In today’s digital world, workflow can literally mean the difference between life and death—a reality that hit home in the treatment of Ebola victim Thomas Eric Duncan. 

Stories vary, and have been changing back and forth, regarding the initial release of Duncan from Texas Health Presbyterian Hospital in Dallas. “During his initial visit, Duncan told a nurse that he had recently traveled to West Africa—a red flag that the CDC says should have sent hospital staff scrambling to test him for the lethal virus,” writes the Atlantic. “Instead, the critical information about his travel was somehow lost in the shuffle among the various doctors and nurses treating him that day.”

Eventually, one of Duncan’s relatives contacted the CDC, which ordered his return to the hospital, where he later died.

At first, the hospital released a statement blaming Epic, the electronic health records (EHR) software the hospital used, reports Health Care IT News.  “In our electronic health records, there are separate physician and nursing workflows,” the hospital wrote. “The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician’s standard workflow.”

Since then, the hospital backpedalled. “We would like to clarify a point made in the statement released earlier in the week,” the hospital now says. “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.” The result, writes Forbes, is that we don’t actually know what happened.

Ironically, the parent company of the hospital had won the Healthcare Information and Management Systems Society's 2013 Nicholas E. Davies Award of Excellence, which recognizes “outstanding achievement in the implementation and value from health information technology, specifically EHRs.” Implementation of the EHR saved the hospital $152.8 million over five years. Regardless of what is to blame for the erroneous workflow in this particular case, the situation should serve as a wake-up call to hospitals, and organizations that use workflow in general, to ensure that the data that’s being collected is actually evaluated and used correctly.

These incidents demonstrate a number of things to watch for when setting up workflows:

  • Test your workflow periodically, ensuring that you are prepared for special cases. In particular, work with end users, who are more familiar with these sorts of special cases, to ensure that the workflow handles them.
  • Be sure to consider various data sources when setting up workflow systems. For instance, EHR systems need to evolve to be able to accept information from public health organizations, healthcare IT workflow and business process management expert Chuck Webster told CIO. In addition, they need to be better designed and simplified for clinical use, rather than the billing they were originally designed for.
  • When you’re setting up the workflow initially, make sure it includes all the steps it should have rather than simply recreating a paper workflow.
  • Make sure that all the users are trained in how the workflow system operates.
  • Make sure that alerts are turned on when necessary—and yet do not become overused so that users become blind to them.
  • Ensure that software and the technology behind it is updated. For example, a number of medical professionals commenting on this incident noted that the U.S. is still using an older form of coding diseases—one that doesn’t separate out Ebola—even though most of the world has switched to a more modern system that does.
  • Ensure that the systems for various departments are coordinated. Watch out for silos separating groups that need to work together.
  • Finally, don’t rely entirely on the workflow system. Be sure you have planned for crisis scenarios. In this case, once the nurse ascertained that the patient with a fever had recently been to West Africa, there should have been some backup mechanism for her to alert the doctor about this, numerous commenters noted. Atul Gawande’s book The Checklist Manifesto talks about the importance of this.

For the healthcare industry, it’s important to get this workflow issue figured out now—because of Ebola, but also because the remaining doctors who haven’t yet moved to EHR are required to do so next year or pay a fine. EHR has the potential to save lives and improve people’s health by tracking all information in a single readable place. Like any workflow system, it needs to be set up properly. 

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