
The Ebola Patient Was Sent Home Because of Bad Software - kdazzle
http://www.theatlantic.com/technology/archive/2014/10/the-ebola-patient-was-sent-home-because-of-an-electronic-health-record-problem/381087/
======
anigbrowl
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.

~~~
twistedpair
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.

~~~
anigbrowl
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.

------
timr
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."_

[http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-
tr...](http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-troops-west-
africa.html)

~~~
Kerlix
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.

~~~
maxharris
_arrogant piece of shit doctor_

Please, be civil.

~~~
tiatia
They are more common than you think.

~~~
pyre
There is a bar for passing to become a doctor. You have no way of knowing if
your doctor just barely passed or was top of the class.

~~~
btown
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.

------
ghshephard
From: [http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-
tr...](http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-troops-west-
africa.html)

"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.”"

------
bleair
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.

------
ams6110
_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.

~~~
twistedpair
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.

~~~
saraid216
[http://xkcd.com/1172/](http://xkcd.com/1172/)

------
robomartin
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.

------
pseale
HISTalk (a website devoted to healthcare IT) has its take on this article:
[http://histalk2.com/2014/10/03/monday-morning-
update-10614/](http://histalk2.com/2014/10/03/monday-morning-update-10614/)
(browse down to the "Other" section)

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.

------
jonstokes
FYI the Dallas hospital has now "walked back" this part of the story. They're
no longer blaming it on the software:

[http://www.latimes.com/nation/nationnow/la-na-dallas-
ebola-h...](http://www.latimes.com/nation/nationnow/la-na-dallas-ebola-
hospital-20141004-story.html)

------
vpeters25
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.

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kens
_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.

------
sparkzilla
For those catching up. Updated Ebola News Timeline
[http://newslines.org/ebola/](http://newslines.org/ebola/)

------
calinet6
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.

------
phaus
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.

------
noonespecial
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."

------
cosmic_shame
*bad software configuration

~~~
pestaa
*users of fine software not understanding how information flows within the system

~~~
gress
Even if this story were true (which it appears not to be), if the users don't
understand the system, it is the design of the system that is at fault.

To paraphrase Jony Ive: When we eat bad food, we don't blame ourselves. Why do
we blame ourselves when we use bad software?

~~~
twistedpair
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.

~~~
gress
Jony assumes you have taste.

------
OoTheNigerian
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.

