There is such a thing as ESP

A report in the new issue of Morbidity and Mortality Weekly Report, a publication of the U.S. Centers for Disease Control and Prevention, gives us a picture of the future, as health insurers and governmental agencies perfect the surveillance capabilities of electronic medical records.

Harvard Pilgrim Health Care,** Atrius Health, the Massachusetts Department of Public Health, and the Department of Ambulatory Care and Prevention at Harvard Medical School collaborated, under the auspices of the CDC Center of Excellence in Public Health Informatics at Harvard Pilgrim Health Care and Children’s Hospital in Boston, to create a system called Electronic Support for Public Health (ESP). This system, designed to be compatible with most commercial electronic medical record systems, will automatically scan medical records, including patient demographics and vital signs, lab tests ordered, prescriptions, diagnostic tests and ICD-9 billing codes to identify illnesses and electronically report them to government health departments. It also includes healthcare provider details.

The MMWR paper, authored by J Dunn, MPH, at Harvard Medical School and Harvard Pilgrim Health Care, said that traditional reporting methods often lack sufficiently detailed information for public health purposes, such as targeted investigations and interventions, nor do they integrate different sources of information in a way to make case identifications.

This paper summarized the findings of the pilot study of their electronic surveillance system that ran from June 2006 to July 2007. While the system creators are developing methods to detect and report all kinds of conditions, according to a Harvard press release, they designed this initial pilot project to report seven infections: Chlamydia, gonorrhoea, active tuberculosis, acute hepatitis A, acute hepatitis B, acute hepatitis C, and pelvic inflammatory disease.

By bypassing physicians and automated laboratory-based reporting methods, this system identified and reported 39% more cases of Chlamydia and 53% more cases of gonorrhoea, as well as reported if those persons were pregnant and whether the correct antibiotics had been prescribed. It also identified 20 cases of pelvic inflammatory disease cases and four cases of acute hepatitis A that hadn’t been reported by healthcare providers under current passive surveillance procedures.

An accompanying CDC editorial note regretted that electronic medical records don’t yet contain “certain pieces of key epidemiologic data in a coded form that can be identified readily by electronic algorithms. Examples include case contacts, risky behaviors, foreign travel, and relevant occupations (e.g., food handler or day care worker).” [emphasis added]

[Read this again. While communicable diseases might make these surveillance and involuntary reporting capabilities seem beneficial, think about the future implications and potentials for abuse (with no protections in place) -- of government and insurer surveillance of any lifestyle behaviors or 'disease' conditions they might consider as risky in the name of public health, the repercussions of the government reporting and sharing information about health conditions or “risk factors” with employers or other stakeholders, and that it even wants to be able to identify people you associate with and your movements. Think about the groundwork being laid. The CDC has already proposed policies for how the government can collect, use and sell our electronic medical records; and demonstrated it can enforce compliance by state health departments for tracking certain conditions by threatening to cut off their federal funding. The HHS has similarly shown it can make people comply with 'healthy' lifestyle and medical prescriptions by restricting healthcare benefits or government benefits; and affect doctors' compliance through pay-for-performance measures. The arguments** opposing legislation to protect the privacy and use of genetic information, used by the country's insurers, described how they envision using genetic information. The significance goes far beyond issues of security, identity theft and the confidentiality of private health information — in which we are regularly provided with examples of violations, such as the report this week of 61 patient medical records improperly accessed at UCLA, including those of California first lady Maria Shriver.]

This new ESP system was designed to work with the existing nationalized electronic health surveillance systems and is a key towards nationalizing medical records. According to the CDC editorial:

ESP complements the existing National Electronic Diseases Surveillance System, established by CDC in 2001 to enable local and state health departments to send electronic data to CDC for public health monitoring of notifiable conditions nationwide. NEDSS-compatible systems currently operate in 38 states and the District of Columbia. ESP can facilitate electronic collection and transmission of case reports from health-care providers to local and state public health departments, which in turn can use NEDSS-compatible systems to deliver summary data to CDC.

Different strategies for implementing EMR-based case detection and reporting will need to be developed for different kinds of medical organizations... Incorporating ESP logic into commercial EMR software or developing stand-alone ESP modules that can operate side by side with EMRs on clinicians’ office-based computers also should be feasible...

The development of ESP is continuing, according to the editorial, adding reportable conditions and installing it in regional health information exchange systems to increase sharing of information. The editorial also said that to make widespread electronic reporting of diseases more comprehensive and complete, and better able to share information, there needed to be greater adoption of electronic medical records nationwide, and standardization of nomenclature for lists of treatments and conditions, and standard reporting elements.

Widespread implementation of electronic case detection and reporting is currently limited by the slow pace of adoption of EMRs by clinical practices, variation in coding practices among proprietary EMR systems, and an absence of standards for identifying cases using electronic data alone. As of 2006, only 29% of ambulatory medical practices were using EMR systems... EMRs that do not include prescription data, for example, limit the sensitivity and specificity of some electronic disease-detection algorithms... [Although they’re already working on a nationalized database of patient prescription records, as already reported here.]

The ESP system is being promoted as a convenience for busy healthcare providers since they will be spared time-consuming reporting, and as a way to increase the completeness of cases identified by health officials. ESP is an example of how to “provide better support for public health activities that benefit everyone,” according to Dr. Richard Platt, a study author from Harvard Pilgrim Health Care. “ESP offers the promise of more rapid detection of threats to the public health,” Dr. Alfred DeMaria, Director of the Bureau of Communicable Disease Control at the Massachusetts Department of Public Health, said in the Harvard press release.

Of course, it all depends on how you look at it.

** Harvard Pilgrim Health Care, a New England healthplan with more than a million members, was last mentioned when its medical director of clinical policy spoke to the U.S. House, opposing the Genetic Information Nondiscrimination Act. [This legislation would prohibit health insurers from using genetic information to set eligibility, premium, and/or contribution standards; prohibit insurers from requesting or requiring genetic tests; prohibit employers from using genetic information in making employment decisions, such as hiring, firing, and promoting; and prohibit employers from requesting, requiring, or purchasing about an employee or an employee’s family member.] The law could get in the way of insurers who want the ability to mandate genetic tests to use in deciding what treatments they will cover or deny, and to identify people for compulsory disease management.