Exclusive Most Wired Survey Data
Percentage Of Hospitals That Have Electronic Disease Surveillance Systems
| 2003 Most Wired | 2003 Least Wired | |
| Partially electronic | 55% | 26% |
| Fully electronic | 32% | 2% |
Disease surveillance may be one of the most important functions in public health, but it has lagged behind. Relying on sporadic information that is often phoned in, push-pin maps and a laborious notification system, health departments have historically been handicapped in their ability to do any meaningful real-time monitoring.
Advanced databases and tracking software, better computer networking and improved communications have helped disease surveillance to mature greatly in the last few years. "Last year, you still had some public health departments without a fax machine," says Kenneth Mandl, M.D., research director in the emergency department at Children's Hospital Boston. "Now, there's a real push for broadband Internet, a robust infrastructure for communication, as well as data exchange,"
The need is growing just as quickly: The anthrax attacks of 2001, and naturally occurring outbreaks such as SARS and West Nile virus, underscore the need for real-time disease surveillance to provide faster treatment, better preventive care, and the ability to combat outbreaks just as they begin. In three areas of the country, Most Wired hospitals have teamed up with each other and with public health or federal agencies to design such systems.
NEW YORK CITY
When North Bronx Health Network, a public system that includes Jacobi Medical Center and North Central Bronx Hospital, rolled out a database to track diagnoses and procedures, it intended to use it as a disease management and decision-support tool. Along the way, the system may have stumbled upon a valuable tool for detecting potential outbreaks.
When doctors asked for data on emergency department visits by diabetes patients, CIO Daniel Morreale was happy to oblige on an ad hoc basis. When he received similar requests for patients with asthma, HIV and other chronic diseases, he made a connection. "We saw that the doctors were asking for similar things," Morreale says. "And we realized that the best way to do this was to automatically generate reports on some key indicators for different categories of diseases."
Morreale and his staff rolled out an electronic reporting tool at the public hospital system in late 1999. Depending on a department's needs, the tool monitors key indicators such as chief complaint, diagnosis, procedures performed and lab results. The reports are sometimes distributed via e-mail, and sometimes via a departmental Web page.
These reports have helped the information-gathering process immensely for a variety of studies, according to Charles Nordin, M.D., chairman of North Bronx's department of medicine. "We can use the computer system for some public health aspects that are quite interesting," he says. The reports have improved Hemoglobin A1C testing rates for diabetics and helped discover an EKG pattern indicating increased risk for heart attack among dual HIV-Hepatitis C patients.
During the fall 2001 anthrax attacks, the system showed potential as an early warning tool, even though no cases were detected at North Bronx. "We started seeing an increase in respiratory instances that fall, and everyone was worried when they saw the data coming back," Morreale says. Some doctors worried that the data might have indicated an anthrax outbreak or some other sort of bioterrorist agent. "But then our ER director put two and two together, remembered this was flu season, and determined this wasn't outside of the norm."
Morreale is quick to point out that his system isn't real-time, nor is it truly a disease-surveillance system; rather, it's a disease-management system with some surveillance capabilities. "The system doesn't actually do anything," Morreale cautions. "We're still at an early stage, and an uptick in, say, respiratory cases won't set off any bells and whistles. We gather and combine the data, but we're still waiting for someone to read the data and interpret it."
Part of the problem is data consistency. Without a solid historical database and with disparities in the way data has been collected over the years, North Bronx has run into trouble comparing actual cases with expected ones.
Though North Bronx is still at an early stage in disease surveillance, the benefits of such a system are clear. "The public health system is at the bottom of the basin; we catch everything, and treat things that other hospitals won't treat," Morreale says. "Because of our size and our patient base, it's important for public hospitals to do this kind of thing." Indeed, Morreale cites the New York City Health and Hospitals Corporation's history of technological investment as a key reason for North Bronx's status on the Most Wired list in each of the last two years.
But he's realistic at the same time. "We've seen some evidence and had some thoughts that this might work as an antiterrorist tool, but we haven't totally gone down that road yet," Morreale says. He cites emerging technology that may soon be adopted by HHC, as well as a pilot project recently launched by the city's health department, as reasons to hold off on pushing his system into full disease-surveillance mode. "We're not sure if we want to go there yet. It's got good potential, but we don't want to reinvent the wheel."
Still, the system shows promise. "We used to do surveillance and epidemiology manually, and it was very cumbersome," says Michael Touger, M.D., associate medical director for North Bronx's emergency department. "Now we're able to see trends, disease clusters, things like that. It's very new for us, and we've got a long way to go, but what we're seeing is exciting."
ALBUQUERQUE, N.M.
Los Alamos National Laboratories, Albuquerque, N.M., has a long history of using technology to build defense systems: nuclear bombs, weapons modeling and guidance programs and "sniffers" for detecting dangerous chemicals. Recently, the lab teamed up with local hospitals to build a much different type of weapon.
The Bio-Surveillance Evaluation Feedback Analysis and Response (B-SAFER) system scans both standard and nontraditional sources of health information to develop an early-warning system for potential outbreaks. "They take automatic feeds from our admitting system, which you would expect," says Keith Rivera, e-business director at Presbyterian Healthcare Services. "But they also looked at medical records, lab results, ambulance run sheets, even our Ask-a-Nurse program. They were just trying to get a multitude of sources for early detection."
Since last July, the B-SAFER program pulled these data sources together, performed a sophisticated set of algorithms, and looked at the number of cases reporting and other patterns. It compared the data with expected numbers of cases and sent alerts to key staffers if it detected potential outbreaks.
By looking outside traditional sources, B-SAFER casts a wider net than systems that only cull ED or admitting data. "As an emergency physician, I have a unique perspective because I interact with all these different venues: EMS, the poison center, patients who die and go to the medical investigator," says Judith Brillman, M.D., B-SAFER's medical director and associate professor of emergency medicine at the University of New Mexico. "We saw all these potential data sources, saw how they could be used for surveillance, and saw how we could put those together."
The system isn't designed to do the actual diagnosis or take the place of an epidemiologist in investigating potential outbreaks. "But many times, individual physicians don't see enough unusual cases to trigger a report to a public health department," says Edith Umland, M.D., an epidemiologist affiliated with both UNM and the New Mexico Department of Health. "By pulling information together from so many sources, this type of program can speed up recognition of an outbreak as it's starting, and give the health department a head start on its investigation."
Though there have been no major public health episodes in New Mexico, either terrorist or naturally occurring, since the system was installed, B-SAFER detected an uptick in respiratory complaints during last winter's flu season. It also tracked gastrointestinal complaints earlier this year at the same time that lab reports showed an increase in rotavirus cases. "That doesn't mean that all the gastrointestinal illnesses can be explained by rotavirus," Umland says. "But we were at least able to see a relationship between the complaints and the virus, and eliminate other possible causes."
Los Alamos provided initial funding for the system and helped develop software and interfaces, while UNM housed the system and provided staff expertise. But federal funding is a two-edged sword.
Los Alamos formally sponsored the project for one year, long enough to establish B-SAFER and bring in some experts, but nowhere near long enough to prove its worth, tweak the system or expand it throughout the state. On June 1, the system stopped collecting and analyzing information, and the project now sits in limbo.
"This is an example of the powerful technology the national laboratory has, that can be put to purposes other than a weapons system," says Ron Margolis, UNM's chief information officer. "But the way government funding often works is unfortunate: You set up a great demonstration and prove the project's usefulness, but you never get to the next step."
Los Alamos officials also report a good experience with the program, and hope to resume B-SAFER in the future. "It isn't in our control," says David Forslund, a laboratory fellow at Los Alamos who helped design the system. "The project was considered to be very valuable. Everyone wanted the data collection to continue, but we just couldn't at this time."
Meanwhile, officials at UNM hope to find other sources of funding, even as Los Alamos searches for ways to resume its support. Margolis hopes B-SAFER will eventually expand across the state, and even across the country. "A concerted, systematic attack would probably take place in several areas, and we'd need to look at it from 10,000 feet," he says. Gathering historical data from around the country, then seeing anomalies in several different areas at the same time, would be a useful red flag, he says.
Medical director Brillman looks forward to the challenge. "We learned a lot from this project," she says. "With more funding, we can build an even better system, with more flexibility and analysis. This will hopefully continue to be an important tool, not just for bioterrorism but for any events of public health significance."
BOSTON
When the Department of Defense approached Children's Hospital Boston about building a bioterrorism early warning system, "We didn't know what they were talking about," admits Kenneth Mandl, M.D., research director in the hospital's emergency medicine department.
This was in 1998, long before the 9/11 hijackings and anthrax-by-mail attacks brought terrorism into the public consciousness. But Defense officials showed some grim data on how bioterrorist incidents could impact the population, increasing the demand for emergency visits, lab orders and prescription drugs.
"If you can mobilize the data in real time, you can get an early warning," Mandl says. "Then you can react within that very narrow window--about 24 hours--between the time symptoms begin and the time you have to start treatment to prevent mortality."
With the go-ahead from his CEO and CIO, who are both physicians, Mandl forged ahead with building a computerized comparison and prediction tool
"With physician leaders at every level of the organization, we tend to think in similar ways and support each others' work," says hospital CEO James Mandell, M.D. "So when Ken came up with something with such a huge potential return, it was easy to give the green light."
Armed with various federal grants, Mandl and a team of about 20 researchers, programmers and physicians designed EDScope, an automated system that compares cases coming into the emergency department with anticipated cases. Children's faced a twofold challenge: uploading about 500,000 patient encounters from an 11-year period into a syndromic database, then developing mathematical formulas to compare incoming data with the historical records.
The formulas themselves were complicated--auto-adjusting for seasonal variations, or eliminating background "noise" caused by sudden but easily explainable temporary spikes in cases. But the framework was largely in place. "The environments and a lot of the tools are off the shelf," Mandl says. "It's the ways that we're using them and the algorithm development that are unique."
Children's recruited nearby Beth Israel Deaconess Medical Center--along with three years of data, encompassing some 200,000 patient encounters--as its first partner in building the system. "We have a long history of sharing emergency department data with Children's, so this was a natural thing to do," says John Halamka, M.D., chief information officer of Beth Israel's parent corporation, CareGroup Healthcare System.
When EDScope went live in August 2001, the system compared data in real time with the historic databases for both Children's and Beth Israel, and recognized if larger-than-expected numbers of cases came through the doors.
"The system gives you a broader window; a trend that might not be noticed by a busy physician during an 8- to 12-hour shift could be noticed by the computer," says Dan Nigrin, M.D., CIO at Children's. "If it notices double the expected number of fever cases or double the respiratory complaints, it lets us know. The system's not diagnosing, but it makes you scratch your head and say, 'What's going on here?' " As an improved feature of the system, last year Children's added a geographical mapping capability, allowing staff to look at the work and home addresses of patients with a given complaint. "If you see that most of your respiratory complaints are coming from patients in the same ZIP code, that might be a clue that you're dealing with a chemical or biological agent," Halamka says.
EDScope brings an unexpected, but potentially lucrative, side benefit. By using previous records to predict hospital volume, personnel and materials managers were able to figure out how many nurses they might need, how many IV bags they might go through, even how often housekeeping might need to do a cleanup. Staffing levels and purchasing orders can then be tweaked to reflect the anticipated load. Mandl says the tool can predict daily emergency volume within 8 percent, and may prove useful as a resource management tool.
More immediately, though, Children's hopes to expand and improve the network to pool more data and make earlier notifications. The hospital has received funding from the Health Alert Network, a CDC-sponsored alliance that builds communications infrastructure, to create an interface for getting reports to key public health officials. Additionally, Children's was awarded a CDC grant in April to recruit other local hospitals into their network. Massachusetts General Hospital and Brigham & Women's Hospital signed on recently, though at press time they hadn't yet gone live with the system.
"This is another example of the tremendous sense of cooperation among the Boston hospitals," says Paul Levy, CEO of Beth Israel Deaconess. "These are research centers, but not just in the sense of lab research or publishing papers. Our staffs are constantly looking for things like disease surveillance, that will ultimately be helpful to the community."
Chris Serb is a Chicago-based freelance writer.
Vital Statistics
North Bronx Health Network, New York City
CEO: Joseph Orlando
CIO: Daniel Morreale
Number Of Beds: 700
Outpatient Visits Per Year: 1 million
Number Of Employees: 3,800
Number Of Is/It Employees: 44
Total IT Capital Budget: $4.5 million
Total It Operating Budget: $13.8 million
IT As Percent Of Capital Budget: 20%
IT As Percent Of Operating Budget: 3%
Daniel Morreale
BIO: Chief information officer, North Bronx Health Network; M.S. in pediatric psychology, Long Island University.
GREATEST REWARD: Improving patient care and safety with technology.
BIGGEST CHALLENGE: Matching funding with initiatives.
E-MAIL: Daniel.Morreale@nbhn.net
Vital Statistics
UNIVERSITY OF NEW MEXICO HOSPITALS, ALBUQUERQUE, N.M.
CEO: Steve McKernan
CIO: Ron Margolis
Number of Beds: 541
Total Number of Employees: 3,900
Number of IS/IT Staff: 101
Total IT Capital Budget: $5.6 million
Total IT Operating Budget: $14.1 million
IT As Percentage of Capital Budget: 22%
IT As Percentage of Operating Budget: 3.4%
PRESBYTERIAN HEALTHCARE SERVICES, ALBUQUERQUE, N.M.
CEO: James Hinton
CIO: Bob Skinner
Number Of Beds: 900
Total Number of Employees: 7,000
Number of IS/IT Staff: 250
IT As Percentage of Overall Capital Budget: 24.2%
IT As Percentage of Overall Operating Budget: 3%
RON MARGOLIS
BIO: Chief information officer, University of New Mexico Hospitals, Albuquerque, N.M.; M.B.A., computer science, University of Missouri.
GREATEST REWARD: Initiating and seeing the success of process improvement.
BIGGEST CHALLENGE: Gaining acceptance from staff and physicians on new processes.
E-MAIL: Rmargolis@salud.unm.edu
KENNETH MANDL
BIO: Research director, emergency department, Children's Hospital Boston; M.D., Harvard Medical School; M.P.H., Harvard School of Public Health.
GREATEST REWARD: Working with phenomenal colleagues, trainees and students.
BIGGEST CHALLENGE: The multitasking load is enormous. Choosing to work on what is going to be important three to five years down the line is high risk, but high payoff when you choose right.
E-MAIL: kenneth_mandl@harvard.edu
Vital Statistics
CHILDREN'S HOSPITAL, BOSTON
CEO: James Mandell, M.D.
CIO: Daniel Nigrin, M.D.
Number of Beds: 324
Outpatient Visits Per Year: 378,000
Number of Employees: 5,500
Number of IS/IT Staff: 239
Total IT Capital Budget: $21.5 million
Total IT Operating Budget: $23 million
CAREGROUP HEALTHCARE SYSTEM/BETH ISRAEL DEACONESS MEDICAL CENTER, BOSTON
CEO: Paul Levy
CIO: John Halamka, M.D.
Number of Beds: 550
Outpatient Visits Per Year: 1 million
Number of Employees: 4,200
Number of IS/IT Staff: 300
Total IT Capital Budget: $7 million
Total IT Operating Budget: $26 million
IT As Percentage of Capital Budget: 10%
IT As Percentage of Operating Budget: 2.6%
JOHN HALAMKA, M.D.
BIO: Chief information officer, CareGroup New England; M.D., University of CaliforniaSan Francisco; M.S., Informatics, Harvard/MIT.
GREATEST REWARD: Making a difference.
BIGGEST CHALLENGE: Managing change.
E-MAIL: jhalamka@caregroup.harvard.edu
TOOLKIT
DOs & DON'Ts
FOR SETTING UP A DISEASE SURVEILLANCE PROGRAM AT YOUR HOSPITAL
DO:
1. Start with the tools you have. You may discover that an existing records system, clinical repository or software platform may prove valuable for disease surveillance.
2. Be careful with HIPAA. Patient confidentiality must be ensured when generating reports on patients in a certain demographic or with a certain complaint.
3. Look for federal funding. Disease surveillance, post-9/11, is a hot-button topic. Funds may be available from the Department of Defense, Homeland Security, the Centers for Disease Control and Prevention, and more.
DON'T:
1. Ask for too much, too fast, from your physicians. If you ask for a robust 20-question electronic survey based on every encounter, it will likely go unfilled. Early steps in the field should mirror the way clinicians have been doing things.
2. Rely on one main source of funding. If a hospital's budget gets tight, or if a government grant expires after one year, you may have to shut down a promising project. Look to diversify funding sources.
3. Delay. Electronic disease surveillance gets more important, with the growing threat of bioterrorism and the growing reality of naturally occurring outbreaks. There's no time like the present to start working on your own system, or to collaborate with other hospitals or health agencies.
RESOURCES
Health Alert Network: www.phppo.cdc.gov/han
CDC's National Electronic Disease Surveillance System: www.cdc.gov/od/hissb/act_int.htm
"Global Health: Challenges in Improving Infectious Disease Surveillance Systems," August 2001. GAO Report, GAO-01-722. www.gao.gov
"Using temporal context to improve biosurveillance," by Ben Y. Reis et al. Proceedings of the National Academy of Sciences, Feb. 18, 2003. www.pnas.org
This article first appeared in the Summer issue of HHN's Most Wired Magazine.
To respond to this article, please click here.
