Health plans search for bioterror symptoms

In matters of homeland security, experts on all sides have long been saying that more cooperation is needed among various levels of government and the private sector in preventing and coping with terrorist attacks. Well, it now looks as if a pilot program of teamwork between the Centers for Disease Control and Prevention and some private health plans is bearing fruit.

The CDC and a handful of health plans are about a year into a collaborative project whose aim is earlier and better detection of potential bioterrorism attacks-spotting disease outbreaks before emergency rooms are suddenly flooded with victims. In essence, the streams of data coming into health insurance plans-phone calls to nurse-help lines and doctors' diagnoses, for example-are sifted by computer programs to look for disease and symptom patterns sorted by ZIP code. Such a system may already be proving valuable in tracking early signs of Severe Acute Respiratory Syndrome, or SARS, as the dreaded and sometimes-deadly illness begins creeping into the United States.

The CDC awarded a grant of $1.2 million about a year ago to Harvard Pilgrim Health Care, a large health plan that serves New England, to begin collecting and analyzing information about certain respiratory and gastrointestinal symptoms that might mark the beginning of a bioterrorism attack. Soon, a handful of other large health plans will begin feeding their patient information to Harvard Pilgrim, which will act as the data-processing hub. New participants will include United Healthcare, HealthPartners in Minnesota, and Kaiser Permanente in Colorado.

Even before this project began, many state-level public health agencies were upgrading their tracking techniques to monitor emergency-room visits and sales of over-the-counter drugs such as anti-diarrhea medicine. The hope is that conducting surveillance through health plans will be quicker than tracking emergency-room visits. "A lot of people are looking at emergency rooms and hospitals, but perhaps the nurse call-in lines and primary-care physicians may be a day or two ahead in the epidemic," said Blake Caldwell, a CDC contractor who is the senior consulting epidemiologist for this pilot project, called the National Bioterrorism Syndromic Surveillance Demonstration Program.

Karen Ignagni, president of the American Association of Health Plans, which worked with the CDC to set up the project, has been considering such collaborations since the terrorist attacks of September 11. "As we began to talk about this issue with medical directors, it became clear that we had a unique set of skills and a unique set of competencies that could provide a real public health benefit," she said.

Members often report symptoms to their health plan first, Ignagni said-sometimes more than a week before they might go to an emergency room. The symptoms of most communicable diseases that could indicate a coming epidemic begin slowly and quietly, she explained; they are not major life-interrupting events, such as heart attacks, that can collapse a patient in short order. Some of the symptoms associated with the most-feared potential biological weapons, such as smallpox and anthrax, may resemble the flu for days before more-telling signs set in.

"When you first start having symptoms, they're not serious enough to drive to the emergency room," Ignagni said. "But you have symptoms, and you feel strange and you don't understand why they're occurring, so you want to talk to somebody." More often than heading for the emergency room, people visit their doctor or seek advice from the nurse call-in lines that many insurance plans make available to their members as a kind of first-line triage.

Early evidence shows that the project is working to spot spikes in the rates of natural disease in Massachusetts, said Richard Platt, principal investigator, and professor of the Ambulatory Care and Prevention Department at Harvard Pilgrim. According to Platt, Harvard Pilgrim has already anticipated increases in hospitalizations for respiratory infection. During this winter's flu season, he said, his system was able to predict an upswing in respiratory infections about two weeks before hospital admissions started to rise.

The idea behind the CDC/Harvard Pilgrim demonstration is to collect information in a variety of ways and then merge it all to reveal trends. A participating doctor's practice, for example, installs sophisticated computer technology that essentially scans the diagnoses that doctors assign to the patients they see in any given day, looking for symptoms associated with commonly suspected bioterrorism agents.

With more doctors keeping patient information electronically, such reporting and collecting should be able to grow quickly, according to Ignagni. Currently, only those physicians who store patient medical records electronically can participate. However, Caldwell said she hopes that the program will soon expand to include physicians who file insurance claims electronically.

Here's how the system works: At the end of each day, the computer at the doctor's office, clinic, or nurse call-in line automatically checks the day's records for specified symptoms. The findings from each office are transmitted-without any names or identifying information-to Harvard Pilgrim, which combines all the data. Harvard Pilgrim sorts the final data by ZIP code and compares it to epidemiological norms for the region and the time of year.

Caldwell noted that health plans and patients should not be concerned about confidentiality. The health plans initially report only the number of people in a particular ZIP code with either respiratory or gastrointestinal trouble. If a worrisome number of people within a particular ZIP code report similar symptoms, Harvard Pilgrim and public health officials can go back to the health plan and ask for more information. The health plan can then look at the individual patient records in question and determine if there is a reasonable explanation for the illness, or whether the patients can be linked in some alarming way. If there is reason to fear an outbreak, the local public health agency then has the right to ask for the identities of the affected patients.

So far, about once a month, Harvard Pilgrim has notified public health officials about spikes in respiratory or gastrointestinal symptoms. In the end, none of those spikes has turned out to be related to bioterrorism.

The beauty of the effort is that collecting and sorting the information is mostly automatic, Platt said. "There's no active human involvement in this. The computer program runs every night and extracts the information that's needed.... It's not asking any of the clinical providers to collect any additional information or to record additional information or to take steps to notify anybody. This information is collected in the course of routine health care delivery," he said. "This is important, because we need a system that is sustainable."

This month, United Healthcare will join the project, gathering information from its nurse call-in line, called Optum. Bob Harmon, vice president and national medical director of Optum, said he's sure his system can help. He cited a study of a 1993 outbreak in Wisconsin of cryptosporidium, a waterborne parasite that comes from animal waste. That outbreak sent 4,400 people to the hospital, killed 50, and sickened hundreds of thousands in Milwaukee. At the time, patients began contacting nurse call-in lines several days before the emergency rooms started to report victims.

"This was the kind of thing that led to this particular project, realizing that this could be valuable for a bioterrorism event, and also for a public health outbreak," Harmon said.

Optum is the largest company offering nurse telephone triage in the United States; it serves more than 23 million people through six call centers. About 400 nurses are on hand to talk to health plan members about symptoms and concerns. Of course, not all 23 million members call the nurse line for help. According to Harmon, up to 10 percent place a call in any given year. But that's more than enough calls to detect a problem, said Reed Tuckson, the senior vice president for consumer health and medical care advancement at United Healthcare. "If there were to be an increasing incidence of disease that was occurring, we are in a position ... from people's use of our service, to be able to detect some of that," Tuckson said.

To be sure, this isn't the only surveillance effort under way. The CDC is still encouraging local authorities to monitor emergency room visits and sales of over-the-counter medications, for example. "The theory now at CDC is to let a thousand flowers bloom," Ignagni said.

"Encourage a variety of systems to develop so that they can have the best of those systems, and see what they want to keep over time and what they want to discard over time."

But Ignagni believes that private health plans can provide one of the earliest warning signs in detecting a possible biological attack. Indeed, as the pilot project begins its second year, AAHP is asking for a larger federal grant, and more health plans want to participate. Kaiser Permanente in California is ready to go, and Caldwell is asking CDC for the funding to get Golden State participants in the system. Several other large health insurers, including Aetna, are considering participating in the project.

Caldwell cautions that this is still a localized demonstration project. But, she said, "I'd like to think that this will grow tremendously. We just have to prove that the system works."