Texas Ebola Outbreak Blamed On Electronic Health Record Workflow Failure

When the first case of the Ebola virus was recognized at a Texas hospital late last week, it was missed the first time around due to a flaw in the Electronic Health Record (EHR) system, the hospital said in a statement late Thursday.

When Thomas Duncan first came to the hospital on Sept. 25, he presented with symptoms of Ebola, which are similar to many other communicable diseases. He was sent home, only to return to be diagnosed on Sept. 29. The hospital now lists him in "serious condition."

While protocols were followed by physicians and nurses, a flaw in the EHR system helped allow the patient's recent travels to Liberia fall through the cracks, according to a report from the Texas Health Presbyterian Hospital Dallas, where the patient was treated.

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More specifically, there are separate workflows for nurses and physicians, where travel history is automatically viewed by nurses, but not by physicians. Since realizing the flaw, the hospital has updated its EHR systems so that travel history is part of both nurse and physician workflows. A specific reference for regions with known instances of Ebola has also been added, the statement 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," the hospital said in the statement.

The hospital did not respond to requests for comment on the vendor of the EHR system or if there was a solution provider involved in the implementation.

Kyle Cebull, CMO at Fort Myers, Fla.-based Entech, said that in these kinds of situations, it is important to understand that EHR systems are incredibly customizable by design to accommodate different types of health-related business of all sizes. The downside, however, is that customization can affect the workflow and flaws are hard to detect until an incident occurs.

"From a channel or managed service provider perspective, [it is important] to be aware that this is a mistake that is easy to make. It can result in something stupid like a patient not getting called back or it can be something serious like a patient dies. ... It's not something to be taken lightly," Cebull said.

For that reason, he said Entech will recommend or even require a full-time person on staff to handle the customizations and be trained directly by the EHR vendor company. That way changes can be done correctly and in real time, he said. The problem, in particular with EHR customizations, he said is that the customizations are often so specific that there isn't a way to fully check workflows all the way through until an incident occurs. There are so many layers, he said, that it is essentially impossible to just look at it and find problems.

"You've got to have somebody who knows what they're doing helping you implement this stuff because you'd never know until you made the mistake," Cebull said.

Rachel Huveldt, RN and CEO of Los Gatos, Calif.-based EMR Consulting Solutions, agreed, saying that anytime a new EHR system is put in place, there needs to be strong project management around the solution to make sure it is functioning correctly. However, after a costly implementation, staff members are not always given the maximum amount of training on the platform, which can result in incidents such as what happened in Texas.

Looking at the Ebola incident in Texas, Huveldt pinpointed the dual workflows as a major point of failure in the EHR system. She said at her organization it is best practice to integrate the workflows to make sure information is communicated clearly between all the staff.

"In my view, that workflow should have been an aligned workflow," Huveldt said.

Even if the EHR systems are set up with best practices, Huveldt said, there are other forms of communication. As an RN herself, Huveldt said she would have communicated the travel information verbally, especially given the nature of Ebola.

Ed Simcox, U.S. Healthcare Practice Leader at New York City-based Logicalis, No. 26 on CRN's SP500 list, said that this sort of situation could happen in any large healthcare organization. That it happened at a center well-known for high-quality healthcare, such as Texas Health Resources, only underscores how important it is to prioritize focus on quality and clinical processes, he said.

"Health IT is an important tool to help close loopholes and enforce quality measures, but it’s imperative to be focused first and foremost on clinical process improvement. Large healthcare providers should ask themselves, ’Would our processes and IT systems have prevented this event? If not, what can we do to prevent this from happening in our organization?" Simcox said.

In light of the incident in Texas, Cebull said that there is an opportunity for managed services providers to touch base with their end users and help educate them on the potential for problems with any custom application. While they can't always fix the problems, Cebull said "savvy ones" will at least bring it to the attention of their end users and continue to act as a trusted advisor.

"From a more strategic perspective on that strategy manager level, we'll have that conversation with our medical clients. If you are a niche provider for medical clients, which is common in the MSP world, you may want to do maybe marketing and education by email ... to say this could be a problem. Have you looked at it? What are you doing? ... If you need help, let us know," Cebull said.