The enormity of the tragedy in West Africa remains hard to appreciate even as Ebola begins to migrate into developed countries. In the U.S. mindless panic stoked by the 24 hour news cycle and fear-mongering politicians are not the only familiar phenomena. In important ways our “Ebola crisis” is only tangentially related to a malicious virus and has much more to do with the state of our health care system. Consider the following “Ebola issues”
- Ebola has been marked by uncertainty as to federal and state responsibilities for infectious disease policy, prevention and reaction. Sadly, first impressions have been confirmed by the appointment of an Ebola “czar”, a sure sign that various branches of government have not been playing well together. Such regulatory fragmentation and lack of coordination is not new. Health care is our most regulated industry emanating from a bewildering array of legislation and regulation enforced by innumerable and frequently dysfunctional federal and state agencies.
- That lack of coordination has been replicated at the local level between agencies and healthcare institutions and between multiple institutions. Regional or local planning appears to be missing or only reactive. In a post-Katrina, post-swine flu world it seems extraordinary that there were not cogent plans waiting to be executed. Of course “There are only four in the U.S. with special isolation units designed to contain biohazards like Ebola” but why weren’t there plans to utilize them? Even now how many localities have a plan to handle, say, a major outbreak by using a centralized, tertiary care facility?
- We don’t know exactly what happened at Texas Health Presbyterian Hospital in Dallas (although some reports are now quite detailed). At the least there are suspicions of fragmentation and lack of coordination within the hospital. That shouldn’t be a surprise. In too many healthcare institutions inadequate systems, lack of teamwork, ambiguity at hand-offs, etc., stubbornly remain part of the narrative.
- In Dallas one or several healthcare workers made a mistake. And, if it is true that Thomas Duncan’s blood was transported through the hospital’s pneumatic tube system, so did the facility. It is now 15 years since the publication of To Err is Human. How can it be that preventable adverse events are now the number 3 killer in the U.S. after heart disease and cancer? Just last week a major hospital in Los Angeles recently suspended elective surgeries after an outbreak of surgical infections. Why would we believe that such institutions could handle a case or two of Ebola?
- Press reports suggest that affected healthcare institutions had either inadequate protocols in place to combat a contact virus like Ebola or that protocols were not properly implemented or followed. Thankfully, the CDC now seems to be working hard to provided updated protocols and guidance. Yet, overall, many healthcare system stakeholders treat protocols or clinical practice guidelines as optional. The Affordable Care Act’s section 3501 mandate to AHRQ has never looked more vital.
- The tragedy of Thomas Duncan’s death was almost instantly overshadowed by a blame game. Someone or something must have been responsible—the CDC, doctors, nurses, the victim, even technology. Once again the urging of the IoM in To Err to concentrate on system and process reform and move away from individual blame seems to have been ignored. Notwithstanding, because we lack any sensible alternative compensation system some healthcare institutions or workers, maybe even airlines could face liability claims and in some cases an OSHA investigation.
- Even seasoned observers of the culture of blame in healthcare likely were surprised to see the Dallas hospital throw their electronic health records system under the proverbial bus. As David Blumenthal later noted the problem in Dallas was “humanware, not the software,” but also reflected on how “providers’ unhappiness with EHRs reflects profound underlying dysfunctions in our health care system.” Sadly that instinctive criticism of the facility’s EHR illustrates a dislike of HIT in hospitals caused by underperforming technologies and poor integration into clinical workflows. Further the general failure of the meaningful use subsidies to improve interoperability does not bode well for tracking patients during large outbreaks, or supplying CDC with good data to plug into its predictive analytics models.
- Of course once the blame game starts almost anything can be criticized and HIPAA has long carried a large target on its back. In the case of the Ebola patients in Dallas HIPAA apparently is simultaneously both too leaky and insufficiently transparent. However, at the moment there seems little need to dispense with our general rules protecting patients’ confidential information. Public health authorities already have access to the PHI they need. And, if there was to a major Ebola outbreak such that the President declared a public health emergency the HHS Secretary can waive some HIPAA rules for hospitals that have instituted an emergency protocol. On a related note the Americans with Disabilities Act (ADA) imposes some privacy-like requirements, for example by limiting the amount of information that can be required of an employee and placing limitations on requiring medical examinations.
In short almost every issue raised so far is not Ebola (or even pandemic) specific but further evidence that the Affordable Care Act was only a baby step towards righting our health care ship. As my colleague Fran Quigley observed about the ongoing catastrophe in Africa, “functioning health systems have proved elusive for the world’s poor.” But here we should be able to do better.
