Separate Work Flows Let Ebola Slip By

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As I hadn’t been preaching the perils of industrialized medicine enough, here may be one of the best examples, which I will now make into a joke (i.e. why did the chicken cross the road, etc.).

“Why didn’t the nurse tell the doctor the Liberian patient was at risk for Ebola?  (wait for it).  Because they have “separate” work flows and no one talks to each other since the advent of EMRs. ”

According to this article (picture above is NOT the doctor and nurse):

The hospital said the Liberian man’s travel history was located in the nurses’ portion of the EHR, but — “As designed, the travel history would not automatically appear in the physician’s standard workflow.”

Of course, the nurse could have actually talked to the doctor.  But that doesn’t happen anymore!!  They are too busy typing in bullshit to think.  The past year I had to retrain the MAs at the place I was working to actually talk to me about every patient instead of just leaving a note for me to read.  The nuances and questioning back and forth give better care and allows two people to hear the story.  You know, like in the good old days.

Here is Stella Fitzgibbons (a frequent contributor to this blog) thoughts on this as she emailed me:

The news media now tell us that the index patient in Dallas had close contact with a very sick febrile woman in one of the countries where the virus is now epidemic. He answered “No” to immigration officials’ questions about contact with the sick, exposed his relatives in Dallas, and when he got sick never offered any reason to worry about him. But he DID tell the ER triage nurse he had come from Liberia, and now the hospital is trying to claim that the nurse did not “fully communicate” that fact.

What exactly was the triage nurse supposed to do, hit the doctor over the head? Slap a red flag on the chart?

And was the nurse’s note in an easily legible form, or was it buried in an EHR that was shoved down doctors’ and nurses’ throats by an administration focused on cutting costs? Was the ER doctor even familiar enough with the local software to check the information available to him? And, of course, how much pressure was the staff under to “improve throughput” while minimizing admissions of uninsured patients?

Watch and see who gets the blame.

(AN HOUR LATER) …on CBS Evening News: the ER nursing electronic records “failed to interface with the doctors'”. Here’s hoping our voices will be heard: EHRs are not just burdensome but a poor one can make patient care worse.

Ten years ago the triage nurse would have filled out a paper format went onto a chart the doctor could read without logging onto a software system that he might or might not know well. When are doctors AND nurses going to put our numbers to use and speak for patient care?

THIS IS WHAT HAPPENS WHEN AN EMR IS BUILT FOR BILLING AND NOT PATIENT CARE!!!

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  5 comments for “Separate Work Flows Let Ebola Slip By

  1. Bridget Reidy MD
    October 5, 2014 at 9:17 pm

    It doesn’t matter if the interfaces between doctors and nurses communicate if so much data has to be entered that sore throat visits in ER’s are 17 pages of gobbledygook. I’m sure an outrageous number of mistakes are made routinely because data entry is valued over data retrieval; retrieval of individual’s data is designed by programmers to be even more cumbersome than it’s entry, because it is of little use to the administrators, employers, and payers, those for whom these programs are obviously designed.

    Yesterday I attended a talk by a young endocrinologist about adherence with diabetes treatment. She seemed to think that asking a patient what they actually take was a new idea. EMR’s being designed on the assumption that the list of what a patient takes is the same as the list of what is ordered no doubt had her thinking previously that a medication history is not necessary. And how come nobody’s ever lost in court based on the argument that we can’t believe a thing you wrote in the chart because you also wrote that the baby is alert and oriented times four? It’s only that kind of thing, or maybe Ebola outbreaks caused by EMR’s, that could ever help with getting us to truly meaningful use or better yet, meaningful design.

  2. October 5, 2014 at 12:59 pm

    It is true that the sick man lied to immigration? (“He answered “No” to immigration officials’ questions about contact with the sick”) If he lives, will he be prosecuted? That was just wrong. I understand why he would want to be treated here and not there. However, he knew he had been exposed to Ebola. He should have gone to a doctor the moment he returned to set the record straight. I’m just saying, the man shares the responsibility for this and should be held accountable.

  3. Pat
    October 5, 2014 at 8:24 am

    And peripheral and upstream of this topic – admittedly – can anyone logically justify why we are not denying U.S. entry to anyone from “hot” areas? Why was a contaminated Liberian even freaking here?

    And don’t give me any “xenophobe” nonsense, this is just stupid.

    “Though we might wish we can seal ourselves off from the world, there are Americans who have the right of return and many other people that have the right to enter this country,” CDC director Dr. Thomas Frieden told a press conference. “We’re not going to be able to get to zero risk no matter what we do unless we control the outbreak in West Africa.”

    This is politics putting larger numbers unnecessarily at risk and it is criminal.

  4. Sir Lance-a-lot
    October 5, 2014 at 6:50 am

    Sorry, Doug, but you’ve got to keep up with these things. The NYT yesterday morning said:

    “… on Friday evening, the hospital effectively retracted that portion of its statement, saying that ‘there was no flaw’ in its electronic health records system. The hospital said ‘the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow.'”

    http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-troops-west-africa.html

    Their EMR may suck, but this, to emphasize your ultimate point, was the result of plain old crappy medicine, in which a guy from Africa, with an African accent and symptoms of Ebola, who said he’d just come from Liberia, was diagnosed with a minor viral URI and sent home with a Z-Pack (one hospital source on NPR actually said, unironically, that he was “diagnosed with a mild virus and send home with antibiotics” a few days ago).

    This is the difference between all of the “planning” and “exercises” that are done, especially on the Federal level, to prepare for X, Y, or Z, and the brutal facts of reality, which lead the bureaucrats of the multi-lettered organizations staring like idiots and shouting about more letters when the shit hits the fan.

    I’ve already had a talk with our nurses about it.

    • DrHockey
      October 5, 2014 at 7:59 am

      I t would not surprise me if the hospital lawyers/risk management had them change their answer. I have seen it before. No matter what the hospital did wrong, it is always the doctor’s fault, making the liability solely the physician’s.

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