PROVIDENCE – The nurse at Texas Health Presbyterian Hospital’s emergency room asked the right question of the patient who had come in complaining of a fever and abdominal pain on Friday, Sept. 26: have you been traveling in West Africa?

The man, Thomas E. Duncan, the first Ebola patient diagnosed in the U.S., answered truthfully, yes, he had recently flown into Dallas from Liberia.

But he was not admitted at that time. Hospital officials said that the travel information had not been passed along to the doctors who examined and diagnosed Duncan. Instead, he had been sent him away with a prescription of antibiotics, only to be readmitted two days later, with more serious – and more contagious – symptoms.

Why not?

Was the nurse not part of a team approach at the hospital, where she was included in the treatment and diagnosis of patients?

Was the nurse not empowered to make decisions – such as immediately placing Duncan in quarantine, pending an examination? If this were a case of suspected measles, would that not be the protocol?

What were Texas Health Presbyterian Hospital’s protocols for its electronic health records system, where such travel information, once entered, could be found and easily viewed?

If it was part of the electronic health record for Duncan, why did the doctors fail to view it and/or consult it?

Were the doctors who treated Duncan influenced by his inability to pay for his care? Was there a racial divide between patient and caregiver that influenced the initial decision not to admit? [Texas is one of the states that had refused to expand access to Medicaid, leaving the emergency room at hospitals the only access for health care for the working poor.]

Some reports have alleged that even when Duncan arrived by ambulance at the hospital a few days later, there was difficulty in getting him admitted – until one of his relatives called the Centers for Disease Control and Prevention, which called the state health agency, which then called the hospital.

Determining what actually happened and why it happened may take years – and could certainly involve a series of legal challenges. The reality is that we probably may never know the answers.

But there are some lessons to be learned. And, more importantly, moving forward, we need to ask: what are the teachable moments for Rhode Island and its health care delivery system?

Blaming it on a software glitch
Texas was one of only 13 states to have completed the CDC’s training in Ebola diagnosis, laboratory verification and containment, according to Texas Gov. Rick Perry. Despite that training, things did not go very well at Texas Health Presbyterian Hospital in Dallas.

What went wrong is now being blamed in part on a software glitch, according to hospital officials in Dallas, regarding the apparent breakdown in communications between nurses and doctors.

“Protocols were followed by both the physician and the nurses,” read the statement from Texas Health Presbyterian Hospital. “However, we have identified a flaw in the way the physician and nursing portions of our electronic health records interacted in this specific case.”

Apparently, the documentation of the travel history was located in the nursing workflow portion of the EHR, but it did not automatically appear in the physician’s standard workflow, according to hospital officials.

As a result of this snafu, the hospital said that the workflows have been modified to alert all providers – nurses and doctors – referencing Ebola-endemic regions in Africa in the future.

What health IT platform was Texas Health Presbyterian Hospital using?

“We use Epic,” a Dallas hospital official told ConvergenceRI – the health IT system now being installed by Lifespan, Care New England and CVS.

The attempt to deflect blame onto the software tool for the breakdown in communications that resulted in Duncan initially being denied hospital admission may have been thought to be a worthwhile legal strategy for the hospital to pursue.

But the hospital backed away from that explanation on Friday, Oct. 3, “correcting” its initial statement: “There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event,” said Wendell Watson, the hospital’s director of public relations.” The patient’s travel history was documented, Watson continued, and it was “available to the full care team in the electronic health record, including within the physician’s workflow.” [It sounds as if Epic, the privately held health IT giant in Verona, Wisconsin, likened in a recent New York Times story to the “Microsoft of the Midwest,” was not about to let itself get thrown under the bus.]

But the alleged “glitch” belies the larger, more indelible problems in health care: the inequities and disparities in accessing health care; the challenges in creating a team-based, patient-centered [if not patient-directed] approach to delivering health care, where the nursing staff is fully integrated as part of the care team; and the changing landscape for hospital reimbursement.

Further, it underscores the importance of face-to-face human interaction skills between patient and caregiver, between nurse and doctor, between hospital officials and providers, between communities and hospitals, between caregivers and family members.

These are exactly the kinds of health innovations that Rhode Island finds itself moving toward, ahead of the curve. All that’s missing is a way of mapping and sharing the information and turning it into a strong economic development asset.

Teachable moments
At each stage, as the drama unfolds about the Ebola patient and his family in Texas, the apparent “mistakes” – from the electronic health records snafu to the lack of permits to handle and transport the infected sheets and towels – offers a number of teachable moments for Rhode Island public health and health delivery systems.

It also reveals the difficulties of containing a virulent virus: the vulnerability caused by the enormous gaps in accessing the health care delivery system by the uninsured or the under-insured.

In times of contagion, wrote Laurie Garrett, a senior fellow at the Council on Foreign Relations, in a recent op-ed in The Dallas Morning News, “Societal risk rises with every uninsured or underinsured individual who struggles to work or go to school with a fever and avoids bankrupting visits to health providers.”

If people suffering early symptoms of Ebola, such as acute fatigue and high fever, Garrett continued, “are immediately taken into hospitals and cared for by doctors and nurses wearing appropriate protective gear, the virus has little opportunity to spread.”

Undercutting that, Garrett said, is the fact that about 43.3 million individuals [in the U.S.] still lack health insurance, and there are millions more whose health insurance policies entail co-payments that are exorbitant for working people. [In Rhode Island, there are still about 50,000 people who do not have health insurance and medical care, according to Marie Ghazal, CEO of the Rhode Island Free Clinic.]

“These are the Americans who routinely tough out the flu, fever, aches and pains because medical care is prohibitively expensive,” she wrote. “If they become sick enough to feel desperate, the uninsured and underinsured of America go to public hospital emergency rooms for care, where waiting times in often-crowded settings can stretch for hours.”

‘The infectious disease challenge of our generation’
It had been a busy week for Dr. Michael Fine, the director of the R.I. Department of Health. He found himself on the front pages of newspapers and on national news programs following the news conference regarding the death of a 10-year-old girl from Cumberland, from a staph aureus sepsis bacterial infection. The young girl also had enterovirus, a respiratory bug, but it did not cause her death, Fine said, despite a flurry of mistaken headlines to the contrary.

Fine is in a unique position to talk about Liberia, infectious diseases, and the needs of its community health care infrastructure: he spent a number of months there in 2009 as a visiting doctor.

Since early spring, he has been prepping Rhode Island’s public health infrastructure – from hospitals to community outreach – to prepare for an expected case of Ebola in Rhode Island, given the state’s large Liberian population.

As the epidemic spread in recent months, Fine and his team have met frequently with the members of the Liberian and West African communities in Rhode Island, offering them accurate medical information to share with their relatives who are living there. Teaming with United Way of Rhode Island, the agency enabled Rhode Island residents to call their relatives to ensure that they have access to accurate details about the disease and how it spreads.

Fine and his department have also worked closely with Rhode Island hospitals and care givers to make sure that they are prepared for an Ebola case, if and when it arrives. “I do expect that there will be a reported case in Rhode Island,” Fine told ConvergenceRI, adding that he felt that Rhode Island was one of the best prepared states.

Ebola, Fine continued, “is the infectious disease challenge of our generation.”

Is there a way to deal with the fears – and the fear-mongering – about Ebola?

“To communicate a lot, to communicate consistently, and clearly. And to answers questions as they occur,” Fine said.

“Watch the numbers in Africa,” Fine continued, his voice rising with emotion. “The response is not anywhere near matching the need. The strategic analysis of what happens if Ebola continues to spread – we’re already at an outrageous number, with more than 7,000 infected and more than 3,000 dead, and CDC’s working [assumption] is that we need to multiply that number by two and a half, because of the number of unreported cases, and we’re in the 20,000 case range. Remember that the rate of infection doubles every 15 to 21 days. You can do the math.”

In terms of lessons learned about the need to develop teams of care, Fine said that Rhode Island “is at the beginning of how to figure out how to that, to deliver care within an effective team function. It clearly needs to be the focus.” In the past, he continued, “We’ve trained people in silos, we’re just at the beginning learning how to do this. It needs a specific set of skills, with totally different training.”

Are the hospitals in Rhode Island prepared for the challenges of an Ebola patient?

“We charge the hospitals with preparing themselves,” he said. “The hospitals are working quite hard on this.”

Rhode Island Hospital has also been working hard on getting its public messaging out that it is prepared to deal with any Ebola eventuality – with coordinated front-page coverage in The Providence Journal and TV coverage on Channels 6,10 and 12.

Dr. Leonard Mermel, medical director of epidemiology and infection control at Rhode Island Hospital, expressed confidence that a new algorithm would help to identify and isolate anyone with Ebola-like symptoms and had traveled outside the U.S. “We are preparing. We are prepared to admit the patients and manage them here,” he told Channel 10.

Sharing the knowledge
On Friday, Sept. 26, the very day that Duncan was being denied admittance to Texas Health Presbyterian Hospital, doctors and nurses in Rhode Island met to discuss how to strengthen their interprofessional relationship.

The event was the third annual gathering of the Massachusetts-Rhode Island Partners Investing in Nursing’s Future Interprofessional Education Collaborative, convened at the Warren Alpert Medical School of Brown University, underwritten by the Robert Wood Johnson Foundation and the Northwest Health Foundation.

The all-day event featured a panel discussion with Dr. Timothy Babineau, CEO of Lifespan, Angellen Peters-Lewis, Chief Nursing Office at Care New England, and Paulette Seymour Route, the dean of the University of Massachusetts Graduate School of Nursing, moderated by Ned Schaub.

The discussion centered on how to build a better professional relationship between doctors and nurses.

For Route, the emphasis needed to be on emphasizing inter-operational values and creating a “respectful dialogue.” She likened the learning experience to how she was programmed to respond to a question from her 16-year-old: “My first response was always no,” she said. What was needed, she continued, was to build a “trust relationship.”

Peters-Lewis spoke about the challenges faced by every hospital in the nation to implement the triple aim of care, with a focus on a team-based approach, with a commitment to a seamless continuum of care. “The brutal fact is that we have no idea how to do it,” she said, with a brutal honesty.

There was a need, Peters-Lewis continued, to create the time and space for experiential learning to make it happen. “Change is also painful,” she said, stressing that executive leadership was key, along with recognizing that everyone’s voice has value, and listening and responding to those voices becomes the organization’s greatest strength. “There is a power in learning together,” she said.

Babineau characterized the change as moving toward the concept that “medicine is now a team sport,” something it hadn’t been in the past. The team-based approach is part of his DNA, Babineau continued. It was also a matter of changing the rewards system within the hospital so that teamwork is rewarded and not just individual accomplishments.

Public health as team sport
This year’s boot camp for the 40 incoming students at the Brown University School of Public Health during the first week of the semester involved a case study of an infectious disease, asking the students to play different roles in the socio-drama.

As Terrie Fox Wetle, the inaugural dean of the school, explained to ConvergenceRI in a recent interview, the two-and-a-half hour exercise allows students “to have an immediate experience as a public health professional.”

Every student has a role, Wetle continued, “As the director of the state department of health, or the head of the CDC, as a concerned parent, as a newspaper reporter. This year, there were three reporters, two from newspapers, one from TV, each with a different personality.”

This year’s boot camp exercise was based on SARS-like case [severe acute respiratory syndrome], Wetle said, because there was a history and experience to play out the scenario.

“We did the case using SARS, but at the end, I spent a half-hour on Ebola, about what the public health issues are, here and internationally, the ethical issues, the financial issues, the political issues,” Wetle said.

Public health students at Brown also had an opportunity to participate and observe the community policy group at the R.I. Department of Health, which meets weekly, discussing preparations to respond to Ebola, according to Wetle.

“Michael Fine is ahead of the curve in saying, we have the third largest Liberian community in the country in Rhode Island, and it’s quite possible that a family member or a colleague coming back and forth will be exposed,” Wetle said.

She praised Fine’s effort to have a team of health care professionals and the state laboratory prepared to respond – as well as the openness in allowing public health students to observe the ongoing discussions.

Two-way communication is key
The important lessons to be culled from what happened in Dallas, said Dr. Ray Powrie, the chief medical quality officer at Care New England and a professor of Medecine at the Warren Alpert School of Medicine at Brown University, is the importance of team work and vigilance.

In an interview with ConvergenceRI, Powrie prefaced his remarks by saying: “I don’t know what actually happened. Any comments I make, I am speaking in generalities. The full story is only known to a few people. And, it may very well be that we will never know all that happened – that’s between the lawyers and the hospital.”

The constant challenge in health care, or in any other business, Powrie began, discussing what could be the teachable moments, was that the “next person in line has all the information, that they have the things they need [to make a good decision].”

Most errors, he continued, are failures of communication. “Communication is a two-way street. Everyone’s responsible for that,” he said.

At Care New England, Powrie said they had invested in team training, to make sure that every team member is empowered and speaks up. “Every single member of the care team has the right to speak up and be heard,” he said.

In an emergency room situation, nurses in triage can get someone into quarantine, Powrie said. He said that Care New England had been spending a lot of time working with its care teams to prepare for patients with Ebola-like symptoms – both in its hospitals and its ambulatory care practices, to have the protocols in place, and to ask the right questions about travel.

“This is a sad thing to have happened [in Dallas], for everyone involved. It is also a major league teachable moment, to use this to teach all of our people how important and real this is,” Powrie said. “We need to be vigilant. Teamwork and vigilance, they are not theoretical. Ebola transmission is completely preventable if we’re vigilant.”