Lost in EPIC Land

One of the many unanswered questions about the handling of the first Ebola case in the United States is the role of the Electronic Health Record (EHR).  Initial reports put at least some of the blame for the patient’s being sent home from the hospital despite a high risk travel history on a failure of communication between the triage nurse and the emergency room doctor, aided and abetted by the EHR system.  Very quickly this story was altered.  On October 2 Texas Health officials were blaming the EHR, stating that “[a]s designed, the travel history would not automatically appear in the physician’s standard workflow.”  The next day, the same officials changed their tune, stating “[t]here was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.” Texas Health Presbyterian Hospital in Dallas uses the EPIC EHR system.  Texas Health officials and EPIC deny that the reversal was related to any “gag order” in the hospital contract with EPIC.  It is not clear (to me at least) if these statements imply that there actually is no gag order in the contract, or the gag order is there but was not a factor in the changed story.  It should be noted that such gag orders are apparently common in contracts with EHR systems.  It should also be noted that EHR systems are very powerful companies.  EPIC’s CEO’s net worth in 2012 was estimated by Forbes to be $1.7 billion.  EPIC has benefited immensely from government largesse in the form of the taxpayer subsidies and mandates requiring physicians and hospitals to purchase EHR systems or risk losing Medicare dollars.  Politicians (especially Democrats) have also benefited from EPIC, with hundreds of thousands of dollars donated to political campaigns.  EPIC is in the running for a huge government contract to provide EHR services to the Department of Defense.  They certainly wouldn’t want the Texas Ebola snafu to sidetrack this.

Could the EHR have played a role in the confusion in the Dallas emergency room the day Thomas Eric Duncan was sent home with some oral antibiotics?  Perhaps we could understand better how communication failures between nurses and doctors using the EPIC EHR might arise if we could look at relevant screenshots.  When a nurse enters a travel history into EPIC, what then appears on the doctor’s screen?  How easy is it to see?  How easy could it be to miss?  Where does it appear on the screen?  How big is the font?  Does it even show up on the screens the emergency room doctor is usually looking at?

One can argue that it shouldn’t matter.  The nurse should have verbally communicated with the doctor the travel history, or the doctor should have taken his own travel history.  This is all true, but remember, EHR systems were supposed to make medicine better.  They were supposed to make sure everything was documented and nothing would fall between the cracks.  So it would be useful to see some screenshots to understand why something entered by the nurse into EPIC was not seen by the doctor.

Don’t hold your breath waiting for the screenshots.  Whether or not EPIC has gag orders in their contracts, they definitely do not allow posting of screenshots.  I found this out personally when I tried to post some EPIC screenshots in the past.  EPIC has a group of people whose job is to be on the lookout for EPIC screenshots on the internet.  When they find them, they contact the offending party and demand their removal.  I had prepared a screenshot with annotations to show how confusing the EPIC user interface is, and how easily one simple fact (Travel History: recent travel to Liberia) could be lost in the morass of toolbars, sidebars, tabs, and menus that is the EPIC user interface, but I can’t chance having the EPIC SWAT Team descend on my house.  So I have attached a blurred redacted screenshot.  If a news agency wants to take on EPIC, I would be happy to provide an unblurred screenshot.  I’m not willing to take the chance, but somebody should.