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"FLAW IN ELECTRONIC RECORDS" - Phatty

Posted: Oct 03, 2014

Ebola patient in Dallas went to this hospital when he first started having symptoms. According to news report, there was a "flaw in the electronic medical records, and doctors were not informed of his travel history." Patient came in from Liberia.

Why oh why was this not caught the first time he came to the hospital???? IJS

EMR flaw sm - just me2

[ In Reply To ..]
EMR is primarily a check mark system. I read somewhere else that in triage there may be a box to write in the chief complaint, but the tobacco history, travel history and such only have a check mark available, and it is very difficult to go back in the system to add additional information. So I imagine the box gets checked yes, there is a travel history, but to where or from where? There is no place to document anything other than putting a check mark in the travel history box, and it gets overlooked. It could be travel to Disney World. There is no place to document it any further.

EMRs are not "primarily just a checkmark system" - Informaticist

[ In Reply To ..]
That is an incorrect statement. EHRs are not primarily just checkmark systems. I have never seen one that allowed a checkmark for travel history with no way to say where.

The problem in Dallas was that the travel history was in the "nursing workflow," not the physician, making it invisible to the physician without him going to look for it, which he did not. They have since changed it to make it visible to both nurse and doctor.

To me, that is not a flaw in the system ... it is stupidity on the part of the folks who set it up. It is also negligence on the part of the physician who failed to use the nursing information, and it is an insult to the nursing function.

This would not have any way to happen with the EHR we use, where everyone's documentation is readily available and ignoring it would have to be a deliberate act requiring more trouble than it was worth. Our nurses are an integral, respected part of the healthcare team, as well. I cannot see them documenting something like that and not verbally informing the doctor, nor letting a doctor get away with ignoring it.

The doctor should have looked at the record - sm

[ In Reply To ..]
I was just to the doc and the doc's nurse made the comment that he was not allowed to see that part of the system (the doc's). I would certainly expect the doctor to look at all parts of the nurse's intake. If I expect the nurse to double-check the doc, then she should also have access to the complete record. I often wonder if what I tell the nurse is being passed along because I hate repeating myself.

I have done Emergency Room dictation, and some of my ER docs sound so flippant, I would not put it past them not to look at the intake.

From my understanding, there are many EHR programs out there--at one time I believe even Walmart was trying to get in on "the action." I would guess that there are a few programs out there where the programmers have dropped the ball on understanding the patient/doc/nurse/computer connection.

I am also appalled that docs do not read their dictations to sign/approve them. We, as MT's, do the best we can, but you can't 100% of the time interpret their intentions and we are also humans who make mistakes.

EMR is not primarily a check system - sm

[ In Reply To ..]
EMR stands for electronic medical record. That, simply put, means it's on a computer and not a piece of paper. SOME systems are using point and click but the majority are not.

It's silly to think you cannot change or adapt information.

EMR flaw - Epic user

[ In Reply To ..]
There are places in the EMR for documentation beyond the checkboxes. If anything is "flawed,"it is the human doing the history taking who either was never probably trained or didn't take time to learn how to use the system.

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