AHRQ RESEARCHERS EXAMINE THE ROLE OF INFORMATICS IN RESPONDING TO BIOTERRORISM, MASS DISASTERS, AND WAR
In the wake of recent terrorist attacks against the United States, three scenarios directly involving and possibly overwhelming healthcare resources were spotlighted: bioterrorism, the threat of widespread delivery of agents of illness; mass disasters, events that produce many casualties and strain the capacity of local healthcare systems; and the delivery of optimal healthcare to remote military field sites. Each of these situations demands the collection, analysis, coordination, and distribution of health information, and recent articles written about research projects sponsored by the Agency for Healthcare Research and Quality (AHRQ) examine the contributions of informatics.
According to a study on the informatics response in critical events, several policy changes are needed to coordinate information better among local, regional, and national agencies to prevent and manage terrorist attacks. Some regions are testing integrated regional data systems that provide biological exposure data from different parts of a region. One such system makes use of real-time data feeds from 17 hospitals. Also, emergency department (ED) computerized registration data can be used to track clusters of viral symptoms, respiratory symptoms, diarrhea, rash, and encephalitis that may indicate bioterrorism. Some newer detection techniques, such as polymerase chain reaction (PCR) and, eventually, biochips, which can detect the DNA sequences of a number of biological agents, need further investigation and testing.
Increasing efficiency in disaster response requires coordination of information from the field to the hospital. One example is Maryland's communication network (known as the Trauma Line), which enables prehospital field care providers to communicate directly with physicians in trauma centers and other referral centers. Information on patient vital signs, estimated time of arrival and means of transport, mechanism of injury, level of consciousness, and priority status is put on a fax notepad linked to a cell phone in the ambulance for transmission to the hospital trauma team.
Another project known as "MobiDoc" uses next-generation wireless technology to create an entirely mobile telecommunications system. This communication kit, which is the size of a briefcase, contains eight cell phones and wireless data acquisition devices connected to the cell phones. A field team can perform charting, monitor vital signs, collect images, and carry out other data acquisition tasks for multiple patients, then send the data to a hospital intranet or disaster control center to be viewed on a Web browser by control personnel. Finally, expert assistance (for example, for trauma evaluation and management, including surgery) can be provided via telemedicine technology to remote medical caregivers in military operations.
The second study, a roundtable on bioterrorism detection, was hosted during the 2001 American Medical Informatics Association annual symposium, during which several researchers discussed public health surveillance systems designed to enhance early detection of bioterrorism events. Six existing systems described at the roundtable are given as case studies. Systems ranged from a geographic scope of 13 counties and 14 hospitals to 14 countries and 395 military installations. Some used data only from EDs, while others used data from EDs, hospitals, and military treatment facilities.
The systems were developed independently but converged on similar solutions to the problem of early detection using similar types of data and relying on the Internet for connecting institutions. All the sites indicated concerns about maintaining security and confidentiality. Most systems used encryption for the transmission of data; those not capable of encryption accepted automated e-mail of de-identified data.
Several systems used clustering of diagnostic (ICD-9) codes to define disease symptoms of interest in bioterrorism detection. By clustering codes in prodromal groups, researchers hope to include all codings that might conceivably be applied to a patient with relatively early symptoms of an infectious or toxic syndrome. Clustering schemes have been proposed by AHRQ and the U.S. Department of Defense but have not yet been universally adopted. Most systems are using visit data for certain diagnoses or syndrome clusters combined with ED volume data (for example, ED visits per day for gastrointestinal complaints).
The third study examines the contributions of informatics in the response to bioterrorism. Experts in biomedical informatics have developed and implemented architectures, methodologies, and tools at the local and regional levels that can be immediately pressed into service for the protection of U.S. populations from bioterrorist attacks. Fortunately, the National Library of Medicine and other organizations have already created the Unified Medical Language system to share descriptions across vocabularies and even link a new bioterrorism monitoring vocabulary to other terminologies. For example, standardized models for describing clinical events in general and ED information in particular have been developed.
The synergy between standardized clinical data models and electronic medical record systems has allowed investigators to use the Internet to rapidly implement large-scale, multi-institutional clinical data gathering and integration. Once raw clinical data are acquired, the detection of signatures of bioterrorism requires sophisticated and prompt interpretation of monitored healthcare data across time and geography. Usually, this has to be done in the context of many diseases with early clinical presentations overlapping those of the bioterrorism-related infectious agents (for example, influenza). The uncertainty associated with this overlap and the variation in degree of overlap require probabilistic inference techniques that have been developed to distinguish subtle signals of diseases from the background of findings.
Sensitivity and specificity are critical, since the costs of missed detection are great, as are the costs and risks of misdiagnosing and treating thousands of unaffected individuals. Even when correct treatments, isolation methods, and testing protocols are known by experts, implementation of the normative, prescribed responses to exposure and disease from bioterrorism events are uneven at best. Clinicians throughout the country have only partial and often out-of-date knowledge of appropriate procedures, and must be trained to deliver state-of-the-art diagnostic workups and treatments to potential and actual victims of bioterrorism.