The Ebola Patient Was Sent Home Because of Bad Software
theatlantic.com
theatlantic.com
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 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.
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.
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.
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect...
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).
"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."
http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-tr...
Please, be civil.
"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.”"
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.
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.
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.
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.
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.
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.
http://www.latimes.com/nation/nationnow/la-na-dallas-ebola-h...
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.
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.
Emphasis on the whole system is the only way to improve quality; not focus on a particular individual failure case.
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."
To paraphrase Jony Ive: When we eat bad food, we don't blame ourselves. Why do we blame ourselves when we use bad software?
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.