Disaster Medical Response
Electronic availability of clinical data through the Department of Veterans Affairs and other systems allowed some large health care providers to have their patients’ data available very soon after Hurricane Katrina destroyed much of their physical infrastructure.[ 43] HIE may further benefit the medical care of refugees and other dislocated individuals by opening up clinical data exchange query functions to providers and HIOs in other areas via a rapid credentialing process that would permit authorization and access.
Public Health Alerting: Patient Level
In most of the previously described scenarios, the flow of information is from HIOs to public health. However, one could conceive of the HIO infrastructure also enabling targeted communication from public health to HIO network users. Health departments are typically constrained in their ability to disclose identifiable surveillance data for clinical purposes, but there are some examples where the duty to warn outweighs this prerogative to confidentiality. For example, emergency department physicians who query the HIO for a patient’s past medical history could receive a highlighted public health alert for patients with active tuberculosis who were lost to follow-up. This alert system would make it possible to isolate infectious patients earlier, when appropriate, thus decreasing the rate of nosocomial spread.[ 44] In this scenario, the public health agency acts as merely another data source on the HIE, but a source with very selective data to share.
A similar use case for patient-level alerting involves antibiotic-resistant organism (ARO) surveillance for early isolation of infected patients when they present to a hospital. AROs such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, and multidrug-resistant tuberculosis can pose a significant threat to hospital staff, visitors, and other patients who are exposed to individuals carrying these organisms — especially immunocompromised patients with HIV or those on medication for organ transplant or other medical conditions. MRSA in particular has gained much attention in the press lately, and not without reason. The incidence of both community-acquired and hospital-acquired MRSA is on the rise in many regions[ 45] and is a significant cause of morbidity, mortality, and increased incremental costs, with some nosocomial infections costing as much as $17,422 [ 46][ 47]
ARO-infected patients who are diagnosed at a given facility may present to an emergency department at another facility without being identified or appropriately isolated for an extended period of time, exposing other patients and hospital staff and putting them at risk for infection with these virulent agents. Early isolation of patients infected with these agents has been shown to decrease nosocomial spread as much as 16-fold[ 48-50] An ARO surveillance use case could be designed around HIE from the hospital’s local health department or neighboring facilities, so that the patient could be flagged on the HIO enterprise master patient index, and the admitting facility could be alerted at registration that the patient should be placed in appropriate isolation.[ 51][ 52]
Public Health Alerting: Population Level
The HIE user interface could also be a gateway to relevant epidemiologic information that the provider might be interested in. For example, an emergency department physician might receive trends in influenza A and B viral cultures in the community and outpatient antibiograms, and a primary care physician might receive updated preventive services recommendations. These findings could be presented to all users, or they could be customized to the particular queried patient’s age, race, neighborhood, or prior medical history. General public health messages could be incorporated into the HIO portal, and more tailored epidemiologic information could be integrated into a patient query. HIOs that offer access to patients through online portals might also enable targeted public health communication with patients in much the same way.