Texas Health Presbyterian Hospital Dallas cites lack of interoperability between nurse and physician workflows as reason Ebola patient was sent home.Lack of interoperability between the nurse and physician workflows in its electronic health record system was the reason Texas Health Presbyterian Hospital Dallas initially sent home Ebola patient Eric Duncan, according to the healthcare facility. And similar interoperability issues could threaten other healthcare organizations, industry executives caution.

Despite telling a nurse he had recently traveled to Western Africa -- hotbed of the disease -- the patient was released when he first visited the emergency department on September 25. Duncan, who agreed to publicly disclose his health information, returned to the hospital on September 28 via ambulance and was admitted, where he remains in "serious condition," according to the hospital. Doctors diagnosed Duncan with Ebola the following day.

In reviewing its processes and procedures, the hospital determined it had "identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case," noting there were separate nursing and physician workflows. The hospital apparently uses Epic, according to an InformationWeek article in early 2014 and press releases from the past few years.

The statement continued:

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. As a result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola.

Texas Health Dallas was an early adopter of EHRs.  "We implemented EHR very, very well, and at the time we did it, five or six years ago, most people did not implement well. We were first in the country -- or tied for first in the country -- to achieve meaningful use," Edward Marx, senior vice president and CIO at the hospital told InformationWeek earlier this year, referring to the federal incentives program for effective use of health IT. Texas Health implemented Epic EHR software across a network of 14 hospitals.

Many hospitals complain about interoperability problems within their EHRs -- between disparate workgroups, such as doctors and nurses, or different departments, including emergency rooms and cardiology -- that lead to errors. The technology is new and many providers are in the early stages of adoption, seeking software and procedures that fine-tune capabilities and eliminate mistakes like this, experts said. Having evolved from billing, newer systems now focus more on clinician and patient needs, they said, and these later editions provide more of the capabilities, tools, and features medical users need.

Michael Nusimow, CEO of drchrono, told InformationWeek:

The new wave of healthcare software coming to market promises features like clinical decision support that will have the EHR system itself analyze cases and raise red flags to the human healthcare providers to reexamine cases like this that might otherwise slip through the cracks in a fast paced environment. We are currently at a tipping point where the majority of healthcare encounters in the U.S. are now being documented in electronic systems (over paper) and it's the challenge of the healthcare software industry to... [make] sure the software does no harm and actually improves patient outcomes and reduces errors.

EHRs should include a mandatory field, nestled between the two workflows, that physicians must read and check before accessing their portion of the EHR, said Divan Dave, CEO of OmniMD, in an interview. This field could include information about anything that alarmed nurses -- from Ebola to dramatic weight loss, he added.

Or healthcare providers can purchase third-party products, such as QPID Health's clinical intelligence software, that discerns patient information from EHRs and other sources, and then delivers it to clinical and administrative workflows. With its Ebola screening system, slated to become available this month, QPID will look at a travel system, marry it to the condition's symptoms, and alert doctors or nurses that a patient could have the disease, said CEO Mike Doyle in an interview. He continued:

I don't think anyone would argue if that [Texas] physician had known that person was from West Africa he would not have discharged that patient. Unfortunately, in today's healthcare world, data is very, very siloed. Intake systems don't talk to outpatient systems. Eighty percent of data in electronic health systems is unstructured so it's very hard to report. As a result, critical and acute information goes unnoticed -- and this is a very prime example of that.

Yet common sense dictates potential cases of headline-making conditions like Ebola would get special treatment, said Dave.

"Just to blame [this] on [the] EHR is wrong. Who says you cannot go and tell your head nurse or whoever, 'I am a nurse here and we have a patient here who has traveled to Liberia and we have a flag raised.' I see this as more of a problem than EHRs," he said.

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EHRs must do much more than simply replace paper charts. By enhancing them with personal health record features, we can create a new tool that deepens patient engagement.

Electronic health record (EHR) systems don't yet satisfy most of the people they're meant to benefit. In fact, all too often they annoy and antagonize many users, including both healthcare professionals and patients.

But recent innovations in cloud computing and big data could soon make investing in EHRs worthwhile and deliver real benefits for clinicians and patients.

Records systems: The who and the what
First let's clarify what we mean by electronic records. The US government draws a distinction among three major types: electronic medical records (EMRs), electronic health records (EHRs), and personal health records (PHRs).

EMRs are electronic versions of classic paper charts and are meant to be used by clinicians for diagnostic purposes. EHRs have a broader mission: They are intended to follow patients throughout their journey, allowing all clinicians involved in their care to access their information. PHRs contain the same information as EHRs but are managed by patients themselves, and, critically (pun intended), they can include information from sources other than clinicians, such as patients themselves, home monitoring devices, and wearables.

As recently as 2008, fewer than 10% of hospitals had even a basic electronic record system in use. As of 2013, 58.6% of hospitals had EMRs in place, but only 3.1% of hospitals meet stage 2 meaningful use criteria (Cerner HIT Trends, August 2014).

Additionally, although patients are legally entitled to access their own records whenever they want, only 10% of EHR systems currently allow them to do so without going through a clinician. While EHR systems in place may meet the Affordable Care Act's first-level criteria for meaningful use, they are often far from being the readily accessible and easily transferable systems they should be.

How can IT innovation alleviate these systemic issues?

Addressing the challenges involved in EHR systems will take time, money, and effort. However, looking ahead and investing in a federated cloud architecture -- solutions that deliver results by combining the capabilities of multiple external and internal cloud services -- for electronic health systems will give patient data greater accessibility and a greater degree of mobility while maintaining privacy and security.

I also believe that PHRs in particular need to be taken a step further. Although early devices have drawbacks, we are seeing rapid innovation in and adoption of wearables. Apple, Google, and Samsung all announced platforms this year, and Apple just released its Apple Watch to favorable reception. Patients should be able to sync data from apps and devices that track fitness and biometrics with their PHRs and securely access that data on any mobile device.

Improving technology
Independent healthcare providers such as social service workers, speech pathologists, and behavioral professionals frequently use small-scale, HIPAA-compliant cloud services to organize records. These services include some of the usual suspects, such as Google Drive and Amazon AWS,

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The owners of electronic health records aren't necessarily the patients. How much control should patients have? Electronic medical records contain highly personal information, from illnesses to family matters to emotional statuses. Yet those records don't necessarily belong to the patient. The question this raises in the digital age is: Just how much control should people have over their own records?

Electronic health records (EHRs) have become invaluable collections of information used by a diverse group ranging from government agencies and disease researchers to marketing firms and for-profit data brokers. Government and for-profit businesses have long collected, parsed, and used collective patient data to track the path of chronic conditions and contagious diseases, follow the success rates of new and old treatments, develop new cures, and improve the quality of providers' services. But because today's electronic records are easily shareable -- and hackable -- and have different rules depending on state and organization, some patients fear they have little to no control over the information that tracks their very personal health information.

"It's like we have a vacation home, and we've given out keys to 50 different people, and they all show up at the same time," says Chris Zannetos, CEO and founder of security developer Courion, which counts healthcare organizations as about one-third of its customers. In other words, as patients we want our data to be shared when needed, but then we're surprised at how quickly we lose control of how it's shared.

Consumers don't "own" their health records any more than they own the vast troves of data that retailers, financial institutions, and government agencies collect about them, says Dr. Josh Landy, a physician and co-founder of Figure 1, a text-messaging app for healthcare professionals. Instead of ownership, healthcare professionals and patients should discuss electronic patient data in terms of "stewardship," he says. Although the creator of the record -- such as a hospital or physician's practice -- controls the record and data, patient data has multiple stewards.

Complete records might well include a combination of handwritten medical notes scanned as PDFs into a patient's file; information manually or electronically entered from monitoring and collection tools such as stethoscopes and scales; and data entered directly into the EHR. And the picture is going to get more complex. Soon, electronic records might collect data from wearable devices -- purchased as consumer gadgets -- that gather health data around the clock.

In addition, consumers often see a variety of healthcare practitioners. Each one -- primary care doctor, orthopedic surgeon, hospital doctor, or psychiatrist -- typically uses the referring doctor's record and creates a copy appended to his own electronic health record for the individual.

With all this sharing, what if a patient has a diagnosis he doesn't agree with or doesn't want shared? Can he contest, say, a diagnosis of alcoholism?

"We have to give due course to the patient," says Richard Rosenhagen, assistant VP for EMR/HIM/CDIP at South Nassau Communities Hospital. "If you're not transparent, you're going to end up in a bad place." The hospital has a process for discussing such conflicts with patients and making their disagreement part of the record, though the diagnosis remains. "If they disagree with what's in there, they have a right to voice their opinion," he says. "That disagreement doesn't give them the right to amend the record."

Incorporating more patient-driven data changes will present a whole new set of challenges for health IT professionals.

One reason is that, as a rule, consumers are "horrible historians," says John Hoffstatter, a physician's assistant and delivery director of advisory services at CTG Health Solutions. People forget to bring in a list of current medications or don't know why they take a particular pill. Having patients read through their electronic record is essential to improve care and reduce costs, he says.