Editor's Note: This story was updated at 2:20 p.m. Dec. 21, 2005, to correct the misspelling of Ina Kichen's name. The story incorrectly had it as Kitchen. We regret the error.

Two days after Hurricane Katrina battered the Gulf Coast, Dr. Julie Boom, medical director of the Houston-Harris County, Texas, Immunization Registry, received news that Louisiana evacuees would begin to arrive in her area the next day, the start of a nationwide diaspora of almost 2 million people.

Boom said she knew those displaced people included thousands of children who would need painful and costly immunization shots before they could attend school in Texas unless she could access their Louisiana records.

Boom asked Scientific Technologies, a company based in Tucson, Ariz., that supports the Immunization Registry and the Louisiana Immunization Network for Kids Statewide (LINKS), if the company could help her connect to the Louisiana registry.

Boom's phone call began a sequence of events that led to the creation of a makeshift regional network of state immunization registries. In the following weeks, it linked to other electronic health record (EHR) networks that cross federal, state and local boundaries as far away as Alaska. Health information technology officials say Katrina relief operations show that a national EHR network is within reach if policy-makers are motivated to create one.

"Development of interoperable health records is not a technology problem but a bureaucracy problem," said Dr. Roxanne Townsend, Medicaid medical director at Louisiana's Department of Health and Hospitals. "Once people figure out a way to get beyond the bureaucracy, things can happen very quickly."

Blog lines

As the health care complications of the Katrina diaspora became clearer, Dr. Mark Frisse, director of regional informatics programs at the Vanderbilt Center for Better Health and a professor at Vanderbilt University, opined about the lack of preparation in his Web log.

"What would be the value to the millions of Katrina refugees if we had established a national health information infrastructure a decade ago?" he wrote.

Frisse, who is also director of Tennessee's Volunteer eHealth Initiative Regional Health Demonstration Project, said the lack of medication information on Katrina evacuees could result in a 5 percent medication error rate, which could lead to hundreds of life-threatening drug reactions.

Frisse said he sent those concerns and a call to action to about 30 people, including Dr. David Brailer, national coordinator for health IT at the Department of Health and Human Services.

Boom's request for access to immunization registries and Frisse's blog posting were catalysts for spontaneous health IT innovations. Within days, public health professionals nationwide could access immunization registries in Alabama, Louisiana and Mississippi. And developers quickly built a system that allows clinicians in all 50 states to access medication records for many Gulf Coast evacuees.

Overnight delivery

After Boom called Scientific Technologies, she discovered that the company's definition of quickly connecting the Houston and Louisiana immunization registries meant overnight. As Gulf Coast evacuees started to fill Houston's Astrodome Sept. 1, Scientific Technologies had already figured out how to link the registries, less than 24 hours after her first call to the company.

Boom said the Houston-Harris Immunization Registry, its Louisiana counterpart and Scientific Technologies programmers tested the links between the two registries during Labor Day weekend, and the "two systems properly joined and [were] ready to go live the Tuesday after Labor Day."

By that time, Boom said, health care professionals working in the Astrodome had wireless Internet access and could tap into the Louisiana registry. They accessed about 2,000 immunization records before Hurricane Rita forced officials to move evacuees out of the Astrodome the week of Sept. 18.

Boom said the registry also gave evacuees an important psychological boost by linking them to their lost past. "These people came here with nothing," she said. "By helping them see some of their personal information, we helped ease their loss."

Boom said the registry link also helped clinicians in the Astrodome and elsewhere determine that some evacuated children needed more immunization shots. They could treat those children on the spot. She never thought the registries could be linked so easily, she said. But "necessity drove it, and it was amazing to watch it happen."

The role of standards

Adherence to Health Level 7 standards by both the Houston and Louisiana registries eased the connection.

"The importance of HL7 standards was never more evident than during Katrina," Boom said, adding that "because each registry was fully HL7-compliant, this link was able to be made quickly and easily."

Mike Garcia, vice president and director of integrated health systems at Scientific Technologies, agreed that HL7 standards made it easier to link the Louisiana and Houston registries. "The HL7 transport methodology supports two-way data interchange using secure Web technology," Garcia said.

Once the company established links between the two systems, a user in the Astrodome could log on to the system and search the Louisiana system, housed on a combination of Hewlett-Packard Unix and Microsoft Windows servers located in Baton Rouge, which survived the hurricane
unscathed.

As Katrina evacuees spread nationwide, health care professionals realized they needed links to state and local registries in Louisiana, Alabama and Mississippi.

Ina Kichen, research and development manager at the American Immunization Registry Association, said she told all association members in an e-mail to use Scientific Technologies as a broker to create links with the Gulf Coast registries. The company dedicated staff and resources to execute user agreements with the Gulf Coast states, set up accounts and provided about 15 minutes of training, Garcia said.

By mid-October, the association and Scientific Technologies had established a connection among all 50 states except the Louisiana registry, Kichen said. And registries in nine states; Washington D.C.; Austin, Texas; and Los Angeles had access to the Mississippi applied immunization database. Kichen added that 17 states had access to the Alabama registry.

By then, the registry system had responded to 17,000 requests for immunization records. Based on an estimated cost of $50 a shot and one shot per child, the network saved at least $850,000 in unnecessary shots, Boom said.

Unintended benefits

Garcia said the crisis helped break down perceived Health Insurance Portability and Accountability Act (HIPAA) and Privacy Act barriers. But it took a hurricane to do it. Garcia added that the scramble to establish post-Katrina registry links also focused on the need to convert all registries to HL7 standards. Eight states and Houston could use HL7 to perform two-way data interchange with the Louisiana registry, but the remainder had read-only access to those registries, Garcia said.

Ron Van Duyne, a public health analyst in the Centers for Disease Control and Prevention's Immunization Registry Support Branch, said the post-Katrina experience should encourage all registries to convert to HL7 as quickly as possible. Registries with HL7 access to Gulf Coast databases could not only access records but also create new ones in their own systems, Van Duyne said. But those with vie