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NINE TECH TRENDS
Healthcare IT advances are pulling together to manage an expanding universe.
EMERGENCY PREPAREDNESS - by Fred D. Baldwin


The most important weapons in fighting bioterrorism and preparing for disease outbreaks and other emergencies, experts are finding, are free and readily available: human awareness and readiness. Sophisticated IT tools--biosurveillance, peer-to-peer networks and crisis management software--are valuable. But as urban sociologist Jane Jacobs concluded, neighborhoods where people sit outside on their doorsteps and know beat cops by name are safer than those where occupants stay inside high-rise apartments and rarely meet cops cruising around in patrol cars.

"Eyes on the street," Jacobs writes, reduce violent crime. Bioterrorism experts offer a similar message. The first step in combating any emergency is recognizing that it exists. Now that homeland security is a national objective, the healthcare industry is increasingly incorporating "eyes on the ward," "eyes in the ER" and "eyes in the clinic."
Expect more use of everyday IT tools for antiterror readiness and more attention to matching antiterror resources to business-as-usual needs.

Readiness through realization
Recognizing an infectious disease outbreak is relatively easy for rare diseases with distinctive symptoms--the later stages of smallpox or anthrax, for example. But early symptoms of these and other diseases, including terrorist-spread pathogens, may resemble those commonly seen in emergency rooms, at least during flu season. No individual doctor, or even a hospital staff, can easily decide when a surge in respiratory or gastrointestinal complaints signals that an epidemic has begun. Biosurveillance (also called syndromic surveillance) software can help. The Centers for Disease Control and Prevention (CDC), Atlanta, has developed a syndromic surveillance system called EARS. Since 2001, the Defense Advanced Research Projects Agency (DARPA) of the Department of Defense has sponsored similar research.

The Potomac Institute for Policy Studies, Arlington, Va., conducted an evaluation of the CDC algorithms and those developed by four DARPA contractors: General Dynamics, Falls Church, Va., in partnership with the Stanford (Calif.) University Medical Informatics group; IBM, Armonk, N.Y.; a Pittsburgh-based University of Pittsburgh/Carnegie-Mellon partnership; and the Johns Hopkins University Applied Physics Laboratory, Baltimore. At least some of this is open-source software available to hospitals for no initial cost beyond set-up fees and some hardware. (However, supporting a surveillance effort requires time commitments from an epidemiologist and IT staffs.)

Results of the evaluation, published in September 2004, show that syndromic surveillance software can identify infectious disease outbreaks with great accuracy—often pinpointing the very day that human experts later agree marked the onset. Even at the most discriminating level tested (one false positive every six weeks), the best-performing software detected outbreaks an average of 18 days sooner than did human experts, potentially a huge advantage for public health officials.

Spotting demand surges early also can help hospitals improve operating efficiency and quality of care. "Hospitals are already stretched very thin," says Monica Schoch-Spana, a Baltimore-based senior fellow with the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC). "They suffer from response-capacity issues in a chronic way. A regular influenza season can really tap out hospitals and their staffs."

That's why Emergency Medical Associates (EMA), Livingston, N.J., began to warehouse patient tracking data as early as 1998. The independent emergency medicine physician group provides emergency services to hospitals in New York and New Jersey, collectively treating about 2,600 patients per day. EMA uses off-the-shelf business intelligence software from Business Objects (U.S. headquarters, San Jose, Calif.) to analyze daily encounter information by syndromic groups (based on filters developed by the New York City Department of Health and Mental Services). The software flags variations of more than two standard deviations from historical norms and automates physician alerts.

"Faster is the key," says Jonathan Rothman, EMA's director of data management. "Last year we were the first in New Jersey to spot that the flu season had hit. This allows us to get prepared in our emergency departments." Recently, EMA identified the "Bill Clinton effect," Rothman says. "Right after he went in for his triple bypass, we saw a doubling in the number of chest complaints."

EMA's experience has helped the CDC and departments of health cope with a difficult technical problem in syndromic surveillance: how to crosswalk from presenting complaint (e.g., fever, aching back) to an ICD-9 code diagnosis (e.g., influenza). Complaint data, while often vague, is available several hours to several days earlier than diagnostic data. But, Rothman warns, the usefulness of mathematical analysis depends on good historical data. "You need at least a year," he says "probably three or four years, so that you can understand the seasonality of certain diseases."

Everyday surveillance
"For any biosurveillance system to detect bioterrorism," says David Siegrist, the principal investigator for evaluation of biosurveillance software by the Potomac Institute, "it has to be useful to clinicians in the hospital on a day-to-day basis. And to be useful on a day-today basis, it will either have to improve patient care or assist in managing the hospital."

That philosophy is central to the work of the UPMC's Center for Biosecurity, which serves a 20-hospital network in western Pennsylvania. The program has been cited as a model of how to prepare for disease epidemics. "If you make a system that is only useful in the time of crisis," says Michael Allswede, an emergency medicine physician and senior fellow at the Center, "nobody will ever use it, including during the time of crisis. But if you create something that people use every day to get patients admitted and moved around the hospital, and use that same system to query bed status, med status, and things like that, you end up with a very functional system."

UPMC relies on a system known as MedCall, an inbound call center begun in 1989 and significantly enhanced since 1998. Robert Schwartz, an emergency physician who serves as UPMC's medical director for physician relations, describes MedCall as "one-stop shopping to get patients transferred in to UPMC." With MedCall, UPMC always knows which hospitals within its network have open beds, operating room suites, or other needed resources. "Since we do that on a daily basis," Schwartz says, "the bioterrorism task of monitoring surge capacity is part of our daily business."

MedCall incorporates a peer-to-peer network that enables any of approximately 7,000 physicians to call a single number and talk to an expert within five minutes, a system UPMC calls curbside consults. "We modeled them," Schwartz says, "on two doctors who meet in the hall, and one says, 'Hey! I'm glad I ran into you. Let me just run a case by you.'" A typical day includes 30 or 40 such consults. Designed to improve patient care, this feature provides a single reporting point for 7,000 pairs of clinically trained "eyes on the street." MedCall knows how each doctor in its network likes to receive data (e.g., by email, fax, a call to a pager).

MedCall can also function as a command-and-control communications center, one that's been tested in small-scale crises like fires, floods and breakdowns of hospital ventilating systems. Western Pennsylvania healthcare providers, public health officials and law enforcement personnel all have the MedCall phone number for emergency contact. In the event of a bioterrorism incident, UPMC has contingency plans for joint public briefings by physicians, public health personnel and elected officials modeled on the kind of briefings former New York mayor Rudy Giuliani gave during a West Nile virus alert.

Sharing the data
UPMC developed MedCall in-house, but commercial crisis management software is available, such as WebEOC, developed by Emergency Services integrators (ESi), Augusta, Ga. It's used by various government agencies (including NASA), Delta Airlines and other clients managing events where security is a major concern (e.g., the Democratic National Committee's 2004 national convention).

An ESi partner, Global Emergency Resources (also headquartered in Augusta, Ga.), focuses on marketing WebEOC to healthcare organizations. Stan Kuzia, Global's president and CEO, says the Web-based product can display information "from personnel resources to sandbags," on either command-center screens or individual PCs. Potential users learn to navigate the system in 10 to 15 minutes and, equally important, he says, remember how to use it a year later. A license fee of about $50,000 provides "perpetual" password-controlled access to any number of authorized users--such as the 10,000 users online simultaneously in an airline's test. Hardware costs vary, depending largely on what customers already have in place.

At the federal level, the Agency for Healthcare Research and Quality (AHRQ), Rockville, Md., has focused much of its research on managing surge capacity and tools to facilitate state and local plans for preparing and, if necessary, responding to mass casualty events. Sally Phillips, AHRQ's director of bioterrorism preparedness research, also cites research on predicting the trajectory of epidemics and on developing computer models for decisions on mass prophylaxis and mass vaccination.

Since 2001, the Health Resources and Services Administration (HRSA) has administered the National Bioterrorism Hospital Preparedness Program, which in 2004 awarded states $498 million to increase healthcare organizations' ability to respond to terrorism or other public health emergencies. Much of this money has been spent on telecommunications technology or software to improve data exchanges between hospitals and state health agencies. It's not just technologies and programs focused on emergency preparedness that are increasing. So is awareness. "Our philosophy since 9-11," says Melissa Sanders, chief of HRSA's hospital bioterrorism branch, "has been that we as healthcare providers have got to re-tool our thinking. We've got to become more comfortable with emergency response, with incident command systems, and that whole structure of how information flows in an emergency."

(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005


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