Editor's note: This story was updated to include comments by Mark Kennedy, general counsel for Hays County, and to clarify the discrepancy between the data the county expected to receive and what Ascension Seton was required to provide.

On Sept. 23, there had been 180 total reported hospitalizations of Hays County residents due to the coronavirus. On Sept. 24, that figure jumped to 341—an 89.44% increase.

The sudden addition of 161 hospitalizations was not due to a new surge in serious cases, but was instead an update issued by Hays County to account for a discrepancy in how a regional medical system recorded COVID-19 hospitalizations and how the county interpreted the data, according to Kim Hilsenbeck, Hays County's communications manager.

"There is a distinction or a difference between what the hospital is interpreting as its legal obligation and what we would like in terms of numbers. We want to express the reality," said Mark Kennedy, general counsel for Hays County. "The legislative obligation, or the statutory obligation, that the hospital has is different than that, and they've expressed that."

The 22 residents of Hays County who were hospitalized as of Sept. 24 remained accurate after the update—a reduction from 23 a day earlier—and reporting of COVID-19 deaths was not affected by the issue, Hilsenbeck said. One of the hospitalizations reported Sept. 24 was a current case.

From the beginning of the pandemic until mid- to late-August, Hays County residents admitted to Ascension Seton hospitals were not tallied as a COVID-19 hospitalization in reports to the county unless testing for the virus was conducted by the hospital, according to Hilsenbeck, who added that was Hays County's understanding of the situation.

Ascension Seton provided the following statement: "Ascension Seton reports cumulative numbers of hospitalizations to the Texas Department of State Health Services. This is done by reporting daily admissions, hospitalizations and deaths to EM Resources. Hays County and all other counties have access to their respective county information at the state level. At the request of Hays County, Ascension Seton currently provides a daily report with this information to Hays County."

Regional hospitalization data determines such policies as when elective procedures can be offered by hospitals and when nursing homes can accept visitors. Having incomplete data can mask the extent of risk factors considered in such decisions.

Kennedy said that it would have been impossible for the county to know about the discrepancy without going into the hospitals to perform their own assessments. In addition, he said the hospital confirmed to the county that it was providing all the data it was required to report.

"They referred it to their legal [department] to confirm what their obligations are," Kennedy said. "They and we received feedback on that, and then of course we had to have a discussion about what we want versus what they're obligated to provide."

According to Kennedy, the discussion of what was required to be reported and what the county believed was necessary to give an accurate representation of the situation contributed to the delay in reporting.

"When legal gets involved, oftentimes the conversation can get a little confusing because legal's oriented around compliance," Kennedy said. "Hays County—the entity that's reporting those numbers to the public—doesn't just want compliance. We want to reflect reality. That's why it took a little while."

Bringing the data to light

The delay between the discovery of the discrepancy and its announcement Sept. 24 was partially due to the process of sifting through the data to weed out duplicates, residents of other counties and other outliers, according to Hilsenbeck.

"You may not see this from the outside, but there's probably a little fatigue inside from all of us because we've been talking about this for a while," she said. "It took hours and hours and hours for our epidemiologist team to scrub the data."

She said the COVID-19 hospitalizations went unreported to local health officials until the miscommunication between Seton and the county was recognized following inquiries made by Texas State Rep. Erin Zweiner in July.

Zweiner had acquired hospital data from Seton that did not match what the county reported at that time and publicly called the county out over discrepancies distinct from the ones reported Sept. 24.

"It came out because of Ms. Zweiner, and I have to say we're pretty grateful that she was so adamant in her belief that the numbers were wrong," Hilsenbeck said. "When Ms. Zweiner was saying, 'Your hospital numbers look wrong, and I have information showing that there were actually more hospital cases,' I think it kind of brought it to light for everybody."

Community Impact Newspaper learned of the discrepancy in mid-September and was working to verify the information when the county released the update.

When asked about the numbers before the county issued its press release, an Ascension Seton spokesperson provided multiple statements via a series of emails that did not acknowledge the discrepancy.

In one statement, Seton stated that its reporting was in line with state law, and it was not required to report when an individual with a previously confirmed communicable disease was hospitalized.

In another statement, Seton declined to say whether or not its data on all coronavirus hospitalizations of Hays County residents was accounted for on the county's COVID-19 dashboard.

Hilsenbeck suggested that the situation could have been caused by a coding error that escaped notice due to the challenges of providing health care during an unprecedented pandemic.

"How do you know there's a problem until you know there's a problem?" Hilsenbeck asked. "How would you have audited or checked that if you didn't know you weren't getting everything?"

While a clear picture of county resident hospitalizations is beginning to come into focus, the impact of these hospitalizations going unreported is still murky.

"The reason these numbers are so important is because they are how Hays County residents make decisions based on what levels of risk they can accept in their day-to-day life," Zweiner said. "Our residents deserve to know that, and to me it's critical that the county is prepared to provide the best possible information to our residents if we have a future spike."

Having an accurate understanding of county-level hospitalizations also has a direct impact on public policy, Hilsenbeck said.

"Because of the nature of what that data is used for, like: should we reopen restaurants; can we bring students back to schools; can we open businesses—those critical pieces of information, like hospitalization cases, are all factored into those types of decisions," Hilsenbeck said. "The county is under whatever orders have been put out by Governor [Greg] Abbott. ... But I know that the factors that they're using at the state—it's the same ones that we're talking about here."

Earlier this month, Abbott used the ratio of COVID-19 hospitalizations to non-COVID-19 hospitalizations at the regional level to declare whether some hospitals could provide elective procedures. He used the same ratio for nursing homes and allowances for their visitors.

Seton, which operates hospitals throughout the Austin metropolitan area, did not address questions from Community Impact Newspaper about whether or not the same discrepancies appear in hospitalization numbers reported in other counties.

Broken up over six months—roughly the time between the first reported COVID-19 case in Hays County and when the reporting issue was discovered—there were an average of 26.66 unreported hospitalizations each month. However, they would likely be skewed toward June and July when the county witnessed a large surge in cases.

Zweiner remains steadfast in her belief that the county bears some responsibility for the delay.

"While I am grateful that they did this update, I remain concerned about transparency issues with Hays County in that this took two and half months to be made public," Zweiner said. "I really hope that in the future, the county will make keeping the public and local elective informed of data discrepancies a bigger priority, and I hope that will change in the future."

Hilsenbeck maintained that the county did not purposefully hold back hospitalization data from Zweiner or the public.

"The accuracy of the data is always dependent upon the accuracy of the information that you're given, and that's what we have all strived to make sure that we're doing," Hilsenbeck said. "When you find these glitches and you find these issues, you just want to correct it. You just want to make sure that doesn't happen again."