Responsiveness and Innovation

Although the attacks of September 11, 2001 helped awaken public health to the demands of emergency response, events like heat waves and disease outbreaks demanded real-time surveillance and communications systems long before. Emergency medicine providers are among the first in a community to see casualties from exposures to fast-breaking environmental hazards, communicable outbreaks, or terrorist events. EMS can provide important real-time public health surveillance and are themselves thirsty for good public health guidance.

The REMI, a secure internet application, has made two-way communications between MHD and other medical providers the most convenient aspect of the community’s surveillance and emergency response capacity. The health department benefited by the willingness of hospitals to share access to the REMI system. Medical providers benefited as the health department drove system enhancements and provided authoritative and timely public health guidance.

Agility is the hallmark of this internet application. Every participant in the system can be instantly alerted by text messaging. For example, information regarding SARS was distributed to EDs within 24 hours of CDC's announcement to begin surveillance for the syndrome. Within 72 hours, all area hospital, including 13 (now 11) emergency rooms were reporting SARS-associated symptoms daily using a triage screening sheet developed by MHD. Because EMSystem® is provided over the internet by an application service provider (ASP), tools developed for Milwaukee SARS surveillance are available to other communities. SARS syndromic surveillance has been replicated in at least four other metropolitan areas.

LHD and Community Collaboration

EMSystem® was designed by an emergency medicine physician group (Infinity Healthcare, Inc.) by the request of the Wisconsin Hospital Association (WHA) to communicate ambulance diversion status. Recognizing the possible public health utility of the system, WHA invited Milwaukee Health Department (MHD) to join the committee governing the application. MHD received the authority to post urgent alerts and reference materials on the system. MHD has suggested upgrades to the system, such as the capacity to develop statistics related to emergency room diversion during the influenza seasons of 1999-2000 and 2000-2001.

The health department could reliably describe when and why ED congestion was occurring. MHD formed the Milwaukee Healthcare Capacity Alert Committee with representatives of the EMS system, WHA and the medical society to issue recommendations for decongesting the system when needed, which included requesting and receiving federal bed-use waivers in 2001.

MHD and Infinity Healthcare began designing syndromic surveillance enhancements to the system in 1999, which were initially used for surveillance of heat-related morbidity during the heat wave of that year. A more ambitious project involved eight emergency departments reporting six bioterrorism sentinel syndromes during the weeks surrounding the 2002 All-Star Game in Milwaukee and the current voluntary SARS surveillance initiative involving 11 hospitals from multiple counties. The ease of regional surveillance is greatly aided by the 1997 decision of suburban local health departments, the Wisconsin Division of Public Health and the Medical Society of Milwaukee County to collaborate with MHD on a single-point-of-contact disease reporting and surveillance system for Milwaukee county - SURVNET. Milwaukee County local health departments now share their own EMSystem® website for secure interagency communications, providing an inexpensive and agile back-up to the state Health Alert Network which is still in the early stages of development.

Since EMSystem® and other REMI applications are typically deployed for EMS-related needs, they already exist in many areas and are supported primarily by healthcare or EMS agencies. System operations costs in Milwaukee are borne by local hospitals, which have been supportive of MHD messaging and application enhancements. Posting alerts and documents, and downloading surveillance information using the REMI is very simple and requires no direct time, money, or system administration (unlike developing and using an independent public health communication application).

MHD has paid a total of $10,000 for some modifications to the system, including the establishment of the separate emergency public health interagency website. Other modifications are made at no cost by Infinity Healthcare, Inc. since they enhance the system’s utility for other communities and expand the numbers of partners interested in REMI applications. EMSystem®, similar to some other REMIs, is provided over the internet using an application service provider (ASP) model, innovations in one region become available to others on a rapid basis. MHD has no commercial interest in EMSystem® and receives no funding from Infinity Healthcare.

Evaluation

Since the REMI is always-on in emergency departments and issues auditory and text alarms for alerts, it has served well for rapid communications with emergency providers. The health department wishes communicating with other health care and human service agencies were so easy. The experience using the system for tracking and responding to healthcare system congestion has been published. The ability to use objective measures of system crowding was important in gaining the attention and trust of healthcare executives and state and federal regulators.

The success of using the REMI for syndromic surveillance has been mixed. Using the REMI to obtain heat-related morbidity saved time previously spent contacting multiple EDs by telephone. SARS surveillance was successful, aided by factors including the relative simplicity of screening, the ability to concentrate screening activities at the ED Triage Desk, because of the intrinsic interest of ED administrators in protecting their ED from SARS exposure, and previous experience with syndromic surveillance using the system.

While the REMI provided good support for more elaborate syndromic surveillance for bioteorrorism, the complexity and time-demand of six-syndrome assessment and tallying led to many human performance problems. This has spurred development of an electronic triage log to replace paper logs while automating syndromic reporting.

Sustainability

Most importantly, no technological system replaces human relationships. While REMI is used to implement surveillance, such efforts still require face-to-face meetings with participants and the maintenance of trustful relationships. On the other hand, the REMI also improves the relationships with the human actors in the emergency medicine realm, since they rapidly see the fruits of the discussions and decisions.

The program has been successful by carefully implementing incremental changes on a preexisting system designed to meet health care system needs, rather than to try to get Eds and EMS providers to use a system designed primarily for the program's needs. REMI should be integrated the HAN infrastructure, rather than insisting that providers change from systems they already use.

In other communities using EMSystem® or other REMIs, local public health agencies can partner with the organization(s) sponsoring the application to gain access to the system for messaging and surveillance. These organizations include hospital associations, EMS agencies and government health authorities. Trust-building is important, for example, assurance of individual hospital information confidentiality, and reserving the system for infrequent, high-priority messaging. Like any public health communication system, procedures should be implemented to assure only authoritative and appropriate use. Should the need arise, specific website enhancements can be designed which are then sharable with other EMSystem® regions.

Overview

Milwaukee hospitals established a Regional Emergency Medicine Internet (EMSystem®) to securely share real-time ambulance diversion information. Participating in the governance and use of REMI allows the Milwaukee Health Department (MHD) to issue 24/7 alerts to all area emergency departments (Eds) and ambulances (e.g., for heat waves, an E. coli outbreak, West Nile, Homeland Security level, SARS); monitor diversion to detect and respond to health system crowding; provide ready access to reference materials (heat wave plan, bioterrorism agent recognition, West Nile tests); and perform syndromic surveillance (e.g., heat-related morbidity, bioterrorism sentinel syndromes, SARS).

All county hospital and EMS providers are connected to the system and can be reached 24 hours a day, seven days a week. Voluntary SARS syndromic surveillance now involves 11 hospitals. EMSystem® now serves 27 regions throughout the US, covering approximately 14% of the US population. Since the system is a national model other local health departments are able to use the system for communications and surveillance within their jurisdictions. Planned enhancements include fully-automated syndromic surveillance.