Public health reporting flaws spell trouble

Doctors complain about requirements that appear to lack follow-through.

By Victoria Stagg Elliott, amednews staff. April 22/29, 2002.

When Karen Smith, MD, medical director of the San Francisco Health Plan, tries to alert the local health department to the occurrence of any one of the numerous medical conditions she is required by law to report, it is not an easy process.

First, she has to fill out a card, but the card doesn't specify the address where it should be sent, so she has to look that up. The form also asks questions that aren't always appropriate to the condition she is reporting. Finally, this official piece of paperwork is so small that it is easy to lose.

A system that needs fixing
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Nonetheless, she takes the time to do it and send it in, and then -- as far as she knows -- nothing happens.

"It's the most backward system. It's broken," she said. "They don't make it easy. You send [the card] in and you never hear back. It just goes into a black box. I don't know if I did it right or even if it matters."

As far as most physicians are concerned, the public health disease reporting system needs urgent repairs. They complain about long lists of diseases that they can't keep track of, awkward reporting systems, unanswered questions about confidentiality, little feedback and few rewards for sharing information. Doctors often don't know if the information was even received.

In addition, most local health departments have limited money to do contact tracing, so people who may have been exposed to an infectious illness don't always get tracked down for treatment. Therefore, physicians don't see any positive results from their efforts. And, although there are penalties for not reporting, punitive action is almost never taken. In addition, reporting sometimes falls through the cracks because it's not clear whose responsibility it is.

Public health officials say only 50% of reportable diseases are actually reported.

"Physicians really don't want to participate in systems they don't feel a part of," Dr. Smith said. "Practitioners are mandated by law to be doing this stuff, but it's the last thing that comes to your attention unless it's really a life-threatening situation."

Reportable diseases and systems vary widely from state to state, although each state requires at least some information to be filed. Most public health officials believe that only about 50% of reportable diseases are actually reported. This number improves when laboratories are also required to submit specific infection information. Reporting is also more complete when handled by specialized clinics and larger health systems that have an infrastructure in place to facilitate the process.

A study in a March issue of Morbidity and Mortality Weekly Report found that large managed care organizations' reporting rates for chlamydial infection and gonorrhea ranged from 64% to 98%. The system with the highest rate required the laboratory to alert the health department and the patient's physician at the same time. The organizations with lower rates relied on infection control specialists and physicians to do the notifying.

Those in the public health system are diplomatic. They talk about more education concerning the ins and outs of disease reporting. They talk about partnerships between public health and medical systems that would create an environment that facilitates disease reporting, treatment and control. And they say the current reporting rates are good.

"There is room for improvement, but in no case was the completeness or timeliness terrible," said Kathleen Irwin, MD, MPH, chief of health services research in the Division of STD Prevention at the Centers for Disease Control and Prevention.

But those who are no longer in the public sector are much less measured in their opinions -- particularly regarding questions of timeliness.

HMO reporting rates for chlamydial infection and gonorrhea range from 64% to 98%.

The MMWR article, for instance, found reporting times ranging from one day to more than a year. The average was between two and three weeks.

"To really be effective, you need 100% reporting and as promptly as possible, with six days as the gold standard," said Richard Levinson, MD, DPH, associate executive director of the American Public Health Assn. "A report that arrives after a year is nearly totally useless, and three weeks is hardly rapid. We've got a long way to go, and we've got to start working on it today."

But despite the apparent clash between the public health community and physicians on this issue, there is a great deal of concern by both parties. The bottom line: An ineffective reporting system makes it very difficult for public health officials to control outbreaks of any sort.

"The medical support system and the public health system are very fragile," said George Pankey, MD, director of infectious disease research with the Ochsner Clinic Foundation in New Orleans. "You're not going to see a lot of improvement without more money put into it."

Public health officials say the MMWR study reinforces the concept that more formalized reporting systems are needed. And many physicians agree. Jonathan Schneider, DO, director of adolescent medicine at Nemours Childrens Clinic in Orlando, Fla., spent 20 years in the U.S. Navy working within structured infection control systems. Now in private practice, he admits that no such processes exist and, therefore, requirements seem less efficient and more difficult to complete.

"If I have an STD in my clinic, if I don't remember to report it -- which is hard most of the time -- it doesn't get reported," Dr. Schneider said. "Unless there a mechanism in place, it's not going to happen."

There are many questions about exactly what form of reporting systems would be the most effective. Laboratory-based approaches work very well. But critics complain that they leave physicians out of the loop.

"It would break the bond between public health and physicians, and that bond is often very tenuous but very important," Dr. Levinson said.

And though many public health officials say electronic medical records would reduce reporting times and increase accuracy, there is a degree of physician resistance. Concerns range from confidentiality issues to how difficult such systems would be for physicians to learn and use.

"The downside to electronic medical records is that not everybody has them, and the learning curve can be tremendous," Dr. Schneider said. "We are years away from that."

ADDITIONAL INFORMATION:

A system that needs fixing

Here's what ails the public health disease reporting system:

Reporting systems vary widely from state to state.
The list of reportable diseases is too long to keep track of.
Reporting procedures are frequently awkward.
Doctors don't know what happens to the information once submitted.
Public health departments frequently don't have funding to conduct contact tracing so physicians don't see any benefit to reporting.
Penalties for not reporting are not enforced.
Questions of confidentiality have not been fully addressed.

Weblink

Article, "Reporting of Laboratory-Confirmed Chlamydial Infection and Gonorrhea by Providers Affiliated with Three Large Managed Care Organizations --United States, 1995-1999," MMWR, March 29 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5112a2.htm)