Achieving Effective Biosurveillance

Public health officials seek to mitigate the impact of health-related events through early detection and rapid response. These events can be predictable, such as the flu season, and unpredictable, such as bioterrorism or food-borne illness. The challenge for biosurveillance is to rapidly identify and characterize these events amid the backdrop of other health and illness patterns. Traditional disease surveillance relies upon vigilant healthcare providers to report suspicious cases presenting to them. While valuable, this is a passive process and, barring greatly heightened levels of awareness, detection is often delayed.

By contrast, contemporary biosurveillance seeks to accelerate this process through automation, integration and analysis. With greater availability of raw data in electronic format, a wide array of information can be automatically collected. This includes electronic health records (EHR) and laboratory results. In addition, other novel information sources, such as news feeds, intelligence reports, over-the-counter sales, school and work absenteeism, and public transit ridership, can be superimposed on health data. Through sophisticated analytics, detection and situational awareness can be enhanced. Applying modeling and simulation that accounts for relevant factors, such as weather conditions, population density, supply chain issues and bird migration patterns, response can be more targeted and effective.

Rate of Adoption

EHRs are a vital source of information for active biosurveillance. They hold the potential to provide real-time data from hospitals, emergency rooms, physician practices and home health providers. When recorded in a standardized form, data can be extracted directly or, such as with text-based systems, run through natural language processors for analysis. In this manner, a comprehensive view of background health conditions can be established with rapid detection of anomalous events or patterns. To protect confidentiality, records can be "anonymized" at the source and, if required, re-identified later.

Unfortunately, the promise of utilizing EHRs for widespread biosurveillance has been hampered by a number of factors. First, there is the very slow rate of EHR adoption nationally as the result of multiple financial, technical and legal barriers. Despite quite compelling evidence for use, only a fraction of healthcare organizations have them installed and fewer still utilize them to a major degree. Second is the challenging environment in which regional health information organizations and other health information exchanges (HIE) are attempting to achieve sustainability and promote the development of the Nationwide Health Information Network (NHIN). While some EHRs have been connected directly to federal, state and local public health agencies, HIEs and the NHIN present perhaps the most efficient opportunity to collect data from large geographic regions. Although there are pockets of robust health information exchange in areas such as Massachusetts, New York and Indiana, most HIEs struggle for survival or have ceased operations, evoking concerns over how quickly public health needs can be supported. Finally, there are significant policy issues surrounding privacy and confidentiality of patient data, including conflicting standards among states. Without clear protections, individuals will be reluctant to have such personal information used, even for the public good.

Government Initiatives

Despite these obstacles, the evolution of biosurveillance continues. On October 18, 2007, President Bush issued Homeland Security Presidential Directive 21 (HSPD-21) on public health and medical preparedness. This directive, which addresses critical components of biosurveillance, countermeasure distribution, mass-casualty care and community resilience, seeks to transform the national approach to protecting the health of the American people against all types of disasters, from hurricanes to terrorism. Coupled with some very ambitious timetables, HSPD-21 specifically calls for a biosurveillance system built using electronic health systems.

Concurrently, the population health workgroup of the American Health Information Community (AHIC), a federal advisory body chartered in 2005 to make recommendations to the Secretary of the U.S. Department of Health and Human Services on health information technology, has been working to accelerate IT for public health. It has identified a minimum data set (MDS) of elements necessary to enable public health functions of initial event detection, situational awareness, outbreak management and response management. This MDS encompasses both clinical information and facility data and is now part of initiatives for both the NHIN as well as the Centers for Disease Control and Prevention on utilizing HIEs for biosurveillance.

EHRs are a vital source of information for active biosurveillance. They hold the potential to provide real-time data from hospitals, emergency rooms, physician practices and home health providers.

Other regional and national initiatives (such as incentives to promote EHR adoption, or pilots to extend broadband networks to rural healthcare facilities) provide hope that some of these obstacles may be overcome. In addition, the use of health IT, as well as privacy and security, has been a focal point of pending legislation and Presidential candidate discussion. However, while these developments may create an environment conducive to electronic health information and improved biosurveillance, critical decisions must be made at the local level.

The Long View

As healthcare organizations begin or continue the challenging process of EHR selection and implementation, it would be prudent to consider taking a broad view of the role EHRs and other applications may play in the future. To some extent, this extension has already begun in areas of quality and patient safety. However, these are internally focused. Physicians and facilities will inevitably be called upon to assume a greater role in a nationwide, integrated biosurveillance system. Consequently, they must be prepared to provide an expanded range of real-time data to support early warning and ongoing characterization of events. This will necessarily include both health data as well as resource and capacity information.

Furthermore, organizations must be prepared to receive and act upon information from federal, state, and local agencies. Simulation and modeling of events often reveals critical gaps in information essential to respond appropriately to an event and mitigate the medical and financial impacts to the institution.

The widespread adoption of electronic health information could dramatically improve the nation’s biosurveillance and response capabilities. When coupled with other information sources, the opportunity exists to detect events far more quickly than we are currently capable; to understand and characterize developing situations; and, to respond more effectively to minimize deleterious effects. Thoughtful planning and system design that integrates clinical needs, resource management and connectivity is an essential first step.

Harry G. Greenspun, M.D., is chief medical officer, Health Solutions, and Robert M. Cothren, Ph.D., is director,
Clinical Information Systems division, for Northrop
Grumman Information Technology. Contact them at harry.greenspun@ngc.com and robert.cothren@ngc.com.