by Andrew Friede, M.D., MPH and Mark Hoffman

     On April 22, 2002, Cerner Corporation of Kansas City, Mo. and the Kansas City Health Department announced the launch of HealthSentry, a system to detect bioterrorism attacks or natural disease outbreaks. Twenty-four laboratories in the Kansas City area are involved in providing data to track outbreak trends, drawing from data and systems already in place with no additional work requirements for lab technicians.

     Currently, the system is designed to page health officials when a patient is tested for a disease – such as anthrax or plague – that would be indicative of potential bioterrorist attack. Ultimately, HealthSentry will enable earlier intervention in communicable disease outbreaks by alerting health authorities when unusually large numbers of tests are ordered for infectious illnesses. Wider public health applications would also be possible, including studies of cost-effectiveness, chronic disease epidemiology, medication safety and resistance patterns.

pt01.JPG (22541 bytes)An alert system could be implemented nationwide for “tens of millions of dollars” by building on systems already in place. In Kansas City, where Cerner’s system is live, talks are already underway to allow hospitals to provide data from computer systems not made by Cerner.— Neal Patterson, CEO

Cerner information management systems are currently running at more than 1,500 client sites, and currently collect approximately 25 percent of all U.S. microbiology data. They also collect data on prescriptions, tests and procedures, and associated clinical states. To make better use of this information, Cerner has expanded its analytic activities over the past two years. In collaboration with its clients, Cerner has built a research center for the analysis of detailed clinical data from 40 hospitals. Studies of practice patterns, medical errors, and resource utilization are ongoing.

     This rich clinical data — collected and analyzed on a much larger scale — represents a new and untapped resource for bioterrorism surveillance. Because these data are timely and precise, they can speed surveillance notifications and responses, improve specificity, and help improve collaborations between primary care providers and public health officials. Furthermore, they can be used for monitoring and measuring other conditions of public health interest, carrying out special studies, and establishing disease registries.

Surveillance and Monitoring
Cerner and its industry partners can provide technology to meet the immediate needs of local, state or national public health communities for rapid disease outbreak detection and bioterrorism surveillance. HealthSentry provides automatic, rapid alerts of outbreak events or adverse trends. It also provides detailed epidemiology reports for short and long-term analysis and trending. This network solution can be implemented today in any city, state, or across the entire country.

     The provider does not have to provide additional information or take additional steps outside of normal workflow. Data is collected and transmitted automatically.

     With the HealthSentry system in place, the quantity, completeness and accuracy of reports/data submitted to health departments all increase. The timeliness of submission, alerting, and notification also improve. Implementation of the system can be accomplished quickly, in 90 days or less for a citywide implementation.

     While HealthSentry may be a model for other systems around the country, it is not a pilot program – it is a real, live, and current capability that addresses an immediate need.

An Improved Approach
The common approach to bioterrorism and disease outbreak surveillance has been either to manually fill out or to submit pre-formatted forms or to create simple Web pages that allow manual collection of patient symptoms. Data collection and tracking with this type of system is burdensome, and reporting is often delayed and incomplete. Automatic alerting of health authorities is virtually non-existent, and analysis of trends across communities is difficult.

     Cerner’s approach provides rapid and automatic collection of public health data. HealthSentry includes easy access to patient demographic data, laboratory orders and results, coupled with automatic alerting and extensive analytical reporting capabilities. Data can also be provided to the Centers for Disease Control and Prevention (CDC).

     Implementation of the HealthSentry bio-surveillance network requires the cooperation of local, state, and federal public health officials, as well as the cooperation of participating hospitals, labs and industry partners. This approach includes Cerner as the data warehouse “operator” and provider of alerts, reports, and normalized data for analysis. IBM serves as the primary installer of interfaces or software and provides consulting services for unique reporting needs. Cerner and other industry partners are the data providers. HealthSentry is based on existing systems and interfaces that the health care industry already has in place.

Microbiology Orders and Results
The most substantial, immediate improvement feasible in bioterrorism and disease outbreak surveillance is the speed of delivery and analysis of data from clinical laboratories to state and local health departments and to the CDC. With 25 percent of all U.S. clinical microbiology events processed by Cerner systems, easy-to-implement interfaces available for other systems, an existing data warehouse, and expert system rules and analytical reporting tools already available, Cerner and its industry partners can deploy this capability now.

     In December 2001, Cerner began collaborating with the Kansas City, Mo. Health Department and the health providers in the Kansas City area to prove this approach by building a laboratory-based surveillance system. HealthSentry provides timely information flowing daily from the hospitals to the health department in Kansas City. The raw data is sent from the hospitals to a data warehouse at Cerner where it is normalized, analyzed, and processed. The local health departments can access reports and geographic maps based on the data through a virtual private network. In addition, key events in the data automatically trigger notifications via e-mail, pager, or cell phone to responsible public health officials. HealthSentry incorporates 60 percent of the microbiology results in the Kansas City metropolitan area. Does it work? The following comment from the Clay County, Mo., director of public health proves that it does: “I believe this is one of the greatest steps forward for public health that I have seen in the past 20 years.”

Syndromic Data
Syndromic surveillance — either used routinely or after being triggered by clinical concerns or warnings from microbiology surveillance — may play an important role in bioterrorism surveillance or for surveillance of new or poorly understood conditions of public health importance. Cerner stands ready to deploy systems that report clinical symptoms (e.g., aching muscles) and signs (e.g., fever), as well as laboratory and radiologic results (e.g., mediastinal widening) that can then be transformed into syndromes. For example, aching muscle, fever, and mediastinal widening, taken together, suggest anthrax. Methodologies for syndromic surveillance are evolving.

Beyond Bioterrorism: An Approach to Public Health
Microbiology/laboratory data represent a small fraction of the data residing at Cerner’s client sites that could be useful for public health work. Cerner clients collect extensive data on disease and risk factor prevalence, costs, drug utilization and radiographic procedures — in short, all aspects of health care — that could be used to study cost-effectiveness, chronic disease epidemiology, medication safety, and resistance patterns. The development of systems that are useful for bioterrorism surveillance will provide that starting point for helping public health workers mine the data that resides within clinical systems. Ideally, the public health community will collaborate with clinical providers who are eager to use their data for research.

Just as was accomplished in Kansas City, Cerner and its industry partners can collaborate with public health agencies and the CDC to provide HealthSentry to any city or state. Alerts, access to analytical reports, graphs and mapping capabilities, and the provision of data in NEDSS format can also be easily provided to the CDC. Significantly improved bioterrorism and public health surveillance can be achieved now, while more complex, time-consuming and costly solutions continue development and pilot efforts. The country needs a faster, more accurate and automatic way of providing early detection of public health events. The public health community also needs accurate and timely data to use for appropriate response decisions.

Andrew Friede is a physician executive, and Mark Hoffman is a research and development architect, both at Cerner Corporation in Kansas City, Mo.