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Biosurveillance Where It Happens:
State and Local Capabilities and Needs PDF

Eric S. Toner, Jennifer B. Nuzzo, Matthew Watson, Crystal Franco, Tara Kirk Sell, Anita Cicero, and Thomas V. Inglesby

Biosecurity and Bioterrorism: Volume 9, Number 4, 2011 © Mary Ann Liebert, Inc. Ahead of print. doi:10.1089/bsp.2011.0049.

 

Introduction: In recent years, improved biosurveillance has become a bipartisan national security priority. As has been pointed out by the National Biosurveillance Advisory Subcommittee and others, building a national biosurveillance enterprise requires having strong biosurveillance systems at the state and local levels, and additional policies are needed to strengthen their biosurveillance capabilities. Because of the foundational role that state and local health departments play in biosurveillance, we sought to determine to what extent state and local health departments have the right capabilities in place to provide the information needed to detect and manage an epidemic or public health emergency—both for state and local outbreak management and for reporting to federal agencies during national public health crises. We also sought to identify those policies or actions that would improve state and local biosurveillance and make recommendations to federal policymakers who are interested in improving national biosurveillance capabilities.

Sections: Recent Efforts | Methodology | Key Questions | Findings | Recommendations | References | Attendees | Meaningful Use Criteria


  
Improved biosurveillance has been a bipartisan national security priority since at least 2001, and its importance has been reiterated a number of times in federal law, regulations, and official guidance, particularly as it relates to bioterrorism, large-scale epidemics, and other large public health emergencies. Early outbreak detection and outbreak management are top goals of biosurveillance.

All biosurveillance systems depend on information gathered by state and local public health departments.1 Many of the activities at the federal level to improve national biosurveillance capabilities have focused on strengthening the surveillance capacity of state and local health departments.2 Since 2001, the Centers for Disease Control and Prevention (CDC) has provided funding to improve state and local response capability, which has included cooperative agreements to state and local health departments for the Public Health and Emergency Preparedness Program (PHEP).3 One of the priority goals of those agreements is to enhance state and local biosurveillance capabilities.4

The Center for Biosecurity undertook a project to better understand the current state of biosurveillance—the strengths and the challenges of current practice—from the perspective of state and local public health practitioners. We sought to determine to what extent state and local health departments have the right capabilities in place to provide the information needed to detect and manage an epidemic or public health emergency—both for state and local outbreak management and for reporting to federal agencies. On the basis of what we found in this project and earlier analysis of these issues, we made recommendations regarding what policies or actions would improve state and local biosurveillance capabilities.

In this project, our scope was to focus on public health departments and information gathered from the public health and medical sectors. While we recognize that animal, plant, and environmental information can provide critical biosurveillance information, examination of these data sources was beyond the scope of this project. We included all manner of information gathered to aid in the detection or management of an epidemic or public health emergency, including disease reporting from clinicians and laboratories, syndromic surveillance, outbreak reports, healthcare capacity and utilization reporting, and medical response resource information.

Recent U.S. Biosurveillance Efforts

Over many years, an array of biosurveillance systems have emerged as a result of the history of U.S. investment in disease detection and control. Government agencies have developed disease-specific systems as new diseases emerged or as government agencies placed new emphasis on their control. For example, a surge of interest in pandemic influenza has resulted in the creation of several new influenza surveillance systems.

Following the events of 2001, government interest in increasing the speed with which outbreaks are detected contributed to the development of new approaches to disease surveillance, including syndromic and event-based surveillance systems.5,6 Recent surveys by the International Society for Disease Surveillance (ISDS) and the Trust for America’s Health (TFAH) have found that such systems are in wide use by health departments.7,8

In 2006, Congress passed the Pandemic and All-Hazards Preparedness Act of 2006 (PAHPA) (P.L. 109-417),9 which called for establishment of “a near real-time electronic nationwide public health situational awareness capability through an interoperable network of systems to share data and information to enhance early detection of, rapid response to, and management of potentially catastrophic infectious disease outbreaks and other public health emergencies.”

In 2007, Congress passed the Implementing Recommendations of the 9/11 Commission Act of 2007 (P.L. 110-53),10 which created the National Biosurveillance Integration Center in the Department of Homeland Security. Also in 2007, the Bush administration issued Homeland Security Presidential Directive 21 (HSPD-21),11 which said:

The United States must develop a nationwide, robust, and integrated biosurveillance capability, with connections to international disease surveillance systems, in order to provide early warning and ongoing characterization of disease outbreaks in near real-time.… State and local government health officials, public and private sector health care institutions, and practicing clinicians must be involved in system design, and the overall system must be constructed with the principal objective of establishing or enhancing the capabilities of State and local government entities.

In 2009, the Obama administration released the National Health Security Strategy, which called for “[a] robust and integrated biosurveillance capability and effective leveraging of information in the private sector health care delivery system..”12(p10) The same year, it released the National Strategy for Countering Biological Threats, which speaks of “[e]nsuring the global availability of life science-enabled capabilities—such as disease surveillance and detection—to mitigate the risks from natural, accidental, and deliberate outbreaks..”13(p6) Finally, in 2010, the administration released the National Security Strategy, which stated, “Recognizing that the health of the world’s population has never been more interdependent, we are improving our public health and medical capabilities on the front lines, including domestic and international disease surveillance, [and] situational awareness.”14(p49)

The National Biosurveillance Advisory Subcommittee (NBAS) was created by HSPD-21 and has been continued under the Obama administration to review federal investments in biosurveillance. In a 2009 review, the NBAS concluded that there are more than 300 separate biosurveillance efforts in existence among federal, state, and local government agencies.1 The NBAS found that many of these systems are disease specific, are not integrated, and may be duplicative.

Methodology

We conducted a review of the literature, including academic articles, open-source government documents, and publications from professional organizations. We also built on prior analysis that our Center has conducted on global biosurveillance,15 a review of NBIS,16 diagnostic technologies and approaches for global biosurveillance,17 and an evaluation of the use of the Department of Health and Human Services’ (HHS) Hospital Available Beds for Emergencies and Disasters (HAvBED) program.18

In advance of a working group meeting (described below), we conducted 16 semi-structured, hour-long telephone interviews with a subset of the meeting attendees, including public health practitioners at the local, state, and federal levels. The individuals invited to participate in this project were chosen because of their prior work in this area. Most were known from previous meetings or were recommended by professional organizations. While there was some attempt to have diversity in the project (eg, geography, size of health department, rural versus urban), there was no attempt to construct a representative sample. These interviews covered the extent to which state and local health departments have the capabilities in place to provide the information needed to detect and manage an infectious disease epidemic or other public health emergency. Additionally, when gaps or deficiencies were identified, participants were asked to describe the optimal corrective action or necessary resources. Telephone interviews were conducted on a not-for-attribution basis.

On March 10, 2011, the Center convened a meeting to discuss issues and challenges in biosurveillance from the perspective of state and local public health practitioners. The meeting addressed the questions: To what extent do state and local health departments have the right capabilities in place to provide the information needed to detect and manage an epidemic or public health emergency? In cases where they don’t have the right capabilities, what concrete steps would improve their capabilities?

Attending the meeting was a small group of public health practitioners from around the country, representatives of national professional organizations, academics, and high-level officials from the federal government who are working on this issue, including officials from the office of the Assistant Secretary for Preparedness and Response (ASPR) in HHS, CDC, the Department of Homeland Security (DHS) Office of Health Affairs (OHA), and the White House National Security staff. The meeting was conducted on a not-for-attribution basis, and consensus was not sought. (See Figure 1 for a list of participating organizations and Appendix A for a list of meeting attendees.)

Figure 1. Participating Organizations

State Public Health Agencies
Maryland • New Hampshire • New Jersey • Virginia • Michigan • North Carolina • Wisconsin
Local Public Health Agencies
New York City, NY • Seattle/King County, WA • Boston, MA • Yolo County, CA • Tarrant County, TX
Federal Agencies
HHS, CDC • HHS, ASPR • DHS, OHA • White House, NSS
Academia
Harvard School of Public Health • University of Texas School of Public Health
Professional Organizations
NACCHO • APHL • ASTHO

Key Outbreak Questions

The meeting was organized around 9 questions that state and federal governments would need to answer in a public health emergency in order to effectively predict the course of the outbreak, estimate risk, distribute life-saving resources, and inform political and health leaders. The questions were derived from our analysis of the events of the 2009 H1N1 influenza pandemic and were vetted and refined through the telephone conversations with participants in advance of the meeting. The questions are a mixture of information needed by public health authorities and elected officials. For example, once the 2009 H1N1 influenza pandemic had begun to spread widely, public health officials were less interested in enumerating the total number of influenza cases; rather, they prioritized gathering information to know how the disease was spreading and what interventions were likely to work. Conversely, throughout the pandemic, political leaders continued to express an interest in knowing how many of their constituents were infected, as this number helped them to gauge the extent of the problem and the degree to which resources were needed.

The 9 questions were subdivided into 3 groups:

What is happening now?

  1. How many people are already sick?

  2. How is the disease spreading?

  3. How severe are the cases?

  4. Who is most at risk?

How is this event likely to unfold?

  1. How will the epidemic unfold?

  2. What interventions are useful?

Do we have what we need to respond?

  1. What treatments are beneficial?

  2. What is the supply of countermeasures?

  3. What medical resources are available?

Findings

These findings represent our synthesis of the comments made by interviewees and meeting participants, supported by our research and analysis. Since we did not seek consensus in our discussions, these findings may not represent the views of all participants. We have included for illustration some anonymous quotes from state and local public health officials who participated in the telephone calls and the meeting. For the most part, the comments relate to the experience of the 2009 pandemic, but they seem to be largely generalizable to other public health emergencies as well.

1. A single comprehensive biosurveillance system is probably not possible, and many systems will be needed.
There was general agreement among the working group participants that although there are many useful biosurveillance systems, no single system provides all the data needed. Furthermore, a single comprehensive system is probably not possible nor necessarily desirable. The type of data that are important for detecting and managing outbreaks is not the same for all causative agents. For example, while syndromic surveillance systems that track influenza-like illnesses (ILI) have been shown to provide earlier indication of the onset of seasonal influenza than is typically available through confirmed influenza-case reporting, ILI-based systems did not function as predictably during the onset of the 2009 H1N1, when visits to emergency rooms were dominated by worried but uninfected patients. In light of the variable requirements for different surveillance information, public health departments typically maintain a variety of different approaches to obtaining and analyzing surveillance data.

As a general principle, project participants seemed to favor biosurveillance data that provide highly specific information. For example, when asked about which federal surveillance systems are the most useful, many participants cited PulseNet, a multistate laboratory-based surveillance system that is used to detect and investigate outbreaks of foodborne illness. In contrast to some other more general surveillance systems, such as syndromic surveillance, PulseNet provides pathogen subtype-specific data, which enables epidemiologists to link cases and to approximate when exposure to contaminated food may have occurred.

2. Rapid laboratory reporting or clinical case reporting are the most important means by which health departments detect outbreaks.
Laboratory reports of known or novel pathogens or clinical reports of unusual cases or cluster of cases are most critical in helping health departments detect outbreaks. Most of the participants noted that while syndromic surveillance systems were initially developed for the purpose of aiding in early outbreak detection, they have largely not been helpful for this purpose; however, they are often useful for determining the scope of an outbreak and providing situational awareness to manage an outbreak. Several participants noted that laboratories often provide the earliest indication of potential outbreaks, as health departments often receive laboratory reports of notifiable diseases or conditions weeks before they are reported by clinicians. Moreover, because information contained in laboratory reports provides specific data pertaining to the disease cause, project participants considered laboratory data to be easier to act on than the nonspecific data provided by syndromic surveillance systems.

3. Public health departments have systems to answer a number of the key outbreak questions, but this takes time.
Most public health departments have developed systems that enable them to answer key outbreak-related questions during routine outbreaks and some public health emergencies, but these answers are not available immediately. Even with better and faster information systems, many participants expressed the belief that few of these questions can be answered in real time. Furthermore, they may have greater difficulty determining answers to these questions during unusual events, such as an outbreak of a novel pathogen or a bioattack.

In most cases, public health departments must launch dedicated investigations to ascertain needed information. Even the most basic question—“How many people are already sick?”—is difficult to answer in real time. It involves more than simply counting cases. First, there is the issue of establishing case definitions and dealing with inconsistent case definitions across jurisdictions. Some existing surveillance systems may not adjust easily as definitions change. Even counting cases is unreliable in real time because of the difficulty in identifying mild or asymptomatic cases. Office visits are greatly underreported, and home-treated cases are nearly invisible to existing surveillance systems. Therefore, early case counts often both underestimate the number of cases and overestimate the severity of cases and therefore can be misleading. In addition, the number of case reports may not accurately reflect the number of cases. Many factors determine whether or not a case is reported to a health department. Some of them relate to capacity, others relate to incentives or disincentives that are in place.

We reported more cases because we had more lab capacity.

If the infection control practitioners report a case, they create a problem for themselves because then we call them and bug them repeatedly.

To answer the question about how the epidemic will unfold, the epidemiology of the outbreak must first be understood. This requires an outbreak investigation, which takes time and may require approaches such as the completion of serologic studies in addition to public health surveillance. Computer modeling can be used to predict the course of the outbreak, but this also takes time, and its accuracy depends on the strength of a number of assumptions about the disease. State and local health departments vary in their ability to conduct epidemiologic investigations. Some small health departments do not have an epidemiologist or even anyone with a degree in public health. Often, small local health departments must rely on assistance from the state or neighboring departments. Although detailed investigations are needed to understand the epidemiology of an outbreak, in a very widespread outbreak, not all departments have to have the same capabilities.

A careful epi investigation is needed, but we don’t have to do one everywhere.

Additionally, public health departments have limited abilities to answer clinical questions in real time. Understanding the severity of cases and what treatments are useful requires getting detailed clinical information from hospitals. Most public health departments do not have the ability to access electronic data from the clinical sector; instead, they rely on telephone calls to clinicians and or onsite reviews of medical records.

In a large city, calling the hospitals is labor-intensive and time-consuming in the midst of a crisis.

A few health departments have developed agreements with some hospitals to give public health access to the hospital’s electronic medical records to facilitate disease investigation. Where this arrangement exists, public health officials have found it to be very useful. Other locations have implemented novel approaches to capturing data from the clinical sector. For example, North Carolina has allocated a portion of its public health emergency preparedness funds to support hospital-based epidemiologists who are employed by and stationed in 11 hospital systems throughout the state. This novel workforce helps to bridge the gap between the clinical community and public health agencies.

4. Private sector medical resource and logistical information is often not readily available to public health departments.
Information about federal and state stockpiles of medicines and vaccines is generally accessible by public health, but the same is not true of information about the availability of pharmaceuticals and medical supplies that are in the possession of the private sector.

How do you advise the governor about what to request from the SNS [Strategic National Stockpile] when you don’t know what’s in the local pipeline?

Parents are calling the governor saying they can’t find Tamiflu for their kids, and he says, “Find some.” So, where do I go?

Generally, public health departments do not have detailed information about the amount of pharmaceuticals and medical supplies in hospitals, clinics, or pharmacies or in the healthcare supply chain.

Understanding the availability of hospital beds, ventilators, and other hospital assets is essential for managing response. Many systems exist to collect hospital bed information, including various state and local systems. Often, however, these systems reside in the emergency preparedness office within the health department, which may not routinely share the information with the surveillance office. For example, a number of the participants involved in surveillance did not routinely see BioSense or HAvBED data being collected in their city or state. Few systems exist to collect information about hospital staff or supplies, and there is concern about the accuracy of information that is provided to health departments.

5. State and local public health agencies do not have sufficient numbers of professionals with the special skills needed to build or run biosurveillance systems.
While there are general shortages in the public health work force, there is a critical shortage of informatics professionals and especially public health informatics professionals (ie, those who have education and training in both epidemiology and information systems).1 State and local public health departments are finding it difficult to retain these employees, because there are more lucrative opportunities in the private sector. Those few informatics experts who remain are overwhelmed by requests for analysis, system building, and information products.7,19,20

We have one messaging specialist and he is doing at least 4 different jobs now.

We have one epidemiologist who can do programming, which is a unique skill set.… This ability is not readily available to many health departments now.

High levels of additional furloughs and staff reductions at public health departments threaten to further exacerbate these workforce shortages.

We have one good epi who has good IT tech skill.… [We] would be lost if we didn’t have this person,… but he is looking for other jobs because he is so frustrated.

6. Federal grant language may prevent health departments from reassigning staff during a public health crisis.
As states face severe budget shortfalls and must lay off or furlough state workers, the percentage of health department employees who are funded by federal grant programs is increasing. Though federal grants are seen by health departments as an important, and, in some instances, the sole, source of funding for necessary public health activities, the way the grants are structured can prevent public health agencies from moving federally funded staff between programs as needed. In particular, there is concern that federal grant restrictions prevent agencies from being able to use other health department staff to help with disaster response.

7. Exchange of electronic health information between clinical and public health communities has the potential to substantially improve biosurveillance.
The ongoing implementation of various forms of health information technology (HIT) offers a great opportunity to improve public health practice by increasing the amount and quality of data available to state and local practitioners.

During H1N1, we were getting pieces of paper faxed to us, and we were entering them by hand. There’s no doubt that electronic reporting could have totally transformed what we knew and when.

There was general agreement that there are 3 categories of health information technology that are foundational to the biosurveillance mission. These are:

  • Electronic health records (EHRs);

  • Electronic laboratory reporting (ELR); and

  • Electronic death registration (EDR).

Public health officials stressed the importance of having ready, electronic access to clinical, laboratory, and death data. They thought that future efforts to improve biosurveillance should focus on increasing public health’s ability to access, analyze, and interpret this information. Future biosurveillance efforts should also strive to make these 3 elements of health information technology interoperable. For example, it would be helpful for health departments to be able to simultaneously call up data from each of these systems and be able to link them to other disease reporting systems (eg, death registration should be able to interface with notifiable disease reporting systems so that it might be quickly recognized if someone dies who has also been the subject of a notifiable disease report). Integration of multiple data streams and the ability to display data in a useful way have been extremely challenging for public health practitioners at all levels of government.

To spur the development of electronic health records, HHS is implementing financial incentives for healthcare providers through Medicare and Medicaid. The incentives are contingent on demonstration of “meaningful use” of electronic health records by the providers. Twenty-five meaningful use criteria have been issued, of which 3 pertain to public health (see Appendix B).21 The implementation of this incentive program and these criteria are being conducted in 3 stages over several years. Stage 1 is completed, and stage 2 criteria are currently under review after public comment.

Many participants felt that current efforts to expand the use of electronic health records and to define what constitutes meaningful use of these records represent an important vanguard of efforts to improve electronic information exchange between clinical and public health. However, some participants felt that specific categories of public health data that are included in current meaningful use criteria—immunization data, reportable laboratory data, and syndromic surveillance—are insufficient for addressing public health’s biosurveillance needs. Among the 3 categories of public health data that are included in current meaningful use criteria, reportable laboratory data was most frequently cited as being important for biosurveillance. However, current meaningful use requirements have not made it mandatory for providers to report these data to public health in order to receive incentive payments for using electronic health records. A number of the project participants did not feel that their health department’s current biosurveillance capabilities would be improved by having providers submit syndromic surveillance data.

Participants were asked, “Aside from the current meaningful use criteria, what kinds of electronic health information would be most helpful to public health departments for biosurveillance?” Several said that having the ability to access electronic health records to look up additional information pertaining to confirmed cases and the ability to query health records to identify additional patients that might meet case definitions would be very helpful for managing outbreaks. In many instances, participants noted that having the ability to perform queries on electronic health records to answer key questions may be preferable to having clinicians routinely submit data to public health departments, as it would not require public health departments to develop systems to house incoming data and would supplement existing incoming data streams.

Receiving data under the current meaningful use criteria, especially syndromic surveillance data, will require significant upfront costs to put in place computer systems able to handle the volume of data that would be sent. In addition, it will require sustained commitment and funding for ongoing data storage, validation, cleanup, and analysis. Public health departments, for the most part, do not have the budgets to implement or maintain the capability to receive these data, and currently very few federal funds are available to public health departments for this purpose.

I am extremely concerned about our ability to handle data from EHRs. We don’t have the money or the staff resources to get ready to be able to receive, store, and analyze these data.

Among these health information technology priorities, most participants in our biosurveillance meeting agreed that electronic laboratory reporting should be the first priority. Many emphasized the importance of laboratory reports in the detection and confirmation of outbreaks. Increased connectivity between public health agencies and laboratories (both public health and clinical laboratories) was seen as critical for biosurveillance to reduce the time to outbreak detection and decrease response time.

We get disease reports from the labs days to weeks before we get them from clinicians.

Not only is transmission of laboratory test results important, but also the ability to monitor test orders could be one of the earliest indicators of a change in health conditions or a means to detect outbreaks of new disease.

Many participants felt implementing electronic laboratory reporting nationally was a realistic goal but that it would require additional federal leadership and support. To date, there has been limited funding available to laboratories and public health departments to facilitate their transition to electronic laboratory reporting. Additionally, more work is needed to develop and promote standards to ensure that electronic laboratory reporting data from different laboratories and different states can be interpreted and compared. Although some work has been done to develop common codes for classifying diagnostic tests and test results, participants noted that a national process is needed to ensure that all laboratories use them and to map diagnostic codes to existing notifiable disease conditions.

Everyone is working hard, but there is no dedicated program for improving electronic laboratory reporting for biosurveillance. Leaders have not made this a priority.

8. State and local public health information technology infrastructure has improved over time, but budget cuts threaten to erode this infrastructure.
While electronic disease reporting and outbreak tracking capabilities are improving, in many places disease reporting still occurs via fax or other paper-based approaches. In addition, the hardware and/or software that is used for various disease and syndrome reporting efforts is not integrated, which has led to the creation of stove-piped or duplicative surveillance systems. Additionally, state and local government efforts to consolidate or outsource IT departments have in some cases reduced the amount of IT support and capacity available to public health departments. This has limited the amount of storage capacity and data maintenance available to health departments.

Our servers are decrepit, we are nearing storage capacity, and we don’t have the money to upgrade our systems.

Recommendations

1. Provide appropriate levels of funding and explicit grant guidance for state and local public health surveillance.
During public health emergencies, state and local health departments are responsible not only for being primary responders to the crisis but also for providing federal decision makers with the majority of the information that is needed to guide deployment of federal resources, development of new countermeasures, and implementation of disease control strategies. However, despite the pivotal importance of state and local biosurveillance systems in supporting the national response to public health emergencies, federal financial support for these systems has been sharply diminishing and additional technical guidance is needed to address key biosurveillance challenges, such as the promotion of electronic laboratory reporting.

If the federal government is going to continue to rely on states to provide critical data during national public health emergencies, it will have to provide appropriate levels of funding to support state and local biosurveillance systems that provide these data. Though federal preparedness cooperative agreements can be used to support biosurveillance activities at the state and local levels, the funding available through this grant program has been in sharp decline since 2005, which has hindered the ability of states to develop and sustain the biosurveillance programs that are critical for the nation. Building health department surveillance IT infrastructure and expertise should be encouraged within this grant program.

Federal agencies should also provide explicit requirements for surveillance to the state and local health departments in their grant guidance. The absence of grant guidance language that specifies that states are to use funding to support and augment their biosurveillance programs has made it difficult for those working in biosurveillance to advocate for these programs in state and local government budget discussions.

Federal agencies should eliminate any language in existing federal grant programs that prohibits recipients from tapping all available resources, regardless of original funding source, during emergencies. To that end, federal agencies should ensure that there are disaster contingency clauses in federal grants to state and local public health departments that permit the use of some minority percentage of the personnel funding for emergency response in declared public health emergencies.

2. Improve public health agencies’ ability to access and use electronic health information.
HHS should expand electronic health records meaningful use criteria in future stages to include requirements for public health. Subsequent stages should mandate that clinicians report specified laboratory data to public health departments. In addition, the HHS Office of the National Coordinator for Health Information Technology (ONC) should ensure through stages 2 and 3 guidance that health information technology systems currently being developed will have the ability to evolve over time, allowing for new features not currently envisioned in existing or proposed expanded meaningful use criteria (eg, additional specifications to encourage the development and adoption of electronic health records that provide public health departments with remote, query-based access to patient records during outbreaks).

HHS should provide financial incentives and technical support to state and local health departments so that they can prepare to receive and use meaningful use data, analogous to resources being made available to providers. A small fraction of the $18 billion that is reserved for incentive payments for healthcare providers who adopt electronic health records would go far in helping state and local health departments to prepare to receive electronic health records data. CDC should fund research to investigate how public health agencies can better apply electronic health information to biosurveillance programs.

3. Promote the implementation of electronic laboratory reporting and electronic death registries.
HHS (CDC, ONC, and with possible inclusion of the Centers for Medicare and Medicaid [CMS]), with input from state and local public health stakeholders, should facilitate a process for developing national data standards for electronic laboratory reporting. CDC should include in its Public Health Emergency Preparedness grants metrics and timelines for public health departments to implement electronic laboratory reporting and electronic death registries.

4. Address key gaps in biosurveillance for responding to public health emergencies: advanced epidemiology and supply/logistical information.
Though state and local health departments expressed confidence in being able to assess routine epidemiologic characteristics during outbreaks, many will likely need outside assistance to launch more detailed investigations aimed at understanding complex epidemiologic questions, such as severity. To that end, CDC should continue its work with state and local health departments to improve the speed with which epidemiologic investigations are conducted, to develop plans for implementing clinical trials during public health emergencies, and to ensure that both interim and conclusive findings from these efforts are quickly shared with the public health and medical communities to aid the national public health and medical response.

Federal agencies should work together to strengthen the availability of logistical and supply chain information— such as data pertaining to availability of pharmaceuticals and medical supplies from public and private sectors, and intelligence information—that is critical for managing public health emergencies. Given its relationships with private sector entities, DHS should continue to work with ASPR, CDC, and other relevant federal entities to improve integration of health and logistical information.

References

  1. National Biosurveillance Advisory Subcommittee. Improving the Nation’s Ability to Detect and Respond to 21st Century Urgent Health Threats: First Report of the National Biosurveillance Advisory Subcommittee. April 2009. http://www.avma.org/atwork/NBASreport072209.pdf. Accessed May 25, 2011.

  2. U.S. Centers for Disease Control and Prevention. Concept Plan for Implementation of the National Biosurveillance Strategy for Human Health. January 2010. http://www.cdc.gov/osels/pdf/Concept_Plan_V1+5+final+for+print+KMD.PDF . Accessed May 25, 2011.

  3. Franco C, Sell TK. Federal agency biodefense funding, FY2010-FY2011. Biosecur Bioterror 2010;8(2):129-149.

  4. U.S. Centers for Disease Control and Prevention. Public Health Preparedness Capabilities: National Standards for State and Local Planning. March 2011. http://www.cdc.gov/phpr/capabilities/Capabilities_March_2011.pdf. Accessed May 25, 2011.

  5. Stoto MA, Schonlau M, Mariano LT. Syndromic surveillance: is it worth the effort? Chance 2004;17:19-24.

  6. Buehler JW, Hopkins RS, Overhage JM, Sosin DM, Tong V; CDC Working Group. Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR Recomm Rep 2004;53(RR-5):1-11.

  7. Uscher-Pines L, Farrell CL, Cattani J, et al. A survey of usage protocols of syndromic surveillance systems by state public health departments in the United States. J Public Health Manag Pract 2009;15(5):432-438.

  8. Trust for America’s Health. Ready or Not? 2010: Protecting the Public’s Health from Disease, Disasters, and Bioterrorism. December 2010. http://healthyamericans.org/assets/files/TFAH2010ReadyorNot%20FINAL.pdf . Accessed May 25, 2011.

  9. Pandemic and All-Hazards Preparedness Act. http://www.govtrack.us/congress/bill.xpd?tab=summary&bill=s109-3678. Accessed May 25, 2011.

  10. Implementing Recommendations of the 9/11 Commission Act of 2007. August 2007. http://intelligence.senate.gov/laws/pl11053.pdf. Accessed May 25, 2011.

  11. Homeland Security Presidential Directive 21. Public Health and Medical Preparedness. October 2007. http://www.fas.org/irp/offdocs/nspd/hspd-21.htm. Accessed May 25, 2011.

  12. Office of the Assistant Secretary for Preparedness and Response. National Health Security Strategy of the United States of America. December 2009. http://www.phe.gov/Preparedness/planning/authority/nhss/strategy/Documents/nhss-final.pdf. Accessed May 25, 2011.

  13. National Strategy for Countering Biological Threats. November 2009. http://www.whitehouse.gov/sites/default/files/National_Strategy_for_Countering_BioThreats.pdf.  Accessed May 25, 2011.

  14. National Security Strategy. May 2010. http://www.whitehouse.gov/sites/default/files/rss_viewer/national_security_strategy.pdf. Accessed May 17, 2011.

  15. Center for Biosecurity . International Disease Surveillance: United States Government Goals and Paths Forward. June 2010. http://www.upmc-biosecurity.org/website/resources/publications/2010/2010-06-01-intl_disease_surveillance.html. Accessed May 25, 2011.

  16. Nuzzo JB. Developing a national biosurveillance program. Biosecur Bioterror 2009;7(1):37-38.

  17. Nuzzo JB, Rambhia KJ, Wollner SB, et al. Diagnostics for Global Biosurveillance: Turning Promising Science into the Tools Needed in the Field. In press.

  18. Toner E, Rambhia KJ, Norwood A, et al. Understanding Healthcare System Capacity and Functioning During Crisis: Lessons from H1N1 (2009) and Recommendations for Future Healthcare Situational Awareness. February 2011. In press.

  19. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: 2008-2010. March 2011. http://www.naccho.org/topics/infrastructure/lhdbudget/loader.cfm?csModule=security/getfile&PageID=188273. Accessed May 24, 2011.

  20. Association of State and Territorial Health Officials. Budget Cuts Continue to Affect the Health of Americans: Update May 2011. http://www.astho.org/Display/AssetDisplay.aspx?id=6024. Accessed May 24, 2011.

  21. Centers for Medicare and Medicaid Services. Eligible Professional Meaningful Use Table of Contents Core and Menu Set Measures. Updated May 2011. https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf. Accessed May 25, 2011.

  22. Centers for Medicare and Medicaid Services. CMS Meaningful Use Overview. Updated April 20, 2011. http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp#BOOKMARK6. Accessed July 27, 2011.

  23. Centers for Medicare and Medicaid Services. Eligible Professional Meaningful Use Table of Contents Core and Menu Set Measures. Updated May 2011. https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf. Accessed May 25, 2011.

Appendix A: Meeting Attendees

Gerrit T. Bakker, Association of State and Territorial Health Officials

Scott J. Becker, Association of Public Health Laboratories

Jim Collins, Michigan Department of Community Health

Lana Deyneka, North Carolina Department of Health and Human Services

Jeffrey S. Duchin, Public Health—Seattle & King County

David Gruber, New Jersey Office of Homeland Security and Preparedness

Julia E. Gunn, Boston Public Health Commission

Rick Heffernan, Wisconsin Division of Public Health

Matthew Hepburn, White House National Security Staff

Vanessa Holley, National Association of County and City Health Officials

Taha A. Kass-Hout, Centers for Disease Control and Prevention

James Kirkwood, Association of State and Territorial Health Officials

Marcelle Layton, New York City Department of Health and Mental Hygiene

Marc Lipsitch, Harvard School of Public Health

Joseph B. McCormick, University of Texas—Brownsville

Jennifer Olsen, U.S. Department of Health and Human Services

Frances Phillips, Maryland Department of Health and Mental Hygiene

Sally Phillips, U.S. Department of Homeland Security

Daniel M. Sosin, Centers for Disease Control and Prevention

William F. Stephens, Tarrant County Public Health

David Swenson, New Hampshire Department of Health and Human Services

Tim Wilson, Yolo County Health Department

Diane Woolard, Virginia Department of Health

Patina Zarcone-Gagne, Association of Public Health Laboratories

Appendix B: Meaningful Use Criteria

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides HHS with the authority to establish programs to promote the adoption of health information technology (HIT), including electronic health records (EHRs). Under HITECH, eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) are to receive Medicare and Medicaid incentive payments for demonstrating ‘‘meaningful use’’ of certified electronic health records.

Meaningful Use Criteria for Medicare and Medicaid

For eligible professionals, there are 25 meaningful use objectives. To qualify for an incentive payment, eligible professionals must meet 20 of these 25 objectives, including 15 core required objectives and 5 objectives from an additional menu set of 10 objectives.

For eligible hospitals and critical access hospitals, there are a total of 24 meaningful use objectives. To qualify for an incentive payment, hospitals must meet 19 of these 24 objectives, including 14 required core objectives and 5 of the 10 menu set objectives.

Objectives for Improving Population and Public Health

Eligible professionals, eligible hospitals, and critical access hospitals must complete at least 1 of 3 public health–related objectives from the menu set of 10 objectives.22

Core Measures

  1. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record, per state, local, and professional guidelines.

  2. Implement drug-drug and drug-allergy interaction checks.

  3. Maintain an up-to-date problem list of current and active diagnoses.

  4. Generate and transmit permissible prescriptions electronically (eRx).

  5. Maintain active medication list.

  6. Maintain active medication allergy list.

  7. Record all of the following demographic information: (a) preferred language, (b) gender, (c) race, (d) ethnicity, and (e) date of birth.

  8. Record and chart changes in the following vital signs: (a) height, (b) weight, (c) blood pressure, (d) calculate and display body mass index (BMI), and (e) plot and display growth charts for children 2-20 years, including BMI.

  9. Record smoking status for patients 13 years old or older.

  10. Report ambulatory clinical quality measures to CMS or, in the case of Medicaid-eligible professionals, the states.

  11. Implement 1 clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule.

  12. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request.

  13. Provide clinical summaries for patients for each office visit.

  14. Capability to exchange electronically key clinical information (eg, problem list, medication list, allergies, and diagnostic test results) among providers of care and patient-authorized entities.

  15. Protect electronic health information created or maintained by the certified electronic health records technology through the implementation of appropriate technical capabilities.

Menu Set Measures

  1. Implement drug formulary checks.

  2. Incorporate clinical lab-test results into electronic health records as structured data.*

  3. Generate patient lists by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

  4. Send patient reminders per patient preference for preventive/follow-up care.

  5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the eligible professional.

  6. Use certified electronic health records technology to identify patient-specific education resources and provide those resources to the patient if appropriate.

  7. The eligible professional who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

  8. The eligible professional who moves his or her patient to another setting of care or provider of care or refers the patient to another provider of care should provide summary care record for each transition of care or referral.

  9. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.*

  10. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.*23

* Criteria in bold denote those that pertain to public health.