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.)

 

Meaningful Use Stage 3: An Urgent Checklist for Public Health

The clock is running for public health advocates to advise what should be included in Stage 3 of the Electronic Health Records (EHR) Incentive Program (“Meaningful Use” (MUse)).

January 14, 2013 is the deadline for comment on the Health IT Policy Committee’s recommendations for Stage 3.

  • A key issue is whether EHRs should be certified in Stage 3 to generate electronic public health reports using a new, standardized approach.   The Public Health Reporting Initiative is finalizing both a harmonized data element profile and a Clinical Document Architecture implementation guide in the next few weeks.*   These are based largely on the Cancer Registry reporting standard that appears in Stage 2 MUse rules and on implementations already in place for the National Healthcare Safety Network (NHSN) and recommended for Stage 3.  Adopting the PHRI approach need not require change to existing MUse reporting activities like electronic laboratory reporting, immunization registries or syndromic surveillance.  However, it provides a reusable, modular, and extensible methodology that could be leveraged by these and many other types of reporting (for example, communicable disease case reports, product safety reports, birth and death reports) into the future.
  • The public health (and health IT) communities should examine the PHRI documents to decide if they represent an achievable step toward more generic interoperability between EHR and public health surveillance systems.  If so, they will have to make their voices heard during the comment period, because MUse Stage 3 certification is NOT recommended by the HIT Policy Committee (rather, it is recommended for some future, unspecified time).
  • The Centers for Disease Control and Prevention (CDC), which funds much US public health surveillance, needs to decide and announce whether it will support pilot implementations, full-scale implementation, and health department migration to the new approach going forward.
  • The Office of the National Coordinator and CDC need to ensure that PHRI products  are harmonized with similar initiatives across the ONC Standards and Interoperability Framework, and curated and maintained over time.
  • Other important issues in the Stage 3 recommendations include EHR data capture of information like occupation and disability; whether NHSN hospital reporting should be included as a new objective; and whether additional public health registries should be offered as choices in the incentive program.
Unfortunately, these decisions are being made at a time of significant vacancies and uncertainty in the decision-making structure at CDC.   Representatives of local and state health departments, who are critical stakeholders in this process, will need to study, act and advise CDC, rather than depend on the agency.  But the CDC Meaningful Use program is sponsoring a half-day Virtual Conference on public health and Meaningful Use Tuesday, December 18 beginning at 12ET.   This should provide a good orientation to Stage 2 changes, and set a foundation for discussion of Stage 3.
Meanwhile, the urgent deadlines of MUse and ONC (sometimes labelled the “Office of No Christmas” for its December demands) loom.  Inaction over the holidays might lead to a lump of coal in the public health stocking for Stage 3.**
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* Disclosure: Author was a lead team member of the of the Public Health Reporting Initiative from October 2011-September 2012.
** References to Christmas are for humorous purposes only and do not imply an endorsement of any particular holiday or religion.  Happy holidays to all, whichever you celebrate.

Interface ATL Public Health Informatics Event

Interface ATL: join public health informatics colleagues for networking, sharing and fun.  Manuel’s Tavern, 602 N. Highland, Atlanta on Wednesday, November 14 6-9pm.  Free event, you pay food and drinks.

informaticians bioinformatics medical informatics Seth Foldy sethfoldy.com health.e.volution