Interoperability continues to pose substantial challenges across all emergency support functions. Although it is most often focused on communications between and among first responders – and on equipment shared through mutual-aid events – health and medical interoperability poses unique challenges as well. In addition to sharing communication challenges, public health and medical professionals involved in preparedness and response activities face a number of interoperability issues ranging from the systems and devices used in clinical settings to electronic medical records, epidemiological surveillance and laboratory data, Geographical Information Systems (GIS), and patient tracking systems. However, large-scale emergencies involving the deployment of public health and medical assets across multiple jurisdictions and/or the widespread sharing of related data are infrequent, which means there are fewer opportunities to test these assets and systems for interoperability.
Meanwhile, the growing complexity of technology across the full continuum of healthcare delivery is posing additional interoperability challenges. Medical devices are rapidly becoming more automated, for example, and generating more patient data than was ever before possible. Even the basic monitoring of vital signs has advanced to the point where it can capture extremely detailed patient data – quickly, and in large quantities – and share it for a variety of uses, including telemedicine. Although this technology has tremendous promise for future emergency response activities, the systems now emerging often cannot communicate with one another. This lack of plug-and-play connectivity and interoperability poses new operational challenges to healthcare providers – and, of greater importance, increases the risks to patient safety.
The transition to electronic medical records (EMRs) has started, though, and promises to change U.S. healthcare as much, and as dramatically, as the introduction of credit cards and on-line banking in recent decades changed personal and corporate financial practices. EMRs will similarly transform the ways care is provided during public health emergencies and major disasters. Today, as individual citizens arrive at emergency treatment or patient evacuation locations, providers seldom have adequate information on the patients’ treatment history, drug allergies, and/or pre-existing conditions. Even if a patient has a paper medical record immediately available, the accuracy and completeness of the information in that record may be questionable, for two reasons: (1) the fragmentation of healthcare delivery in the United States; and (2) the fact that the healthcare records of most U.S. citizens have, over a period of many years – sometimes decades – been compiled by a number of previous primary care physicians in several healthcare delivery settings. The compilation and ready availability of integrated and interoperable EMRs will alleviate this problem considerably by providing much-needed “longitudinal” health information during a response – and, as an additional benefit, also provide an effective mechanism to document the care provided during an emergency, even in austere conditions.
The Two-Headed Challenge Blocking a “Dramatic” Upgrade
An additional challenge to the creation and use of EMR interoperability involves the often conflicting needs to maintain patient confidentiality while also compiling a complex mass of healthcare information. The building of a truly interoperable EMR system, therefore, requires a solution to the perceived dichotomy between the need to rapidly share complex personal information while at the same keeping that information as secure as possible. Nonetheless, when (not if) the U.S. healthcare community resolves this issue and interoperable EMR data becomes the new standard, the national shift to an EMR-based healthcare system will dramatically improve how care is provided during large-scale emergencies.
Effective epidemiological surveillance can usually determine if and when a public health risk is developing, primarily through the early detection of emerging diseases or of a bioterrorism attack. Typically, the surveillance also measures how effectively a response is being managed, in large part by providing population-based data on key health indicators.
Unfortunately, many surveillance systems currently in use are not interoperable. In fact, a high percentage of professionals serving in epidemiologist roles, gathering and analyzing this critical data, still receive much of their information through hand-written notes or faxes. Even worse is the fact that the data they receive is often entered twice – first into a system designed to meet reporting requirements, and then into another program designed to help the epidemiologist complete his or her own analysis. This process not only is labor intensive but also raises legitimate concerns about the integrity and consistency of the data being entered. The implementation of automated and interoperable surveillance systems could alleviate and eventually eliminate these double-entry problems and enhance the effectiveness of epidemiologists by significantly reducing the time it takes medical researchers to detect emerging public health threats.
Much like the challenges facing epidemiology, public health laboratories often receive and share information through the use of written notes and faxes. Progress in modernizing this approach has been made in recent years through the Public Health Laboratory Interoperability Project – a collaborative initiative between the Association of Public Health Laboratories (APHL) and the Centers for Disease Control and Prevention (CDC). The project, which started in 2006 with six state laboratories and the CDC, has since expanded to 22 states. Significant progress toward full interoperability is already being achieved through the collaborative efforts between the IT (information technology) staff and laboratory professionals, who are working together to: (a) define what the ideal laboratory IT infrastructure should look like; and then (b) standardize the complex laboratory messaging and documentation needed to create such an infrastructure.
Numerous Ancillary Benefits Also Predicted
The work being done by the APHL and CDC participants should help reduce the multiple interfaces and communication inconsistencies that are now relatively common. Moreover, as the project defines needs more precisely, shares the lessons learned, and standardizes the processes now used, a high percentage of the nation’s laboratory systems will become better integrated and more interoperable.
As electronic medical records become the new standard and associated epidemiology and laboratory information becomes both more integrated and interoperable, one major result will be the more rapid detection of naturally occurring or emerging infectious disease outbreaks. The new EMR system will also assist in quickly gauging the effectiveness of a specific public health emergency intervention or response. That capacity – combined with other well integrated, and interoperable, GIS and patient tracking tools – can facilitate a robust public health and medical response to any emerging public health threat.
That type of system is attainable today – but unfortunately is likely to be many years away from becoming a reality. The reason is more administrative in nature than it is the technological challenges that still must be overcome. The problem is easy to describe, but difficult to resolve: Engineering interoperability into the nation’s public health and medical preparedness and response system is hampered considerably by the decentralized nature of public health. One of the operational strengths of public health is that it is typically decentralized and locally focused. However, that decentralization makes effective standardization more difficult to achieve. One example: there are and have been for quite a few years many epidemiological surveillance tools available to epidemiologists throughout the country. When funding for public health preparedness rapidly increased after the terrorist attacks of 2001, markets responded to the opportunity by creating even more tools. However, while public-sector vendors were introducing a variety of superb new surveillance systems and devices, there was little consideration of mandating interoperability as one of the goals to be achieved.
Vigorous But Fragmented Responses & a DOD-Based Solution
That problem is likely to continue, and expand, for some time to come. As new requirements emerge in the absence of a singular national approach, vendors will continue to respond as they did before, and the surveillance systems in use will likely remain fragmented. For that reason alone, the nation’s public health and medical leaders should carefully consider how other federal agencies have overcome similar problems in their own areas of responsibility.
One example worth serious consideration is the procurement system used by the U.S. Department of Defense (DOD), which provides detailed specifications of what products will meet its combat needs. U.S. (and foreign) contractors compete with one another by developing various design and program packages that will: (a) build the new weapons systems needed by U.S. military forces; (b) provide the support and maintenance equipment also needed; and (c) field the necessary training programs. For very complex weapons systems – the Joint Strike Fighter, to cite but one prominent example – the RDT&E (research, development, test, and evaluation) process mandated before the start of actual production may take nearly a decade. The long timeline postulated, of course, results primarily from the complexity of the weapons system.
Surprisingly, perhaps, the question facing the U.S. healthcare community is even more difficult to answer. How much more complex is the U.S. public health and medical infrastructure? The answer is not technological but political in nature – more specifically, the fact that the annual nature of federal preparedness funding usually limits spending to off-the-shelf products that lack the much-needed interoperability and integration discussed above.
Nonetheless, the prognosis for the U.S. healthcare community, and for the American people, is promising – but with several conditions attached. There is little doubt that the nation’s healthcare system as a whole will “get there” eventually. But with the current relatively meager funding approach, reaching that elusive goal will probably take many years more than it should.
Bruce Clements is the Public Health Preparedness Director for the Texas Department of State Health Services in Austin, Texas, and in that post is responsible for health and medical preparedness and response programs ranging from pandemic influenza to the health impact of hurricanes. A well-known speaker and writer, he also serves as adjunct faculty at the Saint Louis University Institute for BioSecurity. His most recent book, Disasters and Public Health: Planning and Response, was released in 2009.