Did Electronic Medical Record-mediated problems contribute to or cause the current Dallas Ebola scare?

[10/3/2014 Note:  my suspicions were correct - see addenda below.]

This story merits special scrutiny in relation to EHR dangers (see for instance http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html):

http://bigstory.ap.org/article/44a12c35649f4f6782fcb3c9f476da09/ebola-case-stokes-concerns-liberians-dallas

Oct. 1, 2014:  Ebola-infected passenger was sent home from ER

DALLAS (AP) — The airline passenger who brought Ebola into the U.S. initially went to a Dallas emergency room last week but was sent home, despite telling a nurse that he had been in disease-ravaged West Africa, the hospital said Wednesday in a disclosure that showed how easily an infection could be missed.

The decision by Texas Health Presbyterian Hospital to release the patient, who had recently arrived from Liberia, could have put others at risk of exposure to Ebola before the man went back to the ER a couple of days later, when his condition worsened.

... The patient explained to a nurse last Thursday that he was visiting the U.S. from Africa, but that information was not widely shared, said Dr. Mark Lester, who works for the hospital's parent company.

"Regretfully, that information was not fully communicated" throughout the medical team, Lester said. Instead, the man was diagnosed with a low-risk infection and sent home.

How could a "failure to fully communicate" information about the man's travels have occurred, at a time when the Ebola issue has been prominent in the press and is causing a worldwide scare?

The Texas Health System hospitals, including Texas Health Presbyterian Hospital Dallas, are EHR users and have been recipients of millions of dollars of federal incentives:

http://www.bizjournals.com/dallas/news/2011/05/24/texas-health-gets-19m-for-ehr-upgrades.html?page=all

May 24, 2011: Texas Health Resources has received more than $19.5 million in Medicare incentive payments for meeting “meaningful use” criteria for installation and use of its electronic health records.

It appears these hospitals are using EPIC. From a July 6, 2009 HIStalk blog interview with the CMIO:

http://histalk2.com/2009/07/06/histalk-interviews-ferdinand-velasco-md-chief-medical-information-officer-texas-health-resources/

What are the most important projects you are working on at Texas Health Resources?
The project is our EHR deployment. We’re an Epic customer. We’re in the middle of deploying the EHR. We’re live now with probably close to three-quarters of our beds. We’re a 14-hospital health system.

EHR's are known to disrupt normal, even mundane channels of medical communication (as readers of this blog know, my mother is dead thanks, in part, to this problem).

Per the Agency for Healthcare Research and Quality (AHRQ) of HHS, possibly relevant modes of disruption in this scenario include:

• "information hard to find", 
• "suboptimal support of teamwork (situational awareness)", 
• "confusing information display", 
• "design contributed to entry into wrong patient's record", 
• "lost data", 
• "excessive workload (including cognitive)" ...

... and other potentially relevant factors (including system outage).

Below is a checklist of such failure modes from the May 2012 AHRQ Health IT Hazard Manager Report (http://healthit.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf):

 

AHRQ Health IT Hazard Manager Report - Hazard Modes of Health IT (click to enlarge)

I've worked in ED's and find this matter puzzling.  While I have no evidence as to any role of EHRs in this seemingly strange, cavalier and incomprehensible medical decision to send this man home, resulting in potential exposure of numerous other individuals to Ebola (and I am certainly not in a position to have such evidence), I believe this possibility needs to be investigated fully.

Yet there does not appear to be a rush for investigation of what transpired in the ED.  See "Health regulators not rushing to probe Dallas hospital’s handling of Ebola patient", Miles Moffeit, Dallas News, Oct. 1, 2014 at http://watchdogblog.dallasnews.com/2014/10/health-regulators-not-rushing-into-probe-of-dallas-hospitals-handling-of-ebola-patient.html/.

Finally, by the way, after all the tens of millions of dollars spent by this organization on EHR's at taxpayer expense and with the awards and accolades heaped on them by the likes of HIMSS, Leapfrog etc., at the very least one might have expected a blatantly obvious case like this to have been recognized as a serious matter. Yet it was not. (One can only imagine what happens with more subtle issues.)

One wonders how much in the real world, as opposed to in the world of EHR marketing and hype, these systems really do help in critical decision making and safety.

-- SS

10/3/2014 Update:

My suspicions were apparently correct.

See:

 "Travel Information Wasn't Communicated In Dallas Ebola Case Due To Electronic Health Record Flaw" (Huffington Post),
http://www.huffingtonpost.com/2014/10/02/dallas-ebola-patient-hospital-error-electronic-health-record-flaw_n_5924698.html

and:

"Dallas hospital blames ‘flaw’ in ‘workflow’ for release of Ebola patient as a more complete picture of his travels emerges" (Washington Post), http://www.washingtonpost.com/news/morning-mix/wp/2014/10/02/dallas-hospital-blames-flaw-in-electronic-record-keeping-system-for-release-of-ebola-patient/

-- SS

More:
  
http://www.wptz.com/health/urgent-ebola-texas-hospital-flaw/28381038

(CNN) -- The Texas hospital treating the first person diagnosed with Ebola on American soil says a "flaw" in its electronic health records prevented doctors from seeing the patient's travel history. Patient Thomas Eric Duncan told the nurse he'd been in Africa, but that information was entered into a document that isn't automatically visible to physicians [apparently even after being filled out with positive information, I note - ed.], Texas Health Presbyterian Hospital Dallas said in a statement Thursday. After discovering this, the hospital says it has changed the system so doctors and nurses will see travel history documentation. "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.  

Well, yes it will.  Perhaps that could have been thought of sooner?

Additional thought:  this situation might end up being the "Cybernetic Libby Zion case" I've been predicting - where some major debacle leads to serious attention to EHR safety issues.  (On Libby Zion, see http://en.wikipedia.org/wiki/Libby_Zion_Law.)

-- SS

10/4/2014 addendum:

Now...gee whiz...the hospital changes its tune. "No, it wasn't the EMR after all!" 

See "Hospital reverses explanation for fumbling Ebola case" at http://www.dallasnews.com/news/metro/20141003-hospital-reverses-explanation-for-fumbling-ebola-case.ece. The reversal strains credibility and sounds like redirection, to my ear possibly due to inside attorney and/or EMR company attorney pressure. 

The "new explanation" itself per the new article is that:

... A written statement Thursday said hospital officials identified and corrected “a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case.” That statement implied, without directly saying it, that the flaw left the doctor uninformed about Duncan’s travel history. In Friday’s statement, though, the hospital said, “The patient’s travel history was documented and available to the full care team in the electronic health record.” “There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event,” the statement said.

Again, sounds like redirection and making the doctor (and perhaps the ED doctor's group, if they were contractors) the sole scapegoat.   

"Available to the full care team?"  "Available" in a complex computer system with myriad screens is a very relative term.  The issue seems not "how the physician and nursing portion interacted", it is "how the physician portion made the information readily apparent to the physicians and other team members, or not."
 
The problem here, I believe, still likely amounts to "information hard to find" and "suboptimal support of teamwork (situational awareness)", among others, per the AHRQ hazards taxonomy. 

See, for instance, this.  Either it is true, or not, regarding the travel history:

 (click to enlarge)

I think an impartial investigation is needed to get to the truth.  

What we have now is likely healthcare defense attorney and/or risk management "fog", a phenomenon I have both professional and (sadly) personal experience with.

One also wonders if the EHR vendor had a contractual defects non-disclosure ("gag") clause with the organization, and is now threatening suit, leading to the retraction.  (See http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda for more on that issue, and of corporate "hold harmless" clauses).   

Unfortunately, a comprehensive investigation would be likely to only occur in a courtroom via Discovery if others become infected.

If any reader has knowledge of details, my email address is scotsilv AT aol DOT com.

-- SS