Lessons from Ebola: EHR design can impact medical malpractice litigation

The use and design of a provider's electronic health record can have an impact on medical malpractice litigation, as shown by the recent misdiagnosis of the first Ebola patient in the United States, according to Sharon McQuown, R.N., MSN, LNCC, with the Law Office of Frank L Branson in Dallas, Texas.

McQuown, speaking at the American Bar Association Health Law Section's 16th Annual Conference on Emerging Issues in Health Care Law in Orlando March 6, pointed out that the focus of the problem was the misdiagnosis of the patient in Texas Health Resource's emergency department (ED), which caused the patient to be discharged the same day. He returned and was admitted three days later, confirmed to have Ebola, and died shortly thereafter. The malpractice suit was filed Nov. 12 and settled that day.

Much of the misdiagnosis in the ED was attributable to the EHR, McQuown said. For instance, the physician had access to the nurse's notes, which included the information that the patient had recently been in Liberia and that his vital signs had changed, but the hospital's audit trail could not confirm whether the doctor had read that section of the EHR. The travel information also was not highlighted in the EHR.

Additionally, there was a question about whether any face-to-face communication occurred among the providers before the patient's discharge, which might have also flagged the patient's travel history and vital sign information without having to rely on the EHR.

The hospital instituted EHR changes days after the patient died, including:     

  • Adding a new tool in the EHR requiring a "hard stop confirmation" by the physician that he/she had been told that the patient had recently been to a country of concern
  • Creating a more robust screen that draws attention to travel with a red box on top and specific identification of countries traveled
  • Adding a banner alert screen if a patient is flagged for infectious disease with an alert of steps to be immediately taken
  • Changing the discharge process so that discharge papers could no longer be printed early or if anything was unresolved in the document.

Last October, Texas Health Resources Chief Clinical Officer Daniel Varga testified before Congress about many of the EHR changes the health system had made in the wake of the incident.

Texas Health Resources also made non-EHR changes, such as asking about travel history within 10 minutes at triage so that a potentially infected patient could be contained sooner. It also put more emphasis on face-to-face dialogue among providers.  

McQuown noted that there's still a "fluid" learning curve regarding EHRs and patient safety, such as issues with cutting and pasting or default mechanism errors.

Other studies have shown that tweaking EHRs can make them more effective. However, Texas Health Resources is not yet out of the woods; Nina Pham, one of the nurses infected with Ebola by the patient has just sued the hospital for inadequate training and other issues.

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