3. Case reporting. electronic data on suspect cases, confirmed cases and ancillary case data need to be delivered to other electronic systems than EHRs. EHRs are designed to support the provision of care and there are many needs in these circumstances that EHRs don’t begin to address. Data on these cases need to be provided for management in an outbreak context; to record contacts with other people and exposures, to manage their status from suspect through elimination or confirmation, to monitor the spread of disease at many different population levels and to set-up next steps of action for isolation, countermeasure administration or just policy development and research.

At low case levels, like those currently for Ebola in the US, the number of suspect cases coming from EHRs is low. Electronic case reporting from EHRs to outbreak management systems becomes even more important as rates increase. The syndromic surveillance that is in Meaningful Use does not address this critical need. Public health has approaches for automated case reporting that don’t require significant effort from EHR vendors or clinical care providers but they are not currently being implemented.

• Analysis: Case reporting from EHRs to public health should be a top priority for Meaningful Use. Funds should also be provided to public health to support their side of this data exchange.

4. Case management. When a possible case has been identified (sent from an EHR or received from an airplane manifest or other source) it needs to be received and then managed by a surveillance system that supports outbreak management. Robust and standards-based systems that can accept standards-based case exchange should be available and certified to cover every jurisdiction in the US. There have been numerous exercises that have demonstrated these needs, but always limited funding to implement them. These systems need to be able to link case data with lab results that confirm or refute suspect cases and support other functions. There are both management and analytic needs here and both needs must be considered in the context of data exchange and functionality.

• Analysis: Certification of public health systems to ensure interoperability is needed. Just as in e-prescribing, when the non-EHR system involves more than just data analysis, there is a critical need to have a reliable, active and well-tested connection to it.

5. Contact tracing. Ebola has elevated attention to the process of “contact tracing.” Surveillance systems that support outbreak management need to record the exposures that cases and possible cases have so these contacts can be monitored for the disease. This is a key public health process where IT systems are very helpful. Even when there are low counts for suspect cases, the number of possible contacts can be large. When those contacts start to be confirmed as cases, the contacts of the contacts become a consideration and the math can progress geometrically. Interoperable electronic systems are critical for this management. When SARS hit Toronto, and that more communicable disease had a substantial foothold, it was suppressed though the application of just such computerized processes. US preparedness requires knowing the coverage of interoperable health IT systems to support contact tracing. It also needs public health professionals trained in the use of these systems when they do exist.

• Analysis: Measure and track the functionality of public health systems as well as EHRs. Implement training and routine use of appropriate systems before emergency events and ensure that personnel are certified in their use.

6. Countermeasure administration. An Ebola vaccine is very desirable and would obviate many of the aforementioned health IT needs. There is a temptation, however, to think that in a big emergency, vaccines and pills would be distributed freely. In practice, however, real world examples and disaster scenarios have shown that here too there are needs for systems to track and manage an outbreak response. When a vaccine comes available, it will only be available in limited supply. At that stage, there is a need to coordinate vaccine administration with the possible cases and other potential contacts to support a “ring vaccination” strategy. Experience from the Smallpox vaccination program has also shown that there are frequently heightened needs to monitor the recipients of early vaccines for side effects and efficacy. Connection of surveillance systems to vaccine delivery systems is needed for this type of surveillance as well. Finally, isolation is another countermeasure. Systems need to manage and track possible contacts that need to be isolated or quarantined whether that is in their homes or elsewhere.

• Analysis: Interoperable countermeasure administration systems should be supported, certified, tested, and available to support several different levels of available vaccines, drugs and other countermeasures.

7. Research. The Ebola response has already shown how many things are not known about the spread and management of even this well-established disease. Getting consistently recorded data during and after the event is important to learn how to better handle a recurrence and other public health emergencies. Most of these data will not come from randomized controlled trials, but from real world experiences that are then transmitted to longer term registries. Most of the research work occurs after the crisis is over, but the data need to be considered during the event.

• Analysis: Interoperable EHRs and other systems need to share data appropriately with research-related systems to best learn from emergency events and plan future responses.