Exclusive Article at EMRIndustry.com by Jeff Riggins
There has been quite a bit of finger pointing surrounding the chain of events that led to Eric Duncan’s release from Texas Health Presbyterian Hospital in Dallas. The first confirmed Ebola patient in the US was told to go home after presenting with common early stage Ebola symptoms. Luckily, he returned three days later and had limited contact with others during the intervening 72 hours.
The hospital released a statement effectively blaming their electronic health record system. The hospital then backtracked and admitted that the EHR was not responsible and rather the clinicians who came in direct contact with the patient did not act on the data collected concerning his recent travel history.
The common element in both narratives is a breakdown in communication. Nurses and physicians are tasked with documenting a patient’s medical and social history. A complete history (past procedures, conditions, family and recent travel) may go a long way toward deciding how best to treat the patient. I have implemented EHR’s in multiple care settings (hospitals, home health, clinics, etc.) and have worked with several systems that are not designed specifically to document a patient’s recent travel history (though many of them are). That said, there are notes fields that would easily suffice for recording travel history.
Could the EHR have been designed better? Of course. Is this a valid excuse for discharging the patient? Not quite.
According to the hospital’s initial statement, a nurse documented the patient’s travel history in the electronic record but due to the way the EHR was set up the physician examining Mr. Duncan did not have access to that data. The fault for the mistake may be debated but the take away should be “how do we keep this from happening again?”
Questions like these come to mind: Did the nurse assume the physician could see the data she/he entered into the chart? If the nurse knew that the physician could not see the information did she/he attempt to alert the physician via a different channel? Why did the physician not ask the patient and/or nurse about his travel history when he presented the first time?
A few days later the hospital released an update:
“The patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow.”
A hospital located near an international airport (Dallas-Fort Worth aka DFW is the 4th busiest airport in the US) would be well served to consider travel history very carefully. Especially considering current conditions in West Africa.
It could be that hospital staff have grown complacent and enter only the data into the EHR that is required and react only to alerts and prompts generated by the software. This may also account for the initial response that “bad software” caused the mistake. EHR’s are designed to document encounters and guide clinicians (when decision support tools are in place) to ask certain questions, etc. They are not designed to take the place of clinicians.
For example: I have worked with several EHR systems that include a patient alert box that opens each time the chart is accessed (example fake patient below). A user with the proper security privileges may enter a text string on any subject. Often the message is related to a disease the patient may have or a condition (blind, deaf, etc.) that requires clinical staff to handle the patient differently. Data regarding a patient’s recent international travel or plans to travel could be entered into an alert field such as this. When the patient comes in, no matter their current symptoms, staff would see the alert and hopefully consider presenting problems in light of the travel data collected.
Sounds great, but if administrators do not communicate the proper use of such fields they are of little use.
Considering the available information regarding this incident it appears that internal communication policies within the hospital are the culprit. Open and accurate communication between patients and clinicians must be supported by the healthcare organization’s policies and systems. If there are deficiencies found with electronic health record set up and/or use it’s up to the hospital administration to communicate this information to staff. If employees do not feel empowered to bypass the EHR and do what they feel may be critical to maintain proper patient care this is also something hospital administrators must address.
The EHR records what providers do, it does not tell them what to do.
