Introduction

The healthcare system plays an enormous role in biosurveillance. Its importance derives from a simple fact: when people contract infectious diseases, they seek medical attention.

The healthcare system comprises hospitals, doctor's offices, long-term care facilities, visiting nurse services, laboratories, dental offices, pharmacies, ambulatory and "same day'' procedure facilities, and emergency medical services. All of these organizations are involved in the assessment and care of the sick.

Hundreds of thousands of highly accessible nurses, licensed nurse practitioners, and physicians work in healthcare. These frontline healthcare workers are trained to accurately observe and interpret diagnostic information. They are skilled at eliciting and recording basic elements of an epidemiological case history, and they routinely record data needed for outbreak detection and for characterization. These data include symptoms of disease, temperature, laboratory results, and diagnoses.

At present, the healthcare system plays three roles in biosurveillance. First, the healthcare system reports notifiable diseases and clusters of suspicious illness to state and local health departments. Second, the healthcare system assists outbreak investigators by providing medical records, screening services, and diagnostic work-ups of patients. Third, the healthcare system conducts biosurveillance of its own facilities (especially hospitals and long-term care facilities). Hospitals operate special divisions called infection surveillance and control units that monitor a facility for patients with communicable diseases and for outbreaks. Outbreaks can start or spread quickly in healthcare facilities and then spread to the community, as they frequently did during the 2003 severe acute respiratory syndrome (SARS) outbreak.

At present, the domains of medical and epidemiological practice exchange relatively little data, except in the setting of an outbreak. They exchange these data primarily by fax, mail, telephone, and e-mail and e-mail attachment. These mechanisms of communication are vulnerable to errors of omission and delays. Even when these domains use electronic transfer of data, the exchange is typically via batch transfer of data on a daily or less frequent basis, rather than via a real-time communications.

In the future, the healthcare system will provide significantly more data and services to governmental public health, and it will provide the data in real time. Indeed, this "megatrend'' is already unfolding in many jurisdictions in the United States and abroad. Conversely, governmental public health will transmit case definitions and up-to-the-minute information about disease prevalence electronically to the healthcare system. The untapped potential for biosurveillance of real-time electronic communications among the healthcare system and other biosurveillance organizations, such as governmental public health, is enormous, as we will discuss.

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