After issuing conflicting information on flaws in its Epic electronic health records system that may have contributed to initially misdiagnosing Ebola patient Thomas Duncan, Texas Health Resources (THR) has again clarified changes made to the EHR.

THR originally acknowledged that the attending physician at Texas Health Presbyterian Hospital Dallas did not know that Duncan had traveled to the United States from Liberia. In an Oct. 2 statement, the organization said: “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 interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.

“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. As designed, the travel history would not automatically appear in the physician’s standard workflow.

“As a result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola.”

On Oct. 3, the organization did a complete turnaround: “We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record, including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”

Following its new position, THR spokespersons declined to discuss what changed so that the organization now believed there was no fault in the workflow of the EHR, or if the attending physician at Texas Health Presbyterian Hospital Dallas simply missed the travel history.

In congressional testimony on Oct. 16, Daniel Varga, M.D., chief clinical officer and senior executive vice president at THR, explained lessons learned such as changes in the screening process and additional modifications to the EHR.

“I want to emphasize that we have made a number of changes based on the preliminary lessons learned from our experience with EVD (Ebola Virus Disease) over the last two weeks. Diagnosing Ebola is very different from treating Ebola. THD (Texas Health Presbyterian Hospital Dallas) was and remains well prepared and equipped based upon the best available information to treat patients already identified as having EVD. Where we fell short initially was in our ability to detect and diagnose EVD, as evidenced by Mr. Duncan’s first visit to the ED.

“As a result, following Mr. Duncan’s initial admission, we have changed our screening process in the ED to capture the patient’s travel history at the first point of contact with ED staff. This process change makes the travel history available to all caregivers from the beginning of the patient’s visit in the ED.

“Additionally, we have modified our electronic health record in multiple ways to increase the visibility and documentation of information related to travel history and infectious exposures related to EVD. These include:

* “Better placement/title of the screening tool.

* “Expanded screening questions which include:

-- “Exposure to persons known or suspected to have EVD,

-- “High-risk activities for persons who have traveled to Ebola endemic areas such as: 'Have you touched a dead animal or helped carry someone sick,' and

-- “A pop-up identifying the patient as high-risk for Ebola with explicit instructions for next steps if the answer to any of the screening questions is positive.”

Varga testified to the committee and answered questions via a video link. His complete written testimony is available here.

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