Electronic-Record Gap Allowed Ebola Man to Leave Hospital

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Dallas doctors never saw a nurse’s note that an emergency room patient with fever and pains had recently been in Africa, and he was released into the community with Ebola.

The electronic records system at Texas Health Presbyterian Hospital didn’t flag the information to the physician, hospital officials said. Even so, the doctor should have known to double-check himself rather than depend on someone else, said Ashish Jha, a health policy professor at Harvard University’s School of Public Health in Boston.

“There are so many flaws in the logic of ‘The EMR system made us to do it,’” Jha said in a telephone interview, referring to the emergency’s room’s records. “When a patient walks in the ER with a fever, the standard question is ‘Have you traveled?’ I don’t understand why that question wasn’t asked by the physician.”

Two days after being released, the patient, Thomas Eric Duncan, returned in an ambulance to Texas Health Presbyterian Hospital Dallas, was placed in isolation and subsequently confirmed as having the deadly disease.

Wendell Watson, a spokesman for the hospital, said the hospital had wrongly designed its digital record system so not all of a nurse’s notes are visible to doctors.

While Watson didn’t respond to questions about why that happened, he said the software, made by Epic Systems Corp., has been reconfigured to bring patients’ travel history to the physician’s screen. It has also been modified “to specifically reference Ebola-endemic regions in Africa,” the hospital said in a statement yesterday.

Further Explanation

Watson, in an e-mail sent late yesterday, said the hospital wanted to clarify its explanation about Duncan’s initial release from the emergency room.

“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 (EHR), including within the physician’s workflow,” Watson wrote in the e-mail.

“There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”

Watson and other hospital officials declined to respond to requests to explain the subsequent statement.

Monitoring for Symptoms

Health officials have vowed to stop any spread of Ebola in the U.S. There are now 50 people in Dallas being monitored daily for Ebola symptoms, down from 100, said health officials. Ten are considered high risk and will be physically checked by health workers twice a day. The rest are lower risk and will be examined once daily and check in by phone, Texas health commissioner David Lakey said. So far none has developed symptoms.

Epic, based in Verona, Wisconsin, is one of the biggest providers of electronic medical systems in the U.S., with yearly sales of $1.5 billion and 290 customers, a company spokeswoman said last year. Shawn Kiesau, a spokesman for the company, didn’t respond to requests for comment on the Dallas case made by e-mail and phone.

The Dallas patient, Duncan, was also asked if he had been around anyone who had been ill, according to a hospital statement. “He said that he had not,” the hospital said. Published reports have said that Duncan was exposed to people with Ebola during his time in Liberia.

When Duncan came into the emergency room the first time on the evening of Sept. 25, he had a temperature of 100.1 Fahrenheit, abdominal pain for two days, a sharp headache, and decreased urination, according to the hospital’s statement.

Many Diseases

“These symptoms could be associated with many communicable diseases, as well as many other types of illness,” the hospital said. “When he was asked whether he had nausea, vomiting, or diarrhea, he said no. Additionally, Mr. Duncan’s symptoms were not severe at the time.”

As a result, he was released early the next morning. Duncan returned on Sept. 28 by ambulance, was placed in an isolation unit and health officials subsequently confirmed that he had the deadly Ebola virus, which has infected about 7,500 people in the West African countries of Liberia, Sierra Leone and Guinea, killing about half. Governments and aid agencies are adding resources to try and stop the virus’s deadly spread.

In Liberia, the U.S. plans to deploy 1,800 more soldiers, up from 1,400 announced on Sept. 30, to support aid workers trying to bring the outbreak under control, Rear Admiral John Kirby, a Pentagon spokesman, said yesterday in a news conference in Washington.

As many as 4,000 soldiers may eventually be sent to Liberia, Kirby said, 1,000 more than when President Barack Obama first announced the mission in September.

A U.S.-built hospital for medical workers is scheduled to open by Oct. 18, Kirby said. Aid workers are currently fanning out into Liberian villages to build 10- to 20-bed clinics for Ebola victims and to distribute thousands of kits of protective gear to their families, the director of the U.S. Agency for International Development, Raj Shah, said at the White House.

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