England's little Excel problem

England has not come out smelling of roses in its dealings with COVID-19 since the start of the pandemic and it didn't get much better last week when it was revealed that the use of an old Excel file format meant almost 16,000 positive cases had been left off a list and up to 50,000 close contacts might have been missed.

The rest of the UK is looking a bit better, both in terms of infection rate and death rate, but when the numbers are combined the UK still has the highest rate of deaths in Europe due to some shocking bungling by its government and a silly error like the one discovered by Public Health England (PHE) has not helped much.

According to a nice little explainer here from the BBC, the error was caused after CSV files containing logs of swab tests were automatically added into Excel templates set up for the purpose by PHE. Unfortunately, the templates used the old XLS (.xls) file format rather than .xlsx, even though the new format was introduced back in 2007. It meant that the templates were limited in the amount of data they could hold and thousands of cases simply fell of the end of the list in the week before the error was discovered on October 2.

The use of legacy systems and old file formats by a public health authority would come as no surprise to anyone working in healthcare, but it did to some. The BBC quoted Cambridge University computer scientist Jon Crowcroft as saying Excel “was always meant for people mucking around with a bunch of data for their small company to see what it looked like … But you wouldn't use XLS. Nobody would start with that.”

Hmm. Welcome to the healthcare industry, professor. Excel has a long and glorious history in public health, particularly in clinical research, where it has long been used as an ad hoc patient database. We suspect it continues to be used for such purposes, just as we suspect Excel is used in along with pen, paper and whiteboard for contact tracing in many jurisdictions that haven't made the change to a specialist system or a generic CRM like Salesforce. The odd outlaw may have upgraded to Google Sheets but that's as exciting as it gets.

A bit more exciting is Apple, which this week announced it had partnered with three healthcare institutions in Canada and two NHS trusts in the UK to join the 500+plus health systems in the US that allow patients to see their hospital records on their iPhone through Apple's Health Record app. Apple uses a FHIR API to integrate the app with the hospitals' EMRs, which in the case of the Canadian sites are Epic and Allscripts systems. The two NHS trusts use Cerner.

While giving patients access to their hospital records is the way forward we have yet to see any good figures on actual meaningful use of the app by patients versus simple downloads. If you know of any studies, give us a bell. In the meantime, the three EMR vendors mentioned control the vast majority of the EMR market in Australia between them and we'd be interested to see similar functionality roll out here. If you know of any plans that are afoot, let us know.

Cerner was in the news here in Australia just this week, with NSW Health releasing its promised call for expressions of interest to deploy a single digital patient record platform for the state. This hopes to bring together the different instances of NSW's Cerner eMR along with the Orion system in use in two health networks, as well as the several patient administration systems in use (Cerner and DXC) and the handful of pathology and forensic science laboratory information management systems.

The expression of interest documents also pointed to the development of a clinical health information exchange (CHIE) platform to link up specialist clinical systems and other solutions like the Telstra Health EMR used at Northern Beaches Hospital and St Vincent's Hospital into the SDPR. A shortlist of candidates should be revealed at the end of the year with a successful vendor or consortia of vendors announced in the first half of next year. It's going to be a very interesting project to watch.

In budget news, the Australian government revealed the total budget for MBS-funded telehealth since the pandemic began in March was $2.4 billion, up to and including the recent extension out to March 31 2021. It is quite clear that the government will make this a permanent feature of Medicare, and allocated $18m in the budget to develop an “interim system to support ongoing telehealth in the future”. What that interim system involves is anyone's guess. Hopefully more details will be made available soon.

Speaking of telehealth, last week's poll question asked: Is the ease of use of video-based consultations overhyped? 65 per cent said yes, 35 per cent said no.

This week, we ask:

Are you aware of anyone still using Excel for clinical purposes?

Vote here and feel free to leave your comments below.


0 # Daniel Peyton 2020-10-10 11:33
This in no way surprises me, as a clinician having managed various clinical databases at various hospitals over the past 10 years.

I’ve had a conversation on this very issue this week about the benefits of using excel (cost, low technical barriers to use) vs drawbacks (poor usability, findability of data, poor presentation of data) for a database of services in the community.

I’ve seen Microsoft access database used for keeping a bespoke list of surgical patients (eg their operations, imaging findings, surgeon etc) but a 3am coding upgrade left the list unusable for a week as only one person on the team knew their way around an access database.
The problem with google sheets it less people are familiar with it, and the information is stored on the cloud and this not appropriate for identifiable confidential information.

I would love to know what people’s thoughts are on what the best database is? And one that can be stored locally (in case the database has confidential data), is easy to use, is free, and you can change the way the data is presented to different users depending on their needs?
0 # Alison Johnson 2020-10-12 09:04
Hi Daniel,
Have a look at RedCap. It is being used more and more in the hospital setting for patient data collections and analyses. It has the added benefit of sitting outside of a department based IT folder. So people from different services and departments can input information to the one place.
0 # Alison Johnson 2020-10-12 09:02
In Public health - this is it.
There is no funding for a systematic alternative that is open to all.
RedCap is the tool that appears to be replacing excel for those in clinically based research ... but for most people... excel is it.

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