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.
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.