Researchers: Both human error, EHR inadequacies led to Ebola misdiagnosis

A combination of human errors and electronic health record usability issues caused the misdiagnosis of the first Ebola patient in the United States, according to a recent article published in the online journal Diagnosis.

The authors, from the Urban Institute, Baylor College of Medicine and University of Texas, reviewed testimony and additional publicly available information regarding the misdiagnosis of Thomas Eric Duncan by Texas Health Resources, including medical records provided by Duncan's family to the Associated Press. They found that there were "human factor issues" that led to the misdiagnosis, such as the fact that the information about Duncan's travel history to Ebola-risk area Liberia was not appreciated or acted upon as well as contradictions in the EHR regarding the extent of Duncan's pain level, as well as production pressures in the emergency department and physicians' tendency to ignore nurses' notes.

The EHR system may also have created some of the discrepancies in the record, such as the use of pre-defined EHR patient instructions and erroneous selection of pre-defined symptom options. 

Texas Health originally stated that the misdiagnosis was solely an EHR "flaw"; it later clarified that staff also made mistakes and that the EHR and processes have been modified, such as adding pop up alerts and placing more emphasis on travel history, to reduce the risk of Ebola misdiagnosis in the future.

"Assigning blame to the EHR is not new and often reflects a reluctance to address the complex cognitive and/or performance issues involving front-line staff, especially those related to responsibility and accountability. It is important that we recognize the reality that EHRs suffer from major usability and inter-operability issues but also to acknowledge that they are only tools and not a replacement for basic history-taking, examination skills and critical thinking," the researchers stated.

The authors also suggested that for "EHRs to be most effective, they need to be able to automatically sort through patient data, identify the pertinent findings, and present them in an easy-to-understand manner."

Stakeholders have warned for years about EHRs unintentionally creating new patient safety hazards. However, EHRs do not operate in a vacuum. Ex-ONC head David Blumenthal suggested last week that assigning blame to EHRs is understandable but not wholly justifiable.

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