Being the first U.S. health system to encounter the Ebola outbreak forced Texas Health Resources (THR) to do some rapid learning and reconfiguration of processes, EHR documentation and decision support screens. On Nov. 5, THR’s informatics team offered some lessons learned in an informative webinar sponsored by the Office of the National Coordinator.
Dan Varga, M.D., chief clinical officer, said one lesson learned in the emergency department was that THR had all the elements there to make a diagnosis, but they weren’t in the right place in the sequence of care. The state of physician work flow and the way nurses entered data into the EHR “ran in parallel without appropriate level of communications,” he said. The doctors had different information about the patient than the nurse had, and there was not a conscious reconciliation of data points there for everybody to see. “Things have been done to change that,” he said. “We focused on emphasizing face-to-face dialog to bolster team communications, a move to avoid relying solely on the electronic medical record.” Part of what they did in the EHR was to retool the entry process to make sure travel information is gathered and alerts about Ebola and other infectious diseases are highlighted and acted upon. They capture the patient’s travel history at the first point of contact with ED staff and make the travel history available to all caregivers. If the patient has traveled to affected countries, a pop-up identifies the patient as high-risk for Ebola with explicit instructions for next steps if the answer to any of the screening questions is positive.
Dr. Varga talked about how a multi-disciplinary team redesigned work flow and new EHR screens to manage detection and initial treatment. Asking about the travel history and putting that information in free-text boxes was not enough, he said. “We needed robust clinical decision support to manage this within the EHR.” The primary focus initially had been the emergency department, but they realized they had to look at all work flows and expand the effort to all points of entry, including ambulatory settings.
Mary Beth Mitchell, R.N., chief nursing informatics officer, said a project team of between 20 and 30 people, led by nursing informatics, met daily for several weeks to define the requirements for the new EHR screens. The focus is on detecting infectious patients, warning staff, isolating the patient and initial treatment. “It is an iterative process between informatics, builders, and clinicians, with support from the EHR vendor,” she said. They started on Sept. 29 and the first EHR changes were introduced Oct. 13. The screens are required for all providers using the EHR, and there are standardized paper forms for areas not using THR’s EHR.
Luis Saldana, M.D., chief medical information officer, said the EHR “can create the illusion of communication” between providers. “EHR documentation does not replace verbal communication,” he said. Also, it is important to ensure visibility of high-value data in the EHR, and that requires context, he said. “Screening tools must always be tied to discrete actions.” With the changes that went into effect Oct. 13, all patients are screened for Ebola as well as MERS-CoV (Middle East respiratory syndrome coronavirus).
Ferdinand Velasco, M.D., chief health information officer, spoke about some of the public health implications of the situation. He noted that THR has been submitting syndromic surveillance data on emergency patients since 2003. That data on patients’ presenting symptoms was initially sent from the registration system via HL7 messages. While THR has moved to the EHR technology for sending data, it is still only sending chief complaint data from the point of registration, not later clinical data. “How do we expand what we send over to make it more comprehensive?” he asked. “It should be straightforward to include other discrete data elements such as travel history, but there aren’t standards for how it should be collected, so it would have to be done on an ad-hoc basis initially.” He said another issue is the integration of updated guidelines with clinical decision support at the point of care. “It requires manual effort to convert guidelines into actual tools, and order sets. How do we make them more digestable and actionable?”
Although THR obviously stumbled in its initial reaction to the crisis, its informatics team moved very rapidly to adapt its EHR and work flows to Ebola and has taken advantage of the crisis to expand the work to improve how it handles other infectious diseases. Health systems across the country are following their lead in making similar changes.