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Bioterrorism

and Health System Preparedness

Issue Brief

The Role of Information Technology

and Surveillance Systems in

Bioterrorism Readiness

No. 5

Introduction

In a time of increasing concern over

bioterrorist activity, early response to

disease outbreaks is a key public health

priority and an emerging field of research.

Early knowledge of a disease outbreak

can improve response time and health

outcomes. Recent public health

emergencies such as the severe acute

respiratory syndrome (SARS) outbreak

and the outbreak of monkeypox in the

Midwestern United States in the summer

of 2003 highlight the important role that

early detection plays in mobilizing rapid

response. 

While traditional disease surveillance

relies on often time-consuming laboratory

diagnosis, a new breed of syndromic

surveillance systems has the potential to

significantly speed up detection of disease

outbreaks. These new, computer-based

surveillance systems offer valuable and

timely information to hospitals as well as

to State, local, and Federal health officials. 

This Issue Brief describes syndromic

monitoring systems and how they are

used to track trends within patient

populations and to establish early warning

of disease outbreaks, including potential

bioterrorist activity. A Web-assisted audio

conference sponsored by the Agency for

Healthcare Research and Quality (AHRQ)

in October 2003 examined the role of

information technology and surveillance

systems in disease detection and

bioterrorism preparedness. Presentations

While traditional disease

surveillance relies on often

time-consuming laboratory

diagnosis, a new breed of

syndromic surveillance

systems has the potential to

significantly speed up

detection of disease outbreaks.

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality
were made by the following

researchers and practitioners:

▲ Michael W. Shannon, M.D., M.P.H.

Children’s Hospital, Harvard 

Medical School

Boston, Massachusetts

▲ Michael M. Wagner, M.D., Ph.D.

University of Pittsburgh

Pittsburgh, Pennsylvania

▲ John W. Loonsk, M.D.

Centers for Disease Control 

and Prevention

Atlanta, Georgia

Understanding

Syndromic Surveillance 

Syndromic surveillance is a relatively

new term in clinical medicine; it refers

to the active monitoring of a patient

population for disease outbreaks, said

Michael Shannon, M.D., Chief of the

Department of Emergency Services at

Children’s Hospital at Harvard

Medical School. Syndromic

surveillance systems monitor data that

are routinely collected—in emergency

rooms, for example. Based on

presenting complaints rather than final

diagnosis, these computerized systems

can provide an early signal of unusual

illnesses in a patient population—

including symptoms resulting from

bioterrorist activity. 

Disease detection and diagnosis once

relied solely on the astute clinician.

Now, with advances in information

technology, disease monitoring can be

done electronically using “real-time”

or instantaneous data analysis. While

the astute clinician remains critical to

early detection, this technology

reduces the burden on clinicians to

identify an unusual disease

occurrence. Automated decisionsupport systems also offer an

important tool to clinicians who are

likely to be on the frontlines of

detecting a disease outbreak or

bioterrorist event. These systems

enable the clinician to use computer

programs to make a faster diagnosis. 

Pediatric Disease Surveillance

Technologies 

The Center for Biopreparedness at

Children’s Hospital Boston has

developed both syndromic and

automated decision-support tools for

early disease detection. The Center’s

EDScope prototype is a syndromic

surveillance program that monitors

children’s emergency department visits

and chief complaint patterns, signaling

when the number or type of visits is

outside the range expected. To create

EDScope, the Center reviewed 10

years worth of data on 500,000 visits

to the Children’s Hospital Boston

emergency department. EDScope can

now predict—within 5 to 10 percent—

the number of children who will visit

the hospital’s emergency department

and their chief complaints.

The Center also developed the

Bioagent Diagnosis Program, which

can be used to detect possible bioagent

causes for presenting symptoms. An

automated decision-support tool, the

program allows clinicians to enter

information on a patient’s chief

complaints into a computerized 

worksheet. The program then presents

information on possible bioagent

causes for the patient’s symptoms.

Syndromic surveillance systems can

also be used to improve public health

preparedness for children outside the

hospital. For example, used in the

school setting, syndromic surveillance

can identify a sudden change in

absentee rates or in illnesses among

children visiting the school nurse, both

of which may signal a disease

outbreak. “Children are not small

adults,” says Shannon. “There is a real

challenge in being able to manage

children in the event of a disaster, and

it’s going to require much more

training and education of first

responders.”

Shannon points to five critical areas

that need greater attention and

2

Pediatric Disaster Preparedness—

Areas of Need

▲ School preparedness.

▲ Surge capacity planning for pediatric casualties.

▲ Training of first responders in managing pediatric

disaster victims.

▲ Development of national pediatric disaster response

teams.

▲ Assessment tools to identify children with significant

mental health issues resulting from a disaster.
3

resources to prepare for a potential

public health emergency involving

children (see box at left). In all these

areas, information technology has a

valuable role to play. 

Accelerating the Public

Health Investigation

Cycle

The Realtime Outbreak and Disease

Surveillance Laboratory at the

University of Pittsburgh—known as

the RODS Lab—uses information

technology to improve detection of

disease outbreaks, either naturally

occurring or resulting from

bioterrorism. The Lab’s signature

systems are the National Retail Data

Monitor (NRDM) and its RODS

system. “We’re trying to accelerate the

basic public health investigation cycle

with the use of information

technology,” said Michael Wagner,

M.D., director of the laboratory. 

The Lab’s NRDM system analyzes

sales of over-the-counter health care

products to detect disease outbreaks.

With the cooperation of seven national

pharmacy and grocery companies, the

NRDM gathers, evaluates, and

interprets massive amounts of sales

data routinely collected by the retail

industry on over-the-counter

medications. The standard coding

system for consumer products—the

12-digit Universal Product Code or

UPC printed on every package—

enables collection of this data. 

The NRDM receives data daily from

15,000 stores on sales of over-thecounter health care products such as

cough syrup. This data provides

valuable information on medications

that may be purchased early during the

course of an illness. Computerized

algorithms monitor these data to

detect unusual patterns of sales. At

present, the NRDM captures 30

percent of the Nation’s sales of overthe-counter health care products. The

lab aims to enlist enough additional

retail chains to reach 70 percent and

also hopes to decrease the data’s time

latency to less than 24 hours. Any

public health official can obtain a free

account that provides access to the

NRDM by contacting nrdmaccounts@cbmi.pitt.edu.

The first real-time public health

surveillance system for early detection

of disease outbreaks, the Lab’s RODS

system examines hospital emergency

room data from across the country.

The RODS model analyzes and

integrates clinical data from

emergency departments within a

geographic region to provide an

instantaneous picture of symptoms

and an early warning of disease

outbreaks. The system monitors in real

time information such as chief

complaints that are routinely collected

Information Technology to Support Bioterrorism Preparedness

▲ Detection and monitoring systems support disease and threat surveillance and collect

national health status indicators.

▲ Analytical systems facilitate real-time evaluation of live data feeds and turn data into

information to identify disease outbreaks.

▲ Information resources and knowledge management systems provide reference

information, distance learning, and decision support.

▲ Alerting and communications technologies transmit emergency alerts, facilitate routine

professional discussions, and support collaborative activities.

▲ Response systems help manage vaccine distributions, track side effects, and disseminate

public health information. 

“Children are not small adults. There is a real challenge in

being able to manage children in the event of a disaster,

and it’s going to require much more training and education

of first responders.” 

Michael Shannon, M.D., M.P.H.
from patients visiting emergency

departments. 

Used during the winter 2000 Olympics,

RODS currently operates in several

States, including Michigan, Ohio,

Pennsylvania, and Utah. For more

information about RODS, visit

www.health.pitt.edu/rods. In 2003, the

University of Pittsburgh made the

RODS software publicly available to

accelerate development of software for

disease outbreak surveillance. Source

code and information about RODS can

be found at the RODS Open Source

Project Web site at

http://openrods.sourceforge.net.

Developing a Standard

Language

Currently, many public health

surveillance systems generate data for

public health labs, the clinical

community, and State and local health

departments. Many of these systems

operate in isolation, however, and fail to

capitalize on the potential for electronic

data exchange. The current public

health investigation cycle—from the

first hint of trouble to managing a

disease outbreak—is lengthy and

frequently involves manual exchange of

data across many public health

organizations. For example, during the

anthrax attacks of fall 2001,

investigators communicated thousands

of environmental test results exclusively

by phone and fax.

Dr. John Loonsk, associate director of

the Information Resources

Management Office at the Centers for

Disease Control and Prevention,

explained that surveillance and

preparedness systems fall into several

categories ranging from detection

systems to response systems 

(see box previous page).

When an outbreak is discovered,

systems must be in place to manage the

response by tracking vaccine side

effects, disseminating public health

alerts, and treating cases of the disease.

A unifying framework is needed to

better monitor data streams from

different public health entities to ensure

a successful response. “These systems

need to work together to share data and

use technology approaches that will

allow them to exchange data more

efficiently,” said Dr. Loonsk. 

The CDC’s Public Health Information

Network (PHIN) will provide a

framework to unify data streams from

different organizations to ensure early

detection and an efficient response to

health emergencies. PHIN is currently

under development as an umbrella

system that is building on the

technologies of existing CDC systems

such as the National Electronic Disease

Surveillance System, the Health Alert

Network, and the Epidemic Information

Exchange (see box below). 

4

Major Components of CDC’s PHIN Initiative 

The BioSense Initiative supports early detection activities

associated with possible bioterrorist threats. This CDC

initiative monitors regional health data—combined with

clinical data from the Department of Defense and

Department of Veterans Affairs—to identify trends related to

a possible bioterrorist attack.

The National Electronic Disease Surveillance System

(NEDSS) (www.cdc.gov/nedss/) promotes the use of data

and information system standards to advance the

development of efficient and integrated surveillance systems

at the Federal, State, and local levels.

The Epidemic Information Exchange or Epi-X is the

CDC’s secure, Web-based communications network that

serves as a communication exchange between CDC, State

and local health departments, poison control centers, and

other public health professionals. The system provides rapid

reporting, immediate notification, and coordination of health

investigations.

The Health Alert Network (HAN)

(www.phppo.cdc.gov/han/) ensures communications capacity

at all local and State health departments to broadcast and

receive public health alerts. The initiative also ensures local

capacity to receive distance learning offerings from CDC. 
5

PHIN aims to transform the public

health community with information

systems that enable real-time data flow,

computer-assisted analysis, and rapid

dissemination of information. PHIN

includes five key components that

correspond to the information

technology in the box on page 3:

detection and monitoring, data analysis,

information dissemination, alerting,

and response. 

In the event of a disease outbreak,

PHIN will ensure consistent exchange

of information between public health

organizations through uniform data and

vocabulary standards. The Federal

government has moved aggressively to

standardize data exchange through the

Consolidated Health Informatics, an

initiative to establish a portfolio of

clinical vocabularies and messaging

standards that would ensure compatible

health data systems across Federal

agencies. Key to this activity is the use

of Health Level 7, or HL7, and Logical

Observation Identifiers Names and

Codes, or LOINC. HL7 is a standardsbased protocol for formatting,

transmitting, and receiving data in a

health care environment. LOINC codes

are universal identifiers or names for

laboratory and other clinical

observations. PHIN is incorporating the

codes used in HL7 and LOINC, both of

which are independent, nongovernmental systems.

PHIN is also a process, explains

Loonsk. The initiative requires a

commitment from the public health

community to use its standards and a

commitment to participate in the

development and implementation of

electronic specifications. In fact, the

PHIN technical requirements—both

data and systems specifications—are

included in over $2 billion in

cooperative agreement funds awarded

in 2002 and 2003 by CDC and the

Health Resources and Services

Administration. These agreements are

designed to upgrade the preparedness

of the nation’s public health care system

to respond to bioterrorism, infectious

disease outbreaks, and other public

health threats and emergencies. 

For More Information

For the most current information on

PHIN, including data and technical

specifications, please visit

www.cdc.gov/phin. The PHIN Web site

also provides contact information for

technical assistance offered by the CDC

to support PHIN. 

The complete audioconference on “The

Role of Information Technology and

Surveillance Systems in Bioterrorism

Readiness” is available as a streaming

presentation and as a text transcript on

the AHRQ Web site

(www.ahrq.gov/browse/bioterbr.htm).

This issue brief was prepared for

AHRQ by AcademyHealth under 

contract number 290-98-0003.

AHRQ’s Bioterrorism Preparedness 

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AHRQ Pub. No. 05-0072

March 2005