The Centers for Disease Control (CDC) is warning doctors to watch out for cases of Marburg virus in the U.S. after outbreaks in Uganda and Tanzania. (Marburg is similar in presentation and mortality to Ebola). The CDC issued a similar warning to U.S. physicians during a 2014 Ebola outbreak in Liberia. Unfortunately, the diagnosis was missed at a Dallas emergency room and two nurses ended up with Ebola. The Dallas Ebola outbreak was blamed on a “flaw” in the hospital’s electronic health record (EHR). Yes, you heard me correctly.
In 2014, a Liberian man recently back from that country presented to the ER with non-specific symptoms of fever and abdominal pain. The ER nurse dutifully noted in the nursing records that the man had recently been in West Africa and had been in contact with a sick person. However, the nursing notes and the physician notes in the hospital EHR were in completely separate areas of the chart and the doctors typically did not bother reading the nursing entries. There are a lot of reasons for that, but one of them is the focus that hospitals have on making sure they know exactly who entered anything into the EHR. The easy way to do that is to completely segregate the nurses’ notes from the doctors’ notes.
The Guardian reported on October 10, 2014 that, “It is still not clear why the hospital did not test Duncan for Ebola on his first visit, based on his travel history and symptoms.” The hospital initially said Duncan had not told them of his travel history, and then later said he had, but the nurse had not shared that information with the entire medical team. The following day, the hospital changed its story again, attributing the error to a “flaw” in its online health records system, but then corrected its statement and said there was “no flaw” and Duncan’s travel history had been available to the entire medical team. In other words, it was in the nurses’ notes but no one read them.
A year later, the University of Houston Hobby Center for Public Policy published a report called, “The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, Systems Failures, and Lack of Mindfulness.” The report describes the event in exhaustive detail and identified a lack of “mindfulness” at the core of the debacle. The policy experts go on to suggest more research into healthcare mindfulness. Without over simplifying a complicated series of unfortunate events, I’d say the fundamental problem is completely segregating the nurses’ and the physician notes in the hospital EHR and being more worried about identifying exactly who entered data than what data they entered.
Intellicure has created an EHR specifically designed for the unique regulatory environment of the hospital based outpatient department and the doctor’s office – both of which are “provider-based” settings. That means the doctor is responsible for the care provided by all parties. The best way to handle that is a shared chart in which the doctor and the rest of the staff collaborate on documentation. That’s also how to prevent an outbreak of Ebola or Marburg virus in a U.S. hospital. That’s also how to provide team based wound care. It means the practitioner knows about that low nutritional screening score, that high pain score, those new medications, that recent fall and a host of other important observations that should not be relegated to some part of the chart that only the nurses see. It also means that the doctor and hospital won’t pay back money in an audit because the nurses’ and the physician’s documentation were not in agreement and didn’t support the services provided. A shared chart ensures that everyone is “mindful” of whatever is documented, no matter who documented it.