IEEE-USA strongly believes that information technologies can assist the Federal government, as well as local and state health departments, with their responsibilities as responders to terrorist threats. Protecting against biological, chemical, nuclear, radiological and cyber terrorist threats requires the use of information technologies for detection, planning, preparedness and response. Promoting the use of common information technologies through interoperable systems and standards will improve outcomes and reduce costs by improving efficiency.

IEEE-USA urges Congress, the Departments of Homeland Security and Health and Human Services and other public health policymakers, to develop policies and procedures for adopting information technologies into the national public health information infrastructure. This should include a set of tools that would support increased effectiveness for all State and local health departments and homeland security personnel. Accordingly, IEEE-USA supports:

• Developing policies and procedures for adopting information technologies into the public health information infrastructure.
• Establishing performance indicators for the effectiveness of information technologies that can be used to measure the level of national preparedness for detection, planning, preparedness, and response to biological, chemical, nuclear, radiological and cyber terrorist attacks.
• Creating an inventory of information technology tools for public health purposes. The inventory would include modeling and simulation tools for nuclear disasters (e.g., the Department of Energy) which could also be used for bioterrorism (Centers for Disease Control and Prevention) and for chemical terrorism (Environmental Protection Agency).
• Developing special distance-learning training and education programs for first responders (i.e., police, fire, healthcare and safety personnel) to enhance their response to terrorist threats.
• Developing legislation and regulation to facilitate the exchange of surveillance, environmental, epidemiological, clinical and other healthcare-related information between disaster management planners, government agencies, healthcare stakeholders, first responders, and the lay public as the situation warrants.
• Encouraging the adoption and utilization of electronic medical and longitudinal personal health records by all healthcare stakeholders. The systems used to implement this recommendation must protect patient privacy and ensure a high degree of security.
• Promoting the creation of public health databases that include best practices such as clinical guidelines for adverse drug reactions and treatment guidelines for public health emergencies that can be implemented through decision support systems.

Major goals for improving the U.S. public healthcare system center on a better information infrastructure and include interoperability of health information systems; improving the capability for exchanging patient information (while protecting patient privacy and maintaining systems security); and sharing data, information and knowledge among Federal agencies, States and small communities.

This statement was developed by IEEE-USA's Medical Technology Policy Committee and represents the considered judgment of a group of U.S. IEEE members with expertise in the subject field. IEEE-USA is an organizational unit of the IEEE. It was created in 1973 to advance the public good and promote the careers and public-policy interests of the more than 225,000 technology professionals who are U.S. members of the IEEE. The IEEE is the world's largest technical professional society. For more information, go to http://www.ieeeusa.org.
 

BACKGROUND:

IEEE-USA suggests the following procedures to improve the current system:

• Standardizing Performance Indicators: Numerous discussions have been held about the need to enhance the nation’s preparedness, but national preparedness goals and measurable performance indicators have not yet been developed. Policymakers require certain information to make rational resource allocations, while program managers need to measure progress. The government needs to develop a new statistical index of preparedness and incorporate a range of different variables, such as quantitative measures for special equipment, training programs and medicines; as well as professional subjective assessments of the quality of local response capabilities, infrastructure, plans, readiness, and performance in exercises. This index should go well beyond the current rudimentary milestones of program implementation, such as the amount of training and equipment provided to individual cities. This type of index would allow the government to measure the preparedness of different parts of the country in a consistent and comparable way, providing a reasonable baseline against which to measure progress.
   
• Assessing Tools: How can people determine if a product is doing its job? How can this product be enhanced without making an assessment? When Congress asked how well the United States is prepared for terrorist threats, the Government Accounting Office and other agencies did some inventories. No group has evaluated the current available systems, (i.e., What works? What doesn’t work? Are these systems and/or tools excellent, good, bad?). Nor have they considered the concepts of technology transfer, where a tool used for planning a response to biological attack could also be used for responding to a radiological or chemical one.
   
• Specializing Training and Education: We agree with the following findings from the Federation of American Scientists (see Appendix B):
   
  • Millions of civilian and military medical personnel need to be trained quickly to respond to events involving Weapons of Mass Destruction (WMD), and have continuous access to refresher courses (including “just in time” training during an emergency).
  • Physicians, nurses, emergency medical workers, police, and fire officials feel unprepared for a WMD emergency – particularly at the level of cities and counties. Even with adequate funding, current programs to provide this training are not adequate to the task.
  • New information and training technologies can build a training system that will reach this audience quickly with timely information; allow tailored training to unique local situations; and provide simulated experiences that transfer efficiently into high levels of performance in an actual emergency.
  • It is necessary to form a coordinated interagency plan to build and operate the kinds of new training systems that have become essential.
     
• Creating Public Health Informatician and Healthcare/Medical Informatician Positions in the Federal Government: It is imperative for federal agencies and departments, i.e., the Department of Health and Human Services, to recognize the need for these (professions) individuals within their current system. For example, the Center for Disease Control (CDC) today has a fellowship program that trains physicians, public health professionals and/or computer scientists in Public Health Informatics (PHI). When the fellowships conclude, these professionals may be hired as computer scientists, programmers or public health advisors, but cannot be hired as PHI because the government has failed to define such a profession. The job description for any of these categories does not fit the responsibilities that a PHI should have.
   
• Improving Information Technology: The Office of Public Health Preparedness (OPHP) under DHHS seeks to ensure (on the information technology side) that 90 percent of the population has Internet connectivity to keep the public informed in the event of a biological attack or an epidemic due to infectious disease. The DHHS proposed coverage is not good enough. A 24/7 communications system is as critical for public health as is the ability to deliver vaccines and antibiotics within a 3- to 5-day period; and hospitals’ capability to respond to surges in demand of more than 500 acutely ill patients at one time.

Every citizen whether living in a large or small rural community, should be protected against any terrorist threat. Unfortunately, a digital divide is occurring between those States that already have an IT infrastructure and those that do not, (i.e. some with no email 18 months ago). We need to train and educate those that lack knowledge, so that the tools they purchase will be useful to everyone. While many understand that using the national healthcare information infrastructure can facilitate the linkage of today’s fragmented systems, many believe that lack of education and training is one of the biggest impediments to moving forward.

• Measuring Performance: is critical for assessing program results. The capability of state and local governments to respond to catastrophic terrorist attacks is uncertain, at best. At the federal level, Congress has had a longstanding objective of measuring results. For this reason, Congress enacted the Government Performance and Results Act of 1993 (more commonly referred to as The Results Act). This legislation was designed to focus agencies on the performance and results of their programs, rather than on program resources and activities, as in the past. The Results Act then became the primary legislative framework through which agencies are required to set strategic and annual goals, measure performance, and report on the degree to which goals are met. The outcome-oriented principles of The Results Act include establishing general goals and quantifiable, measurable, outcome-oriented, performance goals and related measures; developing strategies for achieving the goals, including strategies for overcoming or mitigating major impediments; ensuring that goals at lower organizational levels align with and support general goals; and identifying the resources required to achieve the goals.

In a December 2000 white paper, Richard Falkenrath of the Department of Homeland Security noted that a preparedness program lacking broad but measurable objectives is unsustainable (Richard A. Falkenrath, "The Problems of Preparedness: U.S. Readiness for a Domestic Terrorist Attack," International Security, Vol. 25, No. 4, 2001, pp. 14). The Congress has long recognized the need to objectively assess the results of federal programs. Establishing goals and performance measures will guide the nation’s preparedness efforts. For the nation’s preparedness programs, however, outcomes of where the nation should be in terms of domestic preparedness have yet to be defined. Given the recent and proposed increases in preparedness funding, as well as the need for real and meaningful improvements in preparedness establishing clear goals and performance measures is critical to ensuring both a successful and a fiscally responsible effort. Carefully choosing the most appropriate tools of government to best implement the national strategy and achieve national goals is critical. The choice and design of policy tools as grants, regulations and partnerships can enhance the government’s capacity to target areas of highest risk; better ensure that scarce federal resources address the most pressing needs; promote shared responsibilities by all parties; and track and assess progress toward achieving national goals.
 

• Implementing Training and Education: A survey conducted as part of The Gilmore Report (the Advisory Panel’s third annual report to the President and the Congress to assess domestic response capabilities for terrorism involving Weapons of Mass Destruction) indicates that police, fire, Emergency Medical Technicians, hospitals, public health officials and others value the training they have received from federal agencies (favorable responses averaged about 3.5 on a scale of 1 to 5), but that not enough training had been provided. Most felt that they were not prepared for a WMD emergency (Responses in this area averaged 2 on a scale of 1 to 5, where 5 meant that respondents were confident in their training). (The Gilmore Report, December 2001, Appendix G)
   
• Unique and Rapid Response to Biological Agents: Although many aspects of an effective response to bioterrorism are the same as those for any form of terrorism, some features are unique. For example, if a biological agent is released covertly, it may not be recognized for a week or more, because symptoms may not appear for several days after initial exposure, and it may be misdiagnosed at first. In addition, some biological agents, such as smallpox, are communicable and can spread to others who were not initially exposed. These characteristics require responses that are unique to bioterrorism, including health surveillance, epidemiologic investigation, laboratory identification of biological agents, and distribution of antibiotics to large segments of the population to prevent the spread of an infectious disease. However, some aspects of an effective response to bioterrorism are also important in responding to any type of large-scale disaster, such as providing emergency medical services, continuing health care services delivery, and potentially, managing mass fatalities.
   
• Responding to a Bioterrorist Incident. The burden of responding to bioterrorist incidents falls initially on personnel in state and local emergency response agencies. These “first responders” include firefighters, emergency medical service personnel, law enforcement officers, public health officials, health care workers (including doctors, nurses and other medical professionals), and public works personnel. If the emergency requires federal disaster assistance, federal departments and agencies will respond according to responsibilities outlined in the Federal Response Plan. Under the Federal Response Plan, the CDC is the lead department of the Health and Human Services (HHS) agency providing assistance to state and local governments for five functions: health surveillance; worker health and safety; radiological, chemical, and biological hazard consultation; public health information; and vector control.

The agents released in a bioterrorism event could occur by way of the air (as aerosols), food, water or insects. The intentional release of a biological agent may not be recognized for several days, if ever, during which time a communicable biological agent (such as smallpox) can spread to others who were not initially exposed. Some biological agents (such as anthrax and plague) produce symptoms that can be easily confused with influenza or other, less virulent illnesses, leading to a delay in diagnosis or identification. In addition to widespread medical consequences, a bioterrorist attack also could bring about behavioral, social, economic and psychological consequences, such as mass panic. Healthcare providers should be the first authorities to see victims as they seek treatment for symptoms. If large numbers of people are affected, local and state officials may turn to the federal government for assistance with disease surveillance, epidemiologic investigation, healthcare delivery, quarantine management, remediation, and mass fatality management.

• Defining the Problem: A definition and clarification of the appropriate roles and responsibilities of federal, state and local entities is extremely important, since many have found fragmentation and overlap among federal assistance programs. More than 40 federal entities have roles in combating terrorism, and past federal efforts have resulted in a lack of accountability and cohesive effort, and program duplication. State and local officials have noted that this situation has led to confusion, making it difficult to identify available federal preparedness resources and effectively partner with the federal government.

Prior to 9/11/2001 the Public Health Information Infrastructure System was in terrible shape. According to Dr. Akhter, the executive director of the American Public Health Association in declarations to Congress (October 9, 2001): “…the reality is that approximately ten percent of the health departments in the United States do not even have e-mail.” He also added: " We must remember, however, that merely providing funding to bolster technical support is not enough. We also have to change the way we do business to meet the level of the threats now facing us."

These tools will include: systems for detecting biological or chemical agents; biosensors; Geographical Information Systems; computer modeling and simulation (for event/resources needed and for prediction planning and response); information and decision support systems with up-to-date advice for emergency personnel (to enhance preparedness for the delivery of medical care); strong distance education training programs; the creation of a vital technology assessment group; and new Standardized Performance Indicators. There is also a fundamental need to educate and train all personnel involved in using these tools. In addition, state and local health departments need training in how to use emergency and crisis management tools. Information technology professionals must be incorporated into their staffs, as well as public health and medical informaticians to support their operations. U.S. government agencies and the public would be better served with the creation of these professions.

Thanks to the generous funding to the states from the past Congress many of these requirements have been fulfilled. However, as Dr. Akhter predicted, funding alone is not enough, and more questions have arisen. For example, many state and local health departments do not know what to do with purchased equipment. No global strategy or common communications plan exists that explains, in plain English, what to do with it.

APPENDIX A

Definitions:

Bioterrorism is the threat or intentional release of biological agents (viruses, bacteria, or their toxins) for the purposes of influencing the conduct of government or intimidating or coercing a civilian population.

A vector is a carrier, such as an insect, that transmits the organisms of disease from infected to non-infected individuals.

Disease surveillance systems provide for the ongoing collection, analysis and dissemination of data to prevent and control disease.

Epidemiological investigation is the study of patterns of health or disease, and the factors that influence these patterns.

Public health and medical consequences refers to the effects of a biological agent on the population, as well as on the individual.

Information Systems is a set of interrelated components that collect, manipulate and disseminate data, information and knowledge, and provide a feedback mechanism to meet an objective.

An information framework offers a means for comparability and analysis of health information. It coordinates clinical disease management by promoting interoperability by using standard forms, uniform health data sets, electronic networks, and national standards for electronic data transmission.

Information Technologies is a term that encompasses computers, communications, and all forms of technology used to create, store, exchange, and use information in its various forms (i.e. text, voice, graphics, scanned images, dynamic images, video, etc.) and their applications.

Usability of computer and communication systems needs to address the unique needs of diverse populations. Health literacy requires not only the development of patient advocates and the coaches to educate them on the significance and relevance of the information presented, but also different mechanisms for disseminating the information (i.e., a person that can not read or write may get verbal instructions).

Function Descriptions:

Health surveillance assists in establishing surveillance systems to monitor the general population and special high-risk population segments; carry out field studies and investigations; monitor injury, disease patterns, and potential disease outbreaks; and provide technical assistance and consultations on disease and injury prevention and precautions.

Worker health and safety assists in monitoring the health and well-being of emergency workers; performs field investigations and studies; and provides technical assistance and consultation on worker health, safety measures, and precautions.

Radiological, chemical and biological hazard consultation assists in assessing health and medical effects of radiological, chemical and biological exposures on the general population, and on high-risk population groups; conduct field investigations, including collection and analysis of relevant samples; advise on protective actions related to direct human and animal exposure, and on indirect exposure through radiologically, chemically, or biologically contaminated food, drugs, water supply, and other media; and provide technical assistance and consultation on medical treatment and decontamination of radiologically, chemically, or biologically injured or contaminated victims.

Public health information assists by providing public health, disease and injury prevention information that can be transmitted to members of the general public who are located in or near areas affected by a major disaster or emergency. Vector control assists in assessing the threat of vector-borne diseases following a major disaster or emergency; conduct field investigations, including the collection and laboratory analysis of relevant samples; provide vector control equipment and supplies; provide technical assistance and consultation on protective actions regarding vector-borne diseases; and provide technical assistance and consultation on medical treatment of victims of vector-borne diseases. (Source: The Health and Medical Services Annex in the Federal Response Plan, April 1999.)

APPENDIX B

Report from the Federation of American Scientists Training Technology Against Terror: Using Advanced Technology to Prepare America’s Emergency Medical Personnel and First Responders for a Weapon of Mass Destruction Attack (http://www.fas.org/terrorism/wmd/docs/wmd_resp.pdf):

From Introduction: “Skillful management of new information technology must play a prominent role in the solution. These technologies can reach large numbers of people quickly with timely information, allow for the tailoring training to unique local situations, and provide simulated experiences (including group interactions) that transfer efficiently into high levels of performance in an actual emergency.” … “A systematic national strategy can ensure that systems put in place today to meet immediate training needs can continuously improve over the next few years. This requires an interagency approach drawing on expertise in incident management, medical triage and treatment, as well as expertise in managing secure information networks and building innovative training technologies. This paper proposes the framework of such a program, reviewing the activities that must be undertaken and outlining a strategy for managing the process.”

From The Current Status of WMD Training and Mechanisms for Delivering this Education: “The core challenge in preparing professionals for a terrorist incident, therefore, is finding a way to prepare a diverse group of people to (a) quickly recognize that a dangerous incident has occurred, (b) know how to form effective teams quickly in response, (c) mobilize and integrate the response capability, and (d) master specialized skills needed to cope with the unusual search, rescue, triage, and treatment challenges that will be presented.”

From A New Approach: “The challenge, therefore, is to find an efficient way to: (a) integrate WMD training into a system that is decentralized and not designed to move quickly, (b) deliver complex information to a diverse, geographically dispersed audience in a short period of time when the information itself will be constantly changing, (c) provide practical, hands-on experience in situations that can not easily be practiced using real scenarios, and (d) ensure the essential skills are sustained once they are attained by an individual, team and/or organization.”