Inadequate communication processes and over-reliance on an electronic health record system to convey critical information at Texas Health Presbyterian Hospital’s emergency department in Dallas led to the initial misdiagnosis last year of Thomas Duncan, America’s first Ebola patient.

That’s the finding of an independent panel which reviewed the 2014 events at Texas Health Presbyterian related to the care and treatment of Duncan, who was initially treated and released, only to return to the hospital’s ED where he was admitted for treatment of Ebola and later died from the disease. Texas Health Resources (THR), which operates the hospital, publicly released the panel’s report on Friday.

The panel focused on the fact that although information concerning Duncan’s travel from Africa was gathered by a nurse as part of the influenza screening process and documented in the patient record, it was not verbally communicated to a physician as directed by a prompt in the EHR from Epic Systems Corporation.

Also See: Epic Defends Integrity of EHR System at Texas Hospital

“Information about Mr. Duncan entered in the EHR was not verbally communicated among the staff and the EHR configuration did not provide for automatic alerts on questions related to Mr. Duncan’s travel history,” states the report. “Once the information was entered, there were no systems in place that would trigger a review or re-asking of critical travel information.”

In addition, the panel noted that viewing this data would have required a clinician in the ED to look beyond the standard patient assessment screen in the EHR to access the travel history from the nursing assessment documentation that was located in the flu screening part of the EHR.

“The electronic health record is a wonderful tool, but we need to have a high-reliability system in place that doesn’t over-rely on that technology and empowers team members to speak up about the condition of a patient,” said Daniel Varga, M.D., chief clinical officer and senior executive vice president for Texas Health.

Subsequently, according to the panel’s report, the health system’s EHR was redesigned to enhance shared communication of clinical data between physicians, nurses, and other members of the clinical team. In addition, prompts and alerts were activated to facilitate rapid sharing of patient information (i.e., detailed travel history, vital signs, and symptoms) that indicate a risk of an emerging infectious disease.

“Going forward, a key system question for THR and other hospitals and health systems is how information technology, informatics and clinical teams will customize the electronic health record to support high quality patient care,” concludes the report. “This will require in-depth study and understanding of how information is communicated across the care team, the usability of EHRs generally, workflow modeling, and ways to enhance clinicians’ situational awareness.”

Epic declined to comment on the panel’s report.

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