The Centers for Disease Control and Prevention is requesting $40 million in its fiscal year 2014 budget to build advanced molecular detection and informatics systems for tracking infectious disease outbreaks.
The CDC says it currently lacks the molecular sequencing tools and bioinformatics capacity to keep up with emerging threats like the antibiotic-resistant bacteria strains plaguing U.S. hospitals and the H7N9 influenza that recently evolved in China.
“CDC needs next generation diagnostics to find and stop killer microbes before they spread,” said CDC Director Thomas Frieden, MD, in a briefing on the proposal. “It used to take weeks to months to sequence a genome of a bacteria or virus.” Today’s technology — cousins of the same high-throughput sequencing tools bringing down the cost of humane genome analysis — “can do that in just a few hours,” he said, helping researchers identify pathogens and determine the scope of their resistance.
Investing in better systems now would reap dividends down the road, he said.
The advanced molecular detection proposal is envisioned as part of a modernization of state and national CDC informatics and genomics systems, with $40 million requested for systems modernization being part of a $432 million request for programs on infectious disease monitoring and prevention.
That $432 million would represent a $70 million increase over the fiscal year 2012 allocations (fiscal year 2013 is technically still being funded out in a piecemeal fashion, under the federal sequester) and about $51 million would come from the Affordable Care Act’s $18.7 billion Prevention and Public Health Fund.
Even though the agency’s proposed 2014 budget as a whole, at $6.6 billion, would be a $270 million decrease from fiscal year 2012, the CDC is trying to prioritize infectious disease tracking modernization at a time when infectious pathogens are growing more complex.
There are currently five potentially life-threatening microbes that are nearly resistant to all available drug treatments, notably the carbapenem-resistant Enterobacteria (or CRE) that kills nearly half of all patients whose bloodstream get infected with it, according to the CDC.
Bacteria like CRE and C. difficile have troubled for hospitals, where the aim for sterile environments, the coming-and-going of thousands of people and broad-spectrum antibiotic use have lead to persistent infection challenges. About 100,000 Americans die from hospital-acquired infections annually — compared to some 33,000 annual deaths from motor vehicle accidents and about 31,000 deaths from gun violence.
While hoping for Congressional funding to modernize monitoring systems to track and help thwart pathogens like CRE, the CDC is emphasizing the need for best practices at hospitals, as well as local public health and internal monitoring.
The CDC is also trying to expand its monitoring of foodborne pathogens, in an increasingly globalized food chain — with Illinois soybeans and pork being exported to China, for instance, and Europe importing Chinese strawberries, the suspected cause of a norovirus outbreak that affected some 11,000 German school children last October.
About 48 million Americans get sick from contaminated food each year, at a cost of $77 billion in healthcare costs and lost productivity, according to the CDC.
According to federal data recently sifted through by the Environmental Working Group, national sampling by the CDC, FDA and USDA in 2011 found high levels of some form of antibiotic resistant bacteria on 81 percent of ground turkey, 55 percent of ground beef, 61 percent of pork chops and 39 percent of chicken breasts, thighs and wings. About 10 percent of both the ground turkey and chicken samples had anitbiotic resistant strains of salmonella, and over 50 percent of the chicken samples had antibiotic resistant E. coli.
The CDC’s interest in better informatics for tracking and modern sequencing tools for identification is coming along with a sort of paradigm shift in medical thinking on infections.
As Vincent Fischetti, a professor of bacterial pathogenesis and immunology at Rockefeller University, told NPR’s Science Friday recently: “What we really need are diagnostics that will tell you as soon as you walk into the hospital what organism is causing the infection, and then you can use a very specific antibiotic to kill that organism. That way you avoid the whole problem of killing lots of organisms — which are really necessary for health and wellbeing, and cause other problems when you start destroying your whole flora.”
Commentary: Better communication for improved outcomes, reduced readmissions
Despite having one of the most technically advanced healthcare systems in the world, the United States continues to struggle with the most basic of tasks — efficient communication and care coordination amongst different providers.
Poor communication shows up most glaringly with readmissions which the Wall Street Journal recently wrote is “a vexing problem” that costs Medicare an estimated $26 billion every year and affects nearly one in five beneficiaries.
Transitioning a patient from the hospital to the home is a tenuous time and not enough focus is given to this seemingly mundane period in the care of a patient. As an orthopedic surgeon, I can state unequivocally that the post-hospitalization period is a vulnerable time that requires rethinking. The current mindset is to get the patient out of the hospital and hope their discharge follow-up magically works to transition them seamlessly into outpatient care. This couldn’t be further from the truth. Patients do not get what they need, and the lack of communication and coordination falls squarely on the hospital and providers.
Why readmissions cannot be ignored
A study by researchers at Yale and Columbia Universities of three million Medicare patients observed between 2007 and 2009 found that almost 25 percent of those with heart failure, 20 percent of heart attack patients and 18 percent of those with pneumonia were readmitted within 30 days, often for the same condition but also for a wide variety of other diagnoses. These numbers are staggering and, as the baby boomer population gets older, will continue to skyrocket unless we start to rethink how transitions of care are handled for patients moving from inpatient to out-patient.
Obamacare’s overall goal of slowing the growth of healthcare costs includes a major provision for reducing readmissions through a combination of better discharge planning and coordination, followed by better home-based follow-up and improved patient education. The provision’s goal is to encourage hospitals to better coordinate post-discharge care and it includes a number of rewards and penalties to drive improvement.
These penalties cannot be ignored — in 2012 alone “over 2,000 hospitals were penalized for readmissions at a combined cost to those hospitals of about $280 million.”
The need for transitional care teams
The solution is for hospitals to set up multi-disciplinary teams of care providers to help transition patients from inpatient to outpatient. Patients should be given a single contact, available 24/7 to guide them through this transition and not simply rush back to the hospital, where the emergency room defaults to the most conservative option, which is readmission.
Co-ordination within these teams, through better communication, is the cornerstone to their success in reducing hospital readmissions. With poor internal communication mechanisms comes an increased number of mistakes and potential delays in care being delivered, which can lead to longer inpatient stays and higher care costs. Additionally, poor communications leads to inefficiencies in the logistics of care delivery, reducing the efficiency of how medical resources, particularly human resources, are deployed.
In the treatment of complex conditions, any communication and coordination weaknesses will be further exacerbated, so it’s critical for the care delivery team to be fully in synch to deliver the highest quality of care to patients. By attacking communication weaknesses, physicians can provide more personalized patient care that both leads to better outcomes and reduces the potential number of patient readmissions.
The role of technology
Healthcare providers must embrace today’s user-friendly technologies to improve communication between care teams. But change itself is not always easy; especially amongst physicians who have spent years learning processes that utilize legacy technologies that many would avoid outside of the health care environment. With the consumerization of IT technology in our daily lives, most physicians have readily adopted newer technologies like iPhones and other ‘smart’ devices that provide simplified, efficient communications tools that are at odds with the legacy technologies they use in their professional lives.
Regulatory restrictions such as HIPAA can be seen by the health care community as a barrier to taking advantage of technologies, including text messaging, that hold great promise for improving the quality of care that they can deliver. But within this technology transition resides the biggest opportunity for the US health care system to improve the workflow of care delivery, patient outcomes and to reduce readmissions. The key to realizing this opportunity is finding solutions that allow doctors to jump onto this communication revolution, without abandoning the security and privacy controls that have become a bedrock foundation in the American health care delivery system.
EMRs were an important first step in creating a single repository of data that can supply a fountain of information. But now it is incumbent on health systems to embrace communication technology that allows EMRs to become more actionable.
Today’s tech-savvy patient
The patient — or customer — is often overlooked in the conversation around technology for improving care delivery. The customer in today’s US health system is demanding better, faster care at a lower price. While clinicians are as busy as they have ever been, today’s patients and the patients of tomorrow live in a hyper-world of instant gratification. These increasing patient expectations around efficient care delivery are putting even more pressure on the healthcare system to evolve so as to meet expectations.
Only with the adoption of new technologies to improve this care coordination will the American health care system be able to keep pace.
Andrew Brooks, MD, CMO of TigerText, founded Cardo Medical in May 2007, which was acquired by Arthrex in 2011. Dr. Brooks has been in the private practice of orthopedic surgery since 1994, specializing in sports medicine, arthroscopy and joint reconstruction. Brooks is board-certified by the American Board of Orthopedic Surgery and is a Fellow of the American Academy of Orthopedic Surgeons.
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