Public Health Practice Applications: - Objectives

32
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Public Health Practice Applications
Judy D. Gibson / Janise Richards / Arunkumar Srinivasan / Derryl E. Block
• OBJECTIVES
. Define public health informatics and the public health nurse informatician.
1
2. Describe the National Electronic Disease Surveillance System.
3. Describe two public health electronic information systems with implications for
the public health nurse.
4. Discuss the public health informatician role and the emerging role of the public
health nurse informatician in case studies.
• KEY WORDS
Public health informatics
Electronic public health surveillance
Electronic public health information systems
Interoperability standards
Office of National Coordinator for Health Information Technology
National Electronic Disease Surveillance System
Health departments are collecting and analyzing

OVERVIEW data on a scale that was inconceivable even 10 years ago
For many years, public health practitioners stated the (Fig. 32.1) (Centers for Disease Control and Prevention
belief that if nobody thought about public health, then [CDC], 2013a). To be able to manage this overwhelming
public health must be doing its job. The battles that health deluge of data and information, public health practitio-
practitioners waged against infectious diseases (such as ners have tapped into information technology. During
malaria, tuberculosis [TB], and leprosy), chronic diseases, 2000–2010, information systems have become widely
and environmental health hazards were often not high- adapted to fit the special needs within public health.
lighted in the media. In recent years, after recent outbreaks Recognizing the importance of linkages among clinical
of SARS and Influenza A virus (H1N1), dramatic large- care (also known as direct care), clinical care information
scale foodborne disease outbreaks, and the explosion of systems, laboratory information systems, and other data
chronic illnesses that are linked to multiple vectors such as sources to better understand and improve the state of the
obesity, public health is frequently in the media limelight. nation’s health, public health has helped establish data
The continuing need to be alert to emerging public health and information exchange standards to support system
problems, responsive in emergencies, and accountable to interoperability.
the public has intensified health departments’ efforts to This chapter provides an overview of the application
collect data and information from multiple sources. of informatics to public health, describes legislation that
457
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458 P art 5 • A dvanced N ursing I nformatics in P ractice
Schools Civic Groups
Nursing
Homes
EMS Neighborhood
Organizations
Non-profit Community
Organizations Centers
Home
Hospitals Health
Drug Public Health Laboratories

Treatment Agency
Primary Mental
Providers Health
Law Faith Institutions

Pharmacy Enforcement
Fire
CHCs Tribal Health Transit
Employers Elected
Officials
Corrections
• FIGURE 32.1. Local public health information and data Exchange Entities.
(Reproduced from OSTLTS (2009). National Public Health Standards Program. Centers for
Disease Control and Prevention. http://www.cdc.gov/ostlts/.)
has affected public health information systems, and pro- The roots of public health were established in the United
vides examples of electronic data exchange between clini- States when the Public Health Service (PHS) was estab-
cal care and public health. The chapter also introduces the lished in 1798 by the Marine Hospital Service Act. In
emerging role of the Public Health Nurse Informatician 1944, with the passage of the Public Health Service Act
(PHNI) and gives examples of differentiating the public [Title 42 U.S. Code], the PHS mission was broadened
health nurse (PHN) and the PHNI. to protect and advance the nation’s physical and mental
health. To accomplish this mission, public health had to
define the activities clearly that would lead to this desired
outcome.
PUBLIC HEALTH, PUBLIC HEALTH In a seminal study by the Institute of Medicine, The
INFORMATICS, PUBLIC HEALTH Future of Public Health, the functions of public health
NURSING, AND THE PUBLIC were described as assessment, policy development, and
assurance (Institute of Medicine, 1988). Assessment
HEALTH NURSE INFORMATICIAN includes activities of surveillance, case finding, and moni-
In 1920, C.-E. A. Winslow defined public health as “the toring trends, and is the basis for the decision-making and
science and art of preventing disease, prolonging life policy development by public agencies. Policy develop-
and promoting health through the organized efforts and ment is the broad community involvement in formulating
informed choices of society, organizations, public and plans, setting priorities, mobilizing resources, convening
private, communities and individuals” (Winslow, 1920). constituents, and developing comprehensive public health
c32.indd 458 2/5/2015 3:22:36 PM

Chapter 32 • Public Health Practice Applications 459
policies. Assurance covers activities that verify the imple- health information widely, in the sharing of epidemiologi-
mentation of mandates or policies, and guarantees that cal and statistical data, reports, guidelines, training mod-
the provision of necessary resources is provided to reach ules and periodicals” (World Health Organization, 1997).
the public health goals. To enhance further the core public Although there are numerous sources of public health data
health functions, a committee of public health agencies and information, the sources lack standardization in data
and organizations convened by the U.S. Public Health organization, nomenclature, and electronic transmission.
Service described the 10 essential services of public health Innovative methods for storing, organizing, exchanging,
(Public Health Functions Steering Committee, 1994). and disseminating the millions of pieces of data gathered
Figure 32.2 (Centers for Disease Control and Prevention during public health activities have provided the founda-
[CDC], 2013a) describes the relationship between the core tion for the field of public health informatics.
functions and essential services of public health. Public health informatics has been defined as “the
The essential governmental role in public health is systematic application of information and computer sci-
guided and implemented by a variety of federal, state/ ence and technology to public health practice, research,
territorial, and local regulations and laws as well as federal, and learning” (Friede, Blum, & McDonald, 1995). Public
state/territorial, and local governmental public health agen- health informatics, like public health, focuses on popula-
cies. At the local level, tens of thousands of governmental tions. In public health informatics, population-level data
units at the county, municipality, township, school district, and information are collected, analyzed, and dissemi-
and other special jurisdiction levels must interact to provide nated with the ultimate goal of supporting preventive, as
public health services. This complex array of public health opposed to curative, interventions.
functions, services, responsibilities, and interactions is not The demarcation between public health and clinical
a static environment, but one that is constantly changing. healthcare systems is frequently blurred, especially given
Information forms the basis of public health. To make legislation that has provided the funding and legal plat-
informed decisions and policies, public health practitio- forms to build the information systems needed to protect
ners require timely, quality information. The 1996 World and advance the nation’s physical and mental health. The
Health Report cites the continuing need to “disseminate provision in the 2004 Health Insurance Portability and
Accountability Act (HIPAA) that generally prohibits disclo-
sure of an individual’s medical record and payment history
without expressed authorization of the individual is known
AS as the Privacy Rule. For public health purposes, the law
SE
SS provides for the disclosure of patient information to public
M
Evaluate Monitor health without authorization from the patient, for the pur-
EN
Health pose of preventing or controlling disease, injury, or disability,

T
Assure and for conducting public health surveillance, public health

Diagnose investigations, and public health interventions (Health
Competent managem & Investigate
em
ASSURANCE
Workforce Insurance Portability and Accountability Act [HIPAA],

t
en
Sys
2002). The 2010 Patient Protection and Affordable Care Act

t
Link Research Inform, (PPACA) established policies and technically interoperable

to/Provide Educate, and secure standards for federal and state health and human
Care Empower services programs (DHHS, 2010). As public health, clinical
Mobilize care, information science, computer science, and infor-
Enforce Community mation technology continue to come together, the field of
Laws Partnerships public health informatics will continue to expand to support
PO
Develop
LIC
the public health functions of assessment, policy develop-

Policies
Y
DE
VE
LO ment, and assurance to promote a healthy nation.
PM
ENT
Public Health Nursing
• FIGURE 32.2. Three core functions and 10 essential Public health nursing practice “focuses on population
services of public health. (See ASTDN, 2000. Reproduced health through continuous surveillance and assessment
from Public Health Functions Steering Committee (1994). of the multiple determinants of health with the intent to
Public Health in America. DHHS. http://www.health.gov/ promote health and wellness; prevent disease, disability,
phfunctions/public.htm.) and premature death; and improve neighborhood quality
c32.indd 459 2/5/2015 3:22:37 PM

of life. These population health priorities are addressed health. Public health professionals use these data to inform
through identification, implementation, and evalua decisions about the most effective mechanisms for interven-
tion of universal and targeted evidence-based p rograms tions. Information from multiple, sometimes incompatible,
and services that provide primary, secondary, and tertiary systems or sources must be combined for an accurate depic-
preventive interventions. Public health nursing practice tion of problems (Fig. 32.1) (Centers for Disease Control
emphasizes primary prevention with the goal of achieving and Prevention [CDC], 2013a). There is a need for rapid
health equity” (American Nurses Association, 2013). and comprehensive access to data across system boundar-
The Public Health Informatician (PHI) is a “public ies, that is, the system at all levels as well as the healthcare
health professional who works either in practice, research, industry systems (Koo, Morgan, & Broome, 2003).
or academia and whose primary work function is to Data collection and sharing in public health occur at
use informatics to improve population health. The role three levels: local, state/territorial, and federal (e.g., Centers
requires more expertise than the multi-highly functional for Disease Control and Prevention [CDC]). Programs
public health professional that assists with informatics- at each level have similar organization and management
related challenges or supports personal productivity with structures. Since most funding is based on programmatic
information technology” (U.S. Department of Health and need, many information systems have been built to support
Human Services, CDC, 2013). specific programs, thereby creating “silo”-like systems. To
Nursing informatics (NI) “is a specialty that integrates be productive, the program-oriented funding streams and
nursing science, computer science, and information sci- information systems need to flow together.
ence to manage and communicate data, information, Efforts are underway to assist healthcare providers
knowledge, and wisdom in nursing practice. NI supports in overcoming barriers to data collection and sharing
consumers, patients, nurses, and other providers in their through the implementation of regional, state/territorial,
decision-making in all roles and settings. This support is and local health information exchanges (HIEs) (Wild,
accomplished through the use of information structures, Hastings, Gubernick, Ross, & Fehrenbach, 2004) and the
information processes, and information technology” National Electronic Disease Surveillance System (NEDSS)
(American Nurses Association, 2008). (CDC, 2013c) initiative. This comprehensive rather than
The proposed role of the Public Health Nurse disease-specific approach to data collection and sharing is
Informatician (PHNI) combines the competencies of PHI the foundation of public health informatics and warrants
and nursing informatics. A PHNI is a PHN who has spe- further inspection.
cialized in nursing informatics and has skills in support-
ing the establishment of systems to improve public health
surveillance through access to clinical care information. Infectious Disease Electronic Surveillance
Further, the PHNI has advanced skills in using nurs-
The three levels of the organizational structure of public
ing taxonomies and nomenclatures as a tool for nursing
health have distinct data collection and sharing roles in
informatics in public health practice. PHNIs ensure that
support of the electronic surveillance system (Fig. 32.3)
data needs are adequate to measure performance for mul-
(Birkhead & Maylahn, 2000). Each year, the Council of
tiple determinants of health. These are examples of the
State and Territorial Epidemiologists (CSTE) and the CDC
differences between the PHN and the PHNI that will be
jointly update a list of reportable diseases and conditions.
described in this chapter.
The CSTE recommends that all states and territories enact
laws (statue or rule/regulation as appropriate) to make
nationally reportable conditions reportable in their juris-
The Public Health Surveillance Landscape
diction (Council of State and Territorial Epidemiologists
The public health mission is to promote the health of the [CSTE], 2010). The local (city or county) health
population rather than to treat individuals. In support of department—the frontline of public health—interacts
this mission, public health workers collect data on the most closely with clinicians and agencies in the commu-
determinants of health and health risks from factors in nity, gathers reports of communicable diseases, tracks
the pre-exposure environment, the presence of hazard- and monitors cases, conducts investigations, and often
ous agents, behaviors, and exposures (Centers for Disease provides direct services (STD testing, vaccines, contact
Control and Prevention [CDC], 2013b; World Health tracing, directly observed therapy, case management). The
Organization, 2010). Public health workers monitor the state health department uses legislation as well as regula-
occurrence of health events, conditions, deaths, and the tions to require reporting by healthcare entities: to report
activities of the healthcare systems and their effects on certain illnesses, to require vaccinations for school entry,
c32.indd 460 2/5/2015 3:22:37 PM

Other Providers Laboratory was determined that no further modification to NETSS
Required would be made. NETSS differs from NEDSS in several
by state
ways. NETSS was case based; NEDSS is person based. In
statutes
(includes Local Health addition, NETSS used proprietary codes, but NEDSS is
patient Department based on standards so it can capture data already in elec-
identifiers) tronic healthcare data streams. These differences precipi-
tated the need to transition to NEDSS.
State Health
Voluntarily shared per Department
CDC/CSTE agreement National Electronic Disease Surveillance
(without identifiers) System (NEDSS)
CDC
In 1999, the CDC, the CSTE, and state and local pub-
lic health department staff began work on information
• FIGURE 32.3. Notifiable disease surveillance data flow system standards for the NEDSS initiative (National
to public health. (Data from Birkhead & Maylahn, 2000.) Electronic Disease Surveillance System Working Group,
2001). The NEDSS initiative uses standards to advance
the development of efficient, integrated, and interoper-
to coordinate statewide disease surveillance, and to moni-
able surveillance systems at the state and local levels. This
tor incoming reports from counties, and then submit
initiative facilitates the electronic transfer of information
those reports, voluntarily and minus names, to the CDC.
from clinical information systems in healthcare, reduces
The state prioritizes problems and develops programs,
the provider’s burden of providing data, and enhances the
runs the state public health laboratory, and serves as liai-
timeliness and quality of information provided.
son between the CDC and local level. The CDC publishes
Implementation of the NEDSS initiative was supported
national surveillance summaries and conducts research
by the CDC. States were funded to assess their current sys-
and program evaluations to produce public health recom-
tems and develop plans to implement criteria compatible
mendations. The CDC provides grants to states for spe-
with the NEDSS initiative. The criteria included browser-
cific programs, technical assistance, and, by invitation,
based system data entry, an Electronic Laboratory Results
outbreak response for state and local partners (Birkhead
(ELR) system for laboratory staff to report results to health
& Maylahn, 2000).
departments as authorized, and a single repository for
integrated databases from multiple health information
National Electronic Telecommunications systems. Also supported were system-wide electronic
System for Surveillance (NETSS) messaging upgrades for sharing the data. Finally, the CDC
developed a platform called the NEDSS-Base System
In 1984, the CDC, in cooperation with the CSTE and epi-
(NBS) for public health surveillance functions, processes,
demiologists in six states, began testing the Epidemiologic
and data integration in a secure environment. States then
Surveillance Project. The project’s goal was to demon-
had the option to choose this platform or another NEDSS-
strate the effectiveness of computer transmission of public
compatible system.
health surveillance case-based data between state health
Some states developed systems using specified NEDSS
departments and the CDC. By 1989, all 50 states were
standards, while other states used a CDC-developed
participating in the reporting system. The Epidemiologic
system. To understand better how the NEDSS initiative
Surveillance Project was renamed the National Electronic
meets its mission, we will examine the NBS role in sup-
Telecommunications System for Surveillance (NETSS) to
porting public health surveillance.
reflect its national scope (CDC, 2013d). The NETSS sys-
tem includes 22 core data elements for reportable disease
conditions. The CDC analyzes these data and dissemi-
Healthcare Providers Role and the NBS
nates them in the Morbidity and Mortality Weekly Report
(MMWR). This overwhelming volume of data to be man- Healthcare providers are responsible for providing clini-
aged by health departments led to the National Electronic cal care and reporting state-designated reportable condi-
Disease Surveillance System (NEDSS) initiative, which tions to public health departments. As a registered user
provides guidance for the technical architecture and stan- of the NBS, a healthcare provider can directly enter data
dards for nationally reportable condition reporting. When from case and laboratory reports into the state’s electronic
the CDC decided to transition from NETSS to NEDSS, it surveillance system at the point of care. In addition to the
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direct entry of data, healthcare providers can securely and standardized manner and in near real time for analysis
query the database, verify completeness of reporting by CDC program areas. This supports effective policy for-
using analysis tools, and ensure compliance with state mation at the national level when events of public health
public health laws. Healthcare providers can send elec- significance happen. The data are disseminated through
tronic case reports using the Health Level Seven Clinical the Morbidity and Mortality Weekly Reports (MMWR).
Document Architecture (HL7 CDA) format when their
electronic health record (EHR) is equipped to report in the
Privacy Protection and the NBS
standard format.
In order to protect personally identifiable information,
the NBS requires user authentication, authorization, and
Clinical Laboratories and the NBS
auditing protocols. To verify the identity of the user, the
Staff members in public and private laboratories are NBS supports custom authentication. Once authenti-
required by law to notify public health departments of cated, the NBS application authorizes access to data based
state reportable conditions. Timely reports are critical on user role, geographical area(s), disease(s), public health
to public health surveillance because they prompt inves- event(s), and action(s). For example, a local public health
tigations of cases of reportable diseases or outbreaks. practitioner may be assigned access to Foodborne and
Registered laboratory users of the NBS system enter Diarrheal (FDD) investigations and laboratory reports
reports directly using the Web-based laboratory reporting for a public health jurisdiction. The supervisor can be
function of the NBS. This report is then readily available to assigned access to multiple public health jurisdictions
the public health NBS users to conduct the investigation across multiple families of diseases (e.g., FDD and hepati-
(Levi, Vinter, & Segal, 2009). tis). The NBS creates an audit file containing a fingerprint
trail with a timestamp of the user’s activities.
Public Health Practitioner Role and the NBS
Value of Information Solutions to
The local or state public health practitioner responds to
Surveillance Practice
incoming data on reportable conditions and implements
appropriate public health case finding, tracking, and mon- NEDSS-compatible infectious disease electronic surveil-
itoring. Public health practitioners, who are registered lance systems change how public health departments at
users of the NBS, may review reports from laboratories all levels communicate to perform their mission. Access to
and healthcare providers for patients residing within their data repositories is no longer limited to a central location.
jurisdictional boundaries. The public health practitioner Rather, epidemiologists, registered as the NBS users, may
may create an “alert” function for new data received in have data access at all public health levels. These systems
the NBS (such as for reports of meningococcal disease). enhance the capacity of local and state public health agen-
Upon receipt of a new report, the public health practitio- cies to react quickly to disease occurrences.
ner may order a public health field investigation. Clinical,
laboratory, epidemiologic, and follow-up data are entered
Future Directions for Infectious
at point of care and stored in the NBS. Stored data can be
Disease Surveillance
read, analyzed, and shared. The public health practitioner
classifies the case, based on stored data and standard case State public health programs face major funding and
definitions, and forwards the notification to CDC using infrastructure challenges in adopting the standards-driven
the NEDSS messaging format, HL7, or NETSS (if no mes- information systems for electronic disease surveillance.
saging guide exists). A data transfer function in the NBS The CDC encourages adequate and sustained funding
allows users to notify another jurisdiction when a patient by public health programs for the NEDSS initiative and
moves and to transfer records for follow-up. encourages partners and clinical providers at the point of
care to adopt standards and create a uniform, interoper-
able, and bi-directional process for electronic disease
Federal (CDC) Role and the NBS
surveillance. Initiatives such as the CDC’s Public Health
A key part of the public health surveillance process is Informatics Fellowship Program train professionals to
assessment of population health in the United States. The apply information science and technology to the practice
capabilities of the NBS support public health investiga- of public health (CDC, 2013e).
tions and interventions at the state level and allow report- Because public health informatics requires the inte-
ing of nationally notifiable diseases in a more complete gration of computer science, information science, and
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information technology into the public health system and Benefits of the implementation of an IIS for the pub-
with clinical care, one method to better understand how lic include having a private and secure place to safeguard
public health information systems work is to examine their important immunization information from multiple pro-
application in collecting, organizing, exchanging, and dis- viders that will be used throughout a person’s life; receiving
seminating data and information. The following two cases timely immunization reminders; and eliminating duplicate
illustrate public health information systems applied in the immunizations. Benefits for healthcare providers include
context of an immunization information system and a TB consolidating immunization records from different sources;
electronic surveillance system. automatically calculating the immunizations needed; easily
providing official copies of immunization records; reduc-
ing chart pulls for coverage assessments and Healthcare
Using Informatics in an Immunization
Effectiveness Data and Information Set (HEDIS) reviews
Information System
(National Committee for Quality Assurance [NCQA],
Public health has been an advocate for immunization to 2013); automating vaccine inventory and ordering proce-
prevent disease for decades. Currently, vaccine-prevent- dures; allowing for vaccine tracking during vaccine short-
able diseases are at, or near, record lows (Roush, Murphy, & ages or manufacturer recalls; flagging high-risk patients for
Vaccine-Preventable Disease Table Working Group, 2007). timely vaccination recalls; and assisting with vaccine safety
The Every Child By Two organization provides some basic and adverse event reporting. To accomplish these activi-
facts regarding the need for immunization registries. In the ties, the IIS must be able to exchange data and information.
United States, there are around 4 million births each year Data, vocabulary, and transmission standards are criti-
(11,000/day); by age 2, a child will need to have up to 20 cal to IIS success. A core IIS dataset has been defined,
vaccinations; 2.1 million children are under-immunized; current procedural terminology (CPT) codes have been
and 22% of American children see two immunization pro- mapped to CVX (vaccine codes), and MVX (manufacturers
viders in their first 2 years (Every Child By Two, 2010). of vaccines) codes have been developed to facilitate immu-
Immunization records and registries began as paper nization data exchange between IIS, billing and adminis-
forms that were completed by hand at the point of service. trative systems, inventory management systems, and other
The immunization record was kept with the patient’s file, support systems. In addition, HL7 standards are used for
and an official copy was given to the patient or patient’s codes as well as patient demographics, appointment sched-
guardian. On a periodic basis, usually once a month, all the uling, file synchronization, and other data management
immunizations records were aggregated by hand (or calcu- transactions produced and received by the systems.
lator) with patient demographics and vaccine information The IIS has been successfully implemented in many states.
written into a registry that was shared with the local health Examples include the Michigan Care Improvement Registry
agency. This time-consuming process contained many vul- (Michigan Care Improvement Registry [MCIR], 2013), the
nerable points where the data could be wrongly entered, Oregon Immunization ALERT system (Oregon DHHS, 2013),
incorrectly calculated, or not included in the overall tally. the Wisconsin Immunization Registry (WIR) (Wisconsin
Newer immunization registries are based on elec- Immunization Program, 2013), the Iowa Immunization
tronic Immunization Information Systems (IIS). These IIS Registry Information System (Iowa Department of Public
are confidential, computerized information systems that Health, 2013), and the Louisiana Immunization Network for
allow for the collection of vaccination histories and pro- Kids Statewide (LINKS) (Louisiana Immunization Network
vide immediate access by authorized users to a child’s cur- for Kids Statewide [LINKS], 2013).
rent immunization status. One impetus for IIS arose from Challenges to moving IIS forward include funding
the Healthy People 2010 objective (14.26), which stated and human capacity to build and manage the system. The
that 95% of children younger than 6 years of age would HITECH Act (American Recovery and Reinvestment Act
be registered in a fully operational IIS (U.S. Department [ARRA], 2009) that provides funding and educational pro-
of Health and Human Services, 2010). “Nationally, 19.2 grams focusing on informatics will help nurses and oth-
million U.S. children aged <6 years (84%) participated ers develop skills refine and effectively use this important
in an IIS in 2011. Child participation in IIS has increased public health information system.
steadily, from 63% in 2006 to 84% in 2011. Of the 54 grant-
ees with available data in 2011, 24 (44%) reported that
Using Informatics in a Tuberculosis Electronic
>95% of children aged <6 years in their geographic area
Information System
participated in their IIS. An additional 13 (24%) grantees
reported child participation rates ranging from 80% to Tuberculosis is a chronic bacterial infection caused by
94%” (CDC, 2013f ). Mycobacterium tuberculosis. The most common site of
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infection is the lung, but other organs may be involved. programs receiving federal funding for TB prevention and
Healthcare providers are required by laws in all 50 states control. The national reports are used by state programs
to report patients with TB and other conditions on the to set performance targets, measure performance, and
state’s list of notifiable conditions. Confirmed TB cases evaluate the program’s capacity to control and prevent TB
are reported by clinicians and laboratory staff to local (Division of TB Elimination, 2012).
health departments and then to statewide disease surveil- Work continues on managing data quality to improve
lance programs connected to state health departments. A accuracy, completeness, consistency in collecting data,
confirmed case of TB is one that meets the clinical case and timeliness of reporting in the National TB Surveillance
definition or is laboratory confirmed. Reporting is also System. Additionally, future applications are needed to
recommended for patients who have suspected respira- automate data exchange between the TB reporting sys-
tory TB prior to laboratory confirmation, to expedite con- tems and to standardize laboratory data for direct report-
tact tracing and TB transmission control. ing to the National TB Surveillance System.
Multiple systems are involved in electronic TB report-
ing. Data reporting systems include the National TB The Public Health Informatician and
Surveillance System (Division of TB Elimination, 2013a), the Emerging Roles for Public Health
the TB Genotyping Information Management System Nurse Informatician
(Division of TB Elimination, 2013b), and the Electronic
Disease Notification System (CDC: Division of Global The emerging role of the PHNI is illustrated in case
Migration and Quarantine, 2013). studies to demonstrate the core public health functions
The National TB Surveillance System is an electronic of assessment and assurance performed by the PHNI
incidence surveillance system that collects 49 data items and the PHI. In the first case study, the PHI ensured the
on newly diagnosed verified cases of TB in the United retrieval of destroyed health records (immunization data)
States. The appropriate authority transmits the data from for displaced Hurricane Katrina communities by linking
the state or designated health jurisdiction to CDC at three people with their records through informatics. By retriev-
intervals: initially at the time of case verification, at receipt ing health records, the PHI enforced the rules regarding
of initial test results for drug susceptibility, and at treat- immunization record requirements while ensuring provi-
ment closure. Formats for reporting TB cases have evolved sion of needed immunizations. In the second case study,
over decades from paper-based reporting beginning in the PHI, while participating in assessment activities to
1952, to electronic reporting introduced in the mid-1980s, monitor health status and health problems in displaced
to an NEDSS-compatible, electronic surveillance system, Hurricane Katrina communities, identified a norovirus
using HL7 messaging, operational in 2010 for verified TB outbreak. The PHI developed and used a simple data
cases reported in 2009. checklist of symptoms, and compiled daily information
The TB Genotyping Information Management System reports and environmental risk information to evaluate
(TB GIMS) builds upon the established infrastructure of the ongoing effectiveness and quality of emergency public
the CDC’s National TB Surveillance System and incorpo- health services. In the third case study, the PHNI designed
rates genotype data to create a centralized database and an assessment activity for barriers to adherence behaviors
reporting system. State public health laboratories submit with TB treatment. The PHNI described a clinical nurs-
isolates from culture-confirmed cases to one of two desig- ing information system (CNIS) for a behavioral adherence
nated genotyping laboratories for molecular characteriza- model adapted to TB program literature. The resulting
tion, which helps with identifying recent transmission and dataset can be used to manage data, monitor the perfor-
potential outbreaks. mance plan, and evaluate the effectiveness and quality of
The Electronic Disease Notification System alerts state personal health services.
and local health department programs of refugees and
immigrant arrivals to their jurisdictions and provides
overseas medical screening results and treatment follow- CASE STUDY 32.1. IMMUNIZATION
up information. Each refugee or immigrant with a TB REGISTRIES AND EMERGENCY
classification is referred to the TB program for medical RESPONSE AFTER
screening and treatment follow-up.
CDC uses data from these reporting systems to dis-
HURRICANE KATRINA
seminate performance measurement reports for national Hurricane Katrina made landfall in Louisiana on August
TB-related performance indicators (NTIP). CDC shares 29, 2005. To escape the storm, more than 200,000 resi-
these reports electronically with health department dents of New Orleans and the surrounding area evacuated
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to shelters in Houston, Texas. In their hurry, they left on an intake form in medical facilities setup to provide
behind most personal belongings, including immuni- care on an outpatient basis. This information was gathered
zation records or medical records. Since the hurricane and entered into a database, and results were distributed
landed as the fall school session was about to begin, state each morning.
and local school boards in Texas agreed to accept the dis- On September 2, staff observed an increase in adults and
placed children into schools without proof of immuni- children with symptoms of acute gastroenteritis. On some
zation, but stated that proof of immunizations would be days, nearly 21% of adults and 40% of children visiting one
necessary to remain in school. clinic had acute gastroenteritis. They conducted enhanced
To assist families in finding their children’s records, the surveillance to improve identification of acute gastroen-
Houston-Harris County (Texas) Immunization Registry teritis, investigated the apparent outbreak, identified the
(HHCIR) staff contacted their vendor, who was also the infectious agent, and implemented control measures.
vendor for the Louisiana Immunization Network for Kids The reported epidemiologic and laboratory findings
Statewide (LINKS), to investigate the possibility of link- suggested that an outbreak of norovirus gastroenteri-
ing the two IIS. In less than 24 hours, the HHCIR, ven- tis had affected individuals in numerous facilities. These
dor, and LINKS personnel had developed a technological outbreaks are not associated with contaminated food or
bridge built on HL7 standards connecting the two systems. water, but spread through person-to-person contact or
Ten days later, they had created a mechanism that allowed from fomites in crowded settings. This information was
health authorities to acquire child and adolescent immu- used to provide a health alert for epidemiologic features
nization histories from LINKS. This merged Web-based and clinical presentation, and to promote rehydration
immunization registry was made available to public health treatment and measures to prevent secondary transmis-
officials and selected healthcare providers in temporary sion (CDC, 2005).
clinics in the Astrodome and George R. Brown Convention
Center. Originally, the new IIS was a “search and view” only
system; the HL7 data exchanges capability was added to CASE STUDY 32.3. USING
allow the LINKS-HHCIR connection to exchange patient INFORMATICS FOR PUBLIC
data and information from one system to the other.
Over the next month, more than 20,000 records were
HEALTH PROGRAM EVALUATION
searched and approximately 10,000 were successfully A diagnosis of TB disease or latent TB infection in a child
matched for displaced children in the greater Houston area. represents recent transmission of M. tuberculosis; there-
By September 2006, one year later, nearly 19,000 records fore, trends in TB disease and latent TB infection in young
had been successfully matched. The estimated cost savings children are important indicators to assess the effective-
of this on-the-fly, hybrid IIS, just in vaccines for these chil- ness of TB prevention and control efforts. Investigations
dren, is slightly over $1.6 million. These costs do not factor of persons having infectious pulmonary TB can avert TB
in the savings in time, pain, and lost work time or missed in children who have been infected with M. tuberculosis by
school that would have occurred if the children had finding and treating these children before they progress to
needed to be re-immunized. Nor do the costs reflect the TB disease (Lobato et al., 2008).
societal costs that may have occurred if the children had Monitoring standardized nursing activities (investiga-
not been allowed to attend school (Boom, Dragsbaek, & tion and adherence) can help identify missed opportuni-
Nelson, 2007). The use of the IIS immunization registry ties for preventing TB in young children. For example,
post-Katrina empowered patients, parents, and healthcare when a child develops TB disease or latent TB infection,
providers to know immunization history. how timely was the exposed child identified or screened
for TB (case interview/investigation adequacy)? Was the
child recommended for TB treatment but did not start or
CASE STUDY 32.2. NOROVIRUS did not complete treatment (caregiver adherence issues)?
OUTBREAK IN PERSONS DISPLACED Was the person having infectious pulmonary TB and
exposing the child recommended for treatment, but did
BY HURRICANE KATRINA not start or did not complete treatment (adherence issues)?
Collecting and sharing data and information is essen- PHNs use a clinical nursing information system (CNIS)
tial for public health practice. In September 2005, nearly dataset, constructed with standardized nursing terminol-
1000 evacuees from Hurricane Katrina and relief workers ogy recognized by the American Nurses Association, to
in numerous facilities had symptoms of acute gastroen- account for nursing activities, to manage program out-
teritis. A checklist of symptoms was used to collect data comes, and to describe a planned approach to nursing
c32.indd 465 2/5/2015 3:22:38 PM

care. Although PHNs use the CNIS dataset to generate identify, describe, and label interventions that affect those
data on patient assessments and to characterize health- outcomes. The Patient-Centered Care (PCC) Model for
care provider interactions with patients, authors looked Perceived Barriers to Adherence with TB Treatment helps
for a CNIS dataset specifically adapted for identifying bar- the nurse identify and document multiple determinants of
riers to investigation and adherence to treatment. adherence behavior and useful interventions (Table 32.1)
PHNs can select from various CNIS datasets. They (Gibson, Boutotte, Wilce, & Field, 2011).
selected a vendor application of CNIS for the public health
programs in Maine and Minnesota. The CNIS in Maine is
a statewide PHN initiative within the public health system. FUTURE DIRECTIONS IN PUBLIC
It is used to document clinical care and to inform program
evaluation. Common tools are used for nursing care and
HEALTH INFORMATION SYSTEMS
education plans, flow sheets, and encounter forms for indi- Although public health information systems have matured
vidual client services (TB, MCH, childhood lead poison- over the past decade, many challenges remain. In general,
ing) (Correll & Martin, 2009). In Minnesota, the Omaha public health practitioners have not taken an active role
system contributes to the outcomes management program in the development of health information systems within
in local public health departments by providing quantita- their jurisdictions. Since the bulk of public health activi-
tive data and graphs for program planning, evaluation, and ties occur within state/territorial level and local health
communication with administrators and local government departments, public health practitioners must provide
officials (Monsen, Martin, Christensen, & Westra, 2009). support and leadership to local healthcare systems in
PHNs in the TB program described components of a the emerging concept of multiagency responsibility for
planned approach to overcome adherence barriers and health. Local agencies and institutions such as managed
support completion of long-term TB treatment. PHNIs care organizations, hospitals, laboratories, environmental
are in an excellent position to identify, describe, and label health agencies, nursing homes, police staff, community
the issues associated with health outcomes as well as to centers, pharmacies, civic groups, corrections staff, drug
TABLE 32.1 Patient-Centered Care Model (PCC Model) for Barriers to Patient Adherence With Taking Medication
and Keeping Appointments for Tuberculosis Treatment (Gibson, Boutotte, Wilce, & Field, 2011)
Patient Diagnosis (NANDA-I) Nursing Interventions (NIC) Patient Outcomes (NOC)
Ineffective health maintenance Sustenance support Social support

Ineffective protection Infection control Immune status
Adjustment impaired/Risk-prone health behavior Decision-making support Well-being
Decisional conflict: whether to participate in Mutual goal setting Participation in healthcare decisions
treatment
Defensive coping Patient contracting Coping
Fear (stigma) Emotional support Fear self-control
Powerlessness: perceived threat Patient’s rights protection Health beliefs: perceived ability to perform
Ineffective therapeutic regimen management Medication management Medication response
Ineffective family therapeutic regimen management Discharge planning Family participation in professional care
Noncompliance Health policy monitoring Compliance
Knowledge deficit Teaching Knowledge of
•• Disease process •• disease process •• disease process
•• Treatment regimen •• treatment regimen •• treatment regimen
Communication impairment Culture brokerage Communication ability
NANDA-I, Nanda International; NIC, Nursing Interventions Classifications; NOC, Nursing Outcomes Classification.
Reproduced, with permission, from Gibson, J.D., Boutotte, J., Wilce, M., & Field, K. (2010). A patient-centered care model for perceived barriers to
adherence with tuberculosis treatment. (Unpublished Work.)
c32.indd 466 2/5/2015 3:22:38 PM

treatment centers, EMS staff, and home health agencies and population health can be planned. Health reform and
are partners in maintaining the public’s health. Figure related funding is driving the HIT platform. In response,
32.1 (Centers for Disease Control and Prevention [CDC], fellowship programs and internships in surveillance and
2013a) illustrates entities involved in local data/informa- public health informatics are addressing those needs
tion exchange. Additionally, public health practitioners (Drehobl, Roush, & Stover, 2012; CDC; ASPH partner fel-
have the expertise needed to inform developers of the lowship programs; ASPPH Graduate Training Program
health information system about specific data and infor- fellowships and internships; MELDI-Public Health
mation needs for population-based analyses to recognize Informatics Fellowship Program; NIH Nursing Informatics
emergent issues in the community, to assist in diagnostic Internship; Informatics university programs; American
and treatment decisions, and to understand better meth- College of Medical Informatics [ACMI] fellowship).
ods to improve the health of the community. Federal agen- Health reform promises the eliciting of evidence-
cies involved in public health can provide the leadership based practice to improve health (Agency for Healthcare
and expertise in developing consensus on data and health Research and Quality [AHRQ], 2013). Therefore, HIT
information technology (HIT) standards that will allow must capture interventions by multiple providers includ-
for the exchange of public health data and information ing nurses. Many promising practice-based interventions
across public health jurisdictions creating a “network of are addressed by nursing practice (Spencer, Schooley, &
networks” that function as a national public health infor- Anderson, 2013).
mation system. PHN leaders, working in partnership with other stake-
Using data in innovative ways through the use of data holders, monitor and evaluate program performance.
visualization and decision support systems will increase They clarify and describe practice-based interventions
public health’s ability to understand disease trends, make linked with achieving partnership goals and objectives.
decisions, and apply the appropriate resources where For example, The COPE Healthy Lifestyles Teen inter-
needed. The use of decision support based on clinical and vention for the national priority of Nutrition, Physical
prevention guidelines can integrate prevention messages Activity, Obesity (CDC, 2013g) links the nursing role
into primary care. and responsibilities with program goals and objectives by
As some HIT stabilizes and other technology innova- tracking nurse-sensitive indicators for BMI and pedom-
tions occur, public health can be the beneficiary of the focus eter step (Melnick, Jacobson, & Kelly, 2013). As healthcare
and funding that are driving healthcare reform. As clinical reform continues to evolve, PHN leadership will need to
care and public health continue to integrate and support take an active role in the development of the scope and
each other’s goal of keeping people healthy, HIT will pro- standards of public health nursing informatics practice
vide the platform to improve the health of the nation. and informatician competencies associated with these
accountabilities.
The Future of the Public Health Nurse
Informatician Role
“The PHN practice specialty needs a deeper understand-
SUMMARY
ing of informatics theories and methods to practice more In summary, public health, public health informatics, pub-
effectively” (American Nurses Association, 2013). While lic health information systems, and the ever-increasing
the Scope & Standards of Nursing Practice for Nursing integration of public health and healthcare present many
Informatics (American Nurses Association, 2008) and opportunities to improve the Nation’s health. Recent leg-
the Competencies for Public Health Informaticians islation has provided the guidance and funding platforms
(Association of Schools of Public Health, University of to create a seamless integration of health information sys-
Washington Center for Public Health Informatics, 2013) tems to assist with better decision-making in patient care
have been published, literature review did not identify and in policy development. The development of individual
scope and standards of public health nursing informatics data and information system standards is occurring less
(PHNI) or competencies for public health nursing infor- frequently as nationally recognized HIT and data exchange
maticians. It is necessary to describe the nursing profes- standards are stabilizing. Efforts supporting the certifica-
sion’s contributions to addressing national public health tion of the information technology used in health have an
priorities and initiatives. impact on the adoption and integration of these standards
The workforce capacity for public health surveillance by information system vendors. Successful implementa-
is limited but necessary to identify public health needs tions of standards-based information systems have dem-
so that interventions to improve individual, community, onstrated enormous cost savings in time and money.
c32.indd 467 2/5/2015 3:22:38 PM

PHNs contribute data to the standards-based data CDC. (2013d). National Electronic Telecommunications
exchange systems; use information to target care for indi- System for surveillance (NETSS). Atlanta, GA. Retrieved
viduals, families, groups, and populations; and then evalu- from http://www.cdc.gov/ncphi/disss/nndss/netss.htm
ate programs by means of the information systems. The CDC. (2013e). Public health informatics fellowship program.
Atlanta, GA. Retrieved from http://www.cdc.gov/phifp/
PHNI seeks partners to understand variables of concern
CDC. (2013f ). Progress in Immunization Information
to nurses in clinical care, such as barriers to adherence Systems—United States, 2011. Morbidity and Mortality
behaviors, in the development of the standards-based Weekly Report. 62(03), 48. Retrieved from http://www.
data exchange systems. The PHNI provides leadership to cdc.gov/mmwr/preview/mmwrhtml/mm6203a2.htm
the PHNs in the use of health information technology to CDC. (2013g). Winnable battles. Retrieved from http://www.
improve the health of the nation. cdc.gov/winnablebattles/
CDC: Division of Global Migration and Quarantine. (2013).
Disease surveillance among newly arriving refugees and
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munity preventive services. Washington, DC: Author. mmwr/preview/mmwrhtml/ss6207a1.htm
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(2009). Department of Health Human Services, Affordable Care Act (PPACA). Pub. L. No. 111–148.
Pub. L. No. 111-5 (Feb. 17, 2009). Washington, DC. Retrieved from http://www.gpo.gov/fdsys/pkg/PLAW-
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cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid= Division of TB Elimination. (2012). National TB indicators
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Association of Schools of Public Health, University of www.cdc.gov/tb/publications/factsheets/statistics/
Washington Center for Public Health Informatics. (2013). NTIP.htm
Competencies for public health informaticians 2009. Division of TB Elimination. (2013a). Tuberculosis informa-
Birkhead, G. S., & Maylahn, C. M. (2000). State and local tion management. CDC. Atlanta, GA. Retrieved from
public health surveillance. In S. M. Teutsch & http://www.cdc.gov/tb/programs/tims/default.htm
R. E. Churchill (Eds.), Principles and practice of public Division of TB Elimination. (2013b). TB genotyping informa-
health surveillance (2nd ed., p. 253). Oxford University tion management system (TB GIMS) fact sheet. CDC.
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Boom, J. A., Dragsbaek, A. C., & Nelson, C. S. (2007). The programs/genotyping/tbgims/implementation_
success of an immunization information system in the statelab.htm
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33
Informatics Solutions for Emergency
Planning and Response
Elizabeth (Betsy) Weiner / Capt. Lynn A. Slepski
• OBJECTIVES
1. Describe the contributions that informatics can provide to emergency planning
and response.
2. Illustrate various ways that informatics tools can be designed and used to
support decision-making and knowledge base building in emergency planning
and response efforts.
3. Utilize the 2009 H1N1 example as a case study in how informatics was used to
plan and respond to this pandemic event.
4. Project areas of emergency management and response that would benefit from
informatics assistance.
• KEY WORDS
Emergencies
Disasters
Public health informatics
Bioterrorism
Biosurveillance
2014) reported that during 2013 they responded to three

INTRODUCTION major crises: Syria, where 9.3 million people were in need
Unfortunately, both natural and manmade disasters have of urgent humanitarian assistance; the Philippines, where
catapulted us into a world that has resulted in making Typhoon Haiyan/Yolanda killed nearly 6000 people, dev-
emergency planning and response a high priority need. astated the lives of millions, and destroyed over a million
There has been a documented rise in terrorism incidents, homes, and the Central African Republic where rising
as well as natural disasters worldwide. Natural events have tensions between Muslim and Christian communities and
ranged from earthquakes, tsunamis, floods, hurricanes, the collapse of the state have left the entire population of
typhoons, to pandemic disease events affecting billions. the country in fear and affected by the crisis. These emer-
Conflicts and nuclear disasters have added to the complex- gencies can have extensive political, economic, social,
ities. In addition to natural disasters, political and social and public health impacts, with potential long-term
upheavals massively disrupt the lives and livelihoods of consequences sometimes persisting for years after the
populations and result in the forced displacement of mil- emergency (WHO, 2013). As a result, both planning and
lions of people. The World Health Organization (WHO, response efforts have taken on new importance in relation
471
c33.indd 471 2/5/2015 5:03:56 PM

to emergencies and disasters. The purpose of this chap- and enhance informatics support at both the scene of the
ter is to explore the intersection between informatics and disaster and at the community resource levels.
emergency planning and response in order to determine The 2004 earthquake and tsunami that devastated parts
current and future informatics contributions. of Southeast Asia illustrated the uncoordinated invasion of
The United States is not immune from this increased people and organizations that resulted in unnecessary dupli-
emphasis on emergency preparedness. The events of cation, competition, and failure to assist many of the victims
September 11, 2001, forced the United States into the real- in need (Birnbaum, 2010). Subsequently, the Interagency
ization that the country was not adequately protected from Standing Committee (IASC) of the United Nations Office
terrorism. Then, within a short window of time, the anthrax for the Coordination of Humanitarian Affairs (UN-OCHA)
outbreaks stressed the public health infrastructure to the initiated changes called the “humanitarian reform.” This
point that bioterrorism arose as an additional deadly threat. reform effort organized clusters whose principal mission
As a result of these two experiences, the government of the was to assist the impacted government with coordination
United States responded at an unprecedented pace to bet- of all responses and with evaluations of the impact of inter-
ter prepare and manage terrorist events. Furthermore, the ventions. The World Health Organization was appointed as
pandemic H1N1 incident in 2009 created data collection the lead agency for health, which includes coordination and
challenges that caused public health officials to creatively production of health information (WHO, 2009, p. 8). Three
provide solutions for meaningful data acquisition in order of the eight strategic areas of their five-year programme
to be able to effectively manage the event. Events such as the required informatics: (3) improve health information and
mass shooting in Newtown, Connecticut, Hurricane Sandy operational intelligence; (4) provide baseline information on
on the eastern coast of the United States, and the horrific health risks, health risk reduction, and emergency prepared-
tornado in Moore, Oklahoma, serve as recent illustrations ness; and (7) build emergency preparedness knowledge and
of how response efforts have had to be altered to meet var- skills through training, guidance, research, and information
ied situations. Hemingway and Ferguson (2014) reflected services. This organization at the global level was aimed at
on lessons learned during the Boston Marathon bombing discouraging individual and organizational response efforts
and concluded that emergency preparedness plan updates that were not part of this coordinated response. The United
must reflect the changing types of disasters, changing com- States has also organized their planning and response
munication technologies, and the changing workforce. efforts for the same reasons, and informatics is increasingly
Early contributions by the informatics community taking on more important roles in these efforts.
focused on surveillance of threat detection. However,
as informaticists became more familiar with emergency
planning and response, it became clear that contributions THE FEDERAL SYSTEM FOR
toward efficiency, analysis, remote monitoring, telemedi- EMERGENCY PLANNING
cine, and advanced communications would be valued.
The most consistent challenge for emergency and disaster
AND RESPONSE
response continues to be communication and information Most disasters and emergencies are handled by local and
management. Effective response requires high situational state responders. The federal government provides sup-
awareness analyzing real-time information to assess needs plemental assistance when the consequences of a disaster
and available resources that can change suddenly and exceed local and state capabilities.
unexpectedly. There is a critical interdependence between Under the Homeland Security Presidential Directive 5
data collected in the field about a disaster incident, casu- (HSPD5) (White House, 2003), the Secretary of Homeland
alties, healthcare needs, triage, and treatment and the Security, as the principal Federal official for domestic inci-
needed community resources such as ambulances, emer- dent management, coordinates Federal actions within the
gency departments, hospitals, and intensive care units. United States to prepare for, respond to, and recover from
Concurrently, information from the various inpatient terrorist attacks, major disasters, and other emergencies.
facilities and ambulance resources alters the manage- Coordination occurs if and when any one of the following
ment and disposition of victims at the scene of a disaster. four conditions applies: (1) a Federal department or agency
Opportunities abound for new telecommunication tech- acting under its own authority has requested the assistance
nologies. Smart devices, wireless connectivity, and posi- of the Secretary; (2) the resources of State and local author-
tioning technologies are all advances that have application ities are overwhelmed and Federal assistance has been
during disaster events. These technologies are being used requested by the appropriate State and local authorities;
and evaluated to improve patient care and tracking, foster (3) more than one Federal department or agency has become
greater safety for patients and providers, enhance incident substantially involved in responding to the incident; or
management at the scene, coordinate response efforts, (4) the Secretary has been directed to assume responsibility
c33.indd 472 2/5/2015 5:03:56 PM

Chapter 33 • Informatics Solutions for Emergency Planning and Response 473
for managing the domestic incident by the President. and private sector partners, including the healthcare sector,
Further, HSPD5 directs Federal department heads to prepare for and provide a unified domestic response,
provide their full and prompt cooperation, support, improving coordination and integration. The Framework
and resources to the Secretary in protecting national emphasizes preparedness activities that include planning,
security. organizing, training, equipping, exercising, and applying
The National Response Framework, enacted in January lessons learned and assigns lead federal agencies to each
2008, established a comprehensive, national, and all-haz- of 15 Emergency Support Functions (ESF) (Department of
ards approach to respond to disasters and emergencies Homeland Security, 2008b).
(Department of Homeland Security, 2008a). Built on its The ESF group functions are used to provide Federal
predecessor, the National Response Plan, it includes guid- support during a response (Table 33.1), and assigns leads
ing principles that detail how federal, state, local, tribal, for each functional area. The Department of Health
TABLE 33.1 Emergency Support Functions by Lead Department and Scope

Lead Department/
Function Agency Scope
ESF #1— Transportation Aviation/airspace management and control

Transportation Transportation safety
Restoration/recovery of transportation infrastructure
Movement restrictions
Damage and impact assessment
ESF #2— Homeland Coordination with telecommunications and information technology
Communications Security/Federal infrastructures
Emergency Restoration and repair of telecommunications infrastructure
Management Agency Protection, restoration, and sustainment of national cyber and information
technology resources
Oversight of communications within the Federal incident management and
response structures
ESF #3—Public Defense/U.S. Army Infrastructure protection and emergency repair
Works and Corps of Engineers Infrastructure restoration
Engineering Engineering services and construction management
Emergency contracting support for life-saving and life-sustaining services
ESF #4— Agriculture/ Fire Coordination of federal firefighting activities
Firefighting Service Support to wildland, rural, and urban firefighting activities
ESF Scope ESF #5— Homeland Coordination of incident management and response efforts
Emergency Security/Federal Issuance of mission assignments
Management Emergency Resource and human capital
Management Agency Incident action planning
Financial management
ESF #6—Mass Homeland Mass care
Care, Emergency Security/Federal Emergency assistance
Assistance, Emergency Disaster housing
Housing, and
Management Agency Human services
Human Services
ESF #7—Logistics Homeland Comprehensive, national incident logistics planning, management, and
Management and Security/Federal sustainment capability
Resource Support Emergency Resource support (facility space, office equipment and supplies, contracting
Management Agency services, etc.)
(continued)
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TABLE 33.1 Emergency Support Functions by Lead Department and Scope (continued)
Lead Department/
Function Agency Scope
ESF #8—Public Health and Human Public health

Health and Services Medical
Medical Services Mental health services
Mass fatality management
ESF #9—Search and Defense Life-saving assistance

Rescue Homeland Search and rescue operations
Security/Federal
Emergency
Management Agency
ESF #10—Oil and Homeland Security/ Oil and hazardous materials (chemical, biological, radiological, etc.)
Hazardous U.S. Coast Guard response
Materials Environmental short- and long-term cleanup
Response
ESF #11— Agriculture Nutrition assistance

Agriculture and Interior Animal and plant disease and pest response
Natural Resources
Food safety and security
Natural and cultural resources and historic properties protection and
restoration
Safety and well-being of household pets
ESF #12—Energy Energy Energy infrastructure assessment, repair, and restoration

Energy industry utilities coordination
Energy forecast
ESF #13—Public Justice Facility and resource security

Safety and Security planning and technical resource assistance
Security
Public safety and security support
Support to access, traffic, and crowd control
ESF #14—Long- Homeland Social and economic community impact assessment

Term Community Security/ Long-term community recovery assistance to states, local governments, and the
Recovery Federal private sector
Emergency Analysis and review of mitigation program implementation
Management Agency
Urban Development
Small Business
Administration
ESF #15—External Homeland Emergency public information and protective action guidance
Affairs Security/Federal Media and community relations
Emergency Congressional and international affairs
Management Agency Tribal and insular affairs
Reproduced from Department of Homeland Security (2008b).
c33.indd 474 2/5/2015 5:03:57 PM

and Human Services leads public health and medical Many governments believed that if a pandemic-capa-
responses, including biosurveillance. ble virus emerged, there would be rapid worldwide spread
The Federal Emergency Management Agency (FEMA) as the 1918 Pandemic had spread across countries and
received critical public feedback following their poor continents in less than one year in a time without com-
response efforts during the 2005 Hurricane Katrina. Since mercial air travel to facilitate the spread of disease (DHHS,
that time, the agency has creatively added new social 2005). It was understood that a worldwide influenza pan-
media sites, ways to crowdsource disasters, and central- demic occurring in this century could have major effects
ized places to get information. Examples include an inter- on the global economy, especially travel, trade, tourism,
active emergency kit checklist with information about food, consumption, and eventually, investment and finan-
what to do during specific hazards; a disaster reporter fea- cial markets and could lead to widespread economic and
ture where users upload disaster photos with GPS features social disruptions. As a result, many countries engaged in
for posting on a public map; and a new social hub (FEMA, detailed pandemic planning and prepared to adopt draco-
2013). In addition, they have recently added the FEMA nian-like measures to delay but not stop the arrival of the
LinkedIn page and the U.S. Fire Administration Facebook virus, such as border closures and travel restrictions.
page where there are job listings, stories about what a “day Here in the United States, modelers predicted cata-
in the life” looks like at FEMA, other training resources, strophic death estimates (Table 33.3). The 1918–1919 flu
and tips for assisting fire departments or firefighters. pandemic, to date the most severe, had caused the deaths
of at least 675,000 Americans and affected about one-fifth
CASE STUDY 33.1. INFORMATICS of the world’s population. Researchers believed that if a
pandemic of similar severity occurred today, 90 million
AND 2009 H1N1 Americans could become ill, quickly exceeding available
Although there have been other viruses that have surfaced healthcare capacity and result in approximately 2 million
with the potential to become pandemic, the 2009 H1N1 Americans deaths (DHHS, 2005).
influenza pandemic continues to be the most recent pan- Preparedness planners assumed that all populations
demic and illustrates how informatics can contribute to an were at risk. They believed that disease would be wide-
emergency response. Initially concerned that a circulating spread, affecting multiple areas of the United States and
H5N1 virus (Avian Influenza A) was mutating and could other countries at the same time preventing the redistri-
cause a human pandemic, global experts had focused bution of resources. The world would experience multiple
efforts over the last several years on rapidly developing waves of outbreaks potentially occurring for an extended
catastrophic plans even though a pandemic virus had period of time (over 18 months), affecting the entire
not emerged. There were significant concerns, given that United States for a period of 12 to 16 weeks with commu-
during the twentieth century three flu pandemics were nity waves each lasting 6 to 8 weeks (DHHS, 2005). One to
responsible for more than 50 million deaths worldwide and three pandemic waves would occur (Occupational Safety
almost a million deaths in the United States (Department and Health Administration [OSHA], 2007). Further, plan-
of Health and Human Services [DHHS], 2005) (Table 33.2). ners believed that a pandemic could affect as many as 40%
The CDC estimates that 43 million to 89 million people of the workforce during periods of peak flu illness, pre-
had H1N1 between April 2009 and April 2010, and they dicting that employees could be absent because of their
estimate between 8870 and 18,300 H1N1 related deaths own illness, or would be caring for sick family members or
(DHHS, 2014a). On August 10, 2010 the WHO declared for children if schools or daycare centers are closed. They
an end to the global H1N1 flu pandemic (WHO, 2010). also recognized that workers would be absent if public
TABLE 33.2 History of Pandemics by Deaths, Causative Strain, and At-Risk Population
Populations at
Pandemic Estimated U.S. Deaths Estimated Worldwide Deaths Influenza A Strain Greatest Risk
1918–1919 500,000 40 million H1N1 Young, healthy adults

1957–1958 70,000 1–2 million H2N2 Infants, elderly
1968–1969 34,000 700,000 H3N2 Infants, elderly
Reproduced from Department of Health and Human Services Pandemic Influenza Plan (2005), p. B-7.
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TABLE 33.3 Estimates of Numbers of Episodes The Centers for Disease Control and Prevention, part
of Illness, Healthcare Utilization, and of HHS, monitors influenza activity and trends and virus
Death Associated With Moderate and characteristics through a nationwide surveillance system
Severe Pandemic Influenza Scenarios* as well as estimates the burden of flu illness using sta-
in the United States tistical modelling (CDC, 2010). On April, 29, 2009, the
CDC began reporting cases of respiratory infection with
Moderate swine-origin influenza A (H1N1) viruses transmitted
Characteristic (1958/68-like) Severe (1918-like) through human-to-human contact (CDC, 2009a, 2009b).
Illness 90,000,000 90,000,000 It established the case definition for 2009 H1N1 as an
(30%) (30%) acute febrile respiratory illness in a person and laboratory-
confirmed swine-origin influenza A (H1N1) virus infec-
Outpatient 45,000,000 45,000,000
Medical Care (50%) (50%)
tion at CDC by either of the following tests: real-time
reverse transcription-polymerase chain reaction (rRT-
Hospitalization 865,000 9,900,000
PCR), or viral culture (CDC, 2009a). The CDC began
ICU Care 128,750 1,485,000 tracking and reporting the number of cases, hospitaliza-
Mechanical 64,875 742,500 tions, and deaths at state, local, and national levels using
Ventilation standard state reporting mechanisms. It was soon appar-
Deaths 209,000 1,903,000 ent that using actual case counts resulted in dramatically
underreported disease.
Reproduced from Department of Health and Human Services
Pandemic Influenza Plan (2005), p. 18.
On July 24, 2009, CDC abandoned initial case counts,
*Estimates based on extrapolation from past pandemics in the United when it recognized that those numbers represented a sig-
States. Note that these estimates do not include the potential nificant undercount of the actual number of 2009 H1N1
impact of interventions not available during the twentieth-century cases. They found that 2009 H1N1 was less severe and
pandemics.
caused fewer deaths than expected when compared to
the pandemic planning assumptions. As a result, existing
plans, which used case fatality numbers as the trigger for
transportation was disrupted or if they were afraid to leave initiating response actions, were not effective.
home (Department of Homeland Security, 2007). Scientists turned to other means to begin to under-
Adopting a “worst case scenario,” government experts stand the effects of disease and predict its future course.
rapidly developed a number of strategies to help local gov- For example, because trending indicated that children
ernments plan, stating that the Federal government would and young adults were at higher risk, the Department
not likely be able to provide any assistance during the of Education began looking at school closures and
actual pandemic. For example, DHHS (2007) developed a school absenteeism, examining both teacher and student
Pandemic Severity Index (PSI) to characterize the sever- absences. Each of the critical infrastructure key resource
ity of a pandemic. It was designed to predict the impact sectors held weekly calls with private sector partners to
of a pandemic and provide local decision-makers with elicit whether there were trends beginning to indicate
standardized triggers that were matched to the severity business interruption problems, which might forecast
of illness impacting a specific community (Table 33.4). social disruptions. The National Retail Data monitor-
The severity index was based on a case-fatality ratio to ing system tracked the real-time purchase of over-the-
measure the proportion of deaths among clinically ill per- counter (OTC) medications, such as fever reducers and
sons. Recommended actions were identified in advance, influenza treatments, in over 29,000 retail pharmacies,
and communicated to the public in hopes of increasing groceries, and mass merchandise stores. This University
their understanding and compliance. Using the PSI, a of Pittsburgh system (2014a) is used to provide early
severe pandemic influenza, similar to the 1918 Pandemic, detection of naturally occurring disease outbreaks as well
was defined as a category 4 or 5, with 20% to 40% of the as bioterrorism.
population infected. For a severe pandemic, HHS recom- The CDC moved to using estimates. Using the influ-
mended that localities be prepared to dismiss children enza module from BioSense, CDC tracked flu with data
from schools and close daycares for up to 12 weeks, as from over 500 local and state health departments, hospital
well as initiate adult social distancing, which included emergency rooms, Laboratory Response Network labs,
suspension of large public gatherings and modification of Health Information Exchanges, as well as the Departments
the work place schedules and practices (e.g., telework and of Defense and Veterans Affairs. The Real-Time Outbreak
staggered shifts). Disease Surveillance (RODS) was designed in 1999 to
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TABLE 33.4 Matrix of Community Mitigation Strategies by Pandemic Severity Index
Interventions by Setting 1 Pandemic Severity Index 2 and 3 4 and 5
Home
Voluntary isolation of ill at home Recommendb, c Recommendb, c Recommendb, c
(adults and children); combine with
use of antiviral treatment as available
and indicated
Voluntary quarantine of household Generally not recommended Considere Recommende
members in homes with ill personsd
(adults and children); consider combin-
ing with antiviral prophylaxis if effec-
tive, feasible, and quantities sufficient
School
Child social distancing
• Dismissal of students from schools and Generally not recommended Consider: ≤ 4 weeksf Recommend:
school-based activities, and closure of ≤ 12 weeksg
childcare programs
• Reduce out-of-school social contacts Generally not recommended Consider: ≤ 4 weeksf Recommend:
and community mixing ≤ 12 weeksg
Workplace / Community
Adult social distancing
• Decrease number of social contacts Generally not recommended Consider Recommend
(e.g., encourage teleconferences, alter-
natives to face-to-face meetings)
• Increase distance between persons Generally not recommended Consider Recommend
(e.g., reduce density in public transit)
• Modify or cancel selected public gath- Generally not recommended Consider Recommend
erings to promote social distance (e.g.,
postpone indoor stadium events)
• Modify work place schedules and prac- Generally not recommended Consider Recommend
tices (e.g., telework, staggered shifts)
Reproduced from Department of Health and Human Services (2007), p. 12.

Generally Not Recommended = Unless there is a compelling rationale for specific populations or jurisdictions, measures are generally not
recommended for entire populations as the consequences may outweigh the benefits.
Consider = Important to consider these alternatives as part of a prudent planning strategy, considering characteristics of the pandemic such as age-
specific attack rate, geographic distribution, and the magnitude of adverse consequences. These factors may vary globally, nationally, and locally.
Recommended = generally recommended as an important component of planning strategy.
a
All these interventions should be used in combination with other infection control measures including hand hygiene, cough etiquette, and
personal protection equipment such as face masks. Additional information on infection control measures is available at www.pandemicflu.gov
(DHHS, 2007).
b
This intervention may be combined with treatment of sick individuals using antiviral medications and vaccine campaigns, if supplies are available.
c
Many sick individuals who are not critically ill may be managed safely at home.
d
The contribution made by contact with asymptomatically infected individuals to disease transmission is unclear. Household members in homes with
ill persons may be at higher risk and have asymptomatic illness promoting community disease transmission. Therefore, household members of
homes with sick individuals would be advised to stay home.
e
To facilitate compliance and decrease risk of household transmission, this intervention may be combined with provision of antiviral medications to
household contacts depending on drug availability, feasibility, and effectiveness; policy recommendations for antiviral prophylaxis are addressed in a
separate guidance document.
f
Consider short-term suspension of classes, that is, less than four weeks.
g
Plan for prolonged suspension of classes, that is, one to three months; actual duration may vary depending on transmission in the community as the
pandemic wave is expected to last six to eight weeks.
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collect and analyze disease surveillance data in real time Middle East Respiratory Syndrome (MERS-CoV), which
(University of Pittsburgh, 2014b). Interpreting these esti- arose in 2013 in Saudi Arabia (Todd, 2014). Todd con-
mates, one study hypothesized that for every reported cludes that since all viral mutations are unpredictable,
lab-confirmed case of H1N1 between April and July 2009, it is impossible to predict whether any of these viruses
there were an estimated 79 total cases. The same study or yet another emerging virus will be the cause of a new
found that for every identified hospitalized case there were pandemic. We must, therefore, continue our diligence in
more likely 2.7 hospitalized people (Reed et al., 2009). surveillance activities.
Concerned that the limited capacity of the healthcare
system would be overwhelmed and finite resources such
Healthcare Consumers Contribute to
as H1N1 test kits would be consumed, CDC published
Surveillance Activities
updated self-treatment guidance and told the public
that H1N1 testing was no longer necessary. Instead, In the H1N1 case study described above, healthcare con-
persons with minor flu-like illnesses were assumed to be sumer data became an important aspect of the disease
infected and encouraged to utilize advice lines staffed surveillance model that augmented data collected by
by nurses to obtain answers to questions rather than to the CDC. Why was that the case? Now more than ever
seek appointments with healthcare providers. For the before consumers have the opportunity to contribute to
first time, the U.S. government established a one-stop surveillance activities. In some cases, the participation
federal Web site (www.flu.gov) that housed informa- is a conscious decision, but in others consumers may be
tion such as frequently asked questions as well as mes- unknowingly contributing to this informatics process.
saging aimed at individuals and families, businesses, Part of the advantage of externally generated CDC
and healthcare professionals from across the federal surveillance mechanisms is that they shorten the typi-
interagency. The Web site contained tailored planning cal lag time to publication for CDC’s publicly reported
documents for schools and communities, and included data which is currently estimated to be from 10 to 14 days
targeted information for special populations. One par- (Ginsberg et al., 2009). Telephone triage data are now
ticularly helpful site was a Flu Vaccine Locator, which being used to help track influenza in a specified geo-
contained a database that provided the general public graphic location with the added advantage that the data
with the locations of clinics that had vaccine supplies are real time in nature. In addition, patient demograph-
utilizing zip codes (DHHS, 2014b). ics and disease symptoms can also be captured in a stan-
For the first time, HHS used social media to commu- dard format. Another new mechanism for data capture
nicate with young people. Recognizing that large numbers about influenza is through physician group proprietary
of young adults were affected, they launched a Facebook systems. In these systems, the healthcare providers enter
application “I’m a Flu Fighter!” that allowed and encour- the data for suspected or confirmed influenza patients. By
aged users to spread information about H1N1, such as far, the most talked about trend in influenza surveillance
where they received the H1N1 vaccine, to their Facebook for the 2009 H1N1 outbreak was Google’s Flu Trends.
friends (Mitchell, 2010). The assumption made with this system was that there
Other recent viruses have arisen but cannot be cat- was a relationship between how many people search the
egorized as pandemic because they have not caused Internet for flu-related topics and how many people have
sustained and efficient human-to-human transmis- flu-like symptoms. In studies conducted by Google.org
sion. Informatics has been important in this report- comparing Google Flu Trends to CDC published data,
ing and analysis. H5N1, commonly known as avian they found that the search-based flu estimates had a con-
influenza (“bird flu”), is such an example. In July 2013, sistently strong correlation with real CDC surveillance
WHO announced a total of 630 confirmed human cases data (Ginsberg et al., 2009).
which resulted in the deaths of 375 people since 2003,
but did not meet pandemic criteria (WHO, 2013). Also
in 2013, the American Academy of Family Physicians COMPETENCY-BASED LEARNING
(2013) reported that the case numbers of H7N9 stalled in
China, but that the pandemic potential remains. H7N9
AND INFORMATICS NEEDS
is an unusually dangerous virus for humans with cases In order to provide a successful nursing response effort,
resulting in severe respiratory illness, with a mortality nurses must be appropriately and consistently educated
rate of roughly 30% (Li et al., 2014). H7N9 does not kill to provide the right response. Competency-based educa-
poultry, which makes surveillance much more difficult. tion provides an international infrastructure for nurses to
Other recent threats include a new respiratory virus learn about emergency preparedness and response. Yet,
c33.indd 478 2/5/2015 5:03:57 PM

currently there are no accepted, standardized require- related to their systems, but find themselves in a new
ments for disaster nursing training or continuing educa- role as part of a more comprehensive team approach to
tion (Slepski & Littleton-Kearney, 2010). disasters and emergencies. The incident management
There have been, however, a number of competency system (IMS) was first used by firefighters to control
development efforts geared to different nursing audi- disaster scenes in a multijurisdictional and interdepart-
ences. In collaboration with the CDC, researchers from mental manner. The IMS calls for a hierarchical chain of
the Columbia University School of Nursing identified nine command led by the incident manager or commander.
objectively measurable skills for public health workers Each job assignment is consistently followed by assigned
and seven competencies for leaders, followed by an addi- personnel who refer to a specific job action sheet. This
tional three competencies for public health professionals system improves communication through a common
(Columbia University School of Nursing Center for Health language, allows staff to move between management
Policy, 2001). There were also two competencies identi- locations, and facilitates all responders to understand
fied for public health technical and support staff relating the established chain of command. The IMS has been
to (1) demonstration of equipment and skills associated adapted for hospital use and is called the Hospital Incident
with his/her functional role in emergency preparedness Command System (HICS).
during regular drills and (2) description of at least one The Emergency Operations Center (EOC) is the physi-
resource for backup support in key areas of responsi- cal location where the Incident Management Team con-
bility. In 2003, the International Nursing Coalition for venes to make decisions, communicate, and coordinate
Mass Casualty Education (later renamed the Nursing the various activities in response to an incident. Accurate,
Emergency Preparedness Coalition, or NEPEC) gener- real-time data acquisition regarding patient needs, rescue
ated a list of 104 competency statements for all nurses personnel, and resources available is critical to overall
responding to disasters using domains developed by the coordination. Table 33.5 presents functions where tech-
American Association of Colleges of Nursing (Stanley, nology can be used to capture and represent data for pur-
2005). Additional competencies were developed by the poses of increasing situational awareness in the EOC for
University of Hyogo and the International Council of the purposes of making the most informed and efficient
Nurses. All of the competency efforts were considered by decisions. In addition, the informatics processing efforts
a WHO group of nursing experts as they developed com- that contribute to the incident management system are
petency domains during the first consultation on nursing also described.
and midwifery in emergencies (WHO, 2007, p. 10).
Efforts to identify content to match competencies have
Informatics and Volunteerism
also proven successful. An additional group of experts met
following WHO’s first consultation on nursing and mid- Healthcare volunteers are a necessary component of mass
wifery contributions in emergencies to identify possible casualty events but also create challenges. How do you
content that matched the identified competencies at the count volunteers so that they are only entered once? How
undergraduate nursing level (WHO, 2008). Online mod- do you educate them so that they can perform effectively
ules produced by NEPEC (http://www.nursing.vanderbilt. when needed? How are liability issues dealt with? Are there
edu/incmce/modules.html) and the National Nursing certain tasks that lend themselves to volunteer efforts?
Emergency Preparedness Initiative (NNEPI) (www.nnepi. Some states offer their nurses the opportunity to volunteer
org) both received international awards from Sigma Theta when they renew their nursing licensure. It is then possible
Tau International for quality computer-based education for state-wide volunteer databases to be built, but these are
programs. only shared within the state system. Some states require a
The CDC currently sponsors a public health informat- set number of hours of continuing education in emergency
ics fellowship program that is a two-year paid fellowship in preparedness in order to renew licensure.
public health informatics (CDC, 2014). The competency- The federal government does have a system for orga-
based and hands-on training allows students to apply nizing teams that are willing to travel to other regions of
information and computer science and technology to solv- the country in the event of an emergency. These teams are
ing real public health problems. called disaster medical assistance teams (DMATs). When
DMATs are activated, members of the teams are federal-
ized or made temporary workers of the federal govern-
Informatics and Incident Management
ment, which then assumes the liability for their services.
Information technology staff members have long been Their licensure and certifications are then recognized by
familiar with emergency planning for disaster recovery all states.
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c33.indd 480
480 P art 5 • A dvanced N ursing I nformatics

TABLE 33.5 Technology and Informatics Contributions to Incident Management
Functions Possible Technologies Informatics Processing
Data for Incident Smart White Board Organize and detect patterns and trends in data
Command Center Electronic Dashboards Predict resource needs and safety zones
Resource Modeling Access additional data and information
Internet Access to Information Resources Record and process decisions for legal and financial purposes
Staffing and Scheduling Records Analyze data to determine statistical significance
Electronic Logs to Capture Data and Decisions Report and analyze Internet surveillance systems
Resource Inventories Promote standardization of data collection and vocabulary
Resource Distributor Database
Online Disaster Manual with Job Action Sheets
Communications Landlines Standardized vocabulary and roles
Radio Communications Communication standards set in order to prioritize and determine accuracy of
Cell Phones data transmission
in
Satellite phones Data collection from the field is sent back to EOC
P ractice
Amateur Radios Data collection and analysis contributes to situational awareness
Third and Fourth Generation Wireless Devices
Electronic Mail
Internet, Twitter, Facebook, YouTube
Television and Radio announcements E-commerce
Patient Tracking Global Positioning systems (GPS) Data and Information processed for purposes of triage and transport
Bar code tracking Data collected to determine magnitude of disaster
Radio frequency identification
Provider Safety Radiation monitors and badges Data collection and Monitoring to determine safe radiation levels
Radio communications Cellular triangulation to determine location
GPS devices
Cell phones
Ambulance Tracking GPS Monitor for triage and admission purposes
Cell phones
Radio communication
Patient data acquisition Electronic record Collect and analyze to determine trends across geographic area
and monitoring ED status system
Wireless monitoring
Pharmacy electronic records
2/5/2015 5:03:57 PM
The Medical Reserve Corps (MRC) and the Emergency a standardized registry allows for more informed deci-
System for Advance Registration of Volunteer Health sions and increased efficiency of services during times of
Professionals (ESAR-VHP) both represent initiatives of response and relief efforts.
the Department of Health and Human Services to improve
the nation’s ability to prepare for and respond to public
Disaster Electronic Medical Records and Tracking
health emergencies. The MRC is a national network of
community-based volunteer units that focus on improving Expanding the use of the electronic health record should
the health, safety, and resiliency of their local communi- help both patients and their healthcare providers during
ties. MRC volunteers include medical and public health times of emergencies and disasters. Accessing clinical data
professionals such as physicians, nurses, pharmacists, den- for displaced patients should also improve tremendously
tists, veterinarians, and epidemiologists. Many community with interoperable data and the sharing of clinical informa-
members—interpreters, chaplains, office workers, legal tion, all recent initiatives from the Office of the National
advisors, and others—can fill key support positions. For Coordinator for Health Information Technology (ONC).
example, nurses trained in informatics are often used by One project that emerged from that office during Hurricane
MRC units to compile needed databases depending on the Katrina was called KatrinaHealth and illustrated such
response effort at hand. At the time of this writing, there potential with the pooling of information resources across
are 991 units composed of 206,770 volunteers, covering federal and private sectors. KatrinaHealth.org was a free
73.69% of the United States (Medical Reserve Corps, 2014). and secure online service that provided Katrina evacuees
The national ESAR-VHP program provides guidance their authorized healthcare providers and pharmacists with
and assistance for the development of standardized state- a list of the prescription medications evacuees were tak-
based programs for registering and verifying the credentials ing before they were forced to leave their homes, lost their
of volunteer health professionals in advance of an emer- medications, and the medical records (Markle Foundation,
gency or disaster (ESAR-VHP, 2014). Each state program American Medical Association, Gold Standard, RxHub,
collects and verifies information on the identity, licensure & SureScripts, 2006).
status, privileges, and credentials of volunteers. These pro- Another situation served to illustrate the importance of
grams are built to a common set of national standards and the electronic health record when an EF5 tornado struck
give each state the ability to quickly identify and assist in Joplin, Missouri, on May 22, 2011 (Abir, Mostashari,
the coordination of volunteer health professionals in an Atwal, & Lurie, 2012). Significant damage was inflicted on
emergency. These registration systems include information St. John’s Regional Medical Center, claiming the lives of five
about volunteers involved in organized efforts at the local of its 188 patients and one visitor. The EHR system had been
level (such as MRC units) and the state level (DMAT and implemented only three weeks earlier, and fortunately had
state medical response teams). In addition, individuals who a regional backup in Springfield, Missouri. Besides being
prefer not to be part of an organized unit structure can also able to access patient records, the informatics staff were
be entered into the registry in order to allow for a ready able to modify the names and beds in the units to reflect the
pool of volunteers. State ESAR-VHP programs provide a temporary facilities that were needed due to damage in the
single, centralized source of information to facilitate the main facility. A number of regional physician practices were
intrastate, interstate, and state-to-federal deployment or also able to resume caring for patients in alternate sites.
transfer of volunteer health professionals. Several collabo- DeMers et al. (2013) describe a secure, scalable disas-
ration suggestions have been generated in an effort to inte- ter electronic medical record and tracking system called
grate both the MRC and ESAR-VHP initiatives, including the Wireless Internet Information System for medi-
having state coordinators for both initiatives (MRC, 2014). cal Response in Disasters (WIISARD). This system is a
Most volunteer opportunities require education prior handheld, linked, wireless EMR system utilizing current
to responding to the event. MRC units have competency- technology platforms. Smart phones connected to radio
based education requirements. The American Red Cross frequency identification readers can be used to efficiently
has a long history of volunteerism during disasters, and track casualties resulting from the incident. Medical
has education requirements for nurses depending on information can be transmitted on an encrypted network
what roles they will play in disaster relief. Regardless of to fellow team members, medical dispatch, and receiv-
the group, nurses are urged to be a part of an organized ing medical centers. The authors report that the system
group rather than simply showing up on the scene of a has been field tested in a number of exercises with excel-
disaster and contributing to the confusion. All of these lent results. This pre-hospital EMR merges data with the
initiatives require informatics solutions in order to func- receiving hospital EMR using HIPAA-compliant meth-
tion effectively. Organizing the results of these efforts into ods. Fayaz-Bakhsh and Sharifi-Sedeh (2013) are critical
c33.indd 481 2/5/2015 5:03:57 PM

in noting that one of the most typical consequences of Future Advances
disasters is the near or complete collapse of terrestrial
telecommunications infrastructures, resulting in disaster While the 2009 pandemic fortunately was far less severe
managers having difficulty getting Internet connectivity than the “Armageddon-like” event that planners fore-
or cell phone coverage. The WIISARD team recognized casted, it served to highlight many opportunities for the
those concerns and used an ad hoc field network that use of informatics to assist in emergency preparedness
could circumvent challenges around damaged or over- and response. Health information technology invest-
whelmed traditional communication network systems ments are a necessary foundation in healthcare reform,
(Chan, Griswold, & Killeen, 2013). linking potentially valuable information such as vaccina-
Tracking of patient victims is another important tion records and subsequent use of healthcare services to
function needed during disaster and emergency events. provide information about adverse events as well as vac-
The allocation of various resources over multiple geo- cine effectiveness (Lurie, 2009). Already, the CDC works
graphical locations makes for a complex decision- closely with WHO to make certain that many of the
making process, thus allocation of patients to hospitals databases link to one another, but over time this will
and adequate patient tracking and tracing are major improve as well. Continuing to pay attention to social
issues. Accurate and current information is critical for sit- media for crowdsourcing, for trending, and for analysis
uational awareness—the ability to make timely and effec- of text messages will remain an important contribution to
tive decisions during rapidly evolving events. In order disaster care.
to overcome such challenges, these authors developed a Using “grids” to connect multiple computers across
Victim Tracking and Tracing System (ViTTS) (Marres, the country will allow data sources to share and view large
Taal, Bemelman, Bouman, & Leenen, 2013). Their system amounts of health information. Grid participants will be
design allowed for early, unique registration of victims able to analyze data in other jurisdictions without mov-
close to the impact site that was able to later connect to ing the actual data, which is an important step forward in
the receiving systems. overcoming policy barriers to moving data out of a juris-
Mobile health (mHealth) technology can also play a diction to protect individual privacy.
critical role in improving disaster victim tracking, tri- Having interoperable patient data is a current goal
age, patient care, facility management, and theater-wide of the Office of the National Coordinator for Health
decision-making. Callaway et al. (2012) thought that the Information Technology, but it will also serve to improve
delivery of care after disasters like the earthquake in Haiti the data available as victims become dispersed from their
could be better integrated using mHealth. They chose to typical healthcare environments. Pulling that data closer
develop, deploy, and evaluate a novel electronic patient to the point of care with mobile devices will only enhance
medical record and tracking system in the immediate the quality of data available for healthcare providers to
post-event setting. An iPhone-based mobile technol- make critical decisions with limited time and resources.
ogy platform called iChart was selected. During their Allowing these data to be transmitted across international
implementation, there were 617 unique patient entries lines will most certainly assist in our quest to provide
into the patient tracker, resulting in an adequate ability healthcare to victims regardless of where they seek shelter.
to triage patients as they arrived as new transfers. Users International communication standards will also become
rated that the iChart improved provider handoffs and an important factor in improving communication across
continuity of care, and standardized the information into borders.
one language. Given the chaotic nature of volunteer phy-
sicians’ arrivals and departures, the mobile application
also accommodated fluctuating provider schedules by
SUMMARY
keeping a centralized repository of basic patient informa- In conclusion, the 2009 H1N1 outbreak was a recent
tion. The online database was also used to generate daily example of emergency preparedness and response. It rein-
census figures. forced the fact that estimating the number of actual flu
Case, Morrison, and Vuylsteke (2012) reviewed the lit- cases is very challenging as current case counting relies on
erature to determine ways that mobile technology could encounter information, which is prone to underreporting.
help disaster medicine. They classified applications into Informatics is an emerging field that has the potential to
five types: (1) disaster scene management; (2) remote immediately support the early identification of a commu-
monitoring of casualties; (3) medical image transmission; nicable disease such as pandemic influenza, reducing loss
(4) decision support applications; and (5) field hospital of life and the consumption of limited resources. Use of
information technology systems. automated case-specific disease monitoring applications
c33.indd 482 2/5/2015 5:03:58 PM

such as BioSense, ESSENCE, and RODS and tracking retail Centers for Disease Control and Prevention. (2010). CDC
data such as OTC medication purchases allow researchers estimates of 2009 H1N1 influenza cases, hospitaliza-
to collect, analyze, and present real-time disease informa- tions and deaths in the United States. Retrieved from
tion which allows users to have immediate access to infor- http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.
Accessed on April 2009–April 10, 2010.
mation that previously would have taken days to assemble.
Centers for Disease Control and Prevention. (2014). Public
Technological developments will further enhance the abil-
health informatics fellowship program. Retrieved from
ity to use informatics to detect the first warning signs dur- http://www.cdc.gov/PHIFP/About.html
ing an emergency. Chan, T. C., Griswold, W. G., & Killeen, J. P. (2013). Author
Consumers themselves have assumed surveillance reply. Prehospital and Disaster Medicine, 28(6), 647.
roles in their quest to seek data and information resources. doi:10.1017/S1049023X13009047
The increase use of social media provides a new mecha- Columbia University School of Nursing Center for Health
nism for data collection and trending. Policy. (2001, April). Core public health worker competen-
Coordinated response efforts require excellent commu- cies for emergency preparedness and response. Retrieved
nication based on efficient decision-making. Informatics from http://www.phf.org/resourcestools/Documents/
emergencypreparednesscorecompetencies_Columbia_
can contribute to this agenda, particularly in an era when
University.pdf
healthcare resources are dwindling. Informatics infra- DeMers, G., Kahn, C., Johansson, P., Buono, C., Chipara, O.,
structure contributes continuous monitoring of data, Griswold, W., & Chan, T. (2013). Secure scalable disas-
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Public Health Practice Applications: - Objectives

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32

Health departments are collecting and analyzing

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Drug Public Health Laboratories

Law Faith Institutions

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Health pose of preventing or controlling disease, injury, or disability,

Assure and for conducting public health surveillance, public health

Workforce Insurance Portability and Accountability Act [HIPAA],

2002). The 2010 Patient Protection and Affordable Care Act

Link Research Inform, (PPACA) established policies and technically interoperable

the public health functions of assessment, policy develop-

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Ineffective health maintenance Sustenance support Social support

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2014) reported that during 2013 they responded to three

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TABLE 33.1 Emergency Support Functions by Lead Department and Scope

ESF #1— Transportation Aviation/airspace management and control

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ESF #8—Public Health and Human Public health

ESF #9—Search and Defense Life-saving assistance

ESF #11— Agriculture Nutrition assistance

ESF #12—Energy Energy Energy infrastructure assessment, repair, and restoration

ESF #13—Public Justice Facility and resource security

ESF #14—Long- Homeland Social and economic community impact assessment

Reproduced from Department of Homeland Security (2008b).

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1918–1919 500,000 40 million H1N1 Young, healthy adults

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Reproduced from Department of Health and Human Services (2007), p. 12.

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480 P art 5 • A dvanced N ursing I nformatics

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