Procedural flaw in EHR system cited in Texas Ebola case

(Editor's Note: Texas Health Resources subsequently backed off its statement that a flaw in the electronic health-record system had led to miscommunication between nurses and doctors resulting in the patient being sent home after being evaluated in its emergency department.)

A procedural flaw in the electronic health-record system at Texas Health Presbyterian Hospital Dallas prevented a doctor there from seeing a nurse's note that eventual Ebola patient Thomas Duncan had been in Liberia, the hospital said late Thursday.

Duncan—who has not been named by the hospital but identified by family members and the Liberian government—first visited the hospital emergency room on the night of Sept. 25. Nurses recorded his travel history, but doctors did not see that information in the EHR workflow they viewed, the hospital said. Duncan was released, only to be readmitted several days later. The hospital's parent, Arlington-based Texas Health Resources, has an Epic EHR system deployed across its 14 hospitals.

“Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows,” the hospital said in a statement. “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.

The hospital said it has now moved travel history into a portion of the EHR that appears in both doctor and nurse workflows and has modified it to specifically reference regions of Africa hit by the Ebola outbreak.

Duncan is the first Ebola patient identified in the United States and remains in the hospital while people he had been staying with remain in quarantine in their Dallas area apartment.

On his first emergency room visit to Texas Health, he was evaluated by a triage nurse and then an intake nurse. He had a 100 degree fever, abdominal pain for two days, a sharp headache and decreased urination, the emergency room team noted, symptoms common to several communicable diseases.

Duncan told the nurse during that first visit, however, that he was not experiencing nausea, vomiting or diarrhea, and he said that he had not been near anyone sick in Africa, according to the hospital's statement.

Follow John N. Frank on Twitter: @MHJFrank