Ebola, EHRs, and the difficulty of communication

A quick update to a point discussed in the last post. On Thursday night, the Dallas hospital treating the patient suffering from Ebola virus disease explained the mix-up over his travel history. A news release on the hospital's website reads:

10/02/2014
 . . . 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 (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.

The release then explained that the flaw had been remedied, by relocating the "travel history documentation to a portion of the EHR that is part of both workflows" and to "specifically reference Ebola-endemic regions in Africa".

The promptness of the communication was reassuring and helpful, and suggested that an analysis of the situation had been undertaken promptly, a cause of the error identified, and action taken to fix it. But 24 hours after the news release, a perplexing clarification was posted:

10/03/2014
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 (EHR), 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.

It's difficult to interpret the dissonance of these two releases, and I think they highlight a hugely important in hospital care: the challenges of effective communication between all members of the healthcare team.

Joyce Frieden wrote a very nice essay on the Dallas episode (published before the hospital's "clarification"), which I recommend reading. One passage describes some of the challenges to effective communication in the clinic:

Although the EHR could have been configured to import the nursing notes -- or at least their key items -- into doctor's notes automatically, "I'm sure some doctors would say it would be a bad idea because it would fill their notes with stuff they're not interested in," he [Dr Dean Sittig] continued. "So that's the culture of the two professions not respecting what each profession does. Whereas before docs had to flip through the nurse's notes to get to where they wanted, now they're on a separate tab. The flaw was that they weren't pushed into the doctor's face."

The importance of effective communication, from the perspective of the Magnet® process, has been discussed by Swanson and Tidwell, who note that 

One characteristic of exemplary professional practice is meticulous attention to communication processes. . . . This use of SBAR has created a standardized approach to information sharing. It has created a shared mental model for effective information transfer by providing a standardized structure for concise, factual communication among clinicians, whether it is nurse-to-nurse, doctor-to–doctor, or nurse-to-doctor communication. It is now used to ensure that patient information is consistently and accurately communicated, especially during critical events, shift handoffs, and patient transfers between levels of care. [Emphasis added.]

Apparently this critical nurse-doctor communication and information transfer didn't occur during the patient's hospital visit on September 26th.

Effective communication is a human process. Software should be used to improve that process, not replace it.

(image source: David Hartley)

Ebola and the cult of vitamin R

This week saw the appearance of Ebola virus disease in a Liberian visitor to the United States. Active transmission here is not expected and public health authorities have done extensive contract tracing. Fifty individuals who were potentially exposed to the virus are being monitored and a small number are in isolation. 

First, a brief description of the episode. A man who had direct contact on September 15th with a woman suffering from advanced Ebola virus disease in Monrovia, Liberia, traveled to Dallas, Texas, to visit relatives. He flew from Monrovia to Brussels on the 19th of September and took a connecting flight to Washington DC before catching a final flight to Dallas, arriving on the 20th. He was screened for fever and exposure at the airport before departing Liberia; apparently, his answers to a screening questionnaire were inaccurate. After arriving in Dallas he remained asymptomatic for several days and began suffering symptoms on the 24th. On the 26th he presented to the hospital. (Note: some news accounts report the date as the 25th.) At this first visit he was evaluated, prescribed antibiotics, and sent home to the relatives with whom he was staying in Dallas. He subsequently deteriorated and was transported to the ED by ambulance on the 28th. The positive test for Ebola virus was received on the 30th.

Many details about this event are unsettling. To me, especially disappointing is that the man's travel history was not a factor in the clinical diagnosis on the 26th, although a nurse was informed that he was visiting from Liberia. The nurse entered the information into the electronic health record (EHR), following protocol, but that didn't trigger suspicion. The hospital has since clarified why: There are separate physician and nursing workflows, and patient travel history did not automatically appear in the physician's standard workflow. The doctor never saw the information.

I think it's also interesting that the man was prescribed antibiotics for what turned out to be a viral illness. In a sense, this is a familiar story: change the name of the virus and it's a scene that occurs daily in many clinics and office visits. It seems ironic that, a week after the White House released its National Strategy for Combating Antibiotic-resistant Bacteria, this physician-patient encounter resulted in the apparent inappropriate prescription of antibiotics. As the National Strategy tells us, 

. . . a growing body of evidence demonstrates that programs dedicated to improving antibiotic use, known as "antibiotic stewardship" programs, can help slow the emergence of resistance while optimizing treatment and minimizing costs. These programs help providers prescribe the right antibiotic for the right amount of time and prevent prescription of antibiotics for non-bacterial infections. It is imperative that such programs become a routine and robust component of healthcare delivery in the United States. (emphasis added)

To be fair, the man may have had a bacterial infection at the first hospital visit, in addition to the unsuspected Ebola virus infection. We don't know; it's a matter of his private health record. However, I am reminded of how a physician colleague once described the pervasive inappropriate, and often rushed, use of antibiotics,

It's a common problem. Patients present with vague complaints that are plausibly due to bacterial infection and there is a very low threshold for prescribing antibiotics. The patients often request or insist on it, and it often seems harmless to acquiesce. In fact, many doctors view prescribing them as a protection mechanism in case there is an infection or one develops. It's so common that in many clinics and EDs ceftriaxone is referred to as "vitamin R".

Perhaps the antibiotic prescription dimension of the encounter on the 26th is all too understandable.

One can hope that a thorough, transparent investigation and analysis of this entire episode can produce helpful knowledge on how to harden healthcare systems for routine healthcare as well as extraordinary events like this one. In the meantime, the CDC has produced clear guidance for evaluating patients with a history of traveling to epidemic regions.

Acknowledgement: The title is inspired from a Medscape Connect item entitled "The cult of Vitamin R", which no longer appears to be available online.

(image source: Wikipedia)