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Three major health issues have become urgent in the wake of recent terrorist attacks against the United States: bioterrorism, the threat of widespread delivery of agents of illness; mass disasters, local events that produce many casualties and overwhelm the usual capacity of health care delivery systems; and the delivery of optimal health care to remote military field sites. Each of these health issues carries large demands for the collection, analysis, coordination, and distribution of health information.
Informatics can help this effort, according to three recent studies supported by the Agency for Healthcare Research and Quality. The first study discusses the ongoing informatics work in each of these areas. The second study examines information system-based surveillance described during a roundtable discussion on bioterrorism detection. The third study details unique biomedical informatics tools at the local and regional levels that can be immediately pressed into service for the protection of U.S. groups from bioterrorism attacks.
Teich, J.M., Wagner, M.M., Mackenzie, C.F., and Schafer, K.O. (2002, March). "The informatics response in disaster, terrorism, and war." (contract 290-00-0009). Journal of the American Medical Informatics Association 9(2), pp. 97-104.
Several policy changes are needed to better coordinate information among local, regional, and national agencies to prevent and manage terrorist attacks, according to these authors. 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 pre-hospital 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" makes use of 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 that are 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. The data are sent to the hospital's Intranet or disaster control center, where they can be viewed on a Web browser by control personnel. Finally, through telemedicine technologies, expert assistance (for example, for trauma evaluation and management, including surgery) can be provided to remote medical caregivers in military operations.
Lober, W.B., Karras, B.T., Wagner, M.M., and others. (2002, March). "Roundtable on bioterrorism detection: Information system-based surveillance." (contract 290-00-0009). Journal of the American Medical Informatics Association 9(2), pp. 105-115.
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. This article combines case reports of six existing systems described at the roundtable. 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).
Kohane, I.S. (2002, March). "The contributions of biomedical informatics to the fight against bioterrorism." (contract 290-00-0020). Journal of the American Medical Informatics Association 9(2), pp. 116-119.
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 health care 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 missing the detection of a bioterrorism incident 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. Clinicians must be trained to deliver state-of-the-art diagnostic work-ups and treatments to potential and actual victims of bioterrorism.
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