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The H1N1 Probe

November 21, 2009
by Joe Bormel
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Friday, at our Greater Washington Area Health Tech Net meeting, we enjoyed a presentation from Erin Thomas of the Fairfax County Health Department about Emergency Preparedness and Pandemic Influenza threat, aka H1N1. That presentation should be here shortly. We learned about the flu, the vaccine, pandemics, and the importance and challenges of getting appropriate clinical guidance translated into practice. In HCIT language, it is a CDS problem, as in clinical decision support, and all about clinical outcomes impact and reporting.

There were a few particularly interesting things that might be a harbinger for the impact of EHRs as they effectively become mandatory under an ARRA roll-out plan:

  • Many providers abandoned the guidelines for H1N1 when there was a shortage or absence of vaccine in their practices.
  • Dealing with the shortages caused some behaviors that, in retrospect, didn't make great sense, like rationing vaccines by lottery.
  • The transparency of the health resource allocation and concern over inappropriate influence, raised in the news over Goldman Sachs, Citigroup, etc. This certainly raised questions about the appearance of an incomplete strategy, perhaps worsened by the defensive-sounding explanations.

  • The data collection and surveillance degradation when providers decided that testing, tracking, and classifying patients was non-productive. This happened for many reasons. People who had symptoms for more than two days were told not to come in, since the treatment must be administered in the first two days of symptoms. Others were not tested but treated empirically, since it's know that H1N1 is by far the most prevalent flu strain. Both practices reduced or eliminated the documentation necessary to understand the extent of the epidemic.
    • Although we have primarily a fee-for-service care model, where treatment is most often driven by patient's showing up or scheduling appointments, we have a vaccination strategy that target's patients in multiple phases, starting with pregnant women, infant contacts, HCP/EMS, persons 6 months to 24 years old, and high risk adults (those with chronic disease) under 65 years old. We don't have broadly deployed scheduling, out-bound calling, and related systems to execute that strategy. So we broadcast the criteria in the media and other public channels, through employers, etc., and try to hit our target population as efficiently as we can. The planning and execution is best-effort at best.

From what I learned today, the vaccination program is actually going very well. The public health agencies, health providers, employers, and volunteers have been very effective at getting vaccines to most people who want to be vaccinated. At least in many geographies. And production capabilities are improving. Further, we all know from the recent NIAID study that the vaccine is very effective.


CDC Holiday Guidance for H1N1
"Travel only when you are well."
"Wash your hands often."
"Cover your cough and sneeze with tissues or with your sleeve."

"Get vaccinated against flu, particularly if you're in a targeted population."

The H1N1 vaccination and treatment program is both a source of optimism, as well as sobering, relative to what we can expect to be the impact as we move forward to use EHRs to facilitate programs to improve the public's health. My take-away is that we in HCIT should watch the H1N1 diagnosis and treatment experience closely. It can be our vaccination, protecting us from the hazards such as those outlined in the bullets above, characterized by behavioral, resource and logistical issues.



Thanks for your comment. You clearly understood what troubled me about the H1N1 episode, and it's relationship to the series, including this season's theme, ARRA/HITECH.

Your point about the importance of being upbeat, positive and hopeful is critical advise.

I also like seeing the combination of rational plans meeting good luck!

Hi Joe - I suspect that you are prescient here in bringing the behavioral, logistical and by extension organizational, issues of the H1N1 experience into the realm of HCIT in general and any impending reform in specific.

Anthony Guerra has written repeatedly about how the logistics just don't stack up and when logistics break down, psychology, and usually irrational psychology, steps in. There will be lies and rumors and panics and rushed decisions made under pressure. Luck and chance will play as much a role as planning and positioning.

Clear, consistent communication and leadership are the rational antidote to irrational psychology. With a message that is still being shaped, debated and distorted, it is no surprise that communication is currently lacking. We can only hope that once reform takes on a semi-solid shape, Obama, among many political, industry and academic leaders, will step into the communication and leadership gap to proactively call-out logistical challenges, shortfalls and sacrifices. Importantly, this communication also must deliver a sense of hope and progress, even while forthrightly addressing failures.

A good model might be FDRs fireside chats. Although the real trick is to use these "chats" to get inside the vicious and near-instantaneous hype cycle of the bloggers and the sound-bites. No easy task.