Infectious disease/concepts
Health Information Exchange, Biosurveillance Efforts, and Emergency Department Crowding During the Spring 2009 H1N1 Outbreak in New York City

https://doi.org/10.1016/j.annemergmed.2009.11.026Get rights and content

Novel H1N1 influenza spread rapidly around the world in spring 2009. Few places were as widely affected as the New York metropolitan area. Emergency departments (EDs) in the region experienced daily visit increases in 2 distinct temporal peaks, with means of 36.8% and 60.7% over baseline in April and May, respectively, and became, in a sense, the “canary in the coal mine” for the rest of the country as we braced ourselves for resurgent spread in the fall. Biosurveillance efforts by public health agencies can lead to earlier detection, potentially forestalling spread of outbreaks and leading to better situational awareness by frontline medical staff and public health workers as they respond to a crisis, but biosurveillance has traditionally relied on manual reporting by hospital administrators when they are least able: in the midst of a public health crisis. This article explores the use of health information exchange networks, which enable the secure flow of clinical data among otherwise unaffiliated providers across entire regions for the purposes of clinical care, as a tool for automated biosurveillance reporting. Additionally, this article uses a health information exchange to assess H1N1's effect on ED visit rates and discusses preparedness recommendations and lessons learned from the spring 2009 H1N1 experience across 11 geographically distinct EDs in New York City that participate in the health information exchange.

Introduction

Human society has always been susceptible to outbreaks and pandemics. Thanks to new advances in health information technology, we are on the cusp of being able to do more to mitigate or even prevent these occurrences. Technologies including electronic health records, which allow electronic data collection during routine clinical care of individual patients, health information exchange, which enables the flow of electronic data among disparate providers and electronic health records, and biosurveillance, which aggregates and filters electronic data from these and other sources, may come together in the future to allow earlier detection of and situational awareness during outbreaks.

The H1N1 pandemic in the spring of 2009 caught the world by surprise. After first appearing in Mexico in mid-March,1 the virus spread to southern California and Texas2, 3 and then to New York, where the first cases were reported in a high school in Queens on April 25, 2009.4, 5, 6 New York City soon had the largest concentration of confirmed H1N1 cases in the country; by mid- May, it was estimated that 6.9% of adults in New York City had symptoms consistent with influenzalike illness.7 After media coverage of confirmed H1N1 diagnoses and deaths both nationally and locally,8, 9, 10, 11 New Yorkers began to visit emergency departments (EDs) in record numbers, causing an unprecedented crowding crisis.

These large increases inundated a hospital-based emergency system that is already functioning at the breaking point.12 As background, visits to US EDs increased from 90.3 million in 1996 to 119.2 million in 2006, a 32% increase,13, 14 whereas the number of hospital EDs decreased from 4,019 to 3,833.15 Tight control of inpatient beds to optimize hospital fiscal performance has led to lengthy delays in obtaining beds for patients admitted through the ED. This widespread practice of “boarding” admitted patients in EDs, coupled with increasing demand for ED care, has created a crowding crisis in EDs across the country. It has been repeatedly shown that when EDs become crowded, patient care suffers; crowding is associated with increased morbidity and mortality in nearly every condition that has been studied.16, 17, 18, 19, 20, 21, 22, 23 The influx of many thousands of patients with influenza-like illness during spring 2009 into New York City's already crowded hospital EDs raised serious concerns about the indirect effect on the millions of patients who rely on area EDs for other conditions.24

To monitor the surge capacity of the health care system in a given region, public health agencies often request increased reporting of biosurveillance data from provider organizations during a public health crisis. Traditionally, this requires manual reporting by hospital administrators and organizations already functioning in crisis mode because of the outbreak, and the increased reporting burden may lead to low response rates. Recognizing this problem and other benefits of automated reporting documented in the literature, including improved timeliness and completeness of reporting,25, 26, 27 the Centers for Disease Control and Prevention (CDC) created a federal contract to determine how health information exchanges may be leveraged for public health reporting purposes.28, 29

This article makes novel use of data from the New York Clinical Information Exchange (NYCLIX), a regional health information organization and health information exchange, to examine the timing and volume of ED visits to NYCLIX participating hospitals during the spring 2009 H1N1 outbreak.30 The objectives are to demonstrate the utility of this data source in documenting care-seeking behavior in New York City during the spring H1N1 outbreak and use that experience to inform planning efforts for recurrent pandemic flu or other outbreaks.

Section snippets

Background

Health information exchange is generally defined as the electronic movement of health-related information among organizations according to nationally recognized standards, and a regional health information organization is generally defined as a health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them, according to nationally recognized standards, for the purpose of improving health and care

Data Sources and Data Analysis

The NYCLIX database was queried for ED visit rates, returning aggregate counts by day and site from March 15, 2009, to July 15, 2009. Data were analyzed with Excel 2007 (Microsoft, Redmond, WA) and reported anonymously. Several sites were provided with their daily visit rates and asked to review the results with their own internally collected census data to validate the NYCLIX results. Because NYCLIX was not operational in 2008, a direct comparison to the previous year was not possible. A 7-day

Lessons Learned in New York City During the Spring 2009 H1N1 Outbreak

The 2 ED visit peaks (Figure 1) immediately followed the first media-reported cases (April 25, 2009) and death (May 17, 2009) in New York City. Although data were not collected in this study to confirm that the influx of new patients was due to H1N1-related complaints, the timing of the media reports and the unprecedented increase in ED visit rate strongly suggest a correlation. One may infer that the reported events drove care-seeking behavior despite clear messages from the CDC39 and the New

Preparedness Recommendations

Recognizing the central role of EDs in future outbreaks, the Department of Health and Human Services Emergency Care Coordinating Center and Office of the Assistant Secretary for Preparedness and Response contracted the American College of Emergency Physicians to convene a panel of public health and emergency medicine experts to create the “National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza.”42 The plan includes a comprehensive management strategy, a

Future Directions in Public Education and Communication

With novel H1N1 flu continuing to affect communities around the world,44, 45, 46 the public requires accurate information to inform their care-seeking decisions. In early September, the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events hosted a meeting, “Assessing the Severity of Influenza-Like Illnesses: Clinical Algorithms to Inform and Empower Healthcare Professionals and the Public.” As a result of that meeting, several professional organizations

Conclusion

Although the severity of recurrent H1N1 in select patient populations is still being determined,45, 46, 51 EDs risk being overwhelmed by the worried well with influenza-like illness symptoms. Such a resurgence would exacerbate crowding in an already overburdened system, potentially harming the sickest patients, whether or not they are infected with H1N1. Aggressive planning by hospitals and effective public communication should be focused on protecting the EDs' ability to provide emergency care

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  • Cited by (0)

    Supervising editor: Donald M. Yealy, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Shapiro was supported in part by a grant from the National Library of Medicine (4 R00 LM009556-03). Dr. Genes was supported by a grant from the New York State Empire Clinical Research Investigators Program (ECRIP-7002024H).

    Reprints not available from the authors.

    Publication date: Available online January 15, 2010.

    All NYCLIX Clinical Advisory Committee H1N1 Working Group members are listed in the Appendix.

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