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For other articles and previous issues click here. September 23, 2002 Road
to Prevention “The events of September 11, and the subsequent threats of bioterrorism, have placed a spotlight on the inability of our nationís local healthcare delivery model to rapidly move patient-specific and organism/treatment-related data between and among hospitals and private physician practices,” according to a Healthcare Information and Management Systems Society (HIMSS) white paper coauthored by Joyce Sensmeier, MS, RN, BC, CPHIMS, and Kathleen Covert Kimmel, RN, MHA, CHE. “Just as the government built the national highway system after World War II because the existing road system was inadequate to move large numbers of troops rapidly across the country,” Sensmeier and Kimmel wrote, “the government needs to create a national health information infrastructure as a medical communication highway to protect its citizens.” Sensmeier, director of professional services at HIMSS, explains that, as it relates to bioterrorism, there is no existing framework in place across the nationís various healthcare systems and organizations to facilitate a rapid response to a bioterroristic threat or outbreak. “There are so many islands of data,” she says. “For example, each community hospital or public health department has its own network of data, but is not able to determine what is happening in other organizations or regions because they are not connected.” Many within the healthcare community have stressed the importance of a national health information infrastructure, she adds, resulting in a trend within federal and state legislative bodies. “We were beginning to see a trend toward this in the 1980s, within community health networks,” she continues. “With mergers and acquisitions, however, and all that happened in managed care, it was all pushed to the side. Now, unfortunately, we have to leave it to Congress to complete.” The effects of establishing a nationwide information technology (IT) system to protect U.S. citizens against outbreaks of bioterroristic activity cannot be underestimated. From the collection of data to the repository of information for further data mining purposes, a number of IT systems with the ability to conduct symptom-oriented surveillance are in various stages of development. To date, the nation has not maximized the fullest potential of these programs, according to COL Rosemary Nelson, AN, BC, CPHIMS, FHIMSS, chair of the HIMSS National Preparedness and Response Task Force. “If there is a way to utilize the features of technology to better manage symptoms when they are surfacing, and to make information about the best treatment patterns available more rapidly, that would be wonderful,” says Nelson, who stresses that her opinions are solely her own, and that she is acting as a HIMSS spokesperson rather than as a representative of the U.S. military. “More importantly, as a spin-off, if you conducted good surveillance you would also be conducting effective prevention.” IT support could be extremely influential in enabling this surveillance and prevention to occur, Nelson explains, adding that such systems would also play an essential role in nonterrorist-related disaster and emergency response. “Helping to deliver care to patients and documenting that is nothing new,” she adds. “What is new is the ability to improve surveillance, which results in prevention.” Healthcare-related IT surveillance systems are dependent upon accurate and efficient reporting by clinicians, says Nelson. It is not only important to be observant, she explains, but also to understand with whom the documented information should be shared. While reporting of information is voluntary, there are existing guidelines to assist clinicians treating patients presenting with symptoms indicative of communicable diseases. Currently, when patients present with certain symptoms, such as those of AIDS, clinicians are aware of their mandatory obligation to report the incidents. “But now we have begun seeing illnesses like anthrax, for which there are no guidelines and no reporting requirements,” Nelson says. “It will be important to have regulations in place that encourage increased sharing of symptoms. Somehow we need to move to a model that enables us to think of all the possibilities, given the state of the world today.” Among the various disease-surveillance systems currently available, perhaps the most widely used—both inside and outside of government agencies—is the National Electronic Disease Surveillance System (NEDSS), developed by the Centers for Disease Control and Prevention (CDC). NEDSS, Nelson explains, is a national electronic database utilized specifically for surveillance of ailments and symptoms that could potentially arrive at an emergency department. “A clinician is able to enter this information in the computer, send it to the CDC, and quickly receive feedback,” she says. Other systems include the Global Alert Network (GAN), an advisory alert network of IT experts and processes, and the Frontlines of Medicine Project, sponsored by the American College of Emergency Physicians. “GAN is a framework that could be adopted by any institution,” Nelson says. “It provides a model for putting thoughts together related to chemical, biological, nuclear, agricultural, and environmental health concerns. It is a broad-brush approach.” The goal of Frontlines of Medicine is to create standardized, nonproprietary, vendor-neutral processes and data exchange for syndromic surveillance systems, according to Nelson. “There are often trends in emergency departments,” she says. “If there existed a technology-supported mechanism that enabled the sharing of this information among all emergency departments, it would help identify symptoms early and move toward preventing occurrences in areas that have not yet experienced those symptoms.” As HIMSS representatives, Nelson and Sensmeier participated in a recent series of three summits organized by Helga E. Rippen, MD, PhD, MPH, director of the Science and Technology Policy Institute at The RAND Corporation in Arlington, Va. The work produced at the summits has been adopted by the Government Accounting Office as a framework by which to evaluate health systems. “RAND has taken a giant leap forward in identifying and creating the requirements for the direction in which we need to go,” Nelson explains. “In turn, this will serve as guidance to vendors about what types of systems it will be important to build.” There exists a “yearning interest,” she adds, about the topic of IT infrastructures for bioterrorism, resulting in an ongoing demand for knowledge. In addition to her involvement with the RAND institute, Nelson is also chairperson of a newly launched HIMSS Emergency Preparedness Task Force. The society moved forward with the task force when its leaders realized that members have educational requirements related to bioterrorism and disease surveillance technology. “The task force covers the gambit of disaster, emergency, bioevents, and biodefense events,” she says. When forming the task force, it was deemed best to avoid using the word bioterrorism, which tends to connote events that are singularly related to the government or that the government has sole responsibility to fix—both misconceptions, according to Nelson. “Everyone has to deal with emergency preparedness,” she says. “We are attempting to organize a global response that covers emergency preparedness in terms of natural disaster management, as well as for biodefense events.” The sense of urgency extends to the commercial market, where health surveillance systems have been under development since well before September 11. Seven years ago, the U.S. Department of Defense embarked on a program to understand the potential impact of bioterrorist events that evolved into the Lightweight Epidemiological Advanced Detection and Emergency Response System (LEADERS). “The program began by determining the most effective detection and means of coordinating a response in the event of an outbreak,” explains Luke Hannon, regional vice president at Oracle Corporation in Reston, Va. “There were many facets to explore, such as possible organizational responses within different regions, coordination of responses within a given region, and coordination across different governments.” Partnering with Ernst & Young Technologies,
Oracle analyzed the best detection and consequence management methods
and participated in health-related surveillance activities at major
events, including the 1999 World Trade Organization summit, the
2002 Super Bowl, President George W. Bush’s inauguration, and
the most recent Republican and Democratic national conventions,
where officials identified a heightened risk of bioterrorist acts Therefore, LEADERS needed to be simple to use, but highly sensitive, with the ability to detect an emerging outbreak and respond accordingly. The program, now in use in more than 90 hospitals in northern Virginia and Florida, is drawing interest from healthcare professionals and public health officials across the nation. With the focus on security and privacy requirements in both federal and state legislation, the notion of monitoring health-related information and symptomology makes many healthcare administrators a little nervous. But Sensmeier explains this need not be the case. “The Health Insurance Portability and Accountability Act (HIPAA) really lays a foundation for this type of activity,” she says. “Without these requirements in place, we could not safely share the type of data we are talking about.” With HIPAA as a foundation for patient protection, and as more healthcare organizations finalize their plans for HIPAA compliancy, it is possible that the timing for the implementation of health and symptom surveillance technology such as LEADERS could not be better. Of course, there are other concerns, primarily financial, about the requirements for implementing surveillance systems. Electronic medical records systems can be costly, Sensmeier admits, and that expense could make this technology less attractive to smaller organizations. A $4.6 billion bioterrorism defense bill signed into law by President Bush this year includes a provision for $1.6 billion to help state and local programs to develop, among other projects, electronic surveillance systems. Sensmeier adds that cooperative partnerships between government, private, and public coalitions to help facilitate connections between organizations and provide infrastructure would also be beneficial. “This is an area where the government could step in, seeking out partnerships with other organizations,” she continues. “Cost is a big concern for most healthcare organizations, and it would be nice to have some government assistance.” The events of September 11 and the months following merely served to heighten an already existing awareness of the importance and urgency of addressing the nationís vulnerability to potential bioterrorist attacks, according to Hannon. “We are far more aware of our lack of preparedness, which was much more apparent post-September 11 than it was before,” he says. Any sense of urgency, he adds, regarding the implementation of these new systems is priority-based. “This is an immense topic that clearly draws the medical community closer together with public health in our response.” Additionally, the flurry of activity
in response to the crises that occurred last fall have drawn the
attention of the government and increased the likelihood of government
funding, Sensmeier notes. “Many people, I believe, were embarrassed
at the lack of existing technology, huge gaps, and antiquated systems
our government was using. Some of the public health departments
didn’t even have Internet access,” she recalls. “A
wake-up call was needed, and I believe the recent funding for bioterrorism
is going to make a big difference in organizations’ abilities
to obtain what they need. In the end, this could be one of the few
positive outcomes of those events.” Jordan D. Lewis, director of environmental health services for Hillsborough County Health Department, Florida Department of Health, learned of the syndromic surveillance system, developed by Oracle Corporation, in conjunction with the U.S. Department of Defense. “Our county has an ongoing weapons of mass destruction/bioterrorism task force that is responsible for planning, preparation, and prevention activities concerning those issues,” he explains. “The committee decided LEADERS would provide a good data collection system for an early warning system for symptomologies of potential weapons of mass destruction that bioterrorists might use.” Because Hillsborough is interested in studying data collected by LEADERS, officials decided upon nine hospitals reflective of the community which are also connected to the county’s emergency dispatch system. The hospital data stored in LEADERS are downloaded twice daily by the county and are run through a health department statistical application package to detect any aberrations from the hospital’s baseline symptom data. Any aberration detected is investigated by the health department through established protocols. Conditions met by the hospitals included existence of acute-care trauma centers and emergency departments (EDs) that accepted any and all patients. Because controlling data is important, other providers and facilities are not allowed to report to the system, Lewis says. “We had to look at this from a public health perspective and determine the system’s practicality as well as how often we might actually use it,” he explains. “It is important to collect good data and have good baseline information. Data need to be collected systematically, on a timely basis, and in a standardized format. LEADERS offers us a platform to be able to do that.” To date, there have been no detected incidents related to bioterrorism or outbreaks of foodborne diseases, according to Lewis, but the county has been able to determine if symptoms observed in EDs are reflective of the community as a whole. For example, at a time when local EDs noted an increase in diarrhea gastroenteritis, public health officials were able to confirm that the same virus was spreading throughout the community. “This repeated itself last January,” he recalls, “at the peak of our influenza season.” EDs in the county experienced an influx of patients with upper respiratory infections. LEADERS confirmed to public health officials that the methods hospitals were using to gather data accurately reflected the communities they were serving. Lewis feels that LEADERS is currently best suited for large communities with existing communications technologies connecting hospitals and EDs, infection control personnel, the county’s emergency management system, and the public health department. “Smaller communities may not find it effective because it is not a stand-alone system,” he adds. “It needs to be implemented within the context of a total public health surveillance system.” The key to fighting bioterrorism, according
to Lewis, is education and awareness. “In Palm Beach, Fla.,
where they had the single occurrence of anthrax in October 2001,
it was detected by an astute clinician who saw a patient with an
unusual illness and contacted the health department to run additional
tests,” he recalls. Because the patient did not report to an
ED, he notes, LEADERS, on its own, probably would not have detected
that case. “LEADERS is simply another tool that we use. Our
main surveillance system is composed of individual clinicians in
the community reporting diseases or illnesses. In combination, the
two increase the percentage of what could be detected. We call that
an enhanced surveillance system.” |
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