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Nursing alumni use lessons learned from the Ebola and Zika viruses to accelerate diagnoses of emerging infectious diseases.
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By Danette Baker

Photography by Neal Hinkle

ive hours by car separates the Dallas/Fort Worth Metroplex from Lubbock, Texas. In terms of significant health care settings, it’s a next-door neighbor. So, when the first case of Ebola was diagnosed in September 2014 — in Dallas — that was a little too close to home for Steph Hoelscher, DNP, RN-BC, CPHIMS, FHIMSS (Nursing ’19, ’15, ’95).

At the time, she was the chief clinical analyst for the School of Medicine Office of Clinical Transformation. Steph managed the electronic health records (EHR) system for the TTUHSC medical clinics.

That could have easily been us, Steph thought.

The case brought scrutiny from the public and the health care community. How could the hospital have admitted a man from Liberia twice within three days without diagnosing him with the deadly Ebola virus? The man died two weeks later, and subsequent contact tracing later revealed numerous exposures before the diagnosis, including two nurses in direct contact who became infected but fully recovered.

“The public chastised that facility, but in reality, we were all caught unprepared” said Steph, associate professor for graduate nursing informatics in the School of Nursing and an infectious and communicable disease analyst. A post-case review, requested by the hospital’s parent company, identified that several factors contributed to the diagnosis oversight.

Most alarming to Steph and her counterpart at UMC Health System, Dwayne Hoelscher, DNP, RN-BC, CPHIMS, (Nursing ’19): a deficiency in the patient’s EHR configuration and ineffective communication among the clinical team.

Bad data in equals bad data out, as the saying goes.

Steph and Dwayne share more than a last name. They both hold board certifications in nursing informatics. HIMSS, one of their credentialing bodies, defines the specialty field as a combination of “clinical knowledge in nursing with information science to develop and maintain systems that enhance clinical workflows, and ultimately improve patient outcomes.”

The couple has become quite the dynamic duo in terms of EHR protocols for diagnosing infectious diseases. Twice in the past five years, they have developed and implemented alerts ahead of national EHR vendors.

It’s a matter of looking for “virus x,” Steph explains. You have to continually be on the lookout because it’s not a matter of if, but when something like Ebola will strike again. History has an uncanny way of repeating itself.

In October 2019, news of the SARS-CoV-2, which became known as the coronavirus, began spreading rapidly through Wuhan, China. Over the next three months, the virus became a global outbreak. The U.S. confirmed its first case of COVID-19, the disease caused by the coronavirus, on Jan. 20, when a Seattle businessman exposed to the virus on a trip to Wuhan returned home infected. The Hoelschers began to track the virus’ movements through the Centers for Disease Control and Prevention (CDC), Infectious Disease Society of America (IDSA) and World Health Organization as it spread across the country.

Experience told them it was time to act; and quickly.

Our EHR systems weren’t prepared, and we couldn’t afford to let history repeat itself.
— STEPH Hoelscher, DNP, RN-BC, CPHIMS, (NURSING ’19, ’15, ’95).
Nursing informatics background leads to the development of a new clinical decision model
Steph had worked in high-stress direct patient care for 15 years when she joined the School of Medicine to aid its EHR implementation. After working the bone marrow transplant unit and trauma care at UMC, Steph earned a master’s degree in nursing informatics and later a doctorate in nursing practice. Ironically, she had received a commandant scholarship in high school requiring her to choose between computer science and nursing for her college major.

An instance of foreshadowing, perhaps?

Dwayne’s career began the opposite. He studied math and computers before earning his degree as a licensed vocational nurse. He then worked his way up to a doctorate in nursing practice, pursuing his degree at the same time as Steph.

Two heads are better than one, Dwayne mused. Why not two Dr. Hoelschers?

He joined Covenant Health System in Lubbock, gaining clinical knowledge through direct patient care, and then in case management and patient safety/risk management before joining the UMC Health System in his current role as professional clinical systems analyst for core services.

For several years, the couple collaborated from like departments bringing unique views to the overall workflow. Steph thought like a clinician, looking at a protocol model as the process developer and workflow assessor. Dwayne’s approach as the algorithm developer, focused more on the system infrastructure, and custom rules and alerts building.

But they both spoke enough of the same languages — data information flow and clinical usefulness — that made them a natural team, with just the right amount of competitiveness.

In 2016-2017, the Hoelschers turned to lessons learned from the Ebola virus when another global virus began to circulate through the CDC, WHO and IDSA.

There’s not much I haven’t seen in my years of nursing so it takes a lot in medicine to scare me. But the Ebola virus, that scared me. Steph thought. Our EHR systems weren’t prepared, and we couldn’t afford to let history repeat itself.

One of the challenges to EHR alerts, said Dwayne, is data maintenance. Someone has to ensure there is data — evidence-based best practices — that can be easily accessed by the end-user. With the Ebola virus, that was missing.

“When Zika came on the scene, we (collectively as the EHR community) had to take ownership of this process, develop a maintenance cycle and have policies in place to quickly turn on an alert for clinicians that would provide decision support in dealing with an infectious disease,” Steph said, during a February webinar for the Office of the National Coordinator for Health Information Technology (ONC) within the Office of the Secretary for the U.S. Department of Health and Human Services.

As part of their doctoral studies, Steph and Dwayne received CDC funding to develop such a model for the Zika virus. Working in partnership with the CDC and the ONC, the couple brought together focus groups of subject matter experts to establish policy and evidence-based practices for infectious disease protocol in the EHRs. The result: a clinical decision support rapid deployment model that precluded similar offerings from national vendor workflows by months. Steph testified in 2017 at the ONC’s Public Task Force Hearing Brief in Washington, D.C., regarding Zika and its impact on pregnancy, provider order entry and clinical decision support systems.

During the next year, the Zika virus calmed with no additional cases in the U.S., allowing the Hoelschers to re-evaluate their model (now named the Clinical Decision Support Infectious Disease Rapid Deployment Model (CIDRaD). Additionally, Dwayne implemented an architecture for the local EHR system so that alerts fire in order of the disease threat. Ebola, for example, remains high on the list because it’s a deadly virus. Contrast that with the alert for MERS, the Middle East SARS that is more seasonal. It moves up in the architecture during Hajj, the holy pilgrimage to Mecca required of every Muslim once in their lifetime, and then is suppressed the rest of the year.

“Project management for clinical decision support is very cyclical,” said Dwayne. “You always have to come back to base and evaluate the threats and balance those with documentation fatigue for the clinician.”

Our efforts have made an impact nationally with the vendors, which ultimately works for the good of the patient and those who provide care.
— Dwayne Hoelscher, DNP, RN-BC, CPHIMS, (NURSING ’19).
COVID-19: Hoelschers put their model to a real-world test
With news of the first COVID-19 case in the U.S., Dwayne and Steph began tweaking their rapid deployment model for the disease. Within two hours, Dwayne had an alert firing in the EHR for treating the patient — and protecting the provider. 

Having the opportunity to customize the EHR put TTUHSC and UMC Health System ahead of national vendors once again, but the gap was closing. With Zika, the timeframe between when the Hoelschers had their model implemented until national vendors offered one was close to nine months. With COVID-19, the timeline reduced from days to a couple of weeks, depending on the vendor.

“Our efforts have made an impact nationally with the vendors, which ultimately works for the good of the patient and those who provide care,” Dwayne concluded.

Prepping for the next pandemic: A national database for EHR systems and training future health care providers
Today, the Hoelschers are part of a national initiative with the Department of Health and Human Services and the CDC to digitize evidence-based clinical guidelines. Their efforts are to standardize care and provide EHR vendors easier access to data for system maintenance, allowing for more accurate, timely clinical decisions. 

Steph and Susan McBride, PhD, RN-BC, CPHIMS, professor and director of the Masters of Nursing Informatics Program in the School of Nursing, studied the efficacy of such a database, with funding from the American Association of Colleges of Nurses/CDC. Their work published in the June issue of the journal CIN: Computers, Informatics, Nursing.

Steph also hopes to implement the couple’s rapid deployment model in TTUHSC’s simulation centers, based on the Netflix docuseries, “Pandemic: How to Prevent an Outbreak.” The series opens with a simulation of front-line health care workers battling influenza. The team is managed by Syra Madad, DHSc, MSc, MCP, an infectious disease specialist who trains New York’s municipal hospital personnel in pandemic preparation.

“I’ve reached out to Dr. Madad, so I’m hoping we can connect and see how we can implement something like that here,” Steph said. The simulation centers already utilize an EHR system in their training, so this would be a way to expand training, she added.

And Steph and Dwayne will continue looking for the next “virus x.” Because they know, it’s not a matter of if, but when.