The elevation of risk of terrorist attack by the Department of Homeland Security from yellow to orange earlier this year didn’t send much of a shudder down healthcare’s backbone.

Only eight of 170 sessions (less than 5%) at February’s Healthcare Information Management Systems Society (HIMSS) meeting were devoted to bioterrorism disaster planning and recovery.

No disaster management sessions were presented at the National Managed Health Care Congress in March.

Healthcare’s ho-hum attitude got a shot in the arm from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), which issued a March report calling for hospitals to develop community-based emergency response systems.

JCAHO warned that across the nation, communities are unprepared to respond to emergencies, including terrorist attacks. The report urged more coordination among emergency medical services, hospitals, fire and police departments, public health agencies, and local and county officials. JCAHO called on federal and state governments to provide resources and leadership for community response systems.

A sudden surge in demand for medical care to treat symptoms resulting from bio-agents such as anthrax, plaque, or small pox could overwhelm resources.

Ready or Not

No one seems to know for sure if healthcare is ready or not.

According to a March survey conducted by the American College of Healthcare Executives, 84% of hospital CEOs say that since Sept. 11, their hospitals have worked more closely with first responders, including fire, police, and public health departments, making their hospitals safer. Further, 95% of the respondents said their hospitals already have, or within six months will have, a bioterrorism disaster plan in place.

The survey also reported that 85% of respondents are already working with other hospitals or health associations to determine what resources are available to respond to bioterrorism. Of the hospitals not currently communicating with other organizations, 73% are planning to within six months. Also, 60% confirmed that their hospitals have decontamination units in place. Of the hospitals without decontamination units, 70% plan a purchase within the next year.

One means by which healthcare interests are supporting national mandates is with realtime health surveillance.

"Chief complaint logs are sent by the hospital in a de-identified state for review by surveillance software and, if necessary, by an epidemiologist," said Joel Hersh, director, Bureau of Epidemiology, Pennsylvania State Health Department. The process theoretically yields an earlier picture of a disease experience in a community by combining data from several hospitals.

The more timely review would allow public health departments to intervene and reduce the number of people who might become infected, Hersh said. Hospitals are key players since it is assumed patients will present to emergency departments. Radiology is part of the surveillance equation.

Surveillance software will accept radiology report. "Radiology reports, if available quickly, may play a role," Hersh said.

Radiology results could be used in conjunction with other data or be analyzed on their own, said Dr. James H. Thrall, chief of radiology at Massechusetts General Hospital.

"For example, the anthrax cases reminded us that this disease has very characteristic changes in the mediastinum that are well visualized by CT," Thrall said. Radiologists are now all alert to this possibility. Other conditions such as plague may manifest pneumonia, etc, he said.

"Someone has probably already done it but radiologists could create a short list of likely pathogens and a summary of findings that would then be looked for as a pattern in rad reports," Thrall said. "Bottom line, findings could be analyzed continuously for changes in the frequency of respective

findings/diagnoses. Taken in this way, the report content becomes an epidemiological monitor."

The recent worldwide investigation of the outbreak of a suspicious and untreatable illness dubbed Severe Acute Respiratory Syndrome, or SARS, is an apt example.

In March, the nation’s disease surveillance apparatus joined the global search for the cause, treatment, and cure of SARS, a respiratory ailment of unknown etiology with onset after February 1.

The Centers for Disease Control said initial diagnostic testing should include chest radiograph, plus pulse oximetry, blood cultures, sputum Gram's stain and culture, and testing for viral respiratory pathogens.

The World Health Organization warned that suspect cases with either radiographic evidence of pneumonia or respiratory distress syndrome, or evidence of unexplained respiratory distress syndrome by autopsy, are to be designated "probable" cases.

Many emergency departments are already seeding surveillance systems.

PinnacleHealth, a four-hospital group in Harrisburg, PA, for example, collects four elements from every ED visit: age, zip code, sex, and chief complaint. Chief complaints are sorted into seven buckets, including viral, respiratory, encephaletic, rash, diarrhea, bleeding, and botulinic. Information in the database is updated every five minutes.

"From the 70,000 ED visits we get per year, we can see if there is a concentration of ailments from a particular area and then drill down to analyze the problem," said Richard Bagby, PinnacleHealth’s chief information officer and vice president of informatics.

Alerts are being developed to give alarms if identified thresholds are passed so the system can be proactive.

Management of a bioterrorism event will begin with early detection and intervention at the local level. Any large-scale event will require rapid state and federal assistance. The idea is, if this information is collected by each health system, then the state can identify trends faster than individual health systems since territories overlap.

"We’re just scratching the surface of surveillance but it’s a start," Bagby said. These systems could be useful not only for

bioterror incidents but also for community surveillance of infectious disease, such as flu or lime disease.

Health surveillance doesn’t stop at the admitting desk. One flaw of syndromic surveillance is it assumes patients with symptoms possibly related to bioterrorism will present to EDs. Public health officials, therefore, are contemplating surveilling records of over-the-counter medicine sales at retail stores.

"Since people often self medicate with OTC medication for a week or more before seeking medical attention, the use of this data to predict the health of the population may yield an early warning that something unusual is happening," Hersh said.

Salt Lake City, which implemented an automated, realtime disease outbreak detection system, served as a test bed for disease surveillance during last year’s Winter Olympics.

Utah officials monitored over 80,000 acute care visits during three weeks of the Olympics using a system called Real-Time Outbreak and Disease Surveillance (RODS).

Twice during the Games, and the Paralympic Games that followed, University of Utah physician Per Gesteland received an automatic alarm signal through his pager

At 8:43 p.m. on Feb. 19, his alarm indicated in Morgan County the number of daily viral infections seen at acute-care clinics reached seven, just slightly above the RODS alarm threshold of 6.69, the number of expected cases per day.

Again, at 6:21 a.m. on March 3, four days before the Paralympics began, Gesteland was awakened by another alarm,

indicated the number of patients seeking treatment for bleeding - whether bloody noses, rectal or vaginal - reached 33 in the seven monitored counties within a 24-hour period, above the expected level of 29.34. A sudden jump in bleeding cases might reveal an attack using the deadly Ebola virus.

Although Gesteland quickly determined each incident was a false alarm, they demonstrated the utility of surveillance systems.

A number of commercial surveillance systems have emerged, although they appear to be evolving in isolation.

"Everyone is creating their own widget," said Rosemary Nelson, director of HIMSS’ National Preparedness and Response Task Force. "There are detection widgets and syndromic surveillance widgets, but unfortunately we’re going down the same path as the electronic medical record. One system is not going to be able to talk to the other, which defeats the purpose of early detection."

Integrating the Healthcare Enterprise (IHE) may be the vehicle by which these system eventually achieve communications compatibility.

"IHE has been extremely successful in the radiology community, but I don’t think the surveillance product line is

mature enough to move toward integration," Nelson said. "But IHE would be the eventual glide path."

Remaining issues include funding.

Some states have done yeoman’s work in this area with limited funding. "Some of the goals the government wants could be achieved quicker with increased funding," Nelson said.

The President's budget for fiscal year 2003 includes $518 million to enhance preparedness at the nation's hospitals to respond to incidents of biological or chemical terrorism - a 284% increase over the amount provided in 2002. The budget includes another $100 million for programs for bioterrorism training for health care professionals, poison control centers, and emergency medical services for children.

Another issue is the need for a common lexicon across the entire field of emergency preparedness.

Right now, clinicians speak one language, the fire department another, emergency medical technicians, medical IT, and the national emergency disaster system still others.

"We’ve never sat down and resolved a common language across all these communities so we can talk to each other," Nelson said. "Even if we just achieved this for first responders at a local

level it would be the lynch pin enabling us to accomplish much more."

While the value of these embryonic surveillance systems is yet to be determined, it is reasonable to ask whether syndromic surveillance is currently any better than the trained eyes of emergency physicians now focused for the first time on bioterrorism.

"An emergency physician may recognize the very first case of small pox and sound the alarm," said Dr. Carl Schultz, Professor of Clinical Emergency Medicine, UC Irvine Medical Center.

The computer would see fever and rash but it would have to see a certain number of fevers and rashes before it exceeded the confidence interval and triggered an alarm.

"We don't know if syndromic surveillance for bioterrorism is really going to make a difference or not," Schultz said.

Terrorist attacks did not originate on Sept. 11.

"We’ve had terrorism attacks in healthcare all along," said Sean D’Arcy, a consultant with Healthlink, Houston. "Abortion clinic bombings and attacks on cloning research centers have both happened in hospitals."

It’s just a matter of time before a militant abortion opponent or terrorist figures out that the hospital data center or power sub-station is a better target to bomb than blowing out the front wall of an office, D’Arcy said.

The consequences are sobering. Suppose a multi-site hospital data center loses all power due a bomb, or even a storm or blackout. The uninterruptible power supply (UPS) kicks in, keeping the HIS, order entry, pharmacy, and lab systems running, but there is no UPS on the RIS or PACS. Plus, UPS power will last at most 30 minutes.

Immediately, a number radiology-related issues emerge, according to Jonathan Thompson, a senior manager at the StoneBridge (consulting) Group, Minneapolis:

o Radiology images and dictated reports are not available at the point of care.

o Physicians are not able to order new exams or review existing exams and reports.

o Radiologists are unable to do reads and dictate reports.

o Radiology technicians are unable to start and complete exams electronically.

o Final reports are not signed and posted in the system.

Then, after 30 minutes, when the UPS expires, other issues arise:

o No patient registration capabilities.

o No medication orders, dose checking, contraindications.

o No lab orders or results.

Essentially, the hospital has been disabled.

Preparing for terrorism requires an even more radical cultural shift in thinking. Terrorism is not restricted to power outages and disk crashes.

"You expect your hard drive to crash; mean-time-to-failure is a design consideration. Real disasters are improbable events you don’t expect to happen," D’Arcy said.

Until recently, a nuclear nightmare from dirty bombs or other radiological dispersion devices was unexpected. Now, no is sure.

And if one happens, radiologists will be enlisted quickly. In the event of some kind of nuclear attack, radiologists, radiation oncologists, and medical physicists will be expected to play a leading responder role, as well as serve as sources of accurate information for patients, the public, and the medical community.

To help prepare radiology for this, the American College of Radiology recently issued a free primer titled "Disaster Preparedness for Radiology Professionals: Response to Radiological Terrorism" as part of an educational program to enable the radiology community to respond effectively to terrorist attack.

The booklet, available in print or electronic versions, summarizes current information on preparing for a radiation emergency, handling contaminated persons, dose assessment, and radiation exposure health effects. It also includes information on radiological findings related to agents of biological and chemical terrorism since radiologists will likely be involved in the diagnosis of conditions associated with such exposures.