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Bioterrorism: The Use of Information Technologies and Decision Support Systems. Dena M. Bravata, M.D., M.S. Policy Analysis MS&E 290. Case Presentation: Day 1 (11/16).

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bioterrorism the use of information technologies and decision support systems

Bioterrorism: The Use of Information Technologies and Decision Support Systems

Dena M. Bravata, M.D., M.S.

Policy Analysis

MS&E 290

case presentation day 1 11 16
Case Presentation: Day 1 (11/16)

Ottilie Lundgren, a 94 year old widow, living in Oxford, Connecticut presented with a 3-day history of fever, cough, and myalgias.

Her physical examination showed an elderly woman with a fever (102.3F), elevated heart rate (118).

Her chest x-ray and initial laboratory tests were all negative.

She was admitted to the hospital for dehydration and an infection of the kidney tract.

case presentation days 2 4
Case Presentation: Days 2-4

Hospital Day 2-3 (11/17-11/18)

Labs: Bacteria found in her blood and urine but not yet identified

Mrs. Lundgren had progressive respiratory distress and confusion.

Repeat CXR: fluid around the left lung with the suggestion of pneumonia

Hospital Day 4 (11/19)

A sample of fluid from around lung taken for culture.

The Connecticut Department of Public Health was notified by the hospital laboratory of blood culture results

case presentation day 5 6
Case Presentation: Day 5-6

Hospital Day 5 (11/19)

She was transferred to ICU on a ventilator

Blood culture isolates identified as Bacillus anthracis at the State public health laboratory

Hospital Day 6 (11/21)

CDC confirms blood culture isolates as B. anthracis, molecular typing and susceptibility patterns identical to recent cases

Ottilie Lundgren’s condition continued to deteriorate and she died.

current cases of bioterrorism related anthrax
Current Cases of Bioterrorism-related Anthrax

* 4 Deaths associated with inhalational anthrax

biothreat agents
Biothreat Agents
  • Variola major (smallpox)
  • Bacillus anthracis (anthrax)
  • Yersinia pestis (plague)
  • Clostridium botulinum toxin (botulism)
  • Francisella tularensis (tularemia)
  • Filoviruses (Ebola hemorrhagic fever and Marburg hemorrhagic fever)
  • Arenaviruses (Lassa fever, Junin/Argentine hemorrhagic fever) and related viruses
the project
The Project

The objective of our project was to synthesize the evidence on information technologies and decision support systems (IT/DSSs) that may serve the information needs of clinicians and public health officials in the event of a bioterrorist attack.

methodologic challenges of this project
Methodologic Challenges of this Project
  • Conceptualizing the problem
    • Complex topic, no single effect size
  • Finding the literature
    • Not limited to peer-reviewed medical literature
    • Government documents
    • Web-based sources
  • Evaluating the quality of the evidence
    • No single, published quality scale relevant
the methodologic approach
The Methodologic Approach
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
the method
The Method
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
5 key questions
5 Key Questions
  • What are the information needs of clinicians and public health officials in the event of a bioterrorist attack?
  • What are the criteria by which IT/DSS should be evaluated for usefulness in a bioterrorist event?
  • What IT/DSSs are available for detection and diagnosis, management, surveillance, and communication?
5 key questions continued
5 Key Questions Continued
  • What is the quality of the evidence about IT/DSS usefulness?
  • If no existing IT/DSSs meet the information needs of clinicians and public health officials, what considerations are important in the design of future IT/DSSs to support response to bioterrorism events?
the method1
The Method
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
slide14

Structure of the Conceptual Framework

Time period: 1

Decision maker: Clinicians

Events: associated with the initial cases

Time period: 3

Decision maker: Clinicians

Events: associated with subsequent cases

Time period: 2

Decision maker: Public health officials

Events: associated with the initial cases

diagram of the conceptual framework
Diagram of the Conceptual Framework

Exposure

Exposure

Infection Status

(unobserved)

Infection Status

(unobserved)

Clinical

Syndrome

Clinical

Syndrome

Surveillance

Alert

Susceptible

Susceptible

Diagnosis

Diagnosis

Test Result

Test Result

Lives

Saved

Lives

Saved

Management

Management

Prevention

Prevention

Report

Report

Surveillance

Report

Epidemiologic

Control

Outbreak

Investigation

Surveillance

Alert

Time period 1

Time period 2

Time period 3

slide16

Time period 2: Surveillance Systems Detect Potential Events

Surveillance systems receive data from a variety of sources and provide reports to public health authorities.

Foodborne Disease

Reports

Healthcare provider

Reports

Veterinarian

Reports

Coroner

Reports

Laboratory

Reports

Surveillance

Report

Epidemiologic

Control

Detector

Data

Lives

Saved

Outbreak

Investigation

Surveillance

Alert

School/Work

Absenteeism

Data

Pharmacy

Sales Data

Hospital

Discharge Data

EMT Data

slide17

Role for Information Technologies and Decision Support

Exposure

Exposure

Infection Status

(unobserved)

Infection Status

(unobserved)

Clinical

Syndrome

Clinical

Syndrome

Surveillance

Alert

Susceptible

Susceptible

Diagnosis

Diagnosis

Test Result

Test Result

Lives

Saved

Lives

Saved

Management

Management

Prevention

Prevention

Report

Report

Surveillance

Report

Epidemiologic

Control

Outbreak

Investigation

Surveillance

Alert

Decisions marked in blue indicate those that can be affected by decision support systems and arrows marked in blue indicate processes in which information technologies could play a role.

the method2
The Method
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
task decomposition
Task Decomposition
  • Formal framework for specifying, documenting, and evaluating the data that should be contained within the knowledge base of a DSS in order for it to serve its purpose.
  • Literature review to define tasks:
    • U.S. Offensive weapons program
    • Known bioterrorist events
    • Tabletop exercises
    • Infectious disease outbreaks
  • 5 Tasks
    • Surveillance
    • Diagnosis and detection
    • Management
    • Prevention
    • Communication
the method3
The Method
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
literature searches
Literature Searches
  • Literature Sources
    • Peer-reviewed articles and government documents from databases
      • Medline, GrayLit, National Technical Information Service, Catalog of U.S. Government Publications
    • Government documents from websites
    • Web-based information
  • Search Strategies
    • Professional librarians for peer-reviewed and government documents
    • Copernic 2001 metasearch engine for web-based information
  • Search Terms: same for our Government document and Copernic searches
the method4
The Method
  • Identify key research questions
  • Develop a conceptual model
  • Define the tasks IT/DSSs must perform to meet the information needs of clinicians and public health officials
  • Perform literature searches
  • Evaluate the evidence
results of literature searches
Results of Literature Searches
  • Reviewed 16,751 citations and 8,620 websites
  • 251 articles and 41 websites met inclusion criteria
  • Double abstractions (blinded to study author) for all peer-reviewed articles and single abstractions for web-based information
  • Total of 204 systems
    • 52 detection systems
    • 23 diagnostic systems
    • 14 management systems
    • 88 surveillance systems
    • 27 communication systems
    • 7 systems that integrate surveillance, communication, and command and control functions.
results
Results
  • Generally: few clinically evaluated systems
  • No IT/DSSs for Diagnosis or Management have been developed specifically for bioterrorism
  • Systems for Detection, Surveillance, and Communication have been developed for bioterrorism
    • Some show considerable promise but almost none has been evaluated for its sensitivity, specificity, or timeliness
results1
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
results2
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
detection systems overview
Detection Systems: Overview
  • Developed for Military need to be adapted to civilian use
  • Promising projects include:
    • PROTECT (Program for the Response Options and Technology Enhancements for Chemical/Biological Terrorism)
      • Detectors set up in subways, airports, government buildings
      • Developing methods for signal-noise-processing
    • LEADERS (Lightweight Epidemiology and Advanced Detection and Emergency Response System)
      • Integrates detector data with other surveillance data
      • Particularly for event-based surveillance
detection systems collection and identification
Detection Systems: collection and identification
  • BioCaptureTM
    • Only collection system clinically evaluated
    • 50-125% collection efficiency of other devices
    • Used by first responders
  • BioThreatAlert (BTA) Strips
  • Antigen/Antibody system available for a limited number of agents
  • Sensitivity and Specificity not evaluated
  • Used by first responders or clinicians

Conclusions: Systems have not been clinically evaluated, sensitivity and specificity poorly characterized, can only test one sample at a time, tests not available for many worrisome agents (e.g., smallpox)

results3
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
general diagnostic systems overview
General Diagnostic Systems: Overview
  • Purpose: Clinician enters patient information (usually manually) and system provides a differential diagnosis
  • Examples: DXplain, Iliad, QMR (newer handheld versions now available)
  • Clinical evaluations: the differential diagnoses provided are highly dependent on descriptors entered

Conclusions: Have rarely been shown to improve patient outcomes in general, none has been evaluated for diagnostic capability for bioterrorism-related diseases

results4
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
management systems overview
Management Systems: Overview
  • Generally: Depend on electronic medical record to derive patient-specific recommendations
  • Most commonly for antibiotic recommendations for hospitalized patients
management systems
Management Systems

Example: HELP system at LDS hospital in Salt Lake City

  • When patients present to the ED, HELP’s databases are queried every 10 minutes for any new clinical information on the patient. Uses this information to calculate the probability of pneumonia.
  • Specificity 92%, PPV 15.1%, NPV 99.9%

Conclusions: No evidence for their usefulness in a bioterrorist event; would have to incorporate new guidelines for biothreat agent diagnosis and management; typically require EMR.

results5
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
data sources for biosurveillance
Data Sources for Biosurveillance

Earlier Detection Data Later Detection Data

School & Work Absenteeism

Phone Triage Nurses

Pharmacies (OTC)

Environmental detectors

Emergency Department

911 Calls

Laboratory

Hospital admissions &

discharge

Sentinel Physicians

Pharmacies (Rx)

surveillance systems
Surveillance Systems
  • Syndromal surveillance reports (7)
  • Reports from clinicians (6)
  • Influenza-related data (10)
  • Systems for laboratory and antimicrobial resistance data (23)
  • Systems for nosocomial infections (15)
  • Food-borne illnesses (10)
  • Zoonotic illnesses (5)
  • Other types of surveillance data (12)
syndromal surveillance
Syndromal Surveillance
  • Syndromes associated with biothreat agents
    • Flu-like illness
    • Acute respiratory distress
    • Gastrointestinal symptoms
    • Febrile, hemorrhagic syndromes
    • Fever and rash
    • Fever and mental status change
integrated systems
Integrated Systems

Data Analysis and Presentation

results6
Results
  • Detection Systems
  • General Diagnostic Systems
  • Management Systems
  • Surveillance Systems
  • Communication Systems
communication systems overview
Communication Systems: Overview
  • Email systems for communication between patients and clinicians
  • Web-based secure networks linking branches of the public health
  • Radio/Microwave-based systems for linking emergency personnel in the field with EDs
  • Alert systems to notify clinicians of abnormal laboratory tests
communication systems for bioterrorism1
Communication Systems for Bioterrorism

WHO

CDC

State Public Health

Local Public Health

communication systems for bioterrorism2
Communication Systems for Bioterrorism

WHO

CDC

FBI

Zoo

State Public Health

Food Inspectors

Schools

HazMat

Local Public Health

Pharmacies

Police

Laboratories

Fire

Hospitals &

Nursing Facilities

The Public

Clinicians

Coroner &

Medical Examiner

The Media

communication systems for bioterrorism3
Communication Systems for Bioterrorism

WHO

CDC

FBI

*

Zoo

State Public Health

Food Inspectors

Schools

*

HazMat

Local Public Health

Pharmacies

*

Police

Laboratories

Fire

*

*

Hospitals &

Nursing Facilities

*

*

The Public

*

Clinicians

Coroner &

Medical Examiner

The Media

*

communication systems for bioterrorism4
Communication Systems for Bioterrorism

WHO

CDC

FBI

*

Zoo

State Public Health

Food Inspectors

S

Schools

*

HazMat

S

Local Public Health

Pharmacies

*

Police

S

Laboratories

Fire

*

S

*

Hospitals &

Nursing Facilities

*

*

The Public

*

Clinicians

Coroner &

Medical Examiner

The Media

*

communication systems for bioterrorism5
Communication Systems for Bioterrorism

WHO

CDC

FBI

*

Zoo

State Public Health

Food Inspectors

S

Schools

*

HazMat

S

Local Public Health

Pharmacies

*

Police

S

Laboratories

Fire

*

S

*

Hospitals &

Nursing Facilities

*

*

The Public

*

Clinicians

Coroner &

Medical Examiner

The Media

*

conclusions
Conclusions
  • Overall: IT/DSSs have not be subjected to critical evaluations
  • Detection Systems:
    • Rapid
    • Portable
    • Sensitive and Specific
    • Can test for more of the worrisome biothreat agents
  • General Diagnostic Systems:
    • Link to EMR
  • Management systems:
    • Utilize available bioterrorism guidelines
  • Surveillance systems:
    • Greater integration
    • Early warning data
    • Methods for the determination for what constitutes an outbreak
  • Communication systems:
    • Single system for public health officers at various levels
    • Public health  media
future analysis
Future analysis
  • Models of natural history of disease processes of biothreat agents
  • Cost-effectiveness analyses of surveillance systems using different sources of data
  • Cost-effectiveness of prevention and management strategies for the most worrisome biothreat agents
  • Analyses of the adequacies of current capacity of hospitals, law-enforcement, and public health to respond to a bioterrorist attack.
collaborators
Douglas K. Owens

Kathryn McDonald

Wendy Smith

Chara Rydzak

Herbert Szeto

Corinna Haberland

David Buckeridge

Mark Schleinitz

Dean Wilkening

Mark Musen

Bahman Nouri

Bradford W. Duncan

Mariana B. Dangiolo

Hau Liu

Scott Shofer

Justin Graham

Sheryl Davies

Collaborators