Bad software or bad configuration? (EDIT: Hospital has since retracted this claim, presumably because someone on staff was going to expose them as liars.)
There are technical problems beyond the software, too: Ebola isn't even considered its own disease under the current medical classification system for diseases, called ICD. Under ICD-9, the current version, Ebola shares a code with "multiple viral diseases." (The virus will have its own code under ICD-10, which rolls out next year.)
This needs more context. ICD stands for International Classification of Diseases - these codes are the obtuse numerical codes that appear on your medical bills with little explanation. Under ICD-9 there are ~17,000 codes, under ICD-10, 140,000 (although that includes both procedural and diagnostic codes and many, many obscure sub-categories).
ICD-10 has been around for over 20 years, and almost every other developed country uses it because it makes electronic record keeping much easier - for example, different codes distinguish between left and right sides of the body. Under ICD-9 someone who presented with injuries on both hands would have the same code for both, leading to assumptions of duplication, unpaid bills etc. The US is late to the party and the deadline for implementation of this for billing Medicare, Medicaid etc, has been pushed back from 2012 t0 2013 to 2014 to 2015 because hospitals and physicians keep whining about the costs and administrative complexity, and certain politicians would like people to associate those costs and complexity with Obamacare, even though HHS adopted a final rule scheduling the transition to ICD in January 2009, a few days before Obama took office.
> The US is late to the party and the deadline for implementation of this for billing Medicare, Medicaid etc, has been pushed back from 2012 t0 2013 to 2014 to 2015 because hospitals and physicians keep whining about the costs and administrative complexity, and certain politicians would like people to associate those costs and complexity with Obamacare, even though HHS adopted a final rule scheduling the transition to ICD in January 2009, a few days before Obama took office.
Hospitals aren't thrilled about this change, but they haven't been clamoring particularly loudly over this issue (compared to others).
There are rumors that Medicare itself isn't entirely ready for this change on a technical level (it requires a lot of costs on their end too, not just the hospitals), which is why the implementation has been delayed so many times. The most recent postponement (end of March 2014) was noteworthy because it was so sudden - the motion to postpone was expected not to pass until immediately before it was called (often a sign of backdoor shenanigans one way or the other).
Of course, these discussions all happen behind closed doors, so there's no way of knowing for sure. But I wouldn't be so quick to credit hospitals with successfully lobbying to postpone ICD-10, especially since they've been incredibly ineffective at lobbying for a number of policy changes that they care about much more.
That's a good point which I had not considered. I assumed the delay was at the behest of lobbyists, because >90% of the complaints I've seen are from doctors and small clinic administrators, and the medical coding industry is suffering a rather severe labor shortage right now, which is driving wages up at the same time ICD-10 is expected to reduce productivity by about 50% (in terms of # of records processed, although the coding will be of far higher quality). Also, the government's own website seem pretty well organized so I assumed they had the backend stuff squared away.
It's not just a matter of hiring more people and training them quickly - medical coding is an accredited position requiring some 700 hours of training including classes in anatomy and other introductory medical topics. (I'm not a medical coder, I'm just quite interested in this topic because of family background - Dad was a national public health executive in Ireland, my sister's a clinician, and I had some early work experience in both administrative and clinical contexts).
There are many (too many if you ask me) sets of medical codes, ICD being one of them. ICD-9 is widely used in US because Medicare uses it for billing purposes, but it is not considered very good for medical practice and ICD-10 isn't much better really. There are better ones like ULMS [1]. And many code sets have some sort of conversion to ICD-9 for billing.
The problem though is not really the particular medical code set a hospital uses, but rather medical professionals have to know the codes. Codes are for machines not humans. The doctor should just have to put into the medical record the diagnosis, location in or on the body, etc. The software then figures out the right code and sends the code to another system. Some medical software is built that way, but many medical systems require the input of the code itself. It is analogous to making users remember and enter their UUID rather than their username when they login or making users enter the IP address rather than a domain name. It is silly.
So Ebola was first identified 38 years ago as a disease, but not until 2015 (in the US) will ICD-10 recognize it as a unique disease? This, despite having unique codes for the same afflictions to different areas of the body? Perhaps the coding and EMR standards body assumed that African hospitals weren't going to be upgrading soon.
No, not until 2015 will the US require EMR systems to be using ICD-10. The ICDs are developed and promulgated by the World Health Organization, and I suspect the US has been a bit slow to join in because a) anything coming out of the United Nations is politically toxic to about a quarter of the electorate, and b) US healthcare is a patchwork of private businesses and promulgating any sort of new standard leads to endless complaints about 'government red tape' and so on.
Anyone who is already using ICD-10 can code for Ebola, which is A98.4. So if you were a clinician billing the government, they're ready to accept ICD-10 coding, and I imagine most insurance companies are too. But lots of people are still stuck on ICD-9, same way many businesses were stuck on Internet Explorer 6 and windows XP for the longest time.
The hospital has subsequently altered its story. The doctors knew about the patient's travel, and didn't act:
"Friday evening, the hospital effectively retracted that portion of its statement, saying that “there was no flaw” in its electronic health records system. The hospital said “the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow."
Yeah, that's what I suspected: just another arrogant piece of shit doctor who thinks s/he's too important to be bothered learning anything about his/her patients. This patient neglect by way of physician arrogance is endemic and far more dangerous to the health of all the individuals in this country than most of the ailments for which patients initially seek treatment.
On top of this, grades are an imperfect indicator for whether a doctor is detail-oriented when dealing with patients. Just because they ace all the tests doesn't make them a great doctor.
While it is true that errors during care transitions are a well known and difficult to solve problem, they rarely result from people not giving a fuck.
"But on Friday evening, the hospital effectively retracted that portion of its statement, saying that “there was no flaw” in its electronic health records system. The hospital said “the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow.”"
These EHR systems - programs for managing patient information - are some of the absolute worst in terms of frustrating usability and difficulty. Think of how bad the very worst HR applications you've had to use and then go 10x worse than that.
My mother works as an ER nurse and she has to type the same duplicated information into multiple spots. Any single mistake in entry can result in loss of all information or in some cases can't be corrected.
Very often the system forced upon the nursing staff are worse and different than the systems used by doctors. That sounds moronic, but doctors have a bit more influence and can push back hard against horrible mandates from IT departments, while the nursing staff have no such advocates.
Naturally an IT department that has spent 10-20 million dollars on a contract for such and awful computer system isn't going to willingly admit that the system is awful, reduces patient care, and slows down how many patients the nursing staff can see to.
Dallas hospital's debacle highlights the atrociousness of many electronic health records.
Yeah OK health records software mostly sucks. But let's think about it... how often does a patient present at the ER with "fever and abdominal pain" I am guessing dozens of times a day at a busy hospital. Is it really unexpected that the staff would triage this as anything other than a low-priority case to try to "treat and street" so they can deal with the serious immediately life-threatening trauma, heart attacks, strokes, etc. that are also constantly coming in.
He mentioned he had recently been in Africa yes, and yes in hindsight that was not given due attention. Maybe the software could have presented this better, but maybe everyone's mind was already on the next ten more urgent cases. If he instead said "I have had contact with Ebola patients" that would have been another kettle of fish, why didn't he say that? I don't think we can blame the hospital too much here.
> Maybe the software could have presented this better
I think there is plenty of room to improve the software in this area. Other EHRs might do this differently but the EHR that I have worked with previously basically had the "recent travel" field be a simple fill in the blank.
What if instead, the input from the field was matched with a database of locations? Once a location is selected, it could use online data of recent outbreaks and long term viruses/diseases of the region that was inputted.
Like you said, the medical staff wouldn't have ever thought "Ebola" as it has been 24 years since the last (and only) case of Ebola in the US. I am not even sure if Doctors would know the symptoms of Ebola to begin with, its just not something to be expected.
If that doctor was given a list of outbreaks and common viruses/diseases of the country the patient visited, it could have maybe allowed him to diagnose his symptoms by just seeing the word "Ebola" pop up.
Spent a year doing analysis of EMR data. Talk about a tar pit. Few industries are as backward and obstinate to change as healthcare. Every clerk and doc has their way to do something and is quite against change, which is painfully ironic, given the docs are some smart folks. For example: patient phone number, sounds simple? Some clerks enter a number, other leave blank (NULL), others enter ZZZ-ZZZ-ZZZZ for blank, others all 5's, or all 9's, or all 7's, or some other number that only they know means blank. And that's for something as trivial as a phone number, now imagine symptoms, measurements, etc. We've got a long way to go.
I don't agree. He said he'd come from Liberia, and the CDC has issued numerous advisories about the epidemic risk, plus it's been near the top of the news for months. You'd have to be living under a rock not to know about the Ebola outbreak. Being up to speed and prepared for this sort of thing is why hospital administrators and clinicians are paid the big bucks.
Yes but this is our view as outsiders. When you see a dozen patients a day with "fever and abdominal pain" it's going to take something out of the ordinary to set off your alarm bells. Ebola has still affected only thousands of people in the world, and it's never been seen "in the wild" in the USA. It is legitimately almost the LAST thing a health care provider would suspect based on initial symptoms.
The first few cases are going to be misdiagnosed initially.
I think we have to look at this the same way the NTSB looks at airplane crashes. Not to assign blame, but to identify root causes, procedural/training problems, and changes to prevent the same failure from happening again.
Yes, but when someone says they recently came from Liberia, and he outbreak is centered in Liberia, that is something out of the ordinary. I don't expect people to have all knowledge about the management of the disease at their fingertips, but yes I do expect them to be aware of it as a potential danger, in the same way they need to be aware of things like Enterovirus D68 and the current measles outbreak, to name but two. That might simply mean asking the patient to wait while spending a few minutes looking up procedures and arranging for an unusual blood test to be performed (which was apparently done last instead of first: http://www.dallasnews.com/news/metro/20141003-ebola-case-blo...)
What is the point of the CDC sending out bulletins on things to watch out for if the people with the relevant clinical and administrative expertise don't pay attention to them? I'm sorry, I am not buying the idea that having greater domain knowledge is an excuse for being less aware of a major risk factor that has been a headline news story for months.
While it's true that Ebola has only affected a few thousand people so far, it's also true that it's led to the collapse of public health systems in several developing countries, and is threatening the ability of the countries themselves to function. It's fairly fast acting, fairly easily communicable, and kills 60-70% of patients. It seems to me that staying abreast of emergent public health issues is a significant part of what people are paid for. Again, not necessarily knowing in advance what to do about every situation, but the ability to recognize a potentially dangerous situation as something out of the ordinary.
Nah, not bad software (even though most medical software can be horrifically bad). Nope. Incompetent, indifferent or uninformed people (or all of the above). The number of people in the US who have virtually no clue of what is going on in the world is staggering. They can tell you the latest news about Miley of Bieber. Ask them "What's going on in Liberia" and you are far more likely to get a blank stare than an intelligent response. Ask them "Where is Liberia?" extra credit.
So you have a guy with a fever come into the ER saying he just got back from West Africa and, in a huge number of cases, that is likely to be met with "Cool! Got pictures?".
Even if the hospital had no computers, informed and knowledgeable providers would immediately escalate the patient based on two simple bits of data: West Africa + Fever. Someone with more information than the latest on Miley's ass-shaking antics might even ask: "How close were you to the ebola-afflicted area?". In this case the answer to that question should have resulted in immediate isolation and further actions.
You can't blame computers and software for everything.
Here's a glimpse of what they have to say about the Atlantic article:
> Author credentials are fair game if you’re going to editorialize, so let’s check hers: an intern until 2010, moved down from global editor to staff writer after 10 months in the higher position, wrote about home design and architecture, and listed her most recent accomplishment on LinkedIn as, “Talk about beards on the radio.” Nothing makes me angrier than people who’ve never spent a day working in either IT or healthcare blasting out their entirely unqualified opinions in passing themselves off as authoritative.
Anyway, read the HISTalk article for an insider take.
When I learned the hospital which sent that ebola patient home was managed by Texas Health Resources I wasn't surprised.
I personally witnessed their incompetence when I walked to their Arlington ER 10 years ago with appendicitis symptoms.
It took them 6 hrs after drawing blood, an ECO and a freaking MRI but they weren't sure what I had until at around 2am they woke up some doctor and explained the symptoms over the phone.
Before the surgery, this doctor told me he pretty much yelled at them "it's appendicitis you morons, get him a bed and schedule surgery first time in the morning!"
Needless to say, that was the first and last time I ever voluntarily walk to a Texas Health Resources hospital.
Under ICD-9, the current version, Ebola shares a code with "multiple viral diseases."
I looked into this, and Ebola is coded as "065.8
Other specified arthropod-borne hemorrhagic fever". The strange thing is that arthropod-borne means spread by insects, etc. It's puzzling to classify Ebola this way when it's not thought to be spread by insects.
Disclaimer: I don't know anything about ICD except that ICD-10 is the famous flaming waterskis version.
Bad systems. Systems are the responsibility of the people who implement them. They must care about the systems they put in place; and they must care more about the systems the more important the outcome.
Emphasis on the whole system is the only way to improve quality; not focus on a particular individual failure case.
Even if it was a software problem (which according to timr it apparently wasn't), it would still be 100% the fault of the medical staff. Its absolutely ridiculous that the people caring for a patient don't even fucking talk to one another.
I think we should remember that this guy had already been willfully deceptive in order to get to the US with Ebola in the first place. We don't know what or how "slyly" he might have mentioned his "travels in Africa".
He probably didn't march in and say "I'm pretty sure I've got Ebola because I hung out with Ebola victims and then lied to airport screeners to get here."
When I eat that five week old pizza in the fridge or go to that shady Chinese buffet on the edge of town, and then feel ill, I do blame myself. Come on Jony.
Some of my friends while joking about the famed "ignorance of Americans" say that the person that was told he came from Liberia was not alarmed because, after all, it was West Africa that had Ebola.
There is absolutely no excuse. And definitely not the computers problem. Liberia should have raised a flag even if it was a janitor in a hospital that heard it
Anyway, Ebola can be easily contained if taken seriously. Nigeria (Lagos a city of 20 million and not much larger than the bay area to be precise) contained it in a couple of months and all the cases were from the index case. A Liberian too. Everyone should be on the alert and maintain good hygiene and avoid unnecessary body contact.
This is not an excuse to discriminate against Liberians and/or West Africans.
There are technical problems beyond the software, too: Ebola isn't even considered its own disease under the current medical classification system for diseases, called ICD. Under ICD-9, the current version, Ebola shares a code with "multiple viral diseases." (The virus will have its own code under ICD-10, which rolls out next year.)
This needs more context. ICD stands for International Classification of Diseases - these codes are the obtuse numerical codes that appear on your medical bills with little explanation. Under ICD-9 there are ~17,000 codes, under ICD-10, 140,000 (although that includes both procedural and diagnostic codes and many, many obscure sub-categories).
ICD-10 has been around for over 20 years, and almost every other developed country uses it because it makes electronic record keeping much easier - for example, different codes distinguish between left and right sides of the body. Under ICD-9 someone who presented with injuries on both hands would have the same code for both, leading to assumptions of duplication, unpaid bills etc. The US is late to the party and the deadline for implementation of this for billing Medicare, Medicaid etc, has been pushed back from 2012 t0 2013 to 2014 to 2015 because hospitals and physicians keep whining about the costs and administrative complexity, and certain politicians would like people to associate those costs and complexity with Obamacare, even though HHS adopted a final rule scheduling the transition to ICD in January 2009, a few days before Obama took office.