Rx for Ebola: Protect the Perimeter with Decision Support and Surveillance

A man walks into an emergency room with a globally notorious febrile illness wanted for mass killings in other countries.  Instead of being diagnosed and treated, he is released back into the community, continuing to expose health workers and community members without warning.   While this may sound like the September 2014 Ebola virus fumble in Dallas, it was also the scenario that drove the SARS epidemic in 2002-3 when, as today in Africa, health care facilities were a major node of transmission.

Back then, a small cadre of techies and local public health workers developed a scalable process of perimeter screening at emergency departments that fed into a public health surveillance system (the SARS Surveillance Project).   Front line health care workers welcomed a simple decision tool to distinguish routine fevers from possible SARS, allowing them to initiate infection control to protect themselves and their patients.  Health departments received immediate notification of suspect cases and daily trends of respiratory febrile illness.   In a matter of days the system was operational in Milwaukee, and within a few weeks across parts of Ohio, Colorado and Texas too.

The system might be considered laughably simple today (yes, it involved paper, pencil and arithmetic).  It was slapped together with tools at hand and without federal funding.  Nevertheless it scaled far faster than the anticipated SARS epidemic.  (We never found a SARS case, nor were there cases to find in our jurisdictions.)  The Dallas experience proves that a similar approach is needed today.   I hope our old publication might prove useful to today’s Ebola virus fighters.

We failed to get CDC to pick up or even endorse the project.  It fell victim to the “not invented here” syndrome.  (Although we showed we could rapidly scale to EDs serving more than a quarter of the US population, the last conversation ended with “We already work with an emergency department in California, thank you very much” [emphasis mine]).*

A larger question is: are we better equipped to scale up such a system today after US$ billions of investment into health information technology?   The short-term answer is “No”, outside some local centers of excellence.    But there is little reason we couldn’t get there with a little strategic leadership and investment.

Imagine that CDC translates Ebola suspect case definitions (symptoms, signs, travel, sick contacts) into standardized HIT data elements.  Imagine these are loaded into a standards-compliant rules repository accessible to electronic health record systems (EHRs).   Imagine that EHR systems upload these rules to alert triage personnel to ask 4-6 brief questions of febrile patients.   Imagine that responses suggesting Ebola trigger immediate infection control and public health reporting.  Imagine that patients, healthcare workers and the community are protected pending definitive diagnosis.  Imagine that emergency response receives the gift of a head start on the possible emergence of a generation of new cases.

In recent years the pieces of this more automated solution have been largely completed but not assembled and applied: widespread certified EHR use; specifications for capturing most of the needed data elements; methods to distribute clinical decision support rules; specifications for electronic public health reporting.   With a focused vision and public health investment an adaptable system that combines “situational” EHR decision support with surveillance could be achieved fairly rapidly.  In the meantime, I’m told, paper, pencil and basic http are still available to replicate the 2002 approach.

 

*(In fairness it must be told I joined CDC 8 years later, and during my two years there agency budgets for the public health use of health information technology markedly shrank.  Thus I must share responsibility for the current state, despite efforts to the contrary.)

 

Who will you meet? Food, drink, informatics networking in DC near TEDMED April 18

Join our first Washington DC area INTERFACE networking salon for those interested in improving public health through informatics.   After work, just blocks from TEDMED 2013 –there’s no telling who you’ll meet!  Join us Thursday, April 18 from 5:30-7:00 pm at the Notti Bianche bar inside GW University Inn, 824 New Hampshire Blvd NW.   Just steps from the Foggy Bottom Metro.  No charge; excellent food and drink available for purchase.   RSVP at sfoldy@sbcglobal.net.  Pass it on!

Informatics, Global Health and Sutton’s Second Law

I recently attended the 25th anniversary celebration for the Mectizan (ivermectin) Donation Program (http://www.mectizan.org/).  Today the program is closing in on eliminating onchocerciasis, or river blindness, in several nations.  President Jimmy Carter, former Merck CEO Roy Vagelos and former CDC director and Task Force for Global Health founder Bill Foege took the stage to recall how the program was born and succeeded out of a combination of luck and determination.  Each admitted having no clear idea about how to realize the program at first, and each offered grains of wisdom learned since.

Dr. Vagelos recalled that the decision to give Mectizan away, as much and for as long as needed to combat onchocerciasis, was made for lack of an ethical alternative, though several were explored.  Unexpectedly rapid regulatory approval and high expectations forced the executive decision even before the Merck board could be consulted.  The decision had an unexpected long-term impact.  Chemists, doctors, even factory workers flocked to Merck to work for the company with a clear moral compass.  Merck did well by doing right.

President Carter said the program illustrates the oft-overlooked power of volunteers.  The distribution of Mectizan is powered by local volunteers worldwide, including Lions Clubs who mobilize a small army of local business and community leaders in most nations touched by the disease.

Mectizan 25th Anniversary Event

Dr. Foege suggested that this program’s success, in contrast to many other public health campaigns, illustrates Sutton’s lesser known second law: “I get more done with a gentle voice and a revolver than with a gentle voice alone.”(1)   An effective tool made the difference.  “After people took Mectizan, some had the first itch-free day that they could ever remember,” Foege said.  This rapid, obvious improvement in quality of life for some helped sell the drug’s benefits to all.

These lessons should give heart to informaticians who are rapidly prototyping, piloting and iterating real tools in the field, and those using volunteers (such as in open source development) to shape the work collectively.   An application that “scratches the itch,” brings rapid uptake and success.  Vaporous promises and endless planning likely have the opposite effect.  We must not underestimate the power of the “revolver” in the hand over well-intentioned talk, nor the power of volunteers motivated by their communities’ needs.

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Notes: (1) Paraphrased. I could not find attribution of this remark to Mr. Sutton, though he is quoted “You can’t rob a bank on charm and personality,” which carries the same message!

Pictured in the photograph L to R: Dr. William Foege, Dr. Roy Vagelos, President Jimmy Carter, moderator and Task Force for Global Health President/CEO Mark Rosenberg.

Additional information on the 25th anniversary event available at http://www.mectizan.org/news/mectizan-donation-program-celebrates-25-years-of-partnership-and-progress .

Keywords: public health informatics, Seth Foldy, health informatics, open source, Jimmy Carter, William Foege, Roy Vangelos