Report on Bioterrorism Surveillance in the United States

December 10, 2001

John A. Zapp, MD, Chair

The Primary Care Informatics Working Group of the American Medical Informatics Association held a Special Session on November 4, 2001 in Washington, D.C. to address information technology requirements for effective primary care bioterrorism surveillance and rapid response in the United States. While terrorism in many forms has long been faced by most countries, including the United States, the scale of the September 11th attack on the Pentagon and the World Trade Towers, and the subsequent Anthrax letters, have changed the American people and called for homeland defense. Bioterrorism defense is significantly compromised by the lack of clinical information systems.

Presentations were made on bioterrorism and the requirements for primary care physicians in the United States to provide essential surveillance.

Jon Temte, MD, PhD, Chairman of the Wisconsin Influenza Pandemic Planning Executive Committee presented the keynote session on Creating Complete Surveillance, emphasizing the complexity and challenges of medical surveillance for agents that may mimic common illnesses (e.g. anthrax vs. flu)

• Julie Pavlin, MD, MPH, Major United States Army, Chief, Department of Field Studies Walter Reed Army Institute of Research presented the Department of Defense’s automated surveillance systems.
• John Loonsk, MD, MPH, Associate Director for Informatics, Center for Disease Control and Prevention reviewed the public health needs and responsibilities in surveillance and response and described the National Electronic Disease Surveillance System and its relevance to primary care physician surveillance
• Michael Bainbridge, BmedSci, BM, BS, MRCGP, CompBCS, Chair of the Primary Health Care Specialist Group of the British Computer Society demonstrated how UK general practitioners are able to implement, within 24 hours, bioterrorism surveillance utilizing in-place Electronic Medical Records and infrastructure.

The following key points were made:

• Primary Care providers are our nation’s “front line forces” for bioterrorism surveillance, detection and immediate care, accounting for approximately 113 visits/1000 population/month contrasted with 13 emergency department visits/1000 population/month and 1 admission to an academic-medical-center hospital/1000 population/month. (1)
• Our hospitals and emergency departments, frequently at the limits of their capacity now, could not possibly assume the task of evaluating the general population with flu-like syndromes for anthrax or for other conditions that may first present as abnormal epidemics of common symptoms.
• Testing every patient for anthrax with flu-like symptoms and no other risk factors would entail enormous unnecessary cost
• Effective bioterrorism surveillance is a complex task with multiple approaches including Mechanistic, Laboratory, and Sentinel surveillance
• Volunteer reporting of surveillance data is problematic, especially if the condition (e.g. anthrax) does not appear or if the reporting process involves significant time and resources outside the normal practice of the physician.
• In the U.K, 98 % of the GP’s have access to an electronic clinical record system at the point of care as contrasted with the United States where approximately 5% of family physicians are using such technologies.
• The PCIWG has developed, over the past two years, a National Strategic Plan in Primary Care Informatics which calls for standards-based Electronic Medical Records in every physician’s office
• The National Alliance for Primary Care Informatics* has endorsed the Vision Statement that “Every Primary Care Provider will use information technology that includes electronic health records with the ability to access and communicate needed clinical information to achieve high quality, safe, and affordable health care.”

Recommendations:

1. Every primary care physician in the United States must be provided now with information on bioterrorism surveillance and detection using our current resources, especially in anticipation of the flu season, in order to both provide appropriate care and to avoid enormous unnecessary panic and healthcare expense.
2. Every primary care physician in the United States must have and use a fully functional Electronic Medical Record (EMR) with standardized clinical data for current and future domestic surveillance against biological, chemical and nuclear weapons on civilian populations.
   1. Those EMRs must “fit” the primary care environment to be effective
   2. The data obtained must be available for epidemiological surveillance regionally and nationally while protecting patient confidentiality.
   3. Relevant expert knowledge and decision support at the point of care must be linked to the EMR.
   4. Development of such EMRs requires a national commitment to defining standards to which industry can respond.
   5. Primary care acquisition and implementation of such EMRs requires funding mechanisms
3. The Primary Care Informatics Working Group offers its expertise to work with all healthcare organizations, public health officials, the Department of Defense, other agencies, vendors, payers and the public (our patients) to assist in the development of a comprehensive and integrated plan.

Conclusion:

Weapons of mass destruction including biologic, chemical and nuclear devices, are threats to populations in every country today. While resolution of those threats is the task of governments, surveillance for early detection and treatment is the responsibility of the health care systems of each country. Effective surveillance and treatment requires clinical information systems that capture relevant data in a coded and standardized form, permitting rapid analysis of pooled information and decision support directed to health care providers.

We are faced now with the opportunity to create and/ or to adopt global standards that will enable global surveillance. Such standards will, as a critically important by-product, allow for global studies of many health conditions, interventions and outcomes thereby profiting the world population’s health and well being.

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