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TB Notes 1, 2000
TB Control in the Information Age
by Jose Becerra, MD, MPH
Chief, Computer and Statistics Branch
"TRS is a computer-based system devised to furnish
current information on clinical management of patients and up-to-date
statistical summary reports for public health administrative purposes."
- Tuberculosis Branch, State and Community Services
Division, National Communicable Disease Center, Sept. 1969.
Thus was recorded one of the first iterations of an electronic
information management system for the purpose of tracking the epidemiology
and clinical management of TB in the United States. The Tuberculosis
Record Service (TRS), a mainframe system using punch cards and computer
tapes for data processing, was a predecessor of the DOS-based SURVS-TB
(Software for Expanded Tuberculosis Surveillance). SURVS-TB, a microcomputer
system depending on mailed diskettes for data transfer, and the
Tuberculosis Database System (TBDS), a patient management recordkeeping
system, were used until 1998 when the Tuberculosis Information Management
System (TIMS) was implemented. Regardless of names and versions,
TB information management systems pursue the same general objective:
the use of meaningful data, that is, intelligence-added data, to
perform organizational work and monitor outcomes.
Image 1: Logo of the Tuberculosis Information Management System
TIMS is an integrated client-server application in Windows, meaning
that many users ("clients") may simultaneously access
a fully relational database residing in a secure server within a
computer network, using the Microsoft Windows graphics user interface.
TIMS has replaced the mailing of diskettes with dedicated modem
communications for data transfer purposes. Furthermore, TIMS allows
the generation of surveillance data from the patient management
module integrated within TIMS. Soon, TIMS will also be able to import
surveillance data from other systems to completely eliminate the
need for double data entry.
However, when TIMS was originally designed, the Internet revolution
that nowadays dominates the informatics world was just beginning.
The World-Wide Web model, wherein interactive and secure data transactions
are conducted using a common viewer or "browser," regardless
of the original platform in which an application is developed, poses
new opportunities and challenges to the future of TIMS. Among these
challenges are 1) the speed with which information technology is
being adopted (and abandoned); and 2) the call for fully "integrated"
The transition of TIMS into a Web-enabled application will eventually
occur. We can envision a local department of health, with a low-end
("thin") computer and a browser, logging in to a state
or regional server to securely send in interactively validated TB
data or to browse the results of some descriptive trend analyses.
We can also envision a health maintenance organization uploading
data on a batch of TB suspects and contacts to be worked up by local
health department staff. These data would be subsequently sent to
CDC without personal identifiers, using a commonly agreed-upon format.
However, the speed with which information technology is changing
many times hinders the wise selection of platforms, software development
tools, and practices that permit the design of durable and reliable
Web-based surveillance systems.
Image 2: A picture of a woman standing in front of a file drawer.
Old TB record keeping system.
The word integration is trendy nowadays. However, integration is
a value-laden term that may mean consolidation to some, as in block
grants, while it may mean coordination of efforts to others. TIMS
might be considered an integrated system: it integrates patient
management with surveillance data. And TIMS will become fully integrated
with other information management systems once its data import utilities
are completed and a new version is released complying with public
health, clinical, and laboratory informatics standards now in development
as part of the CDC-wide surveillance integration efforts. The future
of TIMS hinges on the assumption that TB will remain a categorically
funded program, possibly integrated with other disease-prevention
efforts in a patient-centered health care delivery model, but ultimately
accountable for its funding. Therefore, TIMS will reflect this funding
accountability by protecting TB data integrity and its proper use
for program evaluation purposes.
Our organizational mission is to promote health and quality of
life by preventing, controlling, and eventually eliminating TB from
the United States. Our National Strategic Plan calls for a reduction
of the TB case rate to less than one per million population by the
year 2010. Therefore, we need to leverage information technology
to manage, analyze, and synthesize practical knowledge at the local,
state, national, and international level to facilitate the organizational
work that will move us closer to that organizational objective.
Data are processed; information is managed; knowledge empowers.
Information becomes knowledge, and thus power, when systematically
structured and functionally organized for a specific purpose. But
there is one crucial premise in this line of reasoning: the existence
of an organizational will. An organizational will requires commitment
to accomplish a mission, and that commitment begins with a will
to know. Once that organizational will is present, and it certainly
is present in the TB prevention community, TIMS is and will be ready
to facilitate the organizational work that will move us closer to
achieve our organizational objectives for the year 2000 and beyond.