Thirty-two hospital emergency departments in 10 cities are part of a pioneering early-warning network designed to give federal and local health officials an immediate indication of bioterrorism attacks or deadly infectious disease outbreaks. But the BioSense network, operated by the Centers for Disease Control and Prevention, has garnered its share of criticism even before starting operations in mid-April.
Lynn Steele, MD, the director of the CDC's division of emergency preparedness and the chief of BioSense, said the near real-time electronic connection between the CDC and hospitals will enable public health departments that participate to access clinical data in their area, and permit local officials to identify more quickly additional illnesses in epidemics or bioterrorism attacks. “And the data could be used to control any biological event,” Dr. Steele said.
But skeptics abound. In March, local health officials and national biosecurity experts told a Senate subcommittee that the CDC network diverts attention from the more important goal of establishing data links between hospitals and their local public health departments. The hearings in the Senate Subcommittee on Bioterrorism and Public Health preparedness were the latest in a series designed to lay the groundwork for reauthorization of the landmark Public Health Security and Bioterrorism Preparedness and Response Act of 2002. Congress could use a reauthorization bill to make changes to the BioSense program even as it is getting off the ground.
Doug Heye, the spokesman for Sen. Richard Burr (R-NC), who is chairman of the subcommittee, said the senator has seen firsthand how North Carolina has been able to connect the hospital emergency department data with other sources of health data in the state at a fraction of the cost of BioSense and with much greater success. In North Carolina, a new Hospital Emergency Surveillance System (HESS) provides the North Carolina Division of Public Health with real-time electronic reports from more than 100 hospital emergency departments. Seven disease investigation strike teams respond immediately to suspicious disease reports anywhere in the state.
Senator Burr's preference for a locally run biosurveillance system over one managed by the CDC was echoed by some witnesses at the March 28 hearing of his subcommittee. Tara O'Toole, MD, MPH, the director and CEO of the Center for Biosecurity at the University of Pittsburgh Medical Center, argued that connecting more hospitals to more state and local health agencies may be a better use of funds.
CDC officials said the local and federal systems can complement one another, not be mutually exclusive. “There is no reason why it has to be either our BioSense system or the local system,” said Jerry Tokars, MD, the associate director for science in the National Center for Public Health Informatics' Division of Emergency Preparedness and Response at the Centers for Disease Control and Prevention.
A key advantage of the BioSense network over state systems is that data are sent from a hospital's computer interface engine every 15 minutes to the CDC. Those data are extremely comprehensive, and are sent from admissions clerks in hospital emergency departments, most outpatient clinics, and inpatient departments. The data covers five categories:
- ▪ Foundation: demographics, chief complaint, diagnosis, disposition, and hospital utilization.
- ▪ Clinical: vital signs, triage notes, clinical notes, discharge summaries, and clinical diagnoses.
- ▪ Laboratory: orders and microbiology results.
- ▪ Pharmacy: medication orders and dispensed medications.
- ▪ Radiology: orders and interpretation of results.
Of course, the key to BioSense as an effective early warning system is not just that data are sent to the CDC every 15 minutes, but that the patient information obtained in the emergency department, for example, is immediately entered into the hospital's information system. Data not entered in real time do not get sent to the CDC in real time, nor are they sent back to the local public health departments in those 10 cities in real time.
Dr. Tokars said foundation data are already flowing, and the other four categories will be added over the course of this year. One of the challenges in adding the additional categories, he explained, is that it takes a certain amount of work to map the computer codes used by various hospitals to standard computer codes.
Once the coding challenge is overcome and the CDC starts receiving hospital data, it will process the data and characterize it into syndromes and subsyndromes, and then send that to the local health departments in the 10 cities. Those departments also can choose to receive a feed of the raw data that the CDC receives from the hospitals in their area.
Dr. Steele added that she hopes to enlist 300 hospitals in 40 cities by the end of the year. BioSense received $50 million for fiscal year 2005, and another $50 million for fiscal year 2006, which began last October, and Dr. Steele expects another $50 million for fiscal year 2007, which starts Oct. 1.
But Dr. O'Toole said before additional funds are invested in what she refers to as BioSense's “stopgap system,” the specific goals of Biosense must be defined and examined in light of the actual operations. It is not clear that the CDC has thoroughly analyzed how hospitals view the time and effort they are putting into BioSense or whether local health departments have had their data needs incorporated into the program.
Critics say BioSense is trying to do too much too fast, and David Allen, a spokesman for the American Hospital Association, declined comment on the program. Other experts said the CDC may not be well positioned to manage information and mount a response once bioterrorism or a disease outbreak is identified.
Jennifer Nuzzo, an analyst at the Center for Biosecurity at the University of Pittsburgh, said the CDC has had trouble communicating with hospitals and local health departments during some past public health crises, and that it has limited resources to coordinate a response to bioterrorism or pandemic outbreaks. “They cannot be everywhere at once,” Ms. Nuzzo explained. It makes more sense, she argued, to make it a priority to help hospitals within the same city or even the same region to communicate with one another and their local public health departments.
GOALS OF THE BIOSENSE NETWORK
- ▪ Provide real-time national surveillance and event detection and management critical in containing and minimizing bioterrorist threats.
- ▪ Support the secure connection of health care and health-related data from the health care system nationally.
- ▪ Include a new software system at the CDC to act as a national safety net and support data analysis in CDC's newly established BioIntelligence Center.
- ▪ Receive, analyze, and evaluate health data from numerous data sources such as emergency departments, ambulatory care physicians and clinics, pharmacies, and clinical laboratories.