Overreliance on its EHR was one of the mistakes Texas Health Resources made that led to the misdiagnosis and release of a patient later confirmed to have Ebola, according to a report from an expert panel convened by the Dallas-based health system.
A series of mistakes led to Thomas Eric Duncan being released from the hospital last October, according to the report. Duncan later died from the disease.
"Inadequate communication processes and overreliance on the electronic health record to convey critical information," was one mistake, according to the report.
Processes in the emergency department "did not optimally address the early identification of Ebola or other emerging diseases during the first ED visit, nor did [the hospital] optimally utilize the full capability of the electronic health record." Although Duncan told a nurse he had recently traveled to Africa and the nurse recorded that information into his record, it was not displayed in the physician's EHR view.
The hospital found a flaw in the way "physician and nursing portions of our electronic health records interacted in this specific case," according to a statement released at the time.
The new report says that while travel history is accessible to everyone in the emergency department, to view the information, a clinician would have to look beyond the initial patient assessment screen.
Texas Health should consider EHR customization to support high quality of care and tailored alerts, according to the report. That requires a better understanding of how information is communicated in a care team setting, how EHRs are used and how to improve clinicians' situation awareness.