May 11, 2009

We Don’t Like Ike
By Judy Sturgeon, CCS
For The Record
Vol. 21 No. 10 P. 6

Having withstood Hurricane Rita, The University of Texas Medical Branch in Galveston thought Hurricane Ike would be a mere drizzle compared with its predecessor’s wrath. But it didn’t turn out that way, and now the facility may be left out to dry.

Even when you think you’re ready for marriage, the reality can be completely different from what you expected. The same can be said for having children, buying a house, or starting your own business.

The University of Texas Medical Branch in Galveston thought its coding office was ready for the hurricanes that clobbered Texas (among other states) in September 2005. Our buildings have withstood plenty of storms, and we are located in offices on the third floor center, with essentially no windows. What could possibly happen besides a delay in coding? As it turns out, we were back in the office in a couple of days following Hurricane Rita, which made landfall as a Category 3 storm.

Much to our surprise, Rita’s only victim was the server for the coding software—it wouldn’t turn back on once it had been shut off in preparation for evacuation. Every time the information services department would fix one thing, something else would quit. We had to modify a “temporary manual coding” process to last nearly two weeks before it was possible to just push the interface button and have a claim drop electronically. We considered doing (shudder) manual coding and looking up all of the codes, faxing them to the billing office, and having them bill manually as well.

Our final decision was to have the coders analyze the charts as usual. Then, instead of actually coding the cases, they would write down the diagnoses and procedures in detail, with the intention of coding them when the software was restored. They added the physician names, discharge dispositions, and procedure dates on paper. Included with each coding sheet was the identifying patient number and discharge date. When the system finally became operable, we slammed data entry during a few evenings of overtime and managed to catch up in an astonishingly small amount of time. Disaster handled, crisis averted, bills out the door, money in the door.

With that experience under our belts, we were positive that the next time a hurricane came our way, we’d be ready for anything. Hurricane Rita didn’t hurt us, and we didn’t flood when Tropical Storm Allison put the Houston Medical Center under water in June 2001. Needless to say, when Hurricane Ike approached as a Category 2 storm, no one was in panic mode. In a coastal city at risk for tropical storms, there is more than 100 years of experience on which to draw for preparation techniques, building protection, and deciding when to leave and when to stay.

What no one expected—and no one predicted until it was too late—was the astonishing mountain of water that Ike was pushing in its path. People whose families have lived on the island for generations and whose homes haven’t flooded in 100 years changed their minds about staying. On Thursday, September 11, 2008, two days before Ike hit, businesses didn’t release employees until midday after the storm had shifted northward. Those trying to move to higher ground found themselves stranded, and lower roads had waves breaking over them before dawn on Friday, before the storm officially made landfall.

Reports say that 75% of Galveston Island’s homes flooded, with the main hospital overcome by several feet of water on the main floor. The morgue, blood bank, radiation oncology department, linear accelerator, cafeteria, sterile supply, and pharmacy were all a reeking, slimy, trash-choked swamp. When asked why we had these critical entities on the first floor after the experience with Allison, an official replied that we had to decide whether to spend limited funds taking care of critically ill patients or moving items upstairs to avoid potential flooding. We chose to spend the money saving people’s lives.

The decision was not without its price: more than $700 million in damage, if you include the university campus.

Were we properly prepared? Most medical records were safely stored on upper floors, away from windows. Plus, the facility has a partial electronic medical record (EMR), allowing that critical information to reside in a digital haven. And we had a new server with a history of regular system tests for reassurance. What we had not anticipated, however, was the effect of global flooding that was 9 to 12 ft deep in many places. Roads had to be bulldozed clear for emergency vehicles, search crews cleared rubble looking for survivors and protecting property, and reentry to the island was prohibited for weeks in the aftermath.

Because many patient files resided in the EMR, the decision was made to plug in remotely. One problem: There was no electricity in the building that held the computers housing the coding software. Information services volunteers were allowed emergency entry to the island and the hospital, sliding their vehicles and themselves in inches-thick slime from the Gulf of Mexico. They moved four coding computers to direct hookup with the coding server in the administration building. Sixteen employees, four PCs, $30 million unbilled. Not good.

We ran account reports that could be coded from the EMR, identified coders living on the mainland who, for the most part, were spared from the ravages of Ike (It was “only a 2,” remember?), and figured we’d better find some way to earn our paychecks.

Remote coding was better in theory than in practice. The remote Web connection coupled with the PCs and some type of hub issue made coding so slow and connections so unreliable that we had to go back to the drawing board. The information services staff were invaluable. They set up Web applications and direct wiring for us to work around the hub issue. They hauled full-sized computers and laptops by the hundreds down seven flights of stairs in the dark through slime in the stairwells to set up an instant billing office in rented space on the mainland.

Physician billing and coding, hospital billing and coding, and everyone’s computer people organized work hours and shifts to maximize access to accounts, PCs, and interfaces. Once enough wreckage was cleared so medical records could be physically transported in a safe, secure manner, the HIM staff manually logged and boxed charts and hauled them to the temporary office and then back to the hospital.

As the weeks dragged on and a few floors regained electricity and fresh air (via huge plastic air tubes running through the buildings), negotiations expanded exponentially. Office space, which had been at a premium before the hurricane, now was practically nonexistent. Hospital coders were donated space for two with the pediatric physician’s service coding office. Admitting services made room for another coder as soon as we were able to start treating a few maternity patients in mid-October.

Part of the HIM office regained electricity, enabling it to donate desks and computers on nights and weekends to get in more coding time. Coders became nouveau geeks. We had to learn to remote in to other PCs. We had to type on tiny laptop keyboards. We had to reconfigure our PCs for new printer access. And, on occasion, this had to be accomplished at 2 am.

Eventually, enough repairs were completed, and we were able to return to our office and charts. We knew that layoffs were inevitable and likely to occur sooner rather than later. We found ourselves in the reprehensible position of doing an excellent job of coding the backlog in order to work ourselves out of a job. But we did it; we did it well, and we did it right. We lost half of our staff, while many departments lost two thirds, three quarters, or all of theirs. Patient capacity was cut to 200 patients instead of 600. Two weeks after Ike hit, the medical branch, a level 1 trauma center, was considered as having one of the best patient survival rates in the country. Then we learned that it might never be restored.

Thousands were laid off before Thanksgiving 2008. Many more never returned to the island or left for jobs where they might still find homes or at least family with homes. More left after the layoffs, seeking a security that no longer existed in Galveston. Our future as a care provider is in suspension, locked in a tug-of-war between politics and finances. As of now, we don’t know how much we will rebuild. We don’t even know if we will rebuild. University of Texas regents have announced that the facility will be rebuilt on the island at or near its former capabilities, contingent on additional funding from the state legislature and other sources. There’s hope but no guarantees.

But we do know this: Prepare for what might occur in a disaster. Have processes; have drills. Have plans and have contingency plans for those plans. When it comes down to the real catastrophe, the most important things you must have cannot be planned; they must be built, nurtured, and valued. Have people who can be flexible, who can work together for a common goal, who can put aside personal agendas and do the most with the least. Build trusting partnerships; nurture creativity; value flexibility. If you have successfully done these things, you can weather any storm to the best of possible outcomes.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for nearly 20 years.