EMR Not Responsible For Ebola Patient’s Misdiagnosis
By Dr. James Palermo // October 7, 2014
TEAMWORK, COMMUNICATION, ATTENTION TO DETAIL KEY TO SAFETY CULTURE
It was being reported in all media venues that when Ebola patient Thomas Eric Duncan first presented to the emergency department of Texas Health Presbyterian Hospital Dallas (THPHD) he told a nurse he had recently traveled from Africa.
According to the hospital, that information was reportedly recorded in the hospital’s electronic medical records (EMR) system, but was not displayed in the physician’s section of the EMR, resulting in a physician’s disposition that sent Duncan home from the emergency department based on a clinical picture that was missing a very crucial element of his history.
The misdiagnosis and subpar treatment resulted in Duncan’s condition deteriorating over the subsequent three days and his return to THPHD with full-blown Ebola, having exposed people with whom he came in contact between hospital visits to the deadly virus.
HOSPITAL INITIALLY REPORTS ‘FLAW’ IN EMR
Criticism of THPHD abounded in the media for not recognizing Duncan as a high risk Ebola patient and making the diagnosis on the first visit. Responding to their critics, THPHD initially released the following statement suggesting that it was a “flaw” in the EMR workflow that led to the misdiagnosis:
“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.”
According to THPHD’s statement, the hospital had since updated its EMR so that travel information is displayed in both workflows to “improve the early identification of patients who may be at risk for communicable diseases, including Ebola.”
EMR IS TOOL ONLY AS EFFECTIVE AS PEOPLE USING IT
EMRs are tools that can and should be revised and refined as circumstances and situations demand.
However, to focus on what is purported to be a design “flaw” in the EMR as the primary cause for a catastrophic wrong clinical decision and mismanagement, which has directly affected dozens of people, is patently ridiculous and ignores the real problem: hospital cultures in which healthcare professionals work in silos rather than as a team, depend on indirect communication, and prioritize moving patients through the system sometimes to the detriment of consistent attention to crucial details.
The Center for Disease Prevention and Control (CDC) guidelines for evaluation of travelers from Ebola-affected areas of the globe have been available to hospitals for months.
If Duncan did indeed report that he had recently traveled from Liberia, one of the West African nations riddled by the disease, that information should have immediately triggered a call to the emergency physician managing the case and a detailed interview of the patient by the physician focused on any risk activity/exposure prior to leaving Liberia.
THPD NOW ADMITS ‘NO FLAW’ IN EMR
On Friday, THPHD acknowledged that there actually was “no flaw” in its health records after all, medical staff had access to the fact that he had just arrived from Liberia, and the error was a human factor breakdown of the clinical evaluation process.
The healthcare industry has been slow in converting to the digital world, and the efficacy and reliability of the EMR continues to be very controversial.
An absolute take-away from what transpired at THPD is that no matter how well or poorly designed an EMR may be, it is just a tool.
The ultimate safety of patients and the community depends on healthcare providers taking individual responsibility to commit, engage, communicate and take ownership of proven clinical guidelines/protocols, and work as a team.