Impact of SARS on the Chinese Health Information System

Liu Aimin

Abstract

Since the first case of SARS was found in Guangdong province of China in 2003, it was soon found in over 30 countries. Beijing was one of the most severely affected cities. In fighting SARS, we have gained a lot of experience. At the beginning, SARS was not recognized as being so tough and harmful to humans and, because it was a new disease, it was not included in the list of infectious diseases reporting system. When it broke out, people were in a great panic because the health information system was not working smoothly. A normal report system of infectious disease did not start, and the logistic support system was not effective. Finally, the Chinese government and the Health Ministry organized to fight against SARS with all its efforts. The public recovered soon from its panic. We won this special war without guns and bombs.

Key words: SARS, Beijing, medical record, health information

Introduction

On November 16, 2002, the first case of SARS (severe acute respiratory syndrome) was found in Guangdong Province. It was soon found in over 30 countries. China was one of the countries suffering from SARS. It struck almost all Provinces and autonomic regions and cities directly under the Central Government. Among them, Guangdong, Shangxi, Neimenggu, and Beijing were the most affected areas. According to the report on June 23, 2003, there were 5,326 diagnosed cases; 1,002 of them were medical workers, and 347 people died.

During the top period of the SARS attacks, over 100 cases a day were received in hospitals. In those days, fewer people walked in the streets, hotels were empty, there were more sellers in shops than customers, and the number of outpatients dropped down to the lowest in its history of many hospitals. SARS affected everyone's normal life. A lack of co-coordinated action among different departments, no good information reporting system, and lack of a properly functioning emergency response mechanism led, in the beginning, to misreporting and inaccuracies concerning the number of SARS cases. This, in turn, led to rumour and counter-rumour and eventual public panic. SARS resulted in a great financial loss for China. SARS taught a lesson to the Chinese government, to hospitals, and to everyone in China.

The Role of Health Information in SARS

Today, everyone accepts that we are in the information age. All social activities rely on information. If we receive wrong information, we may make a wrong decision. Information is the guarantee of social order, the soul of an enterprise's business. Today, when we summarize the experience from SARS, we realize that we should set up a system for an emergency response mechanism. This system should include, at least, an information system, medical care system, transportation system, and logistic support system. In spring 2003, SARS was out of control due to incorrect information. It made the people so nervous. What we learned from the event of fighting against SARS on our information system is described below.

Not immediately starting the infectious disease reporting system. Today, everyone thinks that SARS is an infectious disease, but it took quite a long time to announce it should be reported. Furthermore, when SARS came, we started a new reporting system by doctors and the medical affairs office instead of the normal infectious disease reporting system by doctors and statisticians; a mature system of reporting infectious diseases. For example, we have been reporting HIV, viral hepatitis, and so on to the CDC (Chinese Disease Control) for many years, and it has been going smoothly. The workflow of the report system is that physicians fill out an infectious disease card once they find a case of infectious disease, then, a statistician will report to CDC according to the card. A second check on the reporting systems is performed when medical record staff checks every discharged record. If they find an infectious disease case, they ensure that it has been reported to CDC. A third check involves the doctors responsible for the record quality assurance; they will check once again. These lead to less misreporting of infectious diseases. This time, however, SARS cases were only 5,000 and what a mess we had. If we had immediately taken it as an infectious disease and adopted the infectious disease reporting system, we may have avoided such a disaster.

Duplication of reports.   In the reported cases of SARS, we found that some were actually common pneumonia and other infectious diseases. Another phenomenon was that some cases were reported repeatedly. When people became aware of SARS' seriousness, some related authorities asked hospitals to report. Not only the CDC, but also the government, the health authority, and the health information management department hoped to get some information from hospitals. In Beijing, at least three departments required a SARS report and each report form had different items. The three departments were the headquarters of the SARS Control Center, the Beijing CDC, and the health information department of Beijing Health Bureau.

On the frontline working with SARS, everyone wore three masks, three isolated dresses, and three gloves. To stop air circulation infection, air conditioners were all turned off. It was warm in clinic rooms and hard to breathe for medical staff. A system of six hours of work time was put forward. In such situations, the main tasks for the medical staff were caring for patients, not filling out forms. As more attention was drawn to SARS, staff were asked to complete more forms. Some items on the information forms were complete duplication. Figures did not match because they came from different channels.

No good use of the modern equipment and network.   From daily reports, we found that SARS happened mainly in cities. With computer science development, quite a lot of hospitals in cities are connected to the Internet. In this outbreak of SARS, no standard electronic SARS forms were designed and no authorities asked for Internet reporting of SARS. Some hospitals collected SARS information by fax through fever clinics or SARS wards. Then, staff added the numbers with pen and paper or entered them into computers. The numbers were faxed to related departments of the authorities. It not only wasted time, but may have resulted in duplicate reports. If we could make good use of computers and Internet technology, the information would be more accurate and timely. It would be good for commanding and removing the public panic and emotion.

Medical records pasteurization. Eventually, SARS records were delivered to medical record departments. Before assembling, indexing, and filling, we had to pasteurize them. According to practical experience, using microwaves will damage the paper records and using anprolene will blur handwriting characters. The Beijing Bureau of Health put forward a method of using 15 percent peracetic acid liquid 7-20ml/m3(1-3g/m3) steaming for two hours. This mixture needs to lay on every page. This was really difficult to put into action. In theory, the SARS virus will die in two weeks in a ventilated situation. Most hospitals just put the records aside and dealt with them after 3 weeks.

No standard forms for SARS. After the SARS event, many doctors felt pity while they studied the records and found quite a lot valuable information missing. Each hospital had its own forms for SARS but no standard ones. For further study, Beijing Health Bureau has scanned all SARS records, but it is time consuming to abstract the valuable data.

Solutions

Establishing a SARS information system. From WHO, we know that SARS was attacking humans in the Winter of 2003 and the Spring of 2004. From a prevention aim, the Health Ministry has designated a research project of SARS records and information system to the Chinese Medical Record Association attached to the Chinese Hospital Association. The research will be finished at the end of August of 2004. The research will collect SARS records from some severely affected areas, compare the content of the forms, and extract common, valued items that will be suitable for each level of hospital use. It should include epidemic information, clinical information, and managing information. It is also concerned with reducing doctors' writing work.

The basic methods of research are:

• Collecting SARS forms in a few severely affected areas
• Organizing epidemiologists to study the content of the epidemic part of medical record
• Organizing Health Information Managers to study the management of the health information
• Organizing the medical staff that had been in the frontline of SARS to study the clinical information in medical records
• Trying out new forms by using the original SARS records
• Organizing computer technologists to study the electronic SARS record, meanwhile establishing a common drug database and common laboratory test database for SARS
• Establishing an electronic report system for SARS

Real name registration in hospital out patient clinic. In general, hospitals received a lot out patients because of the great populations in the mainland of China. For example, my hospital, PUMC hospital has 1,700 beds. We receive over 5,000 outpatients a day. Owing to hardware limitations, we have difficulty keeping a medical record for every outpatient. Two-thirds of the patients use a self-carried record system. This is a booklet that is kept by the patient.

When SARS came, we found that we had difficulty in following up patients who were covered by the self-carried records system. We are trying to find an effective way to control this portion of patients in the future. This is a system called real name registration system. For one-third of patients, they are already in the Patient Master Index when they register at the hospital. They are registered with their real name. Another two-thirds of the patients may or may not use their real names when registering in hospital. Even if they use their real name, we still have no tracking system to follow them because we retain no information on them. Now, we are developing a computer registration system, which is based on PMI, ID scanning, bar coding, tracer system, and computer registration. With it, we retain a patient's PMI, ID, even some pictures of them. There is no problem following up when we need to find a patient with a fever or suspected SARS. With this system, we can access information about the patient, such as which clinic he/she is registered with so that we can send the record to the clinic immediately. This system also solves our outpatient statistics problem and it is very good for hospital managers. We even rely on this to count doctors' rewards.

SARS was a great disaster for humans, but it could not beat us. We have learned a lot from the SARS event and found out a lot about the spirit of human beings. We are matched in fighting against SARS.