After Jan. 1, an urban hospital's computer system stopped doing some of the most basic things that keep a complex institution running:
* Renewing passwords for busy nurses and physicians.
* Giving new residents access to medical orders and test results.
* Allowing clinical departments to make certain types of appointments in the automated system that schedules patient visits.
The culprit: an old information system in which two digits represent years. The system assumes all two-digit years are in the 1900s, and thus it can't accept the fact that 00 means 2000, not 1900.
By now, it's a familiar scenario of what could happen Jan. 1, 2000, unless healthcare organizations prepare to meet the threatened disruption of clinical and business operations caused by Y2K computer flaws.
But this urban hospital's plight is no scenario. It happened after the internal clock in the computer system at District of Columbia General Hospital rolled over to Jan. 1, 1999.
The security feature assigning password access to all computer applications failed because in trying to set the required one-year limit on passwords, the programming encroached on 2000, says the original programmer, Loran Clark, who's now retired.
The scheduling system still worked with appointments in 1999, but attempts to schedule care for chronic conditions and other ongoing treatment into 2000 caused the program's internal logic to fail, which locks up the computer, he says.
From his home in San Antonio, Clark fielded urgent questions about how and where to change the one-year time frame to six months instead. Within a week, the password program was restored. But, of course, the fix is temporary; it will bump up against the two-digit glitch again this summer.
Clark-who was a member of the team that installed the system in the early 1990s and who helped keep it running at D.C. General until his retirement in 1997-says the millennium problem will only worsen over time.
"They should have been getting off of our system a long time ago," Clark says. The patient-care application was developed in the early 1980s by Knowledge Data Systems, sold to Ameritech Health Connections in the early 1990s and jettisoned a few years ago to a limbo of ongoing maintenance but no new development.
D.C. General officials declined to respond to questions about the system problems and their resolution.
Computers and more. A nationwide explosion of information system replacements shows that most healthcare organizations have gotten the message about bringing software up to millennium speed.
Resolving flaws in bread-and-butter financial and patient-accounting computerization is such a high priority that it's eclipsing other information technology priorities, such as purchases of clinical information systems (April 5, p. 52).
But just patching or replacing computerized functions isn't enough to ensure business as usual as 2000 nears, industry experts warn.
So many crucial aspects of healthcare operations are beyond organizations' control that contingency planning is warranted regardless of the Y2K readiness of computer chips and programs, says Karen Ondo, vice president and chief information officer at North Broward Hospital District, Fort Lauderdale, Fla.
The network of four hospitals and 40 other ambulatory-care sites began planning for computer readiness three years ago and is wrapping up that phase of the Y2K problem.
But in December, management, top executives and key staffers attended a three-day retreat to condense North Broward's raison d'etre into eight basic categories of business and clinical purpose.
"When you narrow it down, this is what we're all about," Ondo says of the list, which includes activities such as employing people, caring for patients, purchasing supplies and managing the organization financially.
The system analyzed the threats to each process, which helped it develop a range of contingency plans dedicated to maintaining minimum operations despite such problems as payment disruptions, water shortages and delays in resupplying what's now a just-in-time inventory (See related story, below).
Down to basics. Across the country, healthcare organizations are similarly shifting focus from the complexities of information technology readiness and toward simplicity itself-staying in business.
That's why even though Covenant Health System's three key information systems are ostensibly millennium ready, it has devised a backup plan to run laboratory and pharmacy operations manually for days, says Andrew Huff, senior vice president of support for the three-hospital network in Waterloo, Iowa.
Despite that computer readiness, "the potential is there" for problems in passing results between systems, Huff says. "So much medical care is driven off of lab results that we have to make sure we have accurate lab results."
Allina Health System in Minneapolis has focused on alternatives to computerized operation in the departments that must continue functioning in a crisis, either because patients there are unstable or because the department is a key access point for incoming patients. Those departments are emergency, intensive care, surgery, high-risk obstetrics and the cardiac catheterization lab, says Sue Trossen, one of Allina's chief clinical coordinators of Y2K-readiness activities.
A compilation of alternative measures and contingency "templates" is available networkwide. In addition, a team has developed 40 scenarios for high-risk biomedical devices.
But solutions aren't necessarily adapted the same way everywhere, Trossen says. They can be tailored to the different possibilities for trouble that can be imagined at each of Allina's 11 hospitals and 60 clinics in urban and rural areas of Minnesota.
For example, one urban hospital can count on 100% generator backup in a power shortage, but others have only enough generator capacity for emergency life support, especially in rural areas, she says.
As D.C. General found out, the Y2K problem can crop up well before the much-anticipated year-end flash point. That's why Allina is busily weaving its safety net based on a timetable that requires contingency plans to be finished by June 1, and drills and practices to be conducted by Sept. 1, says Alan Abramson, the healthcare system's vice president for information services.
Allina's Y2K preparations are split into two parts-patient-care processes and business continuity, Abramson says.
But the two parts are inseparable in many hospital processes, especially in patient registration, where business management meets clinical support, Trossen says.
The foundation for clinical orders and results from laboratory, pharmacy and radiology departments is a patient-tracking system using a medical record number assigned by the admission-discharge computer application, she says.
Admission mission. After the emergency department, admissions is one of the most important areas to keep going, says Bob Relph, divisional vice president in the Clearwater, Fla., office of Superior Consultant Co., a healthcare information systems consulting firm.
"If the main information system fails," Relph says, "how are you going to move the patient through the (healthcare) system?"
Whether failure results from computer problems or a general power shortage, hospitals should have a backup plan that includes a well-organized and rehearsed switch to manual processes, and that addresses when to tap extra staff, Relph says.
At North Broward, managers are confident in the central admission-discharge information system, but two levels of fallback maneuvers are in place just in case, Ondo says.
A system for clinical order entry and results reporting has a registration capability that's usually turned off because that system takes patient information from the main registration system. But the built-in registration feature can take over when the main system is down, she says.
Registration employees also are trained to use manual forms when both systems are down, which happens at least twice a year during changes to and from daylight-saving time. The system was able to test manual alternatives last year when a major upgrade to a database took the registration system down for 18 hours, she adds.
Tracking patient data. At Covenant Health System, says Huff, the registration system starts the pharmacy system's complex management of medication-posting orders to a patient's name, tracking the administration of medications and changing or stopping orders during patient stays.
Keeping track of all the medication activity is crucial to patient care but virtually taken for granted because of the automated efficiency of computer systems, Huff says.
Covenant is planning a manual backup in case something happens to the pharmacy system, but it won't be easy. To begin with, "we're going to be printing a whole lot of paper on Dec. 31," he says.
That will give the hospital system a baseline of information about all patients, their status and their pharmacy orders just before the rollover to 2000. Then a force of clerks and runners will add to or subtract from the paper record.
The manual management of medication records could continue for about two days before the process became bogged down by subsequent discharges, new admissions and the sheer volume of transactions, Huff says.
At that point, the organization plans to cut off the order and fulfillment activity and start fresh with a new printout of patient census from the registration system.
Another major push at Covenant will be confirming that laboratory results are accurately reported throughout the health system, from the biomedical devices that produce the data to the electronic handoffs between computer systems as the results are distributed.
Although the three main information systems that capture and report lab results have been upgraded to handle 2000 in dates, all three manufacturers used different technical solutions, Huff says, which introduces uncertainty as to how they will mesh.
On Jan. 1, Covenant will station people at laboratory machines to write down results before they're fed electronically into the laboratory system, and other staff will be at the printers at nursing stations or other final destinations of the results.
The written results will be compared with the electronically transmitted information for accuracy until managers are confident that lab values have not been corrupted anywhere along the way, Huff says.
The health system has three labs, and each lab has as few as six analyzers and as many as two dozen to monitor.
"We're hoping we're only going to have to do it one day," Huff says.
Educated assumptions. In addition to internal problems, healthcare organizations must deal with possible threats of Y2K-triggered trouble from power outages, telephone access problems, water shortages and other external disruptions.
Executives are skeptical about dire scenarios such as widespread blackouts. "That's going over the top," Relph says.
But executives should be concerned about the potential for less-severe strains on basic services, he adds. "There are going to be brownouts-spot utility brownouts."
Contingency planners must consult local officials to discern the community's level of readiness and commitments to service for healthcare facilities, says Ed Blonski, executive vice president with the year-2000 practice of Superior Consultant. If utilities give strong assurances, planners can concentrate on other contingencies, he adds.
But be careful how those assurances are worded, says Audie Lewis, director of material program development at Lee Memorial Hospital in Fort Myers, Fla., and a Y2K-readiness consultant. "You've got to dig under the surface," he says.
For example, a hospital that's assured of being a first priority for electrical power should not assume that means full power, Lewis says. The utility may be rationing power to all customers at less than 100%, which might not be enough to keep some operations going.
Hospital power circuits usually are prioritized so life-support areas such as emergency and surgery are covered for a partial loss of wattage, he says. But at 40% of electrical capacity, computer-based records may not be a high enough priority to continue functioning.
Another consideration is power supply to patient rooms. If power is disrupted, one outlet typically remains hot while others die, Lewis says. "The thing that may be most important in a room may not be plugged into the emergency socket," he says.
With technology so pervasive, it also pays to think twice about fallback devices. As a telephone backup, for example, cell phones have replaced citizens band radios and walkie-talkies, which once were unpacked in emergencies. But those low-technology devices could be the best options.
While cell phones normally operate beautifully, they depend on high technology and computerization, which carry the highest Y2K risk of communication options, Lewis cautions.
Limiting the load. Rather than planning to preserve business as usual, some hospitals are deciding to keep core services running and to idle other operations temporarily based on what the year 2000 brings.
The object, Blonski says, is to trim the total operational load to a manageable size. For example, scheduling fewer elective surgeries means hospitals don't have to plan contingencies for a full house, he says. If the registration and order systems fail, there will be less strain on staffers fighting to perform operations manually.
North Broward is planning to release patients before the end of the year if they don't absolutely need to be in the hospital, Ondo says. System hospitals will accept urgent cases but won't schedule elective surgery until Tuesday, Jan. 4.
Some healthcare organizations are planning for disruption during the entire first week of 2000, but North Broward is confident enough in its Y2K planning and investments that it predicts a return to normal procedures after three days, Ondo says.
Allina is focusing first on critical-care and obstetric services and then weighing which other services to include, Trossen says. Changes include moving obstetrics from the third floor of some rural facilities to pre-operative suites in the first-floor surgery department, she says.
Covenant plans to use extra staffers and temporary help for a courier and communication system, Huff says. The health system also has a strong volunteer program, which will press Waterloo-area citizens into service, he says.
Given the lack of work inherent in a Y2K crisis, another source of couriers is staffers who have been assigned to fix problems with personal computers and workstations.
Overall at Covenant, oil tanks will be full, generators will be ready to run, and enough water will be on hand to supply 5,000 to 6,000 gallons per day to boilers in Iowa's January cold, Huff says.
"All of this is with the deep-down hope that we don't need any of it," he says. "We're hoping we can have a big bonfire on Jan. 2 or 3 for all of these contingency plans."