| Bio-terrorism
Early Warning Syndromic Surveillance
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By Ronald A. Hellstern, M.D.,
FACEP
VP Medical Affairs - Emergisoft Corp. |
The foundation of optimum bio-terrorism
event management is early warning. A key epidemiological tenet is that the
detection and reporting process must occur faster than the speed of the spread
of the biological agent to make any difference in outcome. The emergency
department (ED) is an ideal data source area upon which to focus this effort
because it operates continuously around the clock and generally has more
reporting capability than the typical physician’s office practice. Effective
early warning in turn derives from the capabilities of local, state and
federal systems of disease reporting. As medicine in general, and emergency
medicine in particular, moves to integrate computers into what is now a
paper-based world, the use of an electronic medical record (EMR) in the ED
will make possible both real time disease symptom constellation (so called
"syndromic") monitoring and the nearly instantaneous early
identification of an unfolding bio-terrorism event.
Unfortunately, disease-reporting
statutes are currently a hodge-podge of confusing and often conflicting local
and state health department regulations. The timeliness of subsequent federal
reporting varies widely from state to state. Until the period of the anthrax
incidents following the September 11, 2001 World Trade Center/Pentagon
terrorist attacks most communicable disease reporting relied on the completion
and mailing of paper forms. Since the anthrax incidents some states have
instituted 800 telephone numbers for the more immediate reporting of certain
specific disease conditions, but few states currently support any form of
electronic monitoring or reporting. Recognition and reporting timelines for
biological events continues to be measured in days and weeks rather than in
minutes and hours. Furthermore, until this surveillance can occur passively,
without the need for data abstraction from one system and/or entry into yet
another database or reporting system, public health data reporting compliance
will remain as dismally inadequate as it is today.
The Congress and President Bush have
recognized this need and a key provision of the recently enacted (summer 2002)
Homeland Security Funding Bill contains a provision for up to $4.5B to assist
the Centers for Disease Control (CDC) and State Health Departments in creating
an ED-based syndromic surveillance system with local area wrap-up reporting
occurring horizontally to State Health Departments and national reporting
occurring vertically to the CDC.
Syndromic surveillance differs
significantly from presenting complaint or final diagnosis surveillance and
reporting. Monitoring patient presenting ED complaints for the purposes of
bioterrorism early warning is problematic because these complaints are
typically subjective and expressed in non-scientific terms. In addition, no
standardized coding system exists for these so-called chief complaints. Final
ED diagnosis is problematic because it is typically not coded at the time of
the ED visit. In addition, since most EDs continue to operate in a paper-based
environment the content of their medical records is neither searchable nor
reportable, except on a manual basis and after the fact. Final diagnosis also
varies depending upon individual provider interpretation of any given set of
symptoms and signs.
The word "syndrome" implies
within its medical meaning the lack of a discrete diagnosis. A medical
syndrome is a collection of a group of symptoms and signs that are known to
occur together in certain conditions but that do not necessarily add up to any
single definable diagnosis. Most bioterrorism agents present with very
non-specific symptoms or signs that are easily confused with common medical
problems such as allergies, a cold or influenza. These common medical
diagnoses (allergy, cold, the flu, etc.), if used as the basis of early
warning surveillance, are prone to misinterpretation as insignificant
findings.
The best possible early warning
surveillance system should therefore focus on the earliest available patient
data that is free from human interaction-induced variability. In this instance
that is the specific patient symptoms and signs themselves, and not the
presenting chief complaint or the final ED diagnosis. Thus syndromic
surveillance is designed to look in real time for abnormal patterns of
occurrence of groups of symptoms and signs, and to use these to alert the
public health agencies long before any single individual could possibly
identify an evolving event.
Of all the ED information systems
solutions on the market, EmergisoftED is virtually the only one capable
of supporting this real time syndromic surveillance effort without
modification. In EmergisoftED, the Document Guide prompts the clinical
data content and it can easily be quickly reconfigured to adapt to the
specific event so we are sure to collect the appropriate bio-terrorism early
warning data. Each clinical symptom or sign in the "syndrome" we are
seeking for the purpose of early warning is collected and stored in the system
as a discreet data point, making it both searchable and reportable in real
time. EmergisoftED is the only EDIS currently possessing all
of these essential characteristics.
For more information, contact Emergisoft
Corporation, 800-682-7729,
www.emergisoft.com.
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