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8/2/2004

Rapid Data Exchange is Crucial to Disease, Disaster Response

Donna Young

The nation needs to establish a secure means for communicating the most accurate and up-to-date information to hospitals, emergency departments, poison control centers, health care providers, and public health departments to be better prepared for an array of emerging infectious disease outbreaks or a chemical, nuclear, or biological attack, said pharmacist Richard S. Weisman, codirector of hospital terrorism response for Jackson Memorial Medical Center in Miami.

"At present, there is no effective means of getting life-saving technical information to our nation's frontline care providers," he said during his recent testimony before the House Government Reform's technology subcommittee.

The hearing was held to examine the progress and impediments in developing and implementing a national health information-sharing network.

When a patient in the emergency department at Jackson Memorial on October 4, 2001, asked Weisman if he had heard of anthrax, he thought the person was talking about the popular New York City heavy metal rock band.

But unbeknownst to Weisman, Florida's epidemiologist had reported earlier in the day that a patient at JFK Hospital in neighboring Palm Beach CountyRobert Stevens, a 63-year-old editor employed by American Media Inc. (AMI) of Boca Ratonindeed had inhalational anthrax.

"In the emergency department, we are very disconnected from the world and need a way of being kept up-to-date while actively seeing patients," he declared.

After Stevens had been diagnosed, Weisman said, the state's epidemiologist, Steven Wiersma, told the public that there was nothing to panic about and that "anthrax is a naturally occurring disease and that this was not terrorism."

Stevens died the next day.

"The public became very confused, angry, and lost confidence in our government's response to the crisis," Weisman testified.

The day that Stevens died, the Florida Poison Information Center, which Weisman directs, received about 300 calls about anthrax from worried residents, he said. About 50 of those calls came from Stevens's coworkers at AMI and half were from physicians in search of recommendations for patients who wanted prescriptions of ciprofloxacin.

The Centers for Disease Control and Prevention (CDC) sent a "much needed" anthrax information fact sheet to the poison information center, Weisman said. Not knowing if area hospitals had also received the fact sheet, he faxed it to every hospital emergency department in the area.

He learned later that only half of the hospitals had received the fact sheet directly from CDC and about 10% did not receive the copy faxed by the poison information center.

Two days after Stevens died, Weisman said, "all hell broke loose" when a second AMI employee, Ernesto Blanco, tested positive for exposure to Bacillus anthracis and CDC confirmed that anthrax spores had been detected in the AMI building.

The media, in the wake of the Sept. 11, 2001, terrorist attacks on New York and the Pentagon, began reporting that the Florida situation could be another assault on the country.

Panicky residents began flooding Jackson Memorial's emergency department with concerns about potential anthrax exposure, and the 300 calls per day that the poison information center in Miami had been receiving rapidly increased to 300 calls per hour, Weisman testified.

The call center's automatic call-distribution system was "completely overwhelmed, and routine poison calls were unable to get through," he said.

The barrage of calls from worried Florida residents continued to bombard Miami's poison information centers until mid-November, at which time the center began receiving calls about adverse reactions to ciprofloxacin from patients who had been prescribed the antiinfective, he told the subcommittee.

"We have a remarkable opportunity to improve patient care through improved communication strategies and e-technology," Weisman declared. "Information technologies will allow us to provide optimal care and to utilize our scarce resources."

However, he added, if large inner-city hospitals are at 105-percent occupancy and there are patients waiting in the emergency department, "our response to a catastrophe may be less than optimal."

Hospitals, poison control centers, emergency medical services, and public health departments must be provided the necessary resources to manage a surge of affected patients, Weisman maintained.

In the event of another terrorist attack or disease outbreak, he said, the federal government needs to make well-informed experts immediately available to the media.

"We witnessed expert opinions on anthrax from retired microbiologists who were honored to give their uninformed opinion," which, Weisman said, only added to "the confusion and hysteria."

Improving the timeliness, completeness, and accuracy of information exchange among health care providers and public health officials is a critical goal for improving the nation's preparedness for bioterrorism attacks, natural disease outbreaks, and other emergency situations, said Seth Foldy, clinical professor of family and community medicine at the Medical College of Wisconsin at Milwaukee and former chair of the National Association of County and City Health Officials Information Technology Committee.

Had Milwaukee public health authorities known earlier about changes in water quality measurements, surging absenteeism at workplaces and schools, increased orders of laboratory stool tests, and a boom in local sales of antidiarrheal medications, a preventive response to an outbreak in 1993 of Cryptosporidium parvum that killed 100 people and sickened more than 400,000 local residents could have begun sooner, he declared.

The testimony sought by lawmakers, he told the subcommittee, can be boiled down to one critical question: How can health care providers and public health and safety officials get the information they need when and where they need it to make a decision?

"The health care provider makes decisions regarding an individual patient or family; the public health official about an entire community," Foldy said. "In the setting of a communicable disease, a covert bioterrorism attack, or an environmental emergency, poorly informed decisions by either party result in missed opportunities to prevent injury or illness, sometimes on a massive scale."

Ten years after Milwaukee's C. parvum outbreak, he said, the city's experience last year with surveillance for Severe Acute Respiratory SyndromeSARSwas remarkably different, exclaimed Foldy, the city's former health commissioner.

"Within three days of CDC's nationwide request for SARS surveillance, we sent SARS screening forms to local physicians, and 11 emergency rooms voluntarily began transmitting daily counts of [patients with] SARS-related symptoms to our health department," he said.

A rapid response in June 2003 by health officials in several Midwestern states, including Wisconsin, to the Western Hemisphere's first outbreak of monkeypox "helped prevent the virus from becoming permanently established in North American animal hosts," Foldy said.

But, he added, the inability to share information among various databases used by local, state, federal, and agricultural officials hampered the investigation and resulted in a constant stream of telephone calls, faxes, and e-mails in a "futile effort to keep everyone on the same page."

"We must do everything possible to speed the transition of health-related records from paper to secure electronic files, employing interoperable data and transmission standards so information can automatically and rapidly reach those authorized to see itincluding public health officials," Foldy proclaimed.

Public health departments, he said, must be included as active participants in the Bush administration's plan for a nationwide interoperable health information technology infrastructure, which was announced by the administration this past spring.

Public health workers, Foldy said, are the "eyes, ears, hands, and feet" of the nation's public health system.

"The nation's public health preparedness will suffer if local public health agencies are left on the wrong side of the digital divide," he asserted. "Local health departments perform the vast majority of data management or data-dependent tasks related to communicable disease control and environmental health."

Foldy condemned the Bush administration for reducing federal funds for state and local health departments for fiscal year 2005 so that more dollars can be spent on CDC's BioSense surveillance project, which will comb through vast amounts of data to identify disease outbreaks.

He called BioSense a "worthy" but "highly experimental" project.

"It is essential to remember that it will be local health departments that, when alerted to abnormal disease trends, will do the legwork to validate such suspicions and actually manage the outbreaks," Foldy told the subcommittee.