The Paper Chase

In late January, HHS Secretary Tommy Thompson unveiled a $3.5 million command center in Washington, D.C. Seeking to reassure a public nervous about biological and chemical attacks, Thompson explained that this new command post would let him coordinate the response to a bioterrorist attack and bring together everyone from the CIA to the Centers for Disease Control and Prevention, which is part of HHS. As CNN cameras filmed a wall of video screens 24 feet wide and 7 feet tall, correspondent Wolf Blitzer told viewers that they were witnessing "how your life could be saved."

It was all window dressing. In many parts of the country, the primary mechanism for detecting bioterrorism—or any epidemic—is still the little stacks of cards that doctors are required to fill out with the patient’s name, address and diagnosis, and submit to local health departments when they come across a disease that poses a significant health risk.

The diseases that must by law be reported vary from state to state: West Nile in New York; the hantavirus in New Mexico; most sexually transmitted diseases, everywhere. The root philosophy is that sometimes, doctor-patient confidentiality must give way to the risk to public health. (The notable exception to that rule is when a patient has AIDS, or is HIV-positive.)

On a local level, health officials use those reports to track treatment, notify others who may have been infected or quarantine an individual if necessary. On a broader level, epidemiologists look for disease patterns across the city, county, state or nation, and alert health-care practitioners and the CDC to anything unusual.

Some local health departments have started allowing clinicians to submit this information electronically, but not many do. Some local health departments still worry about upgrading their dial-up Internet connections to broadband.

For doctors, the reporting process is so labor intensive that observers put the compliance rate at less than 20 percent. That means that four times out of five, doctors never even bother to fill out a report. Fortunately, the laboratories where they send their tests tend to be more automated and therefore more likely to file that information electronically with the public health department. But no one believes that public health departments have anything like a full window into what’s going on—regardless of the bank of video screens that adorn Thompson’s command center.

"In retail America, they long ago made the entire supply chain of data electronic from cradle to grave," says CDC CIO James D. Seligman. "The chairman of Wal-Mart can find out how many widgets got sold an hour and a half ago anywhere in America. That’s where we’re trying to get with health data, to enable that electronic passage of information from the point of encounter, when a patient sees a health-care professional, and then pass all that data on electronically to the appropriate jurisdictions."