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.)

 

Network with ATL Colleagues: INTERFACE Weds. APRIL 2, 2014

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NTERFACE:ATL networking event WEDNESDAY, April 2nd from 6:30-8:00 pm at Marriott Courtyard lobby bar

Please join my INTERFACE:ATL networking event THIS WEDNESDAY, April 2nd from 6:30-8:00 pm at the Marriott Courtyard lobby bar, 130 Clairemont Ave. in Decatur.
Meet health informatics peers to learn who’s doing what. Several state epidemiologists will likely be on hand. Free to attend, pay own food and drink. See you Wednesday!

Atlanta Networking Sept. 19

Please share as desired with those interested in health informatics.   I look forward to seeing you in Decatur September 19.

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!

Meaningful Use and the Learning Health System-HIMSS

At the 2013 Health Information Management Systems Society (HIMSS) meeting in New Orleans on March 3 I’ll provide guidance to the Physician IT Seminar on how to convert Meaningful Use advances in electronic health records and health information exchange into real learning opportunities to improve care and health.  The Institute of Medicine’s vision for a Learning Health System is “by 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.”  How do the Meaningful Use rules carry us closer to this goal?

I’ve diagrammed critical elements for a learning health system, below.  At its base, and most critically, the electronic health record (EHR) captures information.  This may be entered by clinicians, or received from either patients or other health care providers.  This use of the EHR to “learn about the patient” is fundamental to all other improvements in care.

Various objectives in Stage 1 and 2 Meaningful Use require data capture.  They also require that EHRs be able to exchange information with other clinicians and to some extent with patients.  Meaningful Use objectives also require public health reporting, quality reporting, and decision support, each setting the stage for still more sophisticated learning.

Today, naturally, many providers are obsessed with the implementation of the Meaningful Use objectives and the receipt of incentive payments.  But it is never too soon to consider how these EHR objectives can be pressed into the service of “accurate, timely, and up-to-date clinical information and… the best available evidence.” It is already happening.   For example, in late 2012 a mysterious surge in fungal meningitis cases was detected in Tennessee, and was rapidly traced to certain lots of injection steroids produced by the New England Compounding Center.  Little was known about how to treat the predominant fungus,  Exserohilum rostratum.  Investigators used electronic health record reviews to rapidly identify exposed patients, and to track the success of treatment.   A rapid decline in case mortality among infected persons resulted within just two weeks.  That is truly a learning health system in action.*

Information alone does not bring about learning.  Learning requires a “central nervous system” to process incoming information in light of other knowledge.   Public health agencies, like local and state health departments, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA) are examples of such “central nervous systems.”  But a good brain is useless without being attached to sensory and motor organs.   The Exserohilum rostratum outbreak helps show the Meaningful-Use-certified EHR is beginning to serve a valuable sensory function.   Equipped with decision support tools, it is destined to be a powerful motor organ as well.

 

*Thanks to the American Medical Informatics Association Public Health Informatics Workgroup for a great webcast on informatics use and needs associated with this outbreak.

The “X-Factor” for Health Information Exchange: Is competition toxic?

Early in the Wisconsin Health Information Exchange (WHIE) we realized a high likelihood of finding information for a local provider or patient was key to a successful business case.  (Techies call this “network dependency.”)  So I wasn’t surprised November 28 to hear market share penetration labeled the single item that best distinguishes sustainable from struggling HIEs by the HIE Learning Network of the National eHealth Collaborative (NeHC).  What is surprising is that HIE policy often disregards this vital factor.

At Technology Crossroads, Jeffrey Rose (ICG Group) and Delaware Health Information Network (DHIN) CFO Michael Sims presented factors identified by the Learning Network that distinguish profitable from unprofitable HIEs.  (Other factors in addition to high market share penetration are aggressive pricing and investment in product development.)  DHIN is verging on both 95% market penetration and long-term black-ink performance.  (For more on this and other Learning Network lessons, join the December 17 NeHC University webcast.)*  [Update: Dec 18: the Learning Network report has been published.]

Meanwhile, many HIEs around the country are struggling.  The eHealth Initiative’s 2012 HIE survey lists sustainability as the top obstacle, and found that over half are encountering competition from other HIEs.  They are also competing with HIT vendors providing exchange technologies directly to provider networks.

For example, the November 21 IHealthBeat reprinted a story from the Oct. 18 Tampa Tribune detailing how a public HIE serving hospitals is competing with a private HIE serving physicians.  Meanwhile, in several states, new HIE entities created by the Office of the National Coordinator (ONC) State HIE grant program compete with pre-existing regional efforts.  (Most early regional HIEs focused on medical marketplaces defined by referral patterns, not state lines.)  Adding to the confusion are statements from ONC leaders that put exchanges developed inside Accountable Care Organizations (ACOs) on the same footing as regional “all-provider” HIEs.  This fails to acknowledge that such private entities may aggressively compete, including taking information hostage.  A recent New York Times story details how increasing provider consolidation (neither citing ACOs nor excluding them) can block clinical communication with competing providers.

Perhaps, at least initially, competition is toxic for successful health information exchange.  In a 2007 eHealth Initiative report on HIE sustainability, we described social capital (resilient relationships among HIE stakeholders) as a key element for success.

An alternate scenario is that each electronic health record system will contain its own exchange capabilities (like the Direct “push” standard).  But this model still works best with a “central switchboard” managing directories, authentication, record locators, and other services that an HIE can provide.

It seems that HIE resembles mail service, electrification, telephony, highways and fire services, possibly requiring a period as publicly-regulated, public service monopolies.  Once the infrastructure is well established, competition can be introduced to accelerate innovation and price competition.   Today, however, regional HIEs are competing with Federally-funded state HIE designated entities, which are competing with for-profits and ACOs.  Meanwhile, market share is elusive, and network dependency can kill.

*Disclosure: I am currently on the NeHC University Advisory Board and a former NeHC board member.

“A $300 (NwHIN Direct) HISP in a Box-that’s cool!”

John Halamka describes Will Ross’s open-source approach to affordable Direct exchange at his Life as Healthcare CIO blog.   Federal, state and local health departments are looking for lightweight Direct solutions and should explore this one.  Thanks John!

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