If only the care team had talked among themselves, the crises surrounding a patient eventually diagnosed with Ebola at a Texas Health Resources hospital last year, might have been averted, a panel of experts called in to review the case has concluded.

The expert panel brought in by top leaders at Texas Health Presbyterian Hospital in Dallas to assess the Ebola virus events that began Sept. 25, 2014, after Thomas Eric Duncan arrived at the emergency department at the hospital.

"There are underlying quality concerns about the evaluation that was conducted when Mr. Duncan arrived at the ED the first time," the expert panel wrote in its 15-page report. "The expert panel is concerned that the care provided to Mr. Duncan during his first ED visit may reflect larger organizational issues."

Duncan reportedly told his nurse he had been in Liberia. However the travel history that the nurse duly noted in the EHR escaped the physician's notice. Duncan was released from the hospital the next morning.

It would not be until Sept. 29 when Duncan, who had returned to the hospital the day before, would be diagnosed with Ebola. Two nurses were infected while caring for him. Duncan died on Oct. 8.

"We have identified a flaw in the way the physician and nursing portions of our electronic health records interacted in this specific case," Texas Health officials said in an Oct. 1, 2014, news release. "In our electronic health records, there are separate physician and nursing workflows," Texas Health officials explained in the Oct. 1 media statement. "As designed, the travel history would not automatically appear in the physician's standard workflow."

[See also: Missed Ebola diagnosis leads to debate.]

"Prior to the arrival of Mr. Duncan, information on travel history was collected and recorded in the EHR by THD nurses and was accessible to all clinical staff in the Emergency Department, the expert panel notes in its report. "Viewing this data, however, would have required a clinician in the ED to look beyond the standard patient assessment screen in the EHR to access the travel history from the nursing assessment documentation that was located in the flu screening part of the EHR."

"The lessons shared by THR after the Ebola events also speaks to an over-reliance on the electronic health record for communication of important clinical information between the key members of the patient's clinical care team," the panel wrote.

"The care team responsible for Mr. Duncan did not take action in response to increases in the Systemic Inflammatory Response Syndrome Score," the panel pointed out. "The score had increased to three, which signifies a high risk in terms of the Systemic Inflammatory Response Syndrome Score system; however, the nurse who noted the increase did not verbally communicate that increased score to the physician or the discharge nurse. In addition, although displayed on an electronic board visible to all members of the care team, the alert related to the increase of the SIRS was not acknowledged by the discharging physician or others involved in the discharge of the patient."

This indicates the physician's and clinical teams' potential unfamiliarity with the electronicboard and SIRS score display and in retrospect appears to show a limited focus on the entire care encounter by the clinical team," the panel added.

[See also: Ebola case highlights lack of planning.]

The panel called attention to key findings:

• Training for EVD preparedness had not been fully implemented in the THD ED and the awareness of risk factors for EVD across the entire clinical team was not well known at the time.
• Information concerning travel history from Africa gathered by the nurse was not verbally communicated to the physician because it was already recorded in the EHR.
• The sharing of the travel history data was not adequately designed into the workflow of the entire clinical team, therefore the information was not easily accessible to the physician. This required extra and non-intuitive steps to be taken by the physician to access information highly relevant to clinical decision-making.
• The physician assessment did not include gathering information about travel history, because he didn't see it as a significant question in the scope of the patient's symptoms and the patient's response to questioning about where he was from yielded a different response than what was elicited by the intake nurse.
• The development and deployment of policies, procedures and practices to ensure inter- professional teamwork and communication were inconsistent, and the healthcare team apparently relied too heavily on communication through the electronic health record.

Read the full report here.