By Allison Viola, MBA, RHIA, and Noah Goldstein, PhD
Extreme weather events are becoming increasingly common in the United States and around the world, from chronic, long-term events like droughts to acute, seasonal events like wildfires and floods. As these events continue to increase in frequency and severity, America’s healthcare infrastructure and its ability to deliver quality care will continue to be impacted in ways beyond its original limits.
Extreme weather events, while not new, challenge the physical and operational infrastructure that supports our healthcare system—and yet are often minimized and treated as local problems.
While the acute impacts of natural disasters—casualties, damaged infrastructure, disruptions to people’s daily lives, and negative impacts for businesses—are top of mind in the wake of natural disasters, extreme weather events also exacerbate chronic health conditions such as asthma, expand the range of infectious diseases, and have a negative impact on mental health.1 Over the long term, these events may also trigger persistent health risks that will develop long after the event occurred. Perhaps synthesizing and analyzing patient data with climate data will be the key that unlocks the answers on how our healthcare delivery can prepare for and better serve our population as these changes take place.
According to the Centers for Disease Control and Prevention (CDC), climate change impacts a wide range of health outcomes. Figure 1 illustrates the most significant climate change impacts, their effect on exposures, and the subsequent health outcomes that can result from these changes in exposures.
However, the connection between extreme weather events and long-term health effects is not the focus of the data and information systems supporting the healthcare infrastructure. To mitigate and prepare for what may be considered the “new normal” in care, we must have a better understanding of information that is collected.
In tandem, there needs to be greater clarity as to how health information management and other informatics professionals are preparing for long-term weather event impacts of climate change—if they are preparing at all. To become better prepared for these impending changes, leveraging and synthesizing health, climate, community, and other sources of data to analyze and develop solutions is necessary.
Three to five months after the 37,000-acre Tubbs Fire in the Napa and Sonoma Valleys of California that took place in October 2017, the region’s emergency rooms treated approximately 20 percent more patients for respiratory and cardiac ailments compared with previous years, according to the state data analysis.2
At the time, the Tubbs Fire was the most destructive in California history, killing 22 people and destroying nearly 6,000 structures.3 These respiratory and cardiac issues will persist locally in the region, yet there is no explicit way of connecting the illnesses to the wildfire just yet. There is currently a lack of comprehensive longitudinal research that monitors health conditions and their relationship to persistent severe weather changes.
As we continue to experience a changing climate worldwide, people may be exposed to more vulnerabilities and require more attention from their healthcare providers. With the cycle of rising temperatures, persistent extreme weather events, rising sea levels, and degradation of air and water, quality healthcare organizations will need to prepare for the changing needs of their patient populations, healthcare workforce, medical supplies, pharmaceutical supplies, telemedicine capabilities, and community health service offerings. Research indicates that there is an absence of data and corresponding analysis regarding weather events as it relates to impacts on health over the long term. While providers have known anecdotally there is a need to conduct long-term studies, they acknowledge that now is the time to make a concerted effort towards collecting and studying the data, according to Walter Suarez, MD, MPH, public health and medical information systems specialist and executive director of health IT strategy and policy for Kaiser Permanente. This effort will enable healthcare organizations, communities, lawmakers, and public health experts to make informed decisions on determining a longer-term path forward. For example, as wildfires persist in California and the seasons extend for longer periods of time, providers will need to prepare a shift in their workforce and medical supplies for an increase in cardio-respiratory patients, infant and maternal mortality, asthma in children, and behavioral health needs.
Overview of Recent Wildfire Disasters and Impact
The 2018 Camp Fire in Paradise, CA, was a significant health event, killing 85 people and causing over 52,000 people to be evacuated. However, the health impact of the fire spread hundreds of miles away, causing school closures as far away as the San Francisco Bay Area, home to over 7 million people. Its long-term health impacts are sure to be seen, as well as the mental health impact for those who were evacuated or lost their community to the fire. These types of occurrences have expanded beyond California and beyond just wildfires. Given the breadth of the area impacted by the Camp Fire, the true scale of the impact on the healthcare infrastructure in California is unknown. What makes this more challenging is the siloed nature of natural disaster data and health data, and the inability to seamlessly communicate information across the country. Pairing health data with climate data and weather data, and possibly other data sources, will enable preparation and assessment of those high-impact areas and populations and help drive more effective care management for the long term.
Another complication is the uncertainty of when extreme weather events will occur, and most healthcare systems are focused on maintaining fiscal responsibility and not necessarily planning for events they are unable to predict. Standardizing how healthcare systems can forecast and plan for extreme events is a necessity but putting this process into place is no small task. Organizational obstacles in the public and private sector need to be removed and the importance of this challenge must be elevated in multiple public service communities.
Authorized by HR 6 on January 9, 2019, the US House Select Committee on the Climate Crisis was charged with “delivering ambitious climate policy recommendations to Congress, in order to achieve substantial and permanent reductions in pollution and other activities that contribute to the climate crisis.”5 Chaired by Rep. Kathy Caster (D-FL), the committee members include experts in environmental justice, coastal flooding, clean energy development, and other areas vital to addressing the climate crisis. In a short time, the committee has helped to support the passage of several key bills addressing climate change activity, to secure critical funding, and to conduct over 100 hearings, several of which were hosted by the committee. In early 2019, Sen. Chuck Schumer (D-NY) introduced a resolution to establish a similar committee within the Senate, but the resolution did not advance.
According to Lauren Riplinger, JD, vice president, policy and government affairs at AHIMA, getting any bills passed into law in 2020 will be difficult, as “there are many competing issues such as the Coronavirus Disease 2019 (COVID-19) pandemic, the upcoming election, not many working days left in Congress before the end of the session, and several competing healthcare issues that are resonating with both sides of the aisle right now, such as surprise billing and prescription drugs.” She anticipates that if the Senate flips to a Democratic majority in the new Congress, there may be opportunities to make some progress in climate change laws. However, there will still need to be a president who supports signing bills into law to make any progress.
Historic Event Spurred Environmental Action
The connection between extreme events and long-term health is not new. One of the deadliest air pollution disasters in US history occurred over Halloween in 1948. In Donora, PA, a small town on the Monongahela River approximately 30 miles south of Pittsburgh, 20 people died from what is now known as the Deadly Donora Smog of 1948.6 In the early 1900s, Carnegie Steel, American Steel & Wire Company, and others joined the industrial revolution and replaced farming communities with mills. The mills’ furnaces produced combinations of poisonous gases, heavy metals, and fine particulate matter. Shortly before Halloween, a dense yellow fog blanketed the town, creating a haze so thick that townspeople were barely able to see in front of them. Within days of the arrival of the fog, 20 people were dead and hundreds more with respiratory or cardiac problems were advised to evacuate the city to avoid potential death. From 1948 to 1957, the rate of death from cancer and cardiovascular disease in Donora was significantly elevated.7 It wasn’t until rain arrived on the fifth day of the fog that it dissipated. If not for the rain, experts believed thousands more would have perished.
The Donora Smog incident sparked an interest in public health that elevated research beyond investigating epidemics such as polio or cholera. It ushered in a new era of focusing on chronic exposure to pollutants and their health impacts and initiated the first national air pollution conference in 1950, convened by President Truman. The Clean Air Act wasn’t passed until 1963, but President Nixon created the Environmental Protection Agency shortly after in 1970. Today there is a need for renewed attention to long-term health events and extreme or unpredictable weather events, just as resources were applied to identify and implement solutions to safeguard public health from extreme events in the past. With the capability to integrate diverse and disparate data streams with adaptable data privacy and governance approaches firmly within reach for US data scientists, developing a consistent approach to connect extreme weather events with long-term health impacts would, in essence, cast a light on this current blind spot in the country’s delivery of care.
Implementing Change in Health Systems
A good methodology for creating the connection between extreme weather events and the impact to healthcare systems and care delivery would be to use the “Plan-Do-Study-Act” (PDSA) approach, as recommended by the Institute for Healthcare Improvement.8 This system enables one to test and implement change in a structured system. While the concepts of “extreme weather events” and “long-term impacts on healthcare delivery” are large and vague, it is important for all those working in these systems to test and observe how these two concepts can interact.
Below is an example of how the interactions can be tested or observed using the PDSA approach:
- Plan: In this phase, one sets the boundaries of investigation. For example, one can look to investigate the interaction of flooding on long-term mental health impacts and communicable diseases in a certain region over a given time. Ideally, individual health systems will choose a specific impact over a specific time, so as not to overwhelm the implementers.
- Do: In this step, one carries out an investigation, testing the data availability and associated concerns. The responsible party tracks the extreme event and gathers data associated with that event, tracks the associated health impacts, generates hypothesis of correlation and causation between the events and the readiness of the healthcare system to provide adequate care, and validates the observations with on-the-ground local weather and health experts. It is also possible to do a historical evaluation, using past events as a marker.
- Study: Reflecting on the preparedness of the health system, investigate the ability to inform the connection using data. The investigator observes which data were available and which were not relative to the ideal data set, observes what challenges existed or will exist in data format, transfer, availability, and governance. In addition, one would determine how the key stakeholders understand both the connection between the event and the health effects, and the data challenges associated with them.
- Act: In this final stage, one asks, “How can systems be put in place to prepare for future extreme events?” It is essential to determine what agreements need to be put in place between key public and private stakeholders, what physical (or virtual) systems need to be put in place in order to store and manage data, and how current systems of early warnings of both natural disasters and health event outbreaks better incorporate data. Lastly, one could identify which kinds of alarms or alerts are needed for each major stakeholder group.
The PDSA approach is intended as an iterative cycle. Solving or event identifying the connections between health systems and extreme weather events will not be complete in one iteration of the cycle. We are in the early stages of observing and managing long-term impacts from climate change; we will need to address these issues with an ongoing process.
Connecting the Dots to Prepare for the Future
Connecting the impacts of extreme events to long- and short-term healthcare challenges is becoming an increasingly important step for the healthcare industry to undertake. Incorporating the data and forecasting the impacts of those events is a new challenge, but adequate preparedness is imperative to maximize the efficacy of the system. With improved forecasts, communities and state health systems can be better prepared, both logistically and fiscally, to shoulder the outsized burdens they must take on. It is time for governments, healthcare systems, and their data providers to recognize the connection between the changing landscape of natural disasters exacerbated by climate change and the health impacts they can trigger. The PDSA methodology is well-suited for testing the connections between extreme events and the preparedness of local healthcare infrastructure. Through common data models, consistent data governance, and the deployment of state-of-the-art information systems, the public and private health systems can be better prepared for uncertain health impacts, saving millions of dollars—and lives—in the process.
- Chen, Alice and Vivek Murthy. “How Health Systems Are Meeting the Challenge of Climate Change.” Harvard Business Review, September 18, 2019. https://hbr.org/2019/09/how-health-systems-are-meeting-the-challenge-of-climate-change.
- “The Wildfire Generation: How the Lasting Negative Health Effects from Fires’ Smoke Will Affect Today’s Children.” California Healthline, November 29, 2018. https://californiahealthline.org/morning-breakout/the-wildfire-generation-how-the-lasting-negative-health-effects-from-fires-smoke-will-affect-todays-children/.
- Glantz, Aaron and Susie Neilson. “The smoke’s gone, but hearts and lungs still may be in danger months after wildfires.” Grist, December 3, 2018. https://grist.org/article/the-smokes-gone-but-hearts-and-lungs-still-may-be-in-danger-months-after-wildfires/.
- Centers for Disease Control and Prevention. “Climate Effects on Health.” September 9, 2019. https://www.cdc.gov/climateandhealth/effects/default.htm.
- US House Select Committee on the Climate Crisis. “Who we are.” Accessed December 10, 2019. https://climatecrisis.house.gov/about.
- Boissoneault, Lorraine. “The Deadly Donora Smog of 1948 Spurred Environmental Protection—But Have We Forgotten the Lesson?” Smithsonian Magazine, October 26, 2018. https://www.smithsonianmag.com/history/deadly-donora-smog-1948-spurred-environmental-protection-have-we-forgotten-lesson-180970533.
- Institute for Healthcare Improvement. “Plan-Do-Study-Act (PDSA) Worksheet.” http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx.
Continuing Education Quiz
Review quiz questions and take the quiz based on this article, available online by 5/8.
- Quiz ID: Q2029105
- Expiration Date: May 1, 2021
- HIM Domain Area: Clinical Data Management