Would Clinical Decision Support Have Helped Prevent the Ebola Misdiagnosis?

Art PapierThirteen years ago, in the midst of widespread publicity about anthrax-laden letters poisoning people, emergency room physicians sent a postal worker home with a diagnosis of the flu. He later died from anthrax inhalation.

Fast forward to 2014, with the Ebola outbreak in Liberia dominating healthcare coverage, a man who had just returned from the stricken nation visited an emergency room with symptoms but was not tested for Ebola. He was sent home with antibiotics.

Two days later, he was diagnosed with Ebola. In the intervening days, he potentially exposed family members and many more to the deadly virus. At the hospital where the misdiagnosis occurred, officials acknowledged the doctors had the information about the patient’s recent travel in Liberia but didn’t act on it..

How can this continue to happen? In 2010, the Institute of Medicine (IOM) examined the threat of bioterrorism and infectious disease outbreaks and said the most “crucial step in disease detection is the first one – recognizing that an ill patient has a potentially unusual disease…” But it recognized the potential for misdiagnoses of diseases physicians rarely see – such as Ebola and anthrax poisoning – especially in busy emergency departments where information can get lost or overlooked.

The IOM recommended the use of clinical decision support tools to ensure doctors quickly and accurately detect and diagnose unusual diseases. Four years later, some hospitals have these tools and use them. But most do not, even though they’re readily available, affordable and proven effective.

The entire Veterans Affairs medical system and hundreds of hospitals have clinical decision support tools, which allow international travel history searches and entries of patients’ symptoms.  This information is compared against a database of diseases prevalent in the countries where the patients traveled.   At many hospitals, a system, called VisualDx, is available as an online resource and an app, so physicians can literally have diagnostic support on the mobile devices they have in their pockets.

States, such as South Carolina, have placed the system in every emergency department and push public health alerts and clinical guidelines into the system.  Real benefits ensue, such as the early diagnosis of a child with meningococcemia.

Ironically, the federal government recently cut funding for biopreparedness, which will reduce access to these programs.  However, the Ebola threat will likely force hospitals to see diagnostic accuracy as a “must have” and invest in clinical decision support on their own.  In doing so, they would give their physicians the tools to recognize any infectious disease, not just Ebola.

Art Papier, MD, a University of Rochester associate professor was among those who advised the IOM on the use of clinical decision support tools. Dr. Papier led a team that created for HHS the Centers for Disease Control website and print materials for smallpox.  The IOM sought his advice because he is the CEO and co-founder of Logical Images, the company that created VisualDx, a clinical decision support tool available used by thousands of doctors, clinics, medical school.  For more information, please visit: www.visualdx.com

14 replies »

  1. Nope. But a simple user friendly EHR interface without multiple clicks to find a blood pressure would have…or…simply put the old system back in place with triage notes on the door, underlined in red or highlighted in some other way.

  2. Sad story. I think most doctors do most of their work very fast, while in “fast thinking” mode. And also are paying attention to certain things (possibly the EMR) which makes it hard to notice other things…just think of that video in which people don’t see the gorilla because they are watching the people with white shirts pass the ball.

    I’m definitely a fan of Dr. Larry Weed’s work and am looking forward to the day when we get the right help from technology.

    In the meantime, we probably have the tech to monitor stress and attention levels in today’s front-line clinicians…would be interesting.

  3. Guy walks in with an African accent, from Liberia, recent travel from Ebola endemic area with symptoms consistent with Ebola… It’s a slam dunk Ebola rule out… The physician/pa/np must not have been paying attention or not listening to the patient to miss this diagnosis… Clinical decision support is no substitute for listening to your patient and asking appropriate questions…

  4. This is all BS. You didn’t need clinical support systems for this. A guy walks in and says he was in Liberia, has a fever and is worried he might have Ebola. The first person to hear this should have been doing their Robbie the Robot imitation.


  5. “A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

    Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

    This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively.”

    Lawrence (MD) and Lincoln (JD) Weed, “Medicine in Denial”

    Key phrase, “…AND standards of care for managing clinical information”

  6. “Can any physician memorize the infectious diseases that can be acquired in each country in the world, and know them precisely when seeing patients? Can you tell me which countries Chikungunya virus can be acquired in? Dengue? New World Leishmaniasis? Most clinicians in practice will know that Liberia and West Africa is where Ebola can be acquired today. But what about the worried well that have traveled and are now in your clinic? And people with other travel related illnesses? Or medication reactions? In my clinic i make sure the residents use an app on the phone or desktop and look it up.”

    See, from Medscape, “Can Our Brains Handle the Information Age?”


    Medscape: It’s a common concern that physicians are becoming overreliant on technology to access information.
    Do you think the fact that doctors no longer have to memorize, say, dosages does a disservice to patients? Or
    might externalizing information to computers and smartphones free up valuable neurologic resources that could
    be used for something else?

    Dr Levitin: I see it as a good thing—I don’t want to rely on a doctor’s memory. It’s not that doctors have bad memories, it’s
    that we all have bad memories. It has been shown many, many times that memory is fallible. I want to be able to rely on
    my doctor as having an exquisitely tuned pattern recognition system so that when I walk in the door and he sees a cluster
    of symptoms, he puts it all together in a pattern-matching algorithm in his brain and says, you know, I think we should run
    this test, and you might have this, and this is what I think is going on from a diagnostic standpoint.

    And from a treatment standpoint, I want my doctor to have acquired this pattern matching combined with some sort of
    intuitive Bayesian reasoning so that he or she is prescribing the thing most likely to work given who I am and my medical
    history and my cluster of symptoms.

    But when it comes down to a dose or trying to remember the name of the generic for a brand name or vice versa, I love it
    that my doctor looks things up. It seems less fallible.

    See also the Weeds’ important work “Medicine in Denial” (search it on my blog at Blog.KHIT.org)

  7. (Full disclosure – I use and contribute to the Visual Dx actively). I view the coming challenge as not just capturing information in electronic formats, but more a “get the right information at the the place at the right time.” Clinical decision support tools that can help achieve this and not add to the burden of “alert fatigue” with conventional current generation EHRs will be very valuable. Right now, I might use the VisualDx to generate a differential diagnosis. In the future, imagine an integration of the Visual Dx to an EHR that can use data as I’m recording it (travel history, social history or other such things us ID docs like), and help generate options to consider in my differential. This would help my work be more comprehensive and help my patients as well.

  8. Got you beat with a decade, but I do use epocrates, UpToDate etc. The problem is that everybody knows about Ebola and where it is prevalent and providers today’s are so stressed out BY THE CLUMSY TECHNOLOGY AND MISDIRECTED GOVERNMENT EDICTS that they can’t always think straight. The additional layers of FOMA medical personnel have to contend with appears to be reaching critical mass. The problem in this case wasn’t that the nurse and doctor didn’t use the available technology. The problem is that they did – instead of talk with each other.

  9. I have been practicing for 20 years and I understand fully how technology, medicolegal issues, insurers and red tape has made the practice of medicine very difficult. From reading the first few comments I am realizing how contaminated the term “clinical decision support” is. I would think that most readers of THCB like using tools such as Epocrates, UpToDate, Dynamed, Clinical Key, Lexicomp, VisualDx etc, by searching for information faster than they could in a book or atlas down the hall. In fact, I know most clinicians embrace these references. “Pulling” information from resources like this are looked upon favorably, as opposed to the “pushing” of alerts and alarms that are often meaningless and are seen with contempt. Unfortunately the term “clinical decision support” has become pejorative.. Let me frame it this way: Can any physician memorize the infectious diseases that can be acquired in each country in the world, and know them precisely when seeing patients? Can you tell me which countries Chikungunya virus can be acquired in? Dengue? New World Leishmaniasis? Most clinicians in practice will know that Liberia and West Africa is where Ebola can be acquired today. But what about the worried well that have traveled and are now in your clinic? And people with other travel related illnesses? Or medication reactions? In my clinic i make sure the residents use an app on the phone or desktop and look it up. Demonstrating to patients that you looked up the latest information can be very reassuring for the patient. Using evidence at the point of care is a good for care and says to the patient that you took the time to look it up. The kind of decision support we have developed over the past 15 years allows you to search by country, and by symptoms, signs and other factors and you are in the driver seat. Unfortunately physicians mostly see the drudgery of computing, not the helpful apps that we love in our pocket when they hear the term clinical decision support. Maybe we should call it “quick, contextualized reference”? Appreciate your comments

  10. it could be that the issue is that today’s EHR causes more confusion than clarity…

    and perhaps rather than generating new complexity, we ought to change the incentives so that EHR is only rewarded if it is useful and increases physician and nurse satisfaction.

    more $ for yet another new wave of tech that puts more layers between patient and provider seems the height of insanity.

    The lesson of the Ebola case is that, in spite of all claims, EHR is unnecessary complexity and process over usefulness… of course, if elected officials had been listening to those who actually provide care rather than those who stand to profit from selling EHR and related services, we would not be in this predicament today.

  11. Unfortunetely “decision support” as we know it is not likely to avert errors such as this one. In our daily work with EMRs, we are constantly distracted by irrelevant warnings and prods, like “shouldn’t you order a microalbumin” on a diabetic who might have presented with chest pain or suicidal ideation. Admit it, all the minutiae of “meaningful use” and all the other government edicts are overwhelming and distracting nurses and providers from doing their real job of taking care of patients!

  12. The only kind of decision support needed at Texas Presby in Dallas was a decision by an actual, competent, informed physician to take charge of the situation and err on the side of safety and good judgment. With all the b.s. pushed out by the industry and this administration about this protocol and that guideline, blah, blah, blah, it still comes to do responsible people acting responsibly