misdiagnosis," according to the report. Therefore, the researchers recommended that regulators focus on enhancing EHRs' decision-support tools, sorting methods and alerts (InformationWeek, 10/23).

Epic Defends EHR System

In related news, Epic President Carl Dvorak said the EHR system should not be blamed for the misdiagnosis, Health Data Management reports.

Dvorak said that the system properly displayed information, such as travel history and symptoms, but it was overlooked by various health workers. He said the information "got missed by the nurse who actually documented that the patient came from Liberia -- that's a knowledge gap," adding, "And, it got missed by a physician" (Slabodkin, Health Data Management, 10/21).