Communicating About CommunicabilityBy Larry Dignan | Posted 2003-05-05 Print
The response to SARS has been commendable, but most medical surveillance systems can't communicate electronically.
Using HL7 and the extensible Markup Language (XML), federal-, state- and city-level systems should be able to swap data, such as dates, locations, symptoms, and type of patient, even if their computer systems don't otherwise communicate.
One of the linchpins of a NEDSS system is an integrated data repository, a networked set of databases able to share data, inputs, processes, outputs and interrelationships. Here's how these networked databases would operate: Each disease, symptom or illness will have a unique numeric identifier that could be tracked across the local, state and CDC systems. Such a system would be able to track a person and cross-reference symptoms and diseases.
Safranek is overseeing a pilot of NEDSS that's designed to supply data from Nebraska's hospitals, labs and health agencies to the CDC. By collapsing a host of disease-oriented databases the state will be able to make real-time monitoring and decisions.
If successful, NEDSS will be the first national-disease-surveillance system. Once implemented, the emergence of a single incident of an unfamiliar virus or disease can be communicated to all participants in what businesses would call "real time."
"Most clinical information systems are not standardized nationally," says Dr. John Loonsk, associate director for informatics at the CDC. "It's problematic when you are looking to get information out and the data are in different forms and different systems. They're not accessible."
These incompatible legacy, or "stovepiped," systems make it nearly impossible to search for patterns across databases. If a person with SARS has HIV and tuberculosis and has moved from Los Angeles to New York, it's nearly impossible to cross-reference given the number of databases, locales and divergent health messaging standards. It would take numerous phone calls and paper trails to find a pattern.
Tennessee, for example, is using a 13-year-old system using the almost ancient Disk Operating System (DOS) to report communicable diseases. And the data isn't piped in-it's mailed in, where data entry workers input the relevant data by hand. To get information on reportable diseases to the CDC they are uploaded in a batch.
The federal government is prepared to spend $377 million on medical communications and surveillance improvements in fiscal 2003, according to President Bush's proposed budget. The CDC is linking its bio-terror preparedness funding grants to NEDSS-compliance.
So far, all 50 states and large cities such as New York have received funding for the surveillance system, but the national rollout, is expected to take "several years," says Loontz.
Under a pilot, Tennessee is using federal funds to replace its DOS-based system, with a NEDSS-based system with Microsoft SQL 2000 and BEA Systems WebLogic software running in the background.
"We're very excited to make the switch," says Dr. Allen Craig, Tennessee's state epidemiologist. "The old system was a disaster. It served us for a lot of years but not without some bubble gum and rubber bands."
The stakes are high for swapping out antique systems. Health and Human Services Secretary Tommy Thompson, testifying before a congressional committee last month, noted the SARS epidemic is a dress rehearsal to see how the U.S. could respond to a bio-terror attack. But a day before Thompson's testimony, a General Accounting Office report concluded "work to improve surveillance systems has proved challenging."
The challenges to public health officials are numerous. Cities and states don't have access to data in hospitals' information systems. They also rely on laboratories, hospital staff and physicians to sound early warnings. According to the GAO, several cities are evaluating active systems where databases will comb nontraditional data sources such as pharmacy sales to find suspicious activity or patterns of illness, similar to the way MasterCard and Visa track unusual card activity in different parts of the globe and close down credit.
Active systems are the ultimate goal, say health officials. Craig says the state has more updated systems to track 911 calls and emergency room information to spot different trends. The data is run through an SAS business intelligence program that compares recent data to historical data in order to flag items like an influenza outbreak in August.
New York City also has a system that tracks nontraditional sources such as 911 calls, emergency room data and pharmacy sales to spot health patterns and possible outbreaks. That system hasn't turned up any SARS warning signs such as a run on flu medicine, says Carubis.
A portal, which will allow partners to input health data into a Web form, and a Communicable Disease Surveillance System (CDSS), which will allow electronic data to be exchanged, are planned to launch in June and in the fall, respectively, says Carubis. More importantly, those systems, funded by CDC grants, will be able to communicate with other systems.
Carubis says once the systems are able to take electronic data, all it'll take is hospitals to link up their systems-some are more prepared than others. Carubis agrees that it's difficult to put a timetable on NEDSS compatibility.
The health industry, however, seems determined to link together.
"Nobody is proud of the current approach," says Safranek. "But we are working on it, and there'll be a payoff."
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