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10/3/2014
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Texas Hospital Blames EHR For Ebola Mishandling

Texas Health Presbyterian Hospital Dallas cites lack of interoperability between nurse and physician workflows as reason Ebola patient was sent home.

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25 Years Of Health IT:
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Lack of interoperability between the nurse and physician workflows in its electronic health record system was the reason Texas Health Presbyterian Hospital Dallas initially sent home Ebola patient Eric Duncan, according to the healthcare facility. And similar interoperability issues could threaten other healthcare organizations, industry executives caution.

Despite telling a nurse he had recently traveled to Western Africa -- hotbed of the disease -- the patient was released when he first visited the emergency department on September 25. Duncan, who agreed to publicly disclose his health information, returned to the hospital on September 28 via ambulance and was admitted, where he remains in "serious condition," according to the hospital. Doctors diagnosed Duncan with Ebola the following day.

In reviewing its processes and procedures, the hospital determined it had "identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case," noting there were separate nursing and physician workflows. The hospital apparently uses Epic, according to an InformationWeek article in early 2014 and press releases from the past few years.

The statement continued:

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. As designed, the travel history would not automatically appear in the physician's standard workflow. As a result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. 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.

[Big data can yield life-saving information. Read Big Data Disease Breakthroughs.]

Texas Health Dallas was an early adopter of EHRs.  "We implemented EHR very, very well, and at the time we did it, five or six years ago, most people did not implement well. We were first in the country -- or tied for first in the country -- to achieve meaningful use," Edward Marx, senior vice president and CIO at the hospital told InformationWeek earlier this year, referring to the federal incentives program for effective use of health IT. Texas Health implemented Epic EHR software across a network of 14 hospitals.

Many hospitals complain about interoperability problems within their EHRs -- between disparate workgroups, such as doctors and nurses, or different departments, including emergency rooms and cardiology -- that lead to errors. The technology is new and many providers are in the early stages of adoption, seeking software and procedures that fine-tune capabilities and eliminate mistakes like this, experts said. Having evolved from billing, newer systems now focus more on clinician and patient needs, they said, and these later editions provide more of the capabilities, tools, and features medical users need.

Michael Nusimow, CEO of drchrono, told InformationWeek:

The new wave of healthcare software coming to market promises features like clinical decision support that will have the EHR system itself analyze cases and raise red flags to the human healthcare providers to reexamine cases like this that might otherwise slip through the cracks in a fast paced environment. We are currently at a tipping point where the majority of healthcare encounters in the U.S. are now being documented in electronic systems (over paper) and it's the challenge of the healthcare software industry to... [make] sure the software does no harm and actually improves patient outcomes and reduces errors.

EHRs should include a mandatory field, nestled between the two workflows, that physicians must read and check before accessing their portion of the EHR, said Divan Dave, CEO of OmniMD, in an interview. This field could include information about anything that alarmed nurses -- from Ebola to dramatic weight loss, he added. 

Or healthcare providers can purchase third-party products, such as QPID Health's clinical intelligence software, that discerns patient information from EHRs and other sources, and then delivers it to clinical and administrative workflows. With its Ebola screening system, slated to become available this month, QPID will look at a travel system, marry it to the condition's symptoms, and alert doctors or nurses that a patient could have the disease, said CEO Mike Doyle in an interview. He continued:

I don't think anyone would argue if that [Texas] physician had known that person was from West Africa he would not have discharged that patient. Unfortunately, in today's healthcare world, data is very, very siloed. Intake systems don't talk to outpatient systems. Eighty percent of data in electronic health systems is unstructured so it's very hard to report. As a result, critical and acute information goes unnoticed -- and this is a very prime example of that.

Yet common sense dictates potential cases of headline-making conditions like Ebola would get special treatment, said Dave.

"Just to blame [this] on [the] EHR is wrong. Who says you cannot go and tell your head nurse or whoever, 'I am a nurse here and we have a patient here who has traveled to Liberia and we have a flag raised.' I see this as more of a problem than EHRs," he said. 

The owners of electronic health records aren't necessarily the patients. How much control should they have? Get the new Who Owns Patient Data? issue of InformationWeek Healthcare today.

Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio

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bbrown878
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bbrown878,
User Rank: Apprentice
10/13/2014 | 5:38:56 PM
Re: Stop blaming the systems
"The nurse should have paid attention to the patient in front of her and inform the doctor verbally of her findings, instead of relying on a machine"

You are right ... BUT that is what automation of processes do. The users get to a point of complacency, relying on technology to take the place of what used to be something much more personallized. It happens all over, we (that is the population as a whole) are becoming more and more reliant upon technology. Things that used to be personal and interactive are now being replace by technology. Just try calling an insurance company, or a technical company for support... What are your chances of talking to someone. 

Technology is good, but it is also very dangerous. This is a perfect example.
GAProgrammer
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GAProgrammer,
User Rank: Ninja
10/9/2014 | 4:02:39 PM
Re: EHRs still in progress
Also, never forget the unintended consequences that come with EHRs - the nurses expect that the doctors have access to all the same information, so instead of using common sense and mentioning it in person, they leave it to the computer to relay the info the doctor.
shericadore
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shericadore,
User Rank: Apprentice
10/8/2014 | 3:34:04 PM
Re: Stop blaming the systems
The nurse should have paid attention to the patient in front of her and inform the doctor verbally of her findings, instead of relying on a machine.  The computer or application is as smart as the person who is using it.
Alison_Diana
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Alison_Diana,
User Rank: Author
10/6/2014 | 10:34:24 AM
Re: Stop blaming the systems
Another problem I see with the surplus of data these days is a surfeit of CYA among medical professionals. This, unfortunately, is coming from personal experience with a family member who has been "diagnosed" with an array of horrible conditions, none of which (so far) has, thankfully, been true. All doctors who have "diagnosed" her have come to their theories from good places; they want to heal or at least treat her and use all these test results to arrive at their diagnoses. But, in some ways, this huge array of data is making the condition worse because of the stress caused by all the wrong readings of data and misdiagnoses. 
Alison_Diana
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Alison_Diana,
User Rank: Author
10/6/2014 | 10:31:09 AM
Re: Automation Correction -- Human Error
Thank you, @jastroff. I saw that too -- and was going to post it separately. The notice from the hospital came long after I filed the story. What's striking, however, is the readiness with which many experts agreed it COULD happen in the way the Texas hospital first said; that separate workflows might well prevent doctors from seeing nurses' notes. While, thankfully, that was not the case (apparently, according to this second statement) here, if I was the chief medical officer of a hospital I'd be making sure all workflows either integrated or had some kind of sharing capability, post-Texas.
Alison_Diana
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Alison_Diana,
User Rank: Author
10/6/2014 | 10:28:32 AM
Re: automation
I agree with you, @Jastroff. You've got an illness that is making headlines on everything from CNN and Fox to the New York Times and business media, an individual who has apparently all the medical symptoms and says he has traveled to a region afflictled with Ebola, and you don't pick up the phone, mutter in a colleague's ear, or escalate the patient's treatment in triage?! 
Alison_Diana
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Alison_Diana,
User Rank: Author
10/6/2014 | 10:26:08 AM
Re: There will be more Ebola cases
I agree with you, Charlie, that there will be more cases of Ebola beginning in the United States (as opposed to patients coming to the States after being infected elsewhere). That said, I am more afraid of the enterovirus that has paralyzed several children, killed at least one boy, and sent tens of youngsters to the hospital.
ITSkeptic
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ITSkeptic,
User Rank: Apprentice
10/5/2014 | 3:50:49 PM
Stop blaming the systems
Systems are a reflection of the human processes. What happens at this hospital and others is coded into the EHR systems.

Doctor - nurse communication is so disjointed already that nurses ask all the questions, enter them in. Then two hours later doctor walks in and repeats all the questions. Then reenters everything. 

Entering the data has become such an obsession that the nurse or the doctor barely look at me these days. They are "uh-uhing" me while trying to punch the right keys on the tables or on the laptops. Idiots should have paid more attention to the patient and his state.

Stop blaming the systems. Think about how you work.
jastroff
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jastroff,
User Rank: Ninja
10/4/2014 | 1:06:58 PM
Automation Correction -- Human Error
From the Wall Street Journal –

Looks like they can't blame the system

 

"DALLAS—A day after saying that doctors didn't receive a Liberian patient's travel history due to an electronics records glitch, the Dallas hospital that initially failed to admit the first person diagnosed with Ebola in the U.S. has changed its version of events, stating that information that he had come from Africa was in fact available to doctors.

 

Texas Health Presbyterian Hospital Dallas said in a terse clarification late Friday evening that Thomas Eric Duncan 's travel history was available to physicians as well as nurses in its electronic health records when Mr. Duncan first arrived at the hospital's emergency room on the night of Sept. 25, complaining that he felt ill."
jastroff
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50%
jastroff,
User Rank: Ninja
10/4/2014 | 1:06:44 PM
Automation Correction -- Human Error
From the Wall Street Journal –

Looks like they can't blame the system

 

"DALLAS—A day after saying that doctors didn't receive a Liberian patient's travel history due to an electronics records glitch, the Dallas hospital that initially failed to admit the first person diagnosed with Ebola in the U.S. has changed its version of events, stating that information that he had come from Africa was in fact available to doctors.

 

Texas Health Presbyterian Hospital Dallas said in a terse clarification late Friday evening that Thomas Eric Duncan 's travel history was available to physicians as well as nurses in its electronic health records when Mr. Duncan first arrived at the hospital's emergency room on the night of Sept. 25, complaining that he felt ill."
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