EHR still in play with US Ebola case
EHR modifications were made at THR, officials noted
In a congressional hearing Thursday, a Texas Health Resources executive joined other clinical stakeholders in the U.S. Ebola crisis to shed light on myriad oversights that materialized when the Ebola virus arrived on American soil.
Daniel Varga, MD, chief clinical officer at Texas Health Resources, who video conferenced for the hearing from Texas, appeared somber. He detailed the sequence of events and missteps that transpired at TH Presbyterian Hospital when Thomas Eric Duncan, the nation's first Ebola case, showed up at the hospital emergency room on the evening of Sept. 25. After poor communication, lacking hospital processes, EHR inadequacies and a host of other issues at play, less than two weeks later, Duncan was dead.
[See also: Missed Ebola diagnosis leads to debate.]
What was first described by THR officials as a "flaw" in the hospital's electronic health record, which resulted in the failure of Duncan's travel history appearing in the physician's workflow, was later recanted by the health system.
"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.
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. Officials also added a screening question on high-risk activities for those who have been to Ebola areas.
Judy Hanover, research director of provider IT strategies at market research firm IDC Health Insights, said these pop-ups and flags are typically a "manual process," where one hospital may incorporate in alerts from CDC guidance and another hospital may not. Many of these flags and alerts, she continued, "just don't get incorporated as often as they should."
It's more of an inherent design issue with a lot of EHRs, most of EHRs on the market and not necessarily a flaw," added Hanover.
[See also: Questions raised about EHR workflow in Ebola case.]
Varga joined five others who testified before Congress on the Ebola epidemic, chief among them was Thomas R. Frieden, MD, director for the Centers for Disease Control and Prevention, who was in the hot seat for the majority of the hearing's question portion. Varga was also questioned, however.
Diana DeGette, D-Colo., for instance asked Varga straight out: Seeing as the CDC issued THR guidelines on how to handle Ebola cases July 28, were emergency department personnel properly trained on these guidelines? "No," said Varga.
Some 4,493 people have lost their lives from what the World Health Organization is calling the deadliest outbreak of Ebola in history. Nearly 9,000 people have confirmed and suspected cases reported. As pointed out in the congressional hearing, between 100 to 150 people come to the U.S. from the "hot" areas affected by Ebola. Some 94 percent of those individuals are being screened.