Going the Distance

Nearly 150,000 people gather in close proximity each year -- sometimes in extreme heat, cold or rain -- for the annual rite of spring known as the Kentucky Derby.

It's the time of year when all of Louisville dresses up and welcomes neighbors from around the world. While most Louisvillians use the Derby and its accompanying festival as an excuse to take a few days off to play, it's a time of heightened alert for others.

Derby 2003 saw the return of increased security measures in response to the terrorist attacks of 9-11. It also had the faculty of the University of Louisville School of Public Health and Information Sciences watching carefully in response to a new threat: SARS.

With the influx of international travelers, Severe Acute Respiratory Syndrome could well have been introduced to the local citizenry and guests at the racetrack.

The incubation period is nearly over at this writing, so the public health community is breathing a collective sigh of relief. But it does not relax.

"If SARS behaves like other corona viruses it should fade away as summer arrives," explains Paul McKinney, M.D., acting associate dean for public health in the School of Public Health and Information Sciences.

"We can't make too many assumptions, though. This is a brand-new virus, and we simply don't know."

The new school's unique mix of leading-edge computational expertise and solid, traditional epidemiology provides a level of protection and early detection for the regional population that it has never known before -- at a time when it is needed more than ever.

"The SARS outbreak demonstrates the vulnerability of society to the transmission of new diseases," says Rick Clover, M.D., dean of the SPHIS. "It also underscores the importance of surveillance: Society's ability to manage an outbreak is directly related to its ability to identify it early on."

Built from the ground up

The UofL School of Public Health and Information Sciences was established in 2002, bringing together a range of existing expertise on the Health Sciences Center campus. The result is already greater than the sum of its parts.

"We see public health as an interface between medical and epidemiological know-how and engineering and computer sciences expertise," Clover says.

"We have combined the historical strengths of public health with health information sciences. Across all of health care, the health information sciences are becoming a major focus, and we are developing a center that reflects that trend."

In fact, the school has been built from the ground up to support this philosophy. The school's five departments -- clinical investigation and epidemiological sciences, environmental and occupational health sciences, bioinformatics and biostatistics, health knowledge and cognitive sciences, and health management and systems sciences - each incorporate population-based studies with health information sciences and information technology.

The unique foundation of the SPHIS was laid more than five years before its inception.

The UofL Institute for Public Health Research, directed by McKinney, was established in 1998 and immediately developed highly regarded research and doctoral programs in urban studies, environmental health, and health law and policy.

Drawing on capabilities from UofL's schools of medicine, dentistry, nursing, social work and education, and operating in affiliation with the School of Public Health at the University of Kentucky, the institute is noted for its academic, research and educational excellence.

While strong public health research programs were forging ahead, UofL was in 2000 awarded an Integrated Advanced Information Management Systems grant from the National Institutes of Health to create a cooperative, integrated data-sharing environment across the Louisville Medical Center.

"Five independent organizations in the LMC cooperated on the project," says Pete Walton, M.D., SPHIS acting associate dean for health information sciences. 

UofL, University Hospital, Jewish Hospital, Norton Hospital and University Physicians Group studied different projects to maximize the use of health information and technology.

"We set up health-information sharing experiments in clinical care, research, education, management and infrastructure, community health and consumer health," Walton continues. "Research quickly rose to the top."

By early 2001, plans for a new school that would combine health information sciences and public health were under way. Two events put those plans on the fast track.

In 2000 the Institute of Medicine published its report, "To Err is Human: Building a Safer Health System," which was followed in March 2001 by "Crossing the Quality Chasm: A New Health System for the 21st Century."

The SPHIS was being built to address the implications of the very issues raised in the institute's reports -- that quality health care is the result of a working care system, not individual care-givers. Thus, advanced systems research is needed to effectively bring change.

Then came September 11, 2001, and the anthrax scares that followed. As it happens, the leaders of the developing SPHIS also are the regional experts in bioterror detection and response. 

By the end of October that year, the Center for the Deterrence of Biowarfare and Bioterrorism was formalized at UofL and housed in the new SPHIS, which also absorbed the UofL Institute for Public Health Research, the Integrated Advanced Information Management Systems function and the Clinical Research, Epidemiology and Statistics Training program, also known as CREST.

The overarching theme to all functions of the SPHIS is the full integration of applied information sciences and technology with health sciences and epidemiology. In most cases, the goal is to maximize the efficiency and accuracy of computational functions in order to minimize the potential effects of human error and delay that can overload the system.

Such systems research and monitoring improve the health care industry's ability to treat all patients and diseases more effectively, whether it's a run-of-the-mill upper-respiratory infection or something more ominous.

"We can and do train people to recognize the symptoms and manifestations of a bioterror event," explains Walton. "But you have to have it on your mind to see it. Even for the best-trained physicians, 99.9 percent of the patients they see with respiratory symptoms are not victims of bioterror. Over time awareness declines.

"We are developing methods from a systems standpoint to help primary care physicians keep such things at top of mind."

Top-notch disease surveillance

The school, like any new entity in an emerging field, puts a great amount of effort into defining the breadth and depth of its work and differentiating its goals and structures from that of more traditional schools of public health.

The first step in the process is to establish the terminology, which is still used differently among the leaders in the field.

According to Walton, health information sciences -- which in the broadest terms is the application of information in the health sciences, including clinical care, research and education -- is the umbrella term under which all other health computational functions work.

Bioinformatics, considered by the Louisville team to be a widely overused term, is the general application of computational technology to biological research in real time. Health informatics is the study of how information or databases are used in health research and the health industry. Traditional biostatistics, the analysis of mass biological data, is vitally important and plays a key role in determining population health.

Harnessing expertise in all aspects of health information sciences is key to conducting top-notch disease surveillance. The goal, according to Clover, is to be able to characterize the health status and disease prevalence in the community at any given moment in time.

With a reporting system that complies with the Health Insurance Portability and Accountability Act while combining and normalizing laboratory, physician office, hospital and pharmacy data, the SPHIS team plans to lead the nation in detection capabilities and disease trend analysis.

"We used to depend on manual forms that had to be mailed in or hope that an overworked family medicine physician remembered to call the health department about a potential suspicious case," McKinney explains. "With the new system, we will bypass human delay."

The system, now being expanded in cooperation with the Commonwealth of Kentucky, was demonstrated to be successful in 2002 when the SPHIS was the first center to successfully share immunization data in a specified electronic format directly with the Centers for Disease Control and Prevention.

Of most interest to the CDC and public health officials across the country is that the data were shared in an instantly usable format, with no computational translation or refiguring necessary.

The systems being integrated and expanded in Louisville -- the Electronic Public Health Record System and the Health Research Data System -- allow the SPHIS faculty, in cooperation with local and state public health officials, to conduct monitoring and surveillance of the population for trends, outbreaks and covert acts of bioterrorism in two ways.

First, the team can check for patterns of unusual symptoms or treatments that may raise eyebrows when seen from a system perspective. That is, combining data from laboratory tests, pharmacy activity and hospital admissions may indicate the presence of a disease that public health authorities wish to investigate -- even if there is only one suspicious case.

Second, a team led by Walton specializes in acausal detection, a process that Walton refers to as "peripheral vision for the health care system." In basic terms, a pattern of health care behavior in the community is established, after which changes in the pattern can be identified and investigated.

"We don't necessarily know what has changed at first," Walton explains, "we just know that there is a shift in the usual configuration."

To illustrate the theory, Walton tells the story of his grandfather, who retired to a home overlooking the Ohio River and passed the time watching barge traffic. 

"After about five years, he could predict changes in the economy with a high degree of accuracy -- especially changes related to coal and aluminum -- simply by tracking changes in the pattern of barge traffic.

"At first, he didn't know what changes were significant or what they might mean. But by investigating changes, he was eventually able to distinguish and identify meaningful shifts in the pattern, and was able to advise my father to make wise investments."

In a time of heightened concern over potential bioterroristic threats, the ability to detect changes at such an infinitesimal level is invaluable.

"Bioterrorists aren't likely to act in an expected, obvious way," Walton notes. "They spend a lot of time planning the element of shock and surprise. In our work, we may have 99 false alarms out of 100 pattern changes that we investigate.

"In order to properly protect ourselves from malicious action, we need to be committed to continue the study of every alarm."

War on bioterrorism

UofL's history in the war against bioterrorism dates back to 1998, when UofL microbiologist Ron Atlas, Ph.D., and pathologist Jim Snyder, Ph.D., quickly determined that a letter sent to a local clinic claiming to contain anthrax was a hoax.

Federal authorities were impressed at the speed of the determination and the level of cooperation between UofL faculty, local hospitals, the health department and the FBI.

"Our ability to efficiently show that the letter did not contain anthrax indicated that our community could effectively respond to an attack," Clover says.

Following that event, representatives from all likely first-responding and coordinating agencies began meeting on a monthly basis to plan response strategies. Calling themselves "The Group," they have quietly helped Louisville become one of the most prepared cities for a potentially catastrophic attack.

Not only has Louisville consistently scored well in "table top" mock bioterror exercises led by the CDC, but in 2002 -- just months after the formalization of the Center for the Deterrence of Biowarfare and Bioterrorism -- the CDC designated UofL as one of seven national specialty centers for public health preparedness.

According to Sen. Mitch McConnell, who has secured nearly $3 million in funding for the center, "The designation means that the school's talented researchers will be on the front lines in protecting our communities."

While a great deal of bioterror planning and preparation have occurred over the last five years, Clover admits that UofL was "fortunate enough to have multiple experts who just happened to be here."

Those experts include Atlas, immediate past-president of the American Society of Microbiology, dean of the Graduate School and co-director of the center; Clover, center co-director and liaison member of the CDC's Advisory Committee on Immunization Practices; McKinney, a former CDC Epidemiology Intelligence Service officer and member of the Advisory Committee on Immunization Practices; and Snyder, adviser to the commonwealth on laboratory preparedness for bioterrorism and a colonel in the U.S. Army Reserves 330th Medical Brigade.

Working together, the team is conducting research to establish new thresholds of disease suspicion and creating new ways to educate providers and regularly reinforce the message through ground-breaking systems management.

Public health's 'next generation'

The School of Public Health and Information Sciences is a prime example of a unit that successfully supports the education and research missions of the university.

The education of bright young minds is still the most highly held value among the school's faculty and leadership. The research and service components are considered to be indispensable elements of that education.

"Our educational mission is multi-tiered," Clover explains. "We are graduating very knowledgeable and well-trained traditional public health officials. But at an equal or greater rate we are also graduating clinicians with a greater understanding of research and epidemiology and, hopefully, the next generation of public health researchers and educators."

The CREST program in particular is a hotbed of academic activity. Traditionally used as a mechanism to identify and train the brightest medical residents in outcomes and translational research in preparation for future faculty positions, all CREST trainees must have a grant proposal in hand upon completion of the program. Since 2001, CREST trainees have obtained more than $3.5 million in research funding.

Carlton Hornung, Ph.D., M.P.H., director of the CREST program and acting chair of the Department of Epidemiology and Clinical Investigation Sciences, is constantly updating the curriculum and enjoys seeing the trainees benefit from the interactions between the health sciences schools.

"When resources are scarce, you can cut back or look for new and better ways to do things," Hornung says. "We choose to innovate. This is where innovation in clinical research education should happen."

In fact, SPHIS faculty collaborate with their counterparts in each of the other schools, providing high-level research support and educational opportunities from single courses to full joint-degree programs for students in nursing, dentistry and medicine.

The sense that SPHIS students and faculty are building a program from scratch like no other creates a culture of determined success, open collaboration and boundless opportunity.

"We're very non-traditional," McKinney emphasizes. "We are designing our school from the ground up to incorporate the newest components into the system. We are training people to utilize advances in communications, systems sciences, data analysis and decision sciences to make the best choices with the best outcomes."