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November 27, 2006
The accuracy of electronic information systems and their ability to share data helped lessen the effects of this summer’s spinach-related E. coli outbreak. If you weren’t impressed by the speed that the E. coli outbreak in bagged raw spinach was identified and communicated to the public late this summer, perhaps you don’t know enough about what happened behind the scenes, much less the role HIT played in accelerating the identification and communication processes. Less than one week had passed between the time Wisconsin health officials contacted the Centers for Disease Control and Prevention (CDC) to when the CDC issued its first alert and the FDA issued a press release warning consumers not to eat bagged raw spinach. For many people, particularly those in public health, that time span may still be too long. Nonetheless, by comparison to previous similar outbreaks, the timeframe was considerably more narrow. And if the CDC, the American Health Information Community, and the Office of the National Coordinator for Health Information Technology realize their visions for interoperable electronic health information networks, that timeframe will diminish further, becoming closer to real-time. NETting the Recent E. coli Incident
PulseNet identified the first cluster of cases linked to E. coli-related illnesses in Wisconsin on September 8. By September 13, it identified a second cluster in Washington State and potential cases in several other states. The outbreak was formally identified that same day by OutbreakNet, a network of public health epidemiologists that investigates foodborne disease outbreaks. While PulseNet ran data looking for patterns and fingerprints, Wisconsin epidemiologists began interviewing people who had become ill. Based on these interviews, they suspected spinach as the likely culprit of transmission. Epidemiologists in Oregon held similar suspicions based on comparable interviews with those who had become ill in that state. This and similar data from other states was shared during an OutbreakNet conference call on September 14. The group found the combined data compelling, concluding that spinach was the likely E. coli carrier. Within one hour of the call, CDC and FDA officials worked together to develop a coordinated communications plan involving press releases and public health alerts. These steps activated other electronic information systems that are part of the CDC’s Public Health Information Network (PHIN), a major initiative intended to support public health preparedness for detecting and responding to public health emergencies. Using IT to Better Protect the
Nation’s Health “The CDC has taken a very aggressive stand in recent years, working with our trading partners in both the state and local public health entities as well as commercial sector hospital associations in advancing the importance and use of IT in our business,” says Scott Danos, acting deputy director of the CDC’s Division of Integrated Surveillance Systems and Services. The CDC’s trading partners include national clinical reference laboratories and other national organizations, such as the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and the Association of Public Health Laboratories. “They’re supportive trading partners with the CDC and public health as we all move toward articulating and embracing a set of standards to exchange information, which is a profoundly important component in helping public health do a better job,” says Danos. The PHIN functions and specifications are consistent and compatible with standards promoted by the National Health Information Network and other work of the National Committee on Vital and Health Statistics. PHIN works within the Federal Health Architecture, a collaborative forum for creating a national, interoperable HIT framework for use within the federal government, as well as between other public and private sector organizations. NEDSS: A Cornerstone of PHIN Now one of many PHIN components, NEDSS remains a cornerstone in PHIN’s foundation. “The NEDSS project predated some of the things that are in the forefront today,” says Danos, referring to PHIN. “And in that context, PHIN is helping to inform the process around the work of the American Health Information Community and organizations like that.” NEDSS integrates and replaces several current CDC surveillance systems, such as the National Electronic Telecommunication System for Surveillance, and increases the timeliness and efficiency of data transfer. Its standards, policies, and procedures provide a framework for state and local health departments to follow for designing, developing, and supporting the IT systems that public health needs. Through NEDSS’s standards-based, integrated approach to disease surveillance, the CDC is working to connect public health surveillance to the ever-widening clinical information systems infrastructure. The CDC’s larger aim is to improve the nation’s ability to identify and track emerging infectious diseases, including potential bioterrorism attacks, investigate outbreaks, and monitor disease trends. Over the past five years, NEDSS’s scope has grown to encompass related activities, namely funding and software development, which further facilitate the wiring of public health organizations across the country. According to Danos, NEDSS currently provides approximately $10 million per year in state funding for the specific purpose of supporting IT systems that are interoperable and built around the NEDSS standards and specifications. States that accept funding to build their own systems sign a cooperative agreement with the CDC, which requires them to be compliant with the relevant standards, thus ensuring the interoperability of those systems. NEDSS also builds software that meets these criteria: the NEDSS Base System. This software allows for secure data entry, reporting data analysis via the Web or a secure Internet connection, electronic interchange of laboratory data, and data storage and maintenance. Users enter only enough deidentified data for the CDC to create a national perspective about the reported event. It can also use the system to search demographics and nationally notifiable diseases. Standardized messaging enables the receipt of electronic data into the system. Together, this functionality speeds reporting and allows authorized state and local public health professionals simultaneous access to information. For anyone in public health used to paper-based reporting, the difference using NEDSS Base System can be dramatic. Today, 13 states use the NEDSS Base System and more are in the process of implementing the applications. “States have the option to build systems that improve their ability to meet public health demands rapidly, but in the instance where they aren’t able to or have challenges that they need to work through, the CDC is also in the business of providing some of those solutions to those states,” explains Danos. According to Danos, while states are not required to implement NEDSS, the CDC does provide incentive and encouragement for them to do so through funding, peer support, and even peer pressure. These combined tactics are producing measurable results. “In January 2005, 21 states in the U.S. had Web browser-based integrated surveillance systems,” he says. “Today, there are 35. And states that are able to exchange laboratory results data electronically went from 15 in January 2005 to 35 today. These are just two examples of the progress that we’re seeing.” Danos attributes this progress directly to the work being done by the CDC and its trading partners that maintain a steady focus on the goals of the PHIN and NEDSS. For the first nine months of 2006, the 13 states using the NEDSS Base System sent 137,000 reports of notifiable diseases to the CDC, a significant accomplishment, according to Danos, since NEDSS broadens the database with which state and local health departments work. From Surveillance to Alerts BioSense is a Web-based bio-surveillance system—that is, a system that receives and processes electronic data that are useful for monitoring disease trends. The system is intended to provide awareness of suspect illness and possible disease cases before, during, and after a health event. It’s also designed to help confirm whether an event has occurred, and if so, to monitor its size, location, and rate of spread. “We see [BioSense] as a way to accomplish something we call situational awareness—in other words, to be aware of what’s going on and to assist in an outbreak or other public health situation,” says Jerry Tokars, MD, medical epidemiologist and associate director of science for the Division of Emergency Preparedness and Response at the CDC. BioSense receives electronic data that are useful for monitoring disease trends from system users, who include personnel at state and local health departments, laboratories, and participating hospitals. “Data sources also include outpatient clinics associated with the VA [Veteran’s Administration] and DOD [Department of Defense] facilities and outpatient clinics associated with major hospitals that are a part of our system,” says Tokars. In 2005, the CDC began recruiting volunteer hospitals to transmit real-time data to BioSense. Its intent has been to strengthen the BioSense application by underscoring public health access to real-time, clinically rich data from emergency departments, outpatient clinics, and other hospital settings. Ultimately, the CDC sees BioSense providing a real-time picture of how a community or other geographic area is affected by an emergency public health event as it’s happening. The CDC has developed other PHIN components to allow for and manage the necessary communications about a detected public health event. The Partner Communication and Alerting component includes two tools: Epi-X, a Web-based, secure online investigation tool that is capable of sending alerts through secure channels; and Health Alert Network (HAN), a nonsecure, one-way alerting system that allows the CDC to send information about public health events to a broad group of partners. Epi-X transmits alert information to appropriate public health authorities in the United States and beyond if necessary. Any authorized public health administrator may log on to Epi-X as a contributor. “It’s not unusual at all for such a person to alert the appropriate public health entities around the country to an emerging issue and say ‘please contact me if you see this type of case or if you have this type of experience,’” says Danos. “Epi-X has been in place for quite a number of years, has been very well received, and is very important to public health today.” The HAN sends messages in three distinct categories. Health Alerts provides information that necessitates immediate action or attention; Health Advisories transmits important information for a specific incident or situation, which may or may not require immediate action; Health Update, as its name suggests, provides updated information on an incident or situation. According to Danos, during the recent E. coli event related to raw spinach, PHIN’s Partner Communication and Alert systems were quite active. The HAN component sent its first message about the outbreak the morning of September 14 and subsequent notices in the days and weeks that followed. Communications and alerts over Epi-X were also numerous. What made the response to the recent E. coli event unique for Danos and others at the CDC was that through the use of CDC IT systems, the agency, in consultation with their public health colleagues in state and local health departments, was able to communicate rapidly and effectively while tracing the outbreak to an exact type of E. coli, and further, tracking that particular E. coli to a specific source. “That’s the significance of it being attributed to a single food source that had a national impact,” says Danos. “Clearly, health IT is foundational to what public health does today.” — Aggie Stewart is a freelance writer and editor, specializing in HIM and HIT. She also serves as consulting editor of Health Information Management Manual, 2nd edition. Reference New School: HIT in the Classroom While the Centers for Disease Control and Prevention (CDC) and its trading partners continue to evolve and implement the National Electronic Disease Surveillance System and the Public Health Information Network, some clinicians are already experiencing the value of applying HIT to public health events. One such clinician is Linda Hummingbird, RN, BSN, school nurse and school health services coordinator in the Health Center at the Santa Fe Indian School in New Mexico. This unique school is owned and operated by the remaining 19 Pueblo tribes in New Mexico. Its 700 students in grades 7 through 12 come from those 19 tribes as well as one Navajo and two Apache tribes. Approximately 550 students, who come from communities as far as 100 miles away, live on campus in dormitories; the remaining 150 attend as day students, commuting by bus from the nearest pueblo, which is eight miles north of the school. On average, 25 to 30 students come to the Health Center each day, usually presenting with a range of health complaints. In late September 2005, however, Hummingbird began seeing a rise in the number of students presenting with identical symptoms, all of which pointed to gastroenteritis. When the number rose to five students per day with identical symptoms, Hummingbird e-mailed a pediatrician at the nearby Indian Health Service hospital to ask whether the hospital was also seeing a rise in the number of children and adolescents with these symptoms. He said no and suggested she was seeing a seasonal viral gastroenteritis. “I didn’t buy it because the numbers were too high,” says Hummingbird. And Hummingbird had the numbers to back up her observation that the gastroenteritis she was seeing was neither typical nor seasonal. Her data came from what she documented in HealthOffice Enterprise, an electronic medical record for kindergarten-through-12th grade schools developed by Michigan-based Healthmaster. Designed with input from school nurses and other healthcare professionals, HealthOffice stores demographic information, emergency contacts, medical alerts, immunizations, symptoms, diagnoses, scheduled medications, special education events, and Medicaid billing information. These data can be entered and stored in the software’s database and retrieved vis-à-vis a variety of standardized or customized reports. According to Healthmaster CEO Martin M. Smith, approximately 5,000 healthcare professionals in more than 600 school districts nationwide rely on its software to document, track, analyze, report, and electronically store their student health information. “The data has a great deal of integrity since it is entered at the time of an encounter rather than based on a provider’s memory of what they did,” says Smith. As Hummingbird observed an increase in the number of students presenting with the same symptoms, she confirmed her observations with the daily data stored in HealthOffice. After nearly three weeks, her data confirmed that approximately 10% of the student body had presented with the same symptoms. That’s when she contacted epidemiology at the New Mexico Department of Health (DOH). “The data indicated that I had a small epidemic going on,” Hummingbird says. Up to that point, Hummingbird had been sending ill students home, only for them to be reinfected upon their return. In an effort to break the cycle of contagion, she encouraged the school superintendent to close the school for four days. The data stored in HealthOffice played a large role in winning her case. HealthOffice’s alert feature enabled Hummingbird to act proactively to prevent the school’s more medically fragile students from becoming ill by spotlighting those with special health conditions, such as heart disease and diabetes. Once she realized she had a problem, she ran a report of these students and called their families to pick them up. “I did not want those kids on campus because they were at high risk of contracting the virus,” says Hummingbird. “I assured the parents that I would call them to let them know when it was safe for their children to return to school.” When epidemiology’s field team from the DOH arrived on campus, it expected to start its investigation by sifting through paper charts to track demographics and symptoms of the ill students. The team needed the data broken down by body system and symptom. Although HealthOffice had the data, a custom report had to be written to collate them in a usable format for DOH purposes. During a five-minute call to Healthmaster’s IT department, Hummingbird described what she needed and why. The IT representative wrote a customized report program based on her specifications, then e-mailed it to Hummingbird, who installed and ran it, producing exactly what would have taken the DOH team days to extract from paper records. “It was beyond awesome,” says Hummingbird. “In this day and age of declining customer service, the fact that someone would be that conscientious and helpful to right on the spot devise the program that I needed and e-mail it to me was incredible.” The DOH team was similarly thrilled when Hummingbird handed them five sheets of paper with the information it needed. It meant it could move forward more quickly by looking through the data for commonalities, such as clusters of students from a particular grade, geographic area, and families in which other members had been similarly sick. The DOH further used the data to develop a questionnaire for students and staff that had become ill and those who had people at home who had become ill. Based on the data Hummingbird provided the DOH team, along with the team’s on-site investigation, it determined that the gastroenteritis had been caused by a type of norovirus. The DOH then gave Hummingbird information that she could distribute to the school community about the virus, how to contain it, and how to treat it. “Having the data created an awareness of a possible problem and therefore something that needed to be looked into,” Smith says. “Without the software, it would have been even more of a nightmare,” says Hummingbird. “As it was, I was working 12- to 13-hour days. Without the software, I might have put in even more hours per day and over a longer period of time and wouldn’t have been able to spend as much time taking care of sick kids. And the impact to the school community would have been even greater than it was because it would have taken me longer to pull together the data that reflected the situation.” — AS
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