Ebola's arrival puts IT in spotlight

‘We have modified our electronic health record in multiple ways’
By Erin McCann
02:25 PM
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As the deadly Ebola virus made landfall in the U.S. for the first time in 2014, it raised a host of questions about electronic health records, provider workflow and the readiness of the country’s IT infrastructure to deal with a potential outbreak.

In a congressional hearing in October, a Texas Health Resources executive joined other clinical stakeholders in the U.S. Ebola crisis to shed light on myriad oversights that transpired when the Ebola virus arrived in Dallas this fall.

Daniel Varga, MD, chief clinical officer at the 25-hospital Texas Health Resources, who video-conferenced in from Texas, appeared somber. He detailed the sequence of events and missteps that occurred at TH Presbyterian Hospital when Thomas Eric Duncan, the nation's first Ebola case, showed up at the emergency room Sept. 25.

After poor communication, lacking hospital processes, EHR inadequacies and a host of other issues at play, Duncan was discharged from the ER. Less than two weeks later, after arriving back at the hospital with much worse symptoms, he was dead.

What THR officials first described as a "flaw" in the hospital's Epic electronic health record, which they said resulted in the failure of Duncan's travel history appearing in the physician's workflow, was later recanted by the health system.

In an Oct. 3 statement, hospital officials backtracked, saying there actually was "no flaw in the EHR in the way the physician and nursing portions interacted related to this event," and that the patient's travel history "was available to the full care team.”

Hospital officials declined to comment further.

"Truly, there was no EHR issue here," said John Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center in Boston, in an emailed statement. Typical EHRs, he continued, have alerts, reminders and tasks – all of which "were in production in Texas."

But even Varga acknowledged there were serious issues. "Unfortunately, in our initial treatment of Mr. Duncan, despite our best intentions and a highly skilled medical team, we made mistakes. We did not correctly diagnose his symptoms as those of Ebola," said Varga in his testimony before the congressional committee. "We are deeply sorry.”

In his statement, Varga detailed two big failures at play. One being that Duncan's travel history to Liberia was not captured at the initial point of contact in the emergency department's admission process. This, Varga said, has since been addressed, and the hospital screening process has been amended to capture this information immediately. "This process change makes the travel history available to all caregivers from the beginning of the patient's visit in the ED," he wrote in his testimony.

Another big issue? The hospital's Epic electronic health record did not have adequate pop-up visibility and travel documentation capabilities related to travel history Ebola exposure, Varga added.

"We have modified our electronic health record in multiple ways to increase the visibility and documentation of information," he said. The modifications made included improving the placement and title of the screening tool; adding a pop-up that flags the patient as high-risk for Ebola with subsequent instructions if the patient answers 'yes' to certain screening questions; and exposure to known or suspected Ebola cases.

EHR challenges aside, Ebola raised other questions about how ready the larger IT infrastructure is in the U.S. to handle a potential outbreak.

John W. Loonsk, MD, CMIO, CGI Federal wrote in a guest column, “The health IT requirements for outbreak management and other public health emergencies are known, and they are mostly not about EHRs.” These health information exchange capabilities include "index" case detection, case reporting, contact tracing, countermeasure administration and more.

“Ebola hopefully will stay at low case counts in the US and thus not require all of this health IT infrastructure,” wrote Loonsk. “But if not, or during the next event, any of these needs could be made prominent.

Meanwhile, there have been some gratifying victories controlling the deadly virus, with health IT at the core of it all.

In what’s been hailed as a “spectacular success story,” the World Health Organization on Oct. 20 declared Nigeria Ebola free, with public health agencies and government officials citing an mHealth initiative as largely responsible for the triumph.

Nigerian Minister of Communication Technology Omobola Johnson credited a social media campaign and a real-time reporting Android app used during the outbreak as integral in containing the deadly virus. 

"The phone app helped in reducing reporting times of infections by seventy-five percent," said Johnson, speaking at the International Telecommunication Union's Plenipotentiary Conference Oct. 21. "Test results were scanned to tablets and uploaded to emergency databases, and field teams got text message alerts on their phones informing them of the results."

There’s still much work to be done, however. Calling it the deadliest outbreak of Ebola in history, at press time, the WHO has reported that 4,818 people have lost their lives. More than 13,042 are either confirmed or probable cases of the virus, which has a fatality rate of up to 90 percent.