Nurse Informaticists Address Texas Ebola Case, EHR Design Questions

By Susan McBride, PhD, RN-BC, CPHIMS, professor and program director of the Masters in Nursing Informatics Program, Texas Tech University Health Sciences Center, and Mari Tietze, PhD, RN-BC, FHIMSS, associate professor and director, Interprofessional Health IT Program at Texas Woman’s University (TWU). The views expressed are those of the authors and don’t represent those of Texas Tech or TWU.


EHRs: information ‘siloes’ or interprofessional collaboration?

The recent Ebola case in Dallas—in which a patient was admitted to the hospital three days after he visited the ER exhibiting symptoms associated with Ebola and reporting that he’d recently traveled from West Africa—brought this global public health story close to home for many of us residing in the area. As has been widely reported, the patient died last week after nearly 10 days in the hospital.

An initial focus of media coverage was the suggestion that a failure of nursing communication had contributed to the release of the patient from the hospital on his first visit. Partly reflecting evolving explanations offered by the hospital, the media focus then shifted to a potential flaw in the hospital’s electronic health record (EHR) system, in which information recorded by a nurse about the patient’s travel history might not have been visible to physicians as well.

Although the hospital initially stated that the patient’s travel history was located in the nursing workflow portion of the EHR and would not be visible to the entire health care team, they later clarified that there was in fact no flaw in the way the physician and nursing portions of the EHR interact with each other.

While it remains a matter of debate why, at the first patient visit, the information about the patient’s travel from West Africa was not incorporated by either nurses or physicians into the diagnostic and treatment decisions being made, the general sense is that the workflow design applied to the EHR at this Texas facility was consistent with best practices for infectious disease identification.

If this is the case, institutions across the nation may need to reexamine workflow and documentation design in EHRs, including interprofessional collaboration. We may need to reconsider whether this design currently results in ‘siloes’ of information that are assumed to be more relevant to one kind of health care practitioner or another. Ideally, the clinical status of a patient would be readily available to and used by the entire interprofessional team.

In addition, clinical decision support (CDS) rules can be built into the EHR to guide the clinician by means of alerts. In this case, such an alert is available from the U.S. Centers for Disease Control and Prevention (CDC) and includes recommendations on foreign travel and the CDC algorithm for identifying and handling the Ebola outbreak.

Inevitably, new issues are emerging with the increasingly widespread use of EHRs. While EHRs reflect much more information complexity and capacity than we have historically had in a paper-based world, we need to be able to benefit from this complexity. EHRs should be useful and powerful tools that result in an increased capability to identify and address priorities such as infectious diseases.

As informatics nurses, the first thing we think about is how information technology can help us contain the Ebola outbreak, as it has helped with sepsis management, medication error reduction, and venous thromboembolism (VTE) prevention. This hospital and many others like it have had their EHR systems certified in accord with federal standards of the Office of National Coordinator for Health Information Technology (ONC). But the events in Dallas suggest that this may not be enough.

We now know that Ebola is here, and can anticipate that we may be seeing more cases in hospitals and clinics. EHRs can be changed quickly to address the priorities before us. Nurses need to be full partners with other health care professionals in any redesign of EHRs that does occur.

Lastly, in addition to the EHR issues noted above, more emphasis needs to be placed on reexamining basic communication and interprofessional collaboration to ensure that all communication, electronic and verbal, flows freely.

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  1. Susan McBride October 21, 2014 at 1:49 pm

    In regards to the post,
    “Since hospitals have begun to use the EHR’s there have been dozens to hundreds of mistakes that could be directly linked in some way to the EHR.”

    We believe that some of the fundamentals of quality improvement can be applied to technology and that nursing informaticists, clinicians and quality improvement specialists partnered together to examine events can result in optimizing these systems. Workflow redesign, root cause analysis (RCAs), measurement on pre and post implementation of improvement using control charts are just a few of the “tried and true” methods we can use. We advocate these methods as a “tool kit” for EHR improvements.

    Susan McBride & Mari Tietze

  2. Samantha Stauf October 21, 2014 at 12:08 pm

    I certainly don’t believe that blaming nurses is the answer…although can believe that the flaw came from the EHR. Since hospitals have begun to use the EHR’s there have been dozens to hundreds of mistakes that could be directly linked in some way to the EHR.

    Electronic Health Records are still a fairly new technology, but we need to get on top of this. We can’t afford to make mistakes when diseases as dangerous as Ebola are involved.

  3. Susan McBride October 17, 2014 at 4:13 pm

    The hospital indicated “He volunteered that he traveled from Africa in response to a nurse operating the checklist and asking him the question. The clinicians did not factor that in. It was not part of their decision.” (1)
    As nursing informaticists, regardless of the sequence and level of documentation, we believe that the most important lesson here is that we all think through workflow for admitting and assessing patients to make sure that as we enter relevant information into the electronic record-it gets to those individuals that need the information. In addition, nurses can help think through the CDC algorithm noted in our blog for management of the patient to help our IT teams and vendors design the right way to enter the information to trigger the right response according to those protocols. The CDC and the Office of the National Coordinator had a call yesterday and another today with our EHR vendors to address how we should best accomplish this workflow using the EHR to help inform interprofessional teams effectively. Several comments on yesterday’s meeting came from nurses with excellent information to inform these national recommendations. We encourage you to help think through this workflow for your organizations.
    1. See:
    Susan McBride and Mari Tietze

  4. Marie-Anne Demuynck October 17, 2014 at 2:33 pm

    This opens up many interesting discussion points.
    I agree there should be a RED FLAG type warning. The question remains when such a warning should be set up. When the disease first shows up in the US? When the epidemic is first signaled? Etc.
    I don’t think anyone was expecting that first case when it showed up in the US. All control measures in place now where established after the first case. I think that stressing inter-professional cooperation, rather than compartmental approaches would allow problems to be discovered sooner and solutions found and implemented more rapidly.
    I think these are key issues, that require careful study, as well as personnel in place with the skills to create the algorithms and programs to raise the RED FLAG in EHR systems.
    And yes, not being a healthcare professional, I can still appreciate that they are time consuming. However, the amount of information, insights, patterns, etc. that could be discovered, and discovered rapidly, are almost an “undiscovered country”. Case in point, the example where Google, using big data analysis of its search engine data, was able to more quickly predict the spread and location of a flu epidemic than the CDC.

  5. rlavin10 October 17, 2014 at 1:19 pm

    I spent much of my career in emergency management and one rule was that significant information may be sent electronically, but that was never to be considered confirmation of receipt. It must be confirmed verbally. The article is somewhat unclear as to whether it is speculating on media reports or if they have first hand knowledge of the failures and or reasons for inadequate communication. “Although the hospital initially stated that the patient’s travel history was located in the nursing workflow portion of the EHR and would not be visible to the entire health care team, they later clarified that there was in fact no flaw in the way the physician and nursing portions of the EHR interact with each other.”

    While I see the advantages of the EHR they are very time consuming and as a result there appears to be less time for face-to-face communication. Maybe it is time we reexamine the excessive amount of documentation and study what documentation is actually valuable, what is for legal coverage only, and what actually seems to impact quality of care and outcomes. The old thing we teach students about, if it wasn’t documented it wasn’t done is foolish.

  6. Susan McBride October 17, 2014 at 11:08 am

    We very much agree that interprofessional team’s and enforcing just culture (no “blame games” allowed) as we work together to address the Ebola threat are critical to our successfully addressing likely the most significant public health threat we are all likely to have in our careers. We also believe that EHRs and other technology can be incredibly helpful to interprofessional teams as we think through workflows to reinforce patient centered care with the Ebola crisis.
    Susan McBride and Mari Tietze

  7. Janice October 17, 2014 at 9:53 am

    1. Did the nurse enter the info into the electronic record?
    2. These items need a “red flag” notation or tell the physician VERBALLY. The nurse should have made sure this info was communicated. J Lloyd RN,MSN

  8. Teresa Treiger, RN-BC MA CHCQM-CM/TOC, CCM October 17, 2014 at 9:50 am

    The blame game which started soon after the story broke in the press was (and remains) especially disconcerting to me in today’s supposed team-based, patient-centered care paradigm. Throwing nurses under the bus is not going to engender cooperation or trust over the long haul required for solution finding.

    That said, there appears to be a general lack of common sense when it comes to whether or not one should embark on a trip or vacation after having been knowingly exposed to Ebola (or any other communicable disease). When there is any question in my mind about whether or not something is permissible, I take it as a warning and give it extra consideration. I do not necessarily go looking for a supposed authority to give me permission to do (or not to do) it. Instead, I make a decision about what is the right thing to do. It may mean missing out on a good time but I prefer that to knowingly exposing hundreds, if not thousands, of people to a potentially fatal communicable disease.

Comments are moderated before approval, but always welcome.