During a pandemic, officials need real-time data to make sure resources go where they’re needed; attempts to build a system this year have failed
El Centro Regional Medical Center was overrun with dozens of Covid-19 patients in May, with nowhere to send the critically ill. The only other hospital in Imperial County, Calif., also was swamped.
Chief Executive Adolphe Edward called the state’s emergency medical services director, asking him to intervene. “Please, please help us,” he pleaded.
Doctors and nurses at El Centro swapped text messages and made phone calls, blindly searching for openings at other hospitals.
In the emergency room, coronavirus patient Jose Manuel Abundis Gomez waited. It took 20 hours to find another hospital with a bed for the 71-year-old retired state administrator, said Alidad Zadeh, his primary care physician.
By the time Mr. Abundis was finally transferred, his oxygen levels had dropped. He later died.
During a pandemic, hospitals and local, state and federal agencies rely on a range of real-time metrics to respond to emergencies quickly. They need to know how many beds are available at each facility, whether hospitals need more nurses and the available number of ventilators and other critical supplies. That way, patients can get transferred quickly and medicine distributed to those in most need.
Jose Abundis, center, and his wife, Martha, both contracted coronavirus this spring. Mr. Abundis died after waiting hours to be transferred from El Centro Regional Medical Center.
PHOTO: ABUNDIS FAMILY
The U.S. has tried—and failed—over the past 15 years to build a system to share such information in a crisis. When the pandemic started, nothing like it existed. The limited and inconsistent access to data has been a major impediment to providing hospital care during the pandemic, according to interviews with industry and government officials and thousands of internal documents and emails.
Weeks after the coronavirus surfaced, administration officials began putting together a solution. It was riddled with mistakes and slowed by competing agency attempts to solve the problem, the interviews and documents show. Today, with some U.S. cities bracing for more cases, there is still no viable way to broadly track what’s happening inside hospitals.
“It’s staggering to most people how little visibility there is outside of a particular health system,” said Gregg Margolis, a former U.S. Department of Health and Human Services emergency health planning official. “Every time these things happen everybody throws their hands up and says, ‘I can’t believe these things don’t work more closely together.’ ”
At hospitals like El Centro, the data gaps meant patients couldn’t be moved to another facility quickly for treatment. Between May and August, hospital, county and California state administrators scrambled to transfer nearly 500 patients to about 90 hospitals outside Imperial County, transfer data and emails show. Some were moved as far as 600 miles.
Searching for Beds
Hundreds of Covid-19 patients in Imperial County, Calif., in need of a hospital bed were transferred to other hospitals, some 600 miles away.
In North Carolina, hospitals were cut off from a crucial shipment of the drug remdesivir, one of the few shown to help white serious Covid Symptoms. The federal government is in charge of directing shipments and relied on faulty data to decide how much the state would receive.
“My first thought was how can that be?” said Amanda Moore, a North Carolina health official, after learning the state was cut off from a shipment. “My second thought was how are we going to make it to the next allocation?”
Lawmakers and federal officials have warned for years that up-to-the-minute hospital data would be essential in emergencies. More than $100 million for the technology was cited in legislation but never formally appropriated. Resistance from hospitals and medical-record software companies to report the data has exacerbated the issue, former federal health officials and other experts say.
A spokeswoman for HHS defended the data-reporting system the Trump administration put in place as comprehensive and unprecedented, and said the government is “poised to go even further by making this system fully automated.”
Slow U.S. response
When the pandemic hit, government officials raced to put a makeshift system in place to track hospital data, including the number of beds occupied to ventilator inventory and Covid-19 admissions. From the start, there were competing efforts overseen by HHS.
The Centers for Disease Control and Prevention, an HHS agency, moved quickly to add Covid-19 questions to an existing hospital-disease surveillance system. Known as the National Healthcare Safety Network, the CDC system was used by about 6,000 hospitals to routinely report infection data to the agency.
Robert Shankman, an HHS official working on data gathering, emailed the White House on March 24 to say that the established CDC system would have a higher success rate “than pushing out our own survey and starting a reporting system from scratch,” according to documents viewed by The Wall Street Journal. Hospitals could begin to use the CDC reporting system within days, he added.
HHS nonetheless moved ahead with a prototype for another hospital data-reporting system, granting a contract to a private-sector company, TeleTracking Technologies Inc. HHS announced hospitals could use the newly built option in April.
Mr. Shankman referred a request for comment to HHS. An HHS spokeswoman said he “expressed an opinion on what may be a quick fix for the immediate need for the pandemic response,” not necessarily a long-term solution.
The two systems were meant to be complementary and not competing, the spokeswoman said. Hospitals could choose between the TeleTracking and CDC reporting options.
Both are cumbersome, industry officials say. Each day, hospital staff hunt for data needed for the response—work that can involve multiple software systems, weeding through medical records or walking through hospital units to physically count patients.
Some hospitals have balked. A number of small hospitals skip weekends because they don’t have the staff available to report, said officials familiar with the reporting. Others have submitted identical numbers for weeks.
Deborah Birx, White House coronavirus response coordinator, told health-care industry executives on a June call that it’s easier to get data from HIV clinics in Africa than U.S. hospital data. PHOTO: ERIN SCOTT/BLOOMBERG NEWS
In late June, White House coronavirus coordinator Deborah Birx admonished health-care industry executives on a call as Covid-19 cases surged across the South and West.
It is easier to get data from HIV clinics in Africa than U.S. hospital data, said Dr. Birx, a former ambassador for global AIDS coordination, according to people familiar with the call. Dr. Birx declined to comment through a spokesman.
Industry executives on the call were surprised that hospitals had widely failed to report, and they volunteered to track down offenders. The administration supplied a list.
It was filled with mistakes. Many hospitals on it had properly submitted data, which was missing from government records. Others were closed.
Because of the overlapping data entry systems, the federal officials on a July call told hospital representatives that they had created algorithms to weed out duplicate responses, but these also likely omitted some correct information, people familiar with the conversation said.
An HHS spokeswoman said that raw data wasn’t overwritten but rather published in an erroneous way.
HHS relied on hospital data to decide how much remdesivir to allot each state. Supply was tight.
North Carolina received remdesivir shipments in May and June. Then, as hospitalized coronavirus patients crept above 1,000 for the first time, the state’s 112 hospitals learned North Carolina had been shut out of a shipment.
Ms. Moore, the pharmacist to the North Carolina Department of Health and Human Services public health division, said she began quickly calculating how long remaining supplies would last, culling information hospitals report to the state on remdesivir use and inventory.
She alerted the state’s hospitals. “We are told it is because of low numbers of COVID patients reported by hospitals,” she wrote in an email.
State hospitals moved dwindling supply where it was urgently needed and braced to run out. Ms. Moore reached one hospital system with some doses left and commandeered it to prevent shortages elsewhere.
A later state audit found North Carolina hospital data missing from federal totals, even though the state’s hospitals had been reporting to HHS.
An HHS spokeswoman said the agency regularly reviews corrections from states and North Carolina received “steady” shipments of the drug.
Publicly, the administration faulted hospitals for failing to report.
“The data we are receiving is not always complete or timely enough to be effective,” said a letter to governors in July signed by Dr. Birx and HHS Secretary Alex Azar .
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The letter announced an abrupt change to federal reporting. All data submitted by hospitals must be done through TeleTracking, unless states submitted on hospitals’ behalf, it said. The CDC would stop accepting data as of July 15. Hospitals that weren’t already reporting to TeleTracking had days to make the switch. Not all of them did.
Public health and industry experts said the federal move jeopardized the response and created more risk for errors. Dr. Birx told hospitals in August that there were plans under way to move the system back to the CDC.
In an internal report in September, the CDC found a number of errors in hospital data since the change of systems, according to a report viewed by the Journal. One hospital reported 15,000 beds. Another said it had a negative number of beds occupied.
An HHS spokeswoman said the agency generally collects data without filtering for errors up front, then works to resolve incorrect information.
HAvBED: “It Just Didn’t Work”
HHS first began exploring a nationwide bed tracking system under the Bioterrorism Hospital Preparedness Program. The program was created by Congress after the 2001 terrorist attacks, which exposed hospitals’ poor preparation for large-scale disasters.
Part of the program, which funneled money to hospitals through states and major metropolitan areas, was a hospital-data reporting system called HAvBED, or Hospital Available Beds for Emergencies and Disasters.
It collected essential information on open beds with available staff and ventilator supply. The technology allowed hospitals to upload files or fill out a form online.
Yet its creators at Denver Health in Colorado warned of a flaw. Transferring patients “is a second-by-second issue,” the HAvBED developers said in a report. “Having data entered once a day is not timely enough.”
HHS deployed the system nationwide to stream data from hospitals to the agency and states during the 2009 H1N1, or swine flu, pandemic. Data arrived too late at HHS to inform the federal response. Officials abandoned daily reporting and instead asked hospitals for weekly updates to identify emerging hot spots, according to a former federal official. Regional coordinators would then call hospitals to see if any federal help was needed.
Even with the swine flu spreading, officials stopped using HAvBED.
HHS later raised concerns about HAvBED, saying in a 2012 review that a gap in data was “particularly notable for inpatient hospital care.” HHS officially shelved the program in 2016.
“There was widespread agreement that it just didn’t work,” said Lauren Knieser, a former manager with the HHS hospital preparedness program.
The problem was they had nothing to replace it.
A statewide scramble
During the pandemic, hospitals, states and emergency management agencies had to improvise.
In Texas, Houston-area hospitals can’t see how many beds are available at neighboring rival hospitals. Instead, that information is reported once a day to a regional council, charged with helping communities in disasters.
Charlie McMurray-Horton, head of transfers at Houston’s Harris Health System, pleaded for help from the city’s local disaster council as coronavirus cases surged in early July. By the time she learned of an open bed, it was often gone, she said.
Hospitals surveyed by the Houston-area council on seven days during July had an average of 190 patients combined who needed a bed somewhere else, with dozens waiting for an intensive-care opening.
Arizona had more success. Officials in March began to set up a statewide “surge line” that tapped into other existing data systems for an automated and constantly updated view of beds.
Through late August, the system had transferred about 2,400 patients to other hospitals and the median transfer took only about 87 minutes, according to the state.
In California, doctors, case managers and nurses typically work a network of contacts by phone for the best nearby opening. “It’s the relationships we have built over time,” said Janet Hanley, chief nursing information officer for Sharp HealthCare in San Diego.
Adolphe Edward, El Centro Regional Medical Center CEO Chief Executive PHOTO: ALLISON ZAUCHA FOR THE WALL STREET JOURNAL
The surge of patients in Imperial County began in May, quickly swamping the county’s two hospitals. Coronavirus in the community was spreading, and sick U.S. citizens were driving over the border for medical care.
“Accept all manpower support from anywhere,” El Centro Chief Executive Dr. Edward wrote on May 12 in response to state government officials’ offer to dispatch medical staff.
County emergency officials in San Diego and Riverside saw an influx of Covid-19 patients arriving at local hospitals from Imperial County, and didn’t have full visibility into the transfers.
Studying one transport report that seemed to contradict other data, San Diego’s chief medical officer, Nick Yphantides wrote to county and state officials, “I am not sure if I should a. Laugh b. Cry c. go one f bomb lace email tirade d. give up. Help?”
California’s hospital association sent a plea to executives asking which facilities had open beds. “The state is averaging 40 phone calls to place just one of these COVID patients in need,” Carmela Coyle, president of the association, wrote.
California emergency officials, too, began spot polling hospitals for openings. That effort was labor-intensive and unreliable. Even hospitals that said they could take patients would later seem unable and unaware they had received a request, according to emails viewed by the Journal.
Brad Gates, a state official actively involved in polling hospitals, emailed county and state officials June 15, after hearing nothing back from hospitals in Los Angeles and parts of Northern California.
Twenty-three patients, including 19 in critical care, were waiting to be transferred, he wrote. “This is an urgent matter that needs immediate action!!”
With waits extending to as long as four days, some patients arrived at their destination with damaged lungs from poorly controlled ventilators and without catheters to monitor for septic shock or deliver critical medication, according to medical professionals who saw them. Some traveled as far as Sacramento and San Francisco.
“You are thinking, ‘how can there not be a single ICU bed open south of the Bay Area?’ ” said Andrew LaFree, who runs El Centro’s emergency department.
Warning signs
In 2006, Congress passed a law instructing HHS to set up a near real-time electronic network that would share information from hospitals and other sources in the event of a catastrophic infectious disease outbreak. The demand was twice reiterated in later legislation.
The Government Accountability Office twice — in 2010 and 2017 — found that HHS had made little progress.
In the 2013 reauthorization, Congress said more than $138 million a year could go toward the effort and increased that to more than $160 million in 2019. That money never was appropriated, said former federal officials.
Another hurdle was resistance from hospitals and software companies for electronic medical records. Hospitals often consider bed data proprietary.
“Nobody wants to share information that they think is going to disrupt a competitive advantage,” said Nicole Lurie, former head of the HHS office for the Assistant Secretary for Preparedness and Response, under the prior administration. ASPR oversees health-care disaster response.
Ms. Lurie said she looked into whether large medical record companies could turn over their data several years ago but the companies declined, saying their agreements with hospitals wouldn’t allow them.
While those obstacles could have been overcome, Ms. Lurie said she ran out of time before the change in administration.
When new health-agency officials arrived under the Trump administration in 2017, they were hit with a heavy hurricane season and quickly found that reporting systems were inadequate.
A week after Hurricane Maria hit Puerto Rico officials relied largely on a dashboard of static data on bed capacity, which they found was often out of date and full of errors, according to former officials.
Officials in the federal hospital preparedness program began surveying states and asking them to verify data such as bed capacity and hospital staffing.
What they found alarmed them: Many states didn’t have the information or weren’t able to get it to the federal government in a usable format, according to people with knowledge of the survey.
It wasn’t until August 2019 that HHS sought proposals from companies that could collect real-time hospital data. HHS hadn’t funded one before the pandemic hit.
‘Deteriorating pretty quick’
Jose Abundis served in the U.S. Navy during the Vietnam War. He later spent his career working for California’s employment department, and, before retiring, worked with veterans to try to help them get federal jobs, said his son, Jose Abundis II.
“We all loved him,” said the younger Mr. Abundis.
When he arrived at El Centro in May, the elder Mr. Abundis was already struggling to breathe. There were no ICU beds available and no ventilators, said Dr. Zadeh, his physician.
As the wait time for a transfer mounted, Mr. Abundis’s oxygen levels had depleted, and he became more confused and restless.
“He was deteriorating pretty quick,” Dr. Zadeh said.
Mr. Abundis’s sons, Jose and Carlos Abundis repeatedly called in the middle of the night to find out when he’d be moved, said Jose Abundis. They were told the hospital was “waiting for a doctor to take him.”
Brothers Jose Abundis II and Carlos Abundis PHOTO: ALLISON ZAUCHA FOR THE WALL STREET JOURNAL
After Mr. Abundis was transferred out of Imperial County to Paradise Valley Hospital near San Diego, his wife, who also had coronavirus, found her own symptoms worsening.
This time the couple’s sons took no chances. Carlos put on full protective gear and drove his mother, Martha Abundis, the 120 additional miles from her house to UC San Diego Health’s main hospital.
On May 21, Jose Abundis II got a call from a doctor at Paradise Valley. His father had died.
His mother’s care seemed to go more smoothly, he said. She was intubated but survived and has mostly recovered.
Written by Melanie Evans and Alexandra Berzon for The Wall Street Journal, September 30, 2020