tegrated and flexible disease surveillance, and it points out weaknesses of our current system and opportunities for improvement.

In terms of integration, Milwaukee began enhancing disease surveillance systems long before we were worried about bioterrorism. It really dates back to a massive outbreak of a common but then little known bug called Cryptosporidium. This waterborne outbreak sickened more than 400,000 people suddenly in our city. We had little idea that an outbreak was taking place. Traditional surveillance systems would not report a disease that was not mandated for legal reporting. Similarly, a spate of deaths during the 1995 heat outbreak makes it clear that it was also under the radar of health surveillance systems.

This makes it clear that health surveillance can't be designed for one problem in isolation of others, and in particular, that very finely defined health surveillance systems that might be applicable for the agents we think are going to be responsible for a bioterrorism attack will really not serve us well. We need integrated systems that bring together information of various types, various diseases that are integrated in the public health world and not set up as some separate entity, some separate department of government.

In terms of flexibility, you're going to hear in my presentation that ideas and innovations are bubbling up as well as down, and the creation of very highly standardized systems is important. What we really hope to achieve, I think, in our Nation today are standardized methods of coding information and standardized ways of transmitting information that such that the information can talk to itself, and agencies and information systems can talk to each other in such a way that it actually encourages innovation.

What is important is if you were, for example, to ask the Federal Government to mandate that all health care providers begin to report certain information immediately up at the Federal level, and that all local health providers and State departments do the same, the easiest way to do that is to create a single Web-based entry system where we all spend all of our time filling in the blanks on the instrument that has been provided from above. But what that denies us the opportunity to do is to create flexible instruments we carry into the field that, because of standard transmission of health care information, can then up link to the Federal system.

That is a decision, an important decision, that has to be made, and yet I agree with you. We cannot dilly dally too long in seeking the right balance between mandates and innovation. The weakness of the traditional reporting systems have been pointed out, although they remain absolutely crucial. They are slow. They often give us incomplete information. They rely on paper forms that often sit around in piles, which should surprise no one. Furthermore, it is increasingly being pressured by the fact that a laboratory specimen obtained in Milwaukee may well be analyzed in Atlanta or in Santa Cruz, and that information somehow has to find its way back to the doctor's office and subsequently to the local public health authority.

I agree very much with Dr. Fleming's catalog of improvements in the traditional reporting system: educating the providers, improving our laboratory infrastructure, creating a 24/7 response. But, in

tional disease surveillance system is electronic laboratory reporting.

There are huge numbers of laboratories out there. If each of their laboratory information systems could report data in a standardized fashion so that it would find its way to and through the different health information systems that come between them and the local public health authority, this information could reach quickly, be routed to us, could automatically alert us, could be stored, displayed, analyzed, and tracked, greatly reducing the work of local public health.

My colleague, Rex Archer in Kansas City, has established such electronic lab reporting with a large number of laboratories in Kansas City and has demonstrated increased timeliness of reporting, increased completeness of reporting, reduced time wasted. However, as with all surveillance and public health, we know that it also gives us more complete reporting. He is chasing a lot more disease than he ever knew about before, and that has its real implications.

The real point here is that the standardization of electronic health information is really a critical step. HIPAA really created a basement, a foundation for doing this by creating accountability, about confidentiality, security, and mandating certain standardization; and we really need to let this take root.

The second topic that has been discussed is enhanced or syndromic surveillance. We know that we can look at a lot of different patterns of illness such as symptoms in emergency departments, pharmacy dispensing, test orders. It is very important to recognize that this is a young science, easily oversold, hard to prove how well it works. However, it is very important that we begin to explore these capabilities. This will require again standardized health information, information that can flow electronically so that we are not adding constantly to the workload of busy health care providers.

In addition, it requires connectedness; and I will tell you a brief story from Milwaukee. On their own initiative, because they needed it for their own reasons, all of the local emergency departments established a secure, live Internet site that told them when different emergency rooms were on divert status. When we learned about that this resource was in each of our emergency rooms, we politely asked access to the system and have used it since to post alerts to the emergency medicine community. My pager goes off when more than three emergency rooms at a time go on ambulance divert. I can draw down statistics to see why emergency rooms are going on diversion and what the temporal pattern is.

And, most recently, we have solicited the emergency rooms to provide us with daily updates of certain types of diseases, not on an ongoing basis, because they don't have the labor to do this continuously, but on an as-needed emergency basis. We performed such surveillance for bioterrorism-like syndromes during the AllStar game last summer. But beginning with the SARS epidemic,

gency rooms in our community both screening their patients routinely for possible SARS-related symptoms and then providing us with daily counts of what they were seeing.

Mr. SHAYS. Thank you, Dr. Foldy.

[The prepared statement of Dr. Foldy follows:]

Subcommittee on National Security, Emerging Threats, and International Relations House Committee on Government Reform

Hearing on "Homeland Security: Improving Public Health Surveillance"

May 5, 2003

Good afternoon, Mr. Chairman and Members of the Subcommittee. I am Seth Foldy, MD, Health Commissioner of the City of Milwaukee, Wisconsin. I am pleased to speak with you today on behalf of the National Association of County and City Health Officials (NACCHO). NACCHO is the national organization representing the nation's nearly 3000 local public health agencies. I chair NACCHO's Committee on Information Technology and am glad to share with you from the local viewpoint what we are learning about disease surveillance and how the nation can do it more effectively.

When a disease outbreak or other public health emergency occurs, local public health agencies provide the eyes, ears, hands and feet to find the cause and prevent further harm. We are usually the ones who first detect and investigate unusual occurrences of disease and execute a response. It is important for state and federal governments to alert us to potential problems, but such alerts are useless unless we have the ability to do disease investigation and response on the ground.

Today, the number of threats we face is increasing, as are the number of tools potentially available to help us address them. It will take many years of sustained investment to modernize our local public health workforce and our systems to enable us to do justice to these challenges. It will also require active, sustained involvement by the local public health community in the development of statewide and nationwide disease surveillance systems. Such systems cannot and will not function effectively unless they are designed to account fully for the processes and realities of local public health work.

The need for improved surveillance systems is critical not just to detect a bioterrorism event, but also to detect emerging communicable diseases, such as Severe Acute Respiratory Syndrome (SARS). We can never assume that the diseases we will be trying to track next month will be the same diseases that have concerned us over the past several years.

The Objectives of Disease Surveillance

The purpose of disease surveillance is the same, whether the disease is SARS or smallpox. Our objective in all cases is to detect the occurrence of an infectious disease as early as possible so that we can act to prevent its spread and minimize the number of persons affected. The sooner