Overview

The Nation’s capacity to respond to

bioterrorism depends in part on the ability of

clinicians and public health officials to detect,

manage, and communicate during a bioterrorism

event. Information technologies and decision

support systems (IT/DSSs) have the potential to

aid clinicians (e.g., physicians, nurses, nurse

practitioners, and respiratory therapists) and

public health officials to respond effectively to a

bioterrorist attack. 

The Evidence Report from which this

summary was taken details the methodology,

results, and conclusions of a systematic and

extensive search for published materials on the use

of IT/DSSs to serve the information needs of

clinicians and public health officials in the event

of a bioterrorist attack. The information is

intended to assist clinicians, public health

officials, and policymakers to improve

preparedness for a bioterrorism event.

Reporting the Evidence

The University of California at San Francisco

(UCSF)–Stanford Evidence-based Practice Center

staff, in conjunction with a panel of expert

advisors and the Agency for Healthcare Research

and Quality (AHRQ), developed the following

four Key Questions to be addressed in this report: 

1) What are the information needs of clinicians

and public health officials in the event of a

bioterrorist attack? 

2) Based on the information needs identified for

these decisionmakers, what are the criteria by

which IT/DSSs should be evaluated with

respect to usefulness during a bioterrorism

event? 

3) When assessed by these criteria, in what ways

could existing IT/DSSs be useful during a

bioterrorism event? In what ways are they

limited? 

4) In areas where existing IT/DSSs do not meet

the information needs of clinicians or public

health officials, what functional and technical

considerations are important in the design of

future IT/DSSs to support response to

bioterrorism events? 

Methodology

Conceptual Model

A conceptual model was developed to specify

the decisions and tasks involved in diagnosis,

management, prevention, surveillance, and

communication by clinicians and public health

officials in the event of a bioterrorist attack. The

investigators used a process called task

decomposition to specify the data requirements

that need to be incorporated into an IT/DSS for

it to assist clinicians and public health officials in

making these decisions. This list of tasks and data

requirements served as the foundation of the

evaluation system of the currently available

IT/DSSs.

Inclusion and Exclusion Criteria

Based on input from the expert advisory panel,

the conceptual model, the task decomposition,

and practical considerations, an inclusionexclusion strategy was developed to identify

articles that described or evaluated IT/DSSs. 

Selection of Quality Scales 

A scale developed at McMaster University was

used to rate the quality of evidence from peerreviewed evaluations of IT/DSSs for diagnosis,

management, and communication. For reports of

surveillance systems, an evaluation scale published

Evidence Report/Technology Assessment

Number 59

Bioterrorism Preparedness and Response: Use of

Information Technologies and Decision Support Systems

Summary

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service

Agency for Healthcare Research and Quality
by the Centers for Disease Control and Prevention (CDC) was

used. 

Literature Sources

In consultation with professional research librarians, a

search strategy for references from three sources was developed:

peer-reviewed articles, government reports, and Web-based

information. For the peer-reviewed articles, five databases of

medical, scientific, and government references likely to contain

reports of relevant IT/DSSs were identified: MEDLINE®

(January 1985 to April 2001), the Catalog of U.S.

Government Publications, GrayLIT, the Library of Congress,

and the National Technical Information Service. The

investigators identified the 16 government agencies most likely

to fund, develop, or use IT/DSSs that could also be used by

clinicians or public health officials. Internet searches to retrieve

reports of potentially relevant IT/DSSs from sites other than

those operated by government agencies (e.g., academic and

commercial sites) were also planned. 

Search Strategies

Separate search strategies were developed, one for

MEDLINE® and one for the government documents and

Web-based information. Each included terms such as

bioterrorism, biological warfare, information technology, decision

support system, diagnosis, management, therapeutics,

communication, surveillance, public health, and epidemiology.

Additional articles were identified by members of the expert

advisory panel, from conference proceedings, and by review of

reference lists.

Data Collection and Analysis

Titles, abstracts, and full-length articles were reviewed as

necessary to identify potentially relevant articles. All peerreviewed articles that met the inclusion criteria were blinded to

the investigators, two of whom independently abstracted study

information on to a data-abstraction and quality-assessment

form. 

The following data were abstracted from all included

articles: the purpose and description of the system (e.g.,

detection, diagnosis, management, surveillance, or

communication), whether the system had been clinically

evaluated and the results of these evaluations, what security

measures the system uses, what kind of reasoning the system

uses, and information about the quality of the report. A draft

Evidence Report was critiqued by 16 expert advisors and 17

peer-reviewers who had expertise in nursing, clinical medicine,

public health, hospital management, informatics, diagnostics,

emergency management, epidemiology, national security,

toxicology, and food safety.

Findings

The investigators reviewed a total of 16,888 citations of

peer-reviewed articles, 7,685 Web sites of government

agencies, and 1,107 non-government Web sites. Of these, 251

articles, 36 government Web sites, and 54 non-government

Web sites met the inclusion criteria. From these, descriptions

were abstracted of 217 IT/DSSs of potential use by clinicians

and public health officials in the event of a bioterrorist attack.

They are comprised of 55 detection systems, 23 diagnostic

systems, 18 management systems, 90 surveillance systems, 26

communication systems, and 7 systems that integrate

surveillance, communication, and command and control

functions (some systems have more than 1 function and are

described in more than 1 section). Most reports only described

IT/DSSs; however, 79 studies evaluated 58 systems for at least

1 performance metric. Some types of systems have been

evaluated more than others. For example, 10 of the 18

management systems have been evaluated in at least 1 study;

but none of the 7 integrated surveillance, communication, and

command and control systems has been evaluated. Most of the

217 included systems were not designed specifically for

bioterrorism; instead, they were created for detecting and

managing naturally occurring illness. The few systems that

were designed for bioterrorism are principally for detection

and integrated command and control purposes, and most were

designed by the military and are being converted for civilian

use. There are almost no publicly available evaluative data on

these systems, although the military developers may have

performed comprehensive evaluations. 

Key Question 1

What are the information needs of clinicians and

public health officials in the event of a bioterrorist attack?

Based on the conceptual model and task decomposition, the

information required by clinicians and public health officials

while preparing for and responding to bioterrorist events

relates to the decisions they have to make and the tasks they

have to perform. 

Clinicians require the necessary information to make

diagnostic, management, prevention, and reporting decisions.

Diagnostic decisions require information to accurately estimate

the pre-test probability of disease for a given patient.

Clinicians’ interpretations of test results require information

about the sensitivity and specificity of the test. Management

decisions require information about how to appropriately

distinguish between those patients who need treatment and

those who do not, how best to treat the acutely ill, whom to

isolate and how, how to manage scarce resources, and how to

maintain personal safety. Prevention decisions require

information about prophylaxis and vaccination protocols.

Reporting decisions rely on information about what

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constitutes a reportable case or cluster of cases and about the

kinds of data that public health officials seek. 

The information that public health officials require to

prepare for and respond to a bioterrorism event can be

considered in relation to the decisions they must make: the

interpretation of surveillance data; the investigation of

outbreaks; the institution of epidemiologic control measures;

and the issuance of surveillance alerts. The decision to perform

outbreak investigation requires information about the baseline

characteristics of the surveillance data and threshold levels that

suggest that an outbreak resulting from naturally occurring or

bioterrorism-related illness may have occurred. Once a

bioterrorism event has been identified, public health officials

require information that will enable them to perform ongoing

surveillance in the midst of the crisis to track the extent and

spread of the epidemic. The decisions regarding the institution

of epidemiologic control measures that prevent the spread of

disease require information about the transmissibility of the

suspected biothreat agent(s) and about the criteria for and

effectiveness of prophylaxis and quarantine strategies.

Decisions to issue a surveillance alert require information

about the nature of the suspected bioterrorist attack and the

characteristics and expected natural history of the suspected

biothreat agent(s). Other communication decisions relate to

the specific information that needs to be conveyed to other

public health officials, clinicians, the media, and other

decisionmakers.

Key Question 2 

Based on the information needs identified for these

decisionmakers, what are the criteria by which IT/DSSs

should be evaluated with respect to usefulness during a

bioterrorism event?

The evaluation criteria vary depending on the purpose of

the IT/DSS and the information needs of the users of the

system as determined by task decomposition methodology. 

• All included systems—the purpose of the system; type of

hardware required; methods for maintaining security of

samples and data collected; timeliness; and measures of

the accuracy of the system (e.g., sensitivity, specificity,

collection efficiency, or concentration of organisms

detected). 

• Detection systems—portability; number of samples that

can be run simultaneously; number of biothreat agents

that can be identified; and whether both toxins and

organisms can be identified. 

• Diagnostic, management, and prevention DSSs—the type

of information required by the DSS (e.g., a manually

entered list of signs and symptoms provided by the

clinician or patient information from an electronic

medical record); the type of information provided by the

DSS (e.g., a list of differential diagnoses, antibiotic

recommendation, or quarantine recommendation);

whether the biothreat agents and their associated illnesses

are included in the knowledge base; the method of

reasoning used by the inference engine; and information

regarding the ability to update the probability of

biothreat-related illness as the epidemic progresses or from

reports of a known attack. 

• Surveillance systems—the type of surveillance data

collected; methods for determining when an outbreak has

occurred; and information regarding the public health

importance of the health event under surveillance, the

system’s usefulness, simplicity, flexibility, acceptability,

representativeness, and the direct costs needed to operate

the system.

• Reporting and communication systems—the type of

information the system is intended to communicate; the

intended provider and recipient of the information; and

whether the recipient has to actively seek the information

from the provider (e.g., by visiting a Web site) or the

information is transmitted by phone, fax, e-mail, or other

means to the recipient (i.e., passive on the part of the

recipient).

Key Question 3 

When assessed by these criteria, in what ways could

existing IT/DSSs be useful during a bioterrorism event? In

what ways are they limited?

The review identified 217 IT/DSSs, few of which were

designed specifically for response to bioterrorism events. Most

included systems had other intended purposes but could

potentially be useful to clinicians or public health officials in

response to a bioterrorism event. The evidence by which to

judge the usefulness of these systems is limited. Many of the

systems were not evaluated even for their intended purpose.

Of the studies that did evaluate systems for their intended

purpose, few adhered to published criteria for high-quality

evaluations. In addition, even if a system received a favorable

evaluation for its intended purpose, it may not necessarily be

feasible to evaluate its usefulness for response to bioterrorism.

Detection systems. Fifty-five detection systems that collect

and identify potential biothreat agents within environmental

and clinical samples were identified. Many of these systems

were developed for use by the military and some were adapted

for civilian purposes. Few reports compare detection systems

to a gold standard, and their sensitivity (i.e., the likelihood

that the detection system will give a positive result when

testing a sample containing a biothreat agent) and specificity

(i.e., the likelihood that the detection system will give a

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negative result when testing a sample that does not contain a

biothreat agent) remain poorly characterized in the publicly

available literature. Most identification systems are limited in

that each test cycle can evaluate a sample for only a single

biothreat agent, often run only a limited number of samples at

a time, and cannot test for many of the most worrisome agents

(e.g., smallpox). No reports were found that directly compared

two or more of the commercially available systems in any

given category. The paucity of comprehensive evaluative

information about these systems prevents conclusions about

whether or not these systems are likely to serve the detection

needs of first-responders, clinicians, and public health officials

during a bioterrorist event.

Diagnostic systems. Twenty-three diagnostic systems with

potential utility for enhancing the likelihood that clinicians

consider the possibility of bioterrorism-related illness were

identified. These systems are generally designed to assist

clinicians in developing a differential diagnosis for a patient

who has an unusual clinical presentation. The investigators

found six general diagnostic systems, four systems designed to

improve radiologic diagnoses, four telemedicine systems, four

systems for the diagnosis of infectious diseases, one system for

the diagnosis of dermatologic lesions, one system for the

diagnosis of community-acquired pneumonia, and three

systems for other purposes. None of these DSSs has been

evaluated formally with respect to bioterrorism response. In an

evaluation of a DSS for infectious diseases that has more than

20 biothreat agents in its knowledge base, the system was able

to list the actual diagnosis in an output of possible diagnoses

for nearly 95 percent of 495 actual and hypothetical cases.

However, this system is limited in that it is specific for

infectious diseases; consequently, even those clinicians with

access to this technology may not use it if the patient does not

present with a fever or other signs or symptoms of infectious

disease.

Three of the general diagnostic DSSs have been evaluated

for their intended (non-bioterrorism related) purposes. In

these evaluations, the general diagnostic DSSs typically

performed better than physicians-in-training but not as well as

experienced clinicians. However, the accuracy of the DSSs

decreased for difficult cases. The need for clinicians to

manually enter patients’ signs and symptoms into diagnostic

DSSs—a laborious step that may be a barrier to the use of

these systems and has been demonstrated to increase inter-user

variability—is eliminated by the few systems that

automatically collect patient data from an electronic medical

record. For example, there are diagnostic DSSs currently

available in hospitals with electronic medical records that

provide clinicians with an estimate of the likelihood of

community-acquired pneumonia or active pulmonary

tuberculosis based exclusively on data collected from the

medical record. Many diagnostic DSSs use probabilistic

information about the likelihood of disease. Because

bioterrorism-related illness is relatively rare, in the event of

bioterrorism these systems will have inappropriately low pretest

probabilities for biothreat agents. None of the reports of

diagnostic DSSs described the ability to change the probability

of disease based on information about suspected bioterrorism

events.

Management and prevention systems. Management and

prevention systems are designed to make recommendations to

clinicians by abstracting clinical information from electronic

medical records to make patient-specific recommendations.

None of the 18 systems identified in this review has been

specifically designed or evaluated for utility in providing

management or prevention recommendations during a

bioterrorism event; however, 10 of them have been evaluated

for their intended purpose. These evaluations demonstrate that

the expert systems that continuously search electronic medical

records (including data from the laboratory, radiology reports,

and clinician notes) for new evidence of infection and apply

clinical practice guidelines to those data are able to affect

clinicians’ antibiotic selection decisions and increase

compliance with clinical practice guidelines. No information

was found as to whether the knowledge bases of these systems

include comprehensive information about bioterrorism-related

illnesses. The systems that are not linked to electronic medical

records share many of the limitations of the general diagnostic

systems—including that clinicians may not use the system to

seek advice for patients presenting with common viral

syndromes (i.e., the bioterrorism-related syndromes).

Antibiotic recommendation programs are typically designed to

provide recommendations for antibiotics with the narrowest

possible spectra, thereby reducing the risk of developing

resistant organisms. If clinicians make antibiotic selection

decisions while unaware of the true bioterrorism-related

diagnosis and select narrow-spectrum antibiotics, they may not

be effective against biothreat agents. Therefore, whether the

use of these systems would be helpful or detrimental is not

known.

Surveillance systems. Ninety surveillance systems that

collect a variety of surveillance reports were identified: 7 for

syndromal surveillance, 6 for reports from clinicians, 11 for

influenza-related data, 23 for laboratory and antimicrobial

resistance data, 16 for hospital-based infections data, 10 for

food-borne illness data, 6 for zoonotic illness data, and 11 for

other types of surveillance data. For a surveillance system to

detect a covert bioterrorist event, it must collect data that are

sensitive and specific for biothreat agents, analyze the data, and

report results to public health decisionmakers in a timely

manner. None of 90 included surveillance systems has been

evaluated for its utility in detecting a bioterrorism event. Forty

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of 61 reports of evaluations or descriptions of surveillance

systems described the timeliness, importance of the health

event under surveillance, and usefulness of the system.

However, less than one-third of the reports of evaluations of

surveillance systems described the representativeness,

simplicity, sensitivity, specificity, acceptability, or flexibility of

the system. The quality of the evidence regarding the

effectiveness of the systems reported by these articles is

therefore limited. Most of the evaluations of surveillance

systems demonstrated that the electronic collection and

reporting of surveillance data improved detection over older,

manual methods. When the 90 surveillance systems described

in this report are considered, there are relatively few systems

collecting the earliest surveillance data—such as school and

work absenteeism, calls to telephone care nurses, over-thecounter pharmacy sales, or veterinary or zoonotic illness—a

potentially significant gap in available surveillance systems. 

• Syndromal surveillance. The earliest symptoms caused by

most biothreat agents are flu-like illness, acute respiratory

distress, gastrointestinal symptoms, febrile hemorrhagic

syndromes, and febrile illnesses with either dermatologic

or neurologic findings. Therefore, patients with these

syndromes are the targets of bioterrorism-related

syndromal surveillance programs. None of the seven

syndromal surveillance systems identified has been

clinically evaluated; however, several evaluations are

ongoing. These systems are highly heterogeneous with

respect to the syndromes under surveillance, the

definition of the syndromes, and the type of data

collected. Some systems use routinely collected diagnostic

codes, others use syndromal reports collected from triage

nurses for all patients presenting to an emergency

department, and several use clinicians’ reports of

syndromal data collected on selected patients. No

evidence was found to determine which of the methods

of collecting syndromal data is the most sensitive, timely,

acceptable, and cost-effective. 

Syndromal surveillance systems have been used both for

ongoing surveillance and for event-based surveillance.

One syndromal surveillance tool, designed for ongoing

collection of demographic and clinical data from remote

regions of the developing world, downloads information

daily to a national public health department. In eventbased surveillance, the system is deployed for a limited

period before, during, and after an event thought to be a

potential target for bioterrorism, such as a major sporting

or political event. 

• Surveillance networks of sentinel clinicians. Because

clinicians may be the first to recognize unusual or

suspicious illnesses, reports from clinician networks are an

important source of surveillance data for detection of

bioterrorism-related diseases. Of the systems that have

been evaluated for the collection of clinician reports,

Eurosentinel provides the timeliest data (however, this is

only true for influenza; data on other diseases and

syndromes have a longer delay). The timeliness of the

other systems varies from days to months. Systems that

collect data on a weekly basis will be substantially less

useful for bioterrorism surveillance than systems that can

provide more rapid collection and analysis. 

• Influenza surveillance. Although none of the 11

surveillance systems that collect influenza data has been

evaluated specifically for the detection of bioterrorismrelated illness, they are potentially useful for bioterrorism

surveillance in 3 ways. First, sentinel clinicians who report

on patients with suspected influenza are experienced at

applying a case definition to a clinical population for the

collection of public health data. Because many

bioterrorism-related illnesses present with a flu-like illness,

this network of trained sentinel clinicians could provide

valuable surveillance data. (One should note that the

evaluation of these sentinel clinicians is derived from

heterogeneous surveillance networks in North America,

Europe, and Australia. It is difficult to know whether the

cultures of medicine, the training that sentinel clinicians

receive, and their commitment to public health

surveillance efforts are sufficiently similar that one can

assume that the results of an evaluation of a surveillance

network in France will be generalizable to clinicians in the

United States.) Second, examples exist of effective

influenza surveillance systems that integrate clinical and

laboratory data for the detection of influenza outbreaks.

Surveillance for bioterrorism may be aided by similar

integration of multiple data sources. Finally, influenza

surveillance, like bioterrorism surveillance, requires a

coordinated global effort. New programs for the

surveillance of bioterrorism-related illness could utilize the

historical relationships that have been developed for

influenza surveillance. Several of the influenza systems

rely on weekly reporting by clinicians—for bioterrorism

surveillance, this time lag is likely to be problematic. 

• Laboratory surveillance. Laboratory surveillance systems

are an essential component of any system for the

detection of a covert bioterrorist event, both for the

detection of uncommon organisms (e.g., smallpox,

anthrax, and Ebola) and common organisms with

unusual antimicrobial resistance patterns. Systems that

facilitate the collection, analysis, and reporting of

notifiable pathogens and antimicrobial resistance data

could potentially facilitate the rapid detection of a

biothreat agent. This search identified 12 systems for the

surveillance of laboratory data (4 of which were described

in peer-reviewed evaluation reports) and 11 systems for

the surveillance of antimicrobial data (1 of which was

5
described in a peer-reviewed evaluation report). In

general, the evaluative and descriptive reports of the

systems collecting laboratory and antimicrobial resistance

data suggest that the electronic systems improve the

timeliness and sensitivity of conventional methods. Few

reports specifically described how laboratory samples are

handled, acceptability, or cost of implementation.

Laboratories that already report data in an electronic

format to local public health officials could be

incorporated into bioterrorism surveillance systems at

local, State, national, and international levels—creating a

“network of networks.” A principal challenge for

laboratory networks is the timely communication of data

from collection sites to central surveillance agencies.

Efforts are ongoing to address these issues. Specifically,

the Laboratory Response Network, which builds on

existing laboratory capacity and is currently under active

expansion, has been designed with the specific intention

of being able to be integrated into surveillance networks

(such as the CDC’s National Electronic Disease

Surveillance System) and communication networks (such

as the California initiative to develop a Rapid Health

Electronic Alert, Communication, and Training

[RHEACT] system). These systems are under

development and have not been evaluated.

• Hospital-based surveillance. The 16 hospital-based

surveillance systems could play 2 roles in the early

detection of a covert bioterrorist attack: the identification

of a cluster of cases recently admitted suggestive of a

community-based outbreak, and the identification of a

cluster of cases within the hospital suggestive of inpatients

with an unrecognized communicable disease. However,

the reports of the surveillance systems for hospitalacquired infections suggest that, although these systems

could be a valuable tool for hospital infection control

officers, there is little evidence to demonstrate that they

have sufficient sensitivity, specificity, or timeliness to

detect a community-based bioterrorism event. 

• Foodborne and zoonotic disease surveillance. Terrorism

attacks may be made against food and agriculture

production facilities (domestically or abroad),

transportation systems, water supplies (for either human

consumption or to contaminate food production), farm

workers, food handlers, and processing facilities. Similarly,

concerns exist that a bioterrorist attack could involve the

dissemination of a zoonotic illness among animal

populations with the intention of infecting humans or

livestock and causing economic and political chaos. Six

ITs designed to collect, process, and disseminate

information on zoonotic and animal diseases were found,

none of which has been described in a peer-reviewed

evaluation. Mosquito-borne viruses such as West Nile

Virus, St. Louis encephalitis, and Western equine

encephalomyelitis are all targets of ongoing zoonotic

surveillance programs. The search found reports of only

two zoonotic surveillance systems—a major gap in the

literature of bioterrorism surveillance efforts. Most of the

reports provided little or no information about the

timeliness of these systems; those that did suggest lag

times that would be too long for effective bioterrorism

surveillance. None has been specifically evaluated for this

purpose. In addition, the surveillance systems that collect

data on food-borne illnesses and laboratory information

about DNA strains of food-borne pathogens are limited

in that they only collect routine surveillance data on a

small number of pathogens (and do not typically include

all of the most worrisome agroterrorism-related agents). 

Communication systems. Eight of the 26 communication

systems were designed for communication among public

health officials at local, State, and Federal levels (e.g., Webbased discussion and reporting of surveillance data). In pilot

evaluations directed by individual State health departments,

these systems securely managed the disease reporting needs of

local and State public health officials. However, these systems

were limited to communication within a State. No single

system was found that effectively links members of the public

health community at national, State, and local levels. However,

there are ongoing efforts (such as the Urban Security Initiative

project of Los Alamos National Laboratory, EpiX, Health Alert

Network and RHEACT) designed to integrate

communication of public health information vertically and

horizontally within the U.S. public health system. Five systems

were designed for the automated communication of

information from hospital-based electronic medical records to

clinicians (e.g., alerting systems to notify clinicians of

abnormal laboratory tests). These systems have been subjected

to the greatest evaluation of all the communication systems.

Despite being limited to institutions with electronic medical

records, they could potentially play an important role in

improving the timely recognition of bioterrorism-related

illness. Three systems facilitated communication between

emergency departments and first-line emergency response

personnel. ProMED© has demonstrated the capacity for rapid

reporting and dissemination of information on a wide range of

infectious diseases resulting from both naturally occurring and

bioterrorism-related events. During a bioterrorism event,

clinicians must be able to rapidly communicate with their

patients. Systems exist that enable Web-based communications

between these parties in a manner compliant with the Health

6
Insurance Portability and Accountability Act of 1996

(HIPAA). Robust security measures that ensure patient

confidentiality and resist cyberattack will be a necessary

component of any bioterrorism-related communication

system. 

Key Question 4 

In areas where existing IT/DSSs do not meet the

information needs of clinicians or public health officials,

what functional and technical considerations are

important in the design of future IT/DSSs to support

response to bioterrorism events? 

No evaluations or studies that directly assess the functional

and technical requirements that are important for future

IT/DSSs were identified. This section provides the

investigators’ interpretation of factors that could be considered

for the design of future IT/DSSs. 

• IT/DSSs for bioterrorism need to have documented

sensitivity, specificity, and timeliness that are appropriate

for their intended use. Because both false-positive and

false-negative results can result in serious adverse

outcomes, sensitivity and specificity should generally be

high. Similarly, timeliness is of critical importance for

IT/DSSs that aid with detection, diagnosis, management,

communication, and surveillance. Systems should have

measures to maintain security of samples and data

collected.

• Detection and diagnostic systems must be in use in the

affected area. In the event of a covert attack, collection

systems will have to be in place in areas of likely attack. In

the event of a known attack, these systems must be

portable and sufficiently rapid that they can be used in a

variety of field and clinical situations. 

• Clinicians would be helped by detection methods that

include all of the most worrisome biothreat agents, by

systems that can test an individual sample for multiple

biothreat agents simultaneously, and by systems that can

run multiple samples simultaneously.

• Because the individuals collecting and analyzing the

environmental and clinical samples are often at

considerable distance from public health decisionmakers,

detection systems could benefit from the capacity for

secure transmission of data to these decisionmakers. 

• Efforts to link diagnostic and management or prevention

DSSs to other hospital information systems would reduce

the data entry burden substantially.

• The knowledge bases of diagnostic and management

systems need to include current information and clinical

practice guidelines about bioterrorism-related illness. The

systems need to be able to appropriately adjust the

probability of disease caused by biothreat agents if a

known bioterrorism event has occurred. 

• Efforts to integrate surveillance data may benefit from

definitions of the syndromes under surveillance;

comprehensive analysis of the sensitivity, specificity, and

timeliness of each source of surveillance data; improved

spatial and temporal analysis methods; and systems that

collect sources of data reflecting disease earlier in the

course of illness (e.g., school and work absenteeism and

over-the-counter pharmacy sales).

• Communication systems that protect patient

confidentiality and have adequate security measures

would be useful for the rapid dissemination of outbreakrelated information among all relevant decisionmakers,

including public health officials, clinicians, and the

public.

Conclusions

IT/DSSs have the potential to help clinicians and public

health officials make better decisions when responding to a

bioterrorism event. IT/DSSs were identified that could

potentially aid with detection, diagnosis, management,

prevention, surveillance, and communication. However, most

of these systems were not designed specifically for

bioterrorism. Many of these systems have not been described

in peer-reviewed literature, and fewer still have been evaluated

rigorously. The existing evaluations primarily assess the

usefulness of systems for their intended purpose, and often do

not provide direct evidence about the usefulness of the

IT/DSSs for bioterrorism. 

The lack of evaluative studies creates difficulties in assessing

the usefulness of IT/DSSs. For detection systems, almost no

information is available on sensitivity and specificity. Without

this information, interpretation of test results is highly

problematic. Diagnostic DSSs have not been used widely, and

several of the available systems require time-consuming

manual input of patient data, which is impractical in many

clinical settings. Whether management DSSs could be useful

for bioterrorism-related disease remains unanswered.

Surveillance systems hold promise, and although many are

undergoing evaluation, the systems designed for bioterrorism

response have been fielded only recently. Web-based

communication systems are increasingly available to link

public health officials with clinicians and the public; however,

their efficacy in crisis situations is untested. 

This review suggests important gaps in the available

literature. One should note, however, that lack of evidence

about effectiveness is not evidence for lack of effectiveness.

Many of the systems reviewed may indeed be useful for

response to bioterrorism and are reasonable candidates for

further evaluation. Such evaluations would clarify their value

7
both for response to bioterrorism and for the other purposes

for which they were designed. 

Future Research

In addition to the development of systems described in the

answer to Key Question 4, the following future research could

provide additional insights into the information needs of

clinicians and public health officials and the types of IT/DSSs

that may best serve those needs:

• Further research is needed for the development and

evaluation of systems as outlined in the answer to Key

Question 4.

• Further research is needed that investigates the decisions

and tasks of specific types of clinicians (e.g., primary care

providers, emergency medicine specialists, and infectious

disease specialists), different types of public health officials

(e.g., those working in county public health departments,

at the CDC, and in the Department of Health and

Human Services), and other groups of relevant

decisionmakers (e.g., laboratory personnel, paramedics,

veterinarians, and hospital administrators).

• Evaluations of current systems and the interaction of these

systems during simulated bioterrorism events are currently

under-reported, not available yet, or potentially classified.

Detailed evaluations of IT/DSSs and situations where

their use might enhance decisionmaking would guide

further system development and evaluation research.

• Methodologies other than systematic review would

provide additional valuable insight into the answers of the

Key Questions addressed in this report. For example,

surveys of clinicians and public health officials could be

used to better describe the information needs of these

groups in preparing for and responding to bioterrorism

events, the IT/DSSs currently in use, and the

performance of these systems in routine use and times of

crisis. 

• Further research is needed on how to provide effective

training in the use of IT/DSSs and how to provide

effective continual medical education to enhance the

diagnostic capabilities of clinicians for bioterrorismrelated illness through DSSs or other approaches.

• Further research is needed on how to maintain the

security and availability of systems in times of crisis. 

Ordering Information

The full Evidence Report from which this summary was

taken was prepared for AHRQ by the UCSF-Stanford

Evidence-based Practice Center under contract No. 290-97-

0013. It is expected to be available in summer 2002. At that

time, printed copies may be obtained free of charge from the

AHRQ Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 59, Bioterrorism Preparedness and Response: Use

of Information Technologies and Decision Support Systems.

Internet users will be able to access the report online through

AHRQ’s Web site at www.ahrq.gov.

AHRQ Pub. No. 02-E027

June 2002

ISSN 1530-440X
9