GAO Health Info Tech

Attachment H

United States Government Accountability Office

GAO

Report to Congressional Committees

November 2008

HEALTH
INFORMATION
TECHNOLOGY
More Detailed Plans
Needed for the
Centers for Disease
Control and
Prevention’s
Redesigned BioSense
Program

GAO-09-100

November 2008

HEALTH INFORMATION TECHNOLOGY
Accountability Integrity Reliability

Highlights
Highlights of GAO-09-100, a report to
congressional committees

More Detailed Plans Needed for the Centers for
Disease Control and Prevention’s Redesigned
BioSense Program

Why GAO Did This Study

What GAO Found

In 2003, the Centers for Disease
Control and Prevention (CDC), an
agency within the Department of
Health and Human Services (HHS),
developed an electronic syndromic
surveillance system called
BioSense that uses health-related
data to identify patterns of disease
symptoms prior to specific
diagnoses. In late 2007, CDC began
to redesign the program to improve
collaboration with stakeholders
and address identified management
weaknesses. Pursuant to House
Report 110-231, GAO evaluated the
BioSense program, focusing on the
cost and timeline estimates and
performance measures and
benchmarks for implementing the
program, among other objectives.
To accomplish this, GAO analyzed
relevant program documentation
and interviewed CDC officials
responsible for developing and
implementing BioSense.

While CDC identified annual and long-term cost and timeline estimates and
performance measures for the initial design of BioSense, these estimates and
measures did not reflect the implementation of its redesigned program. CDC
subsequently developed a draft plan for the redesigned program that
described high-level cost and timeline estimates; however, the estimates are
not reliable, and the plan did not include performance measures.

What GAO Recommends
GAO is recommending that CDC
develop reliable cost and timeline
estimates and outcome-based
performance measures for
implementing the redesigned
BioSense program. In written
comments on a draft of this report,
HHS stated it welcomed the
conclusions and recommendations
and provided updated information
about current efforts intended to
address the recommendations.

To view the full product, including the scope
and methodology, click on GAO-09-100.
For more information, contact Valerie C.
Melvin at (202) 512-6304 or
[email protected].

•

According to best practices, cost estimates should be well-documented,
comprehensive and accurate, and must be credible before they can be
considered to be reliable. However, CDC’s cost estimates for the
redesigned program are not reliable because they are only partially
documented, are not comprehensive and accurate, and therefore are not
credible.

•

Best practices for reliable timeline estimates include the identification of
resources to complete each task, establishment of a critical path, and
analysis of risks to the schedule. However, the agency has not
implemented these practices, resulting in timelines for the redesigned
program that are not reliable.

•

The Office of Management and Budget directs agencies to define outcomebased performance measures to gauge program results early enough for
stakeholder review, and industry experts describe the need for
stakeholder input in developing performance measures in order to
monitor performance. While CDC established performance measures and
benchmarks for the initial implementation of the BioSense program, it has
not yet developed outcome-based performance measures to monitor the
progress of the redesigned program and does not intend to complete their
development until the end of 2009.

Until program officials develop reliable cost and timeline estimates and
outcome-based performance measures for the redesigned BioSense program,
they will lack key components needed to effectively manage the program,
increasing the risk that the agency will perpetuate weaknesses identified in its
initial implementation of the program and related system.

United States Government Accountability Office

Contents

Letter

1
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

4
4
5

Appendix I

Briefing Slides

7

Appendix II

Comments from the Department of Health and
Human Services

78

GAO Contact and Staff Acknowledgments

81

Appendix III

Abbreviations
CDC
DHS
DOD
ESSENCE
HHS
NBIS
NHIN
OMB
RODS
VA

Centers for Disease Control and Prevention
Department of Homeland Security
Department of Defense
Electronic Surveillance System for the Early Notification of
Community-based Epidemics
Department of Health and Human Services
National Biosurveillance Integration System
Nationwide Health Information Network
Office of Management and Budget
Real-time Outbreak and Disease Surveillance
Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.

Page i

GAO-09-100 CDC’s Redesigned BioSense Program

United States Government Accountability Office
Washington, DC 20548

November 20, 2008
The Honorable Tom Harkin
Chairman
The Honorable Arlen Specter
Ranking Member
Subcommittee on Labor, Health and Human Services,
Education, and Related Agencies
Committee on Appropriations
United States Senate
The Honorable Dave Obey
Chairman
The Honorable James T. Walsh
Ranking Member
Subcommittee on Labor, Health and Human Services,
Education, and Related Agencies
Committee on Appropriations
House of Representatives
In 2002, President Bush signed the Public Health Security and
Bioterrorism Preparedness and Response Act, which required specific
activities aimed at improving the nation’s preparedness for bioterrorism
and other public health emergencies.1 In response to the passage of this
act, the Centers for Disease Control and Prevention (CDC), an agency
within the Department of Health and Human Services (HHS), developed,
in 2003, an electronic syndromic surveillance information system called
BioSense.2 In 2004, CDC established the BioSense program office to
improve the nation’s capabilities for conducting syndromic surveillance by
providing federal, state, and local public health officials access to existing
data from health care organizations across the country through use of the
BioSense system. In late 2007, the agency initiated efforts to redesign the
program to improve collaboration with public health stakeholders and to

1

42 U.S.C. § 247d-4(b).

2

According to CDC, syndromic surveillance is a technique that uses health-related data to
identify patterns of disease symptoms prior to specific diagnoses. Effective use of this
technique can provide both situational awareness—knowledge of the size, location, and
rate of spread of an outbreak—and early event detection, signaling a probability of an
outbreak sufficient to warrant a public health response and leading to early identification
of illnesses and other events of public health importance.

Page 1

GAO-09-100 CDC’s Redesigned BioSense Program

address management weaknesses identified in its initial implementation.
CDC’s National Center for Public Health Informatics is responsible for
managing the program.
Pursuant to House Report 110-231,3 we evaluated BioSense, focusing on
(1) the costs and benefits of operating the BioSense system as compared
to other state and local surveillance systems, (2) the usefulness of data
provided by the system to hospitals and state and local public health
officials, and (3) the cost and timeline estimates and performance
measures and benchmarks for implementing the program. We provided
subcommittee staff with preliminary results from our study on April 1,
2008, and subsequently agreed with your offices to continue our evaluation
of CDC’s plans for implementing BioSense, focusing on the annual and
long-term cost and timeline estimates and performance indicators and
benchmarks for implementing a redesigned program. On August 26, 2008,
we provided your offices with briefing slides that outlined the final results
of our study. The purpose of this report is to issue the published briefing
slides to you and to officially transmit our recommendations to the
Director of the Centers for Disease Control and Prevention. The slides,
which discuss our scope and methodology and incorporate edits made
since we initially provided the briefing, are included in appendix I.
We conducted this performance audit from October 2007 to August 2008 at
CDC’s headquarters in Atlanta, Georgia, in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on our
audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
In summary, our study highlighted the following:
•

The costs and benefits of using data from the current BioSense system and
other similar syndromic surveillance systems are difficult to measure and
compare. Further, public health and hospital officials with whom we
spoke said that because of the difficulty of doing so, they do not track the
costs and benefits of using syndromic surveillance systems.

3

H.R. Rep. No. 110-231, at 122 (2007).

Page 2

GAO-09-100 CDC’s Redesigned BioSense Program

•

Federal, state, and local public health officials expressed mixed views on
the usefulness of BioSense data as compared with the usefulness of data
from similar systems. While stating that they find the data from the
BioSense system useful to varying degrees, about half of the officials with
whom we spoke said that they rely on other systems as their primary tool
for syndromic surveillance. For example, officials with the Department of
Defense (DOD) stated that, rather than BioSense, the department’s public
health personnel use DOD’s Electronic Surveillance System for the Early
Notification of Community-based Epidemics (ESSENCE). In contrast,
Department of Veterans Affairs (VA) public health personnel do not
regularly rely on syndromic surveillance system data; however, they use
the civilian version of ESSENCE more often than BioSense. Both DOD and
VA officials stated that ESSENCE allows more flexibility in evaluating and
viewing data than BioSense.4

•

Although CDC identified annual and long-term cost and timeline estimates
and established performance measures and benchmarks for the initial
implementation of the BioSense program and its related system, these
estimates and measures did not reflect the implementation of its
redesigned program. CDC subsequently developed a draft plan for the
redesigned program that described high-level cost and timeline estimates;
however, these estimates were not reliable, and the plan did not include
performance measures.
•

According to best practices, cost estimates should be well-documented,
comprehensive and accurate, and must be credible before they can be
considered to be reliable. However, CDC’s cost estimates for the
redesigned program are not reliable because they are only partially
documented, are not comprehensive and accurate, and therefore are
not credible.

•

Best practices for reliable timeline estimates include the identification
of resources to complete each task, establishment of a critical path,
and analysis of risks to the schedule. However, the agency has not
implemented these practices, resulting in timelines for the redesigned
program that are not reliable.

•

The Office of Management and Budget directs agencies to define
meaningful annual and long-term outcome-based performance

4

DOD developed the ESSENCE system in 1999. A civilian version of the system is available,
at no charge, to any health department that wants to use the system locally.

Page 3

GAO-09-100 CDC’s Redesigned BioSense Program

measures to gauge the results of a program or activity early enough to
allow time for stakeholder review, and industry experts describe the
need for stakeholder input in developing performance measures in
order to monitor project performance. CDC has not yet developed
outcome-based performance measures to monitor the progress of the
redesigned program and does not intend to complete their
development until the end of 2009.
Until program officials develop reliable cost and timeline estimates and
outcome-based performance measures for the redesigned BioSense
program, they will lack key components needed to effectively manage the
program.

Conclusions

The costs and benefits of using data from the current implementation of
the BioSense system and other similar systems are difficult to measure
and compare, and public health and hospital officials with whom we spoke
do not document or track the costs and benefits of using these systems.
These officials also expressed mixed views on the usefulness of BioSense
data as compared to data from other systems.
While BioSense program officials have developed cost and timeline
estimates for the initial implementation of the program, they have not yet
reliably estimated costs and timelines for the redesigned program.
Additionally, program officials do not expect to complete the development
of outcome-based performance measures for the redesigned BioSense
program before the end of 2009. Until CDC develops these key
components of effective information technology program management,
BioSense officials will lack the management and planning tools needed to
gauge the success of the redesigned BioSense program in improving
federal, state, and local partners’ abilities to respond to public health
events and will risk perpetuating weaknesses identified in the initial
implementation of the program and its related system.

Recommendations for
Executive Action

To ensure that CDC defines reliable plans for effectively managing the
development and implementation of the redesigned BioSense program and
its related system, we are recommending that the Director of CDC instruct
the Director of the National Center for Public Health Informatics to take
the following three actions while in the planning phase of the redesigned
BioSense program:

Page 4

GAO-09-100 CDC’s Redesigned BioSense Program

Agency Comments
and Our Evaluation

•

develop reliable cost estimates for the program that are well-documented,
comprehensive and accurate, and credible;

•

develop reliable timeline estimates for implementing the program; and

•

with stakeholder input, develop outcome-based performance measures
that address all phases of the program and that focus the success of the
program on CDC’s federal, state, and local partners’ use of the system for
responding to public health events.

The Department of Health and Human Services’ Assistant Secretary for
Legislation provided written comments on a draft of this report. In the
comments, HHS welcomed the conclusions and recommendations
discussed in our report.
In its comments, HHS provided information about steps the department
has begun taking to address the conclusions and recommendations in our
report. In particular, the department stated that it has launched a planning
and implementation process to ensure that the program develops reliable
cost estimates and timelines and identifies appropriate outcome-based
performance measures. According to the department, among other
activities, the program has initiated working groups of internal and
external stakeholders to establish detailed tactical plans for projects,
tasks, deliverables, and resources. The department stated that it intends to
use the tactical plans to derive future cost and timeline estimates and
involve stakeholders in establishing outcome-based performance
measures. It added that a program plan for the redesigned Biosense is
scheduled for completion by February 2009. If effectively implemented,
HHS’s stated actions toward developing reliable cost and timeline
estimates and defining outcome-based performance measures should help
improve the department’s management of the redesigned BioSense
program.
Finally, with regard to the program, the department stressed the
importance of noting that BioSense is not intended to replace local
systems, but rather to add value by providing data, tools, and funding
intended to improve surveillance efforts. HHS’s written comments are
reproduced in appendix II.
DOD and VA also reviewed the draft report and provided technical
comments, which we have incorporated as appropriate.

Page 5

GAO-09-100 CDC’s Redesigned BioSense Program

We are sending copies of this report to interested congressional
committees, the Director of the Office of Management and Budget, and the
Secretaries of the Departments of Health and Human Services, Defense,
and Veterans Affairs. In addition, the report will be available at no charge
on the GAO Web site at http://www.gao.gov.
Should you or your staffs have any questions concerning this report,
please contact me at (202) 512-6304 or [email protected]. Contact points
for our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Key contributors to this report are listed in
appendix III.

Valerie C. Melvin
Director, Human Capital and Management
Information Systems Issues

Page 6

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Appendix I: Briefing Slides

Health Information Technology: More Detailed Plans
Needed for The Centers for Disease Control and
Prevention’s Redesigned BioSense Program
Briefing for Staff Members of the
House and Senate Subcommittees on Labor, Health and Human Services,
Education, and Related Agencies, Committees on Appropriations
August 26, 2008

1

Page 7

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Overview

Introduction
Objectives
Scope and Methodology
Results in Brief
Background
Results
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

2

Page 8

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Introduction

A catastrophic health event could cause hundreds of thousands of casualties,
weaken our economy, damage public morale and confidence, and threaten our
national security. Threats of bioterrorism and high-profile disease outbreaks, such
as a pandemic influenza outbreak, have drawn attention to the need for surveillance
systems for the early detection of and response to public health emergencies.
In 2002, President Bush signed the Public Health Security and Bioterrorism
Preparedness and Response Act, which required specific activities intended to
improve the nation’s preparedness for bioterrorism and other public health
emergencies.
• The act required the Secretary of Health and Human Services to establish
an integrated system of public health alert communication and surveillance
networks among federal, state, and local public health officials, and
laboratories, hospitals, and other health care facilities.

3

Page 9

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Introduction

In response to the passage of this act, in 2003 the Centers for Disease Control and
Prevention (CDC) developed an electronic syndromic surveillance information
system called BioSense.
In 2004, the agency established the BioSense program office to improve the
nation’s capabilities for conducting surveillance by providing federal, state, and
local public health officials access to existing data from health care organizations
across the country through the use of the BioSense system. In late 2007, CDC
initiated efforts to redesign the program in order to improve collaboration with
federal, state, and local public health stakeholders and to address management
weaknesses identified in the initial implementation of BioSense. The program is
managed by CDC’s National Center for Public Health Informatics.

4

Page 10

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Introduction

According to CDC, syndromic surveillance is a technique that uses health-related
data to identify patterns of disease symptoms prior to specific disease diagnoses.
Effective use of this technique can provide both situational awareness and early
event detection.
• Situational awareness is the knowledge of the size, location, and rate of
spread of an outbreak.
• Early event detection provides signals that a sufficient probability of a
disease outbreak exists to warrant public health response and lead to the
early identification of illnesses and other events of public health importance.
In this regard, syndromic surveillance can facilitate preventing and controlling the
spread of diseases.

5

Page 11

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Introduction

Pursuant to House Report 110-231,1 we evaluated BioSense, focusing on the costs
and benefits of operating the BioSense system as compared to other state and
local surveillance systems; the usefulness of data provided by the system to
hospitals and state and local public health officials; and cost and timeline estimates
and performance measures and benchmarks for implementing the program. As
agreed with staff of the House Committee on Appropriations, Subcommittee on
Labor, HHS, Education, and Related Agencies, we provided preliminary results
from our study on April 1, 2008. Subsequently, we agreed with staff of the House
and Senate Committees on Appropriations, Subcommittees on Labor, HHS,
Education, and Related Agencies to continue our evaluation of CDC’s plans for
implementing BioSense, focusing on the annual and long-term cost and timeline
estimates, and performance indicators and benchmarks for implementing a
redesigned program.

1

H.R Rep. No. 110-231, at 122 (2007).

6

Page 12

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Objectives

The specific objectives addressed in our study were to
• Compare the cost and benefits of operating the BioSense system with the
cost and benefits of operating state, local, and private surveillance systems.
• Identify the views of hospitals and federal, state, and local public health
officials on the usefulness of data provided by the BioSense system versus
data provided by local surveillance systems for responding to emergencies.
• Identify annual and long-term cost and timeline estimates and performance
indicators and benchmarks for the initial implementation of BioSense, and
evaluate CDC’s plans for implementing the redesigned BioSense program,
focusing on annual and long-term cost and timeline estimates, and
performance indicators and benchmarks.

7

Page 13

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

To compare the cost and benefits of operating the BioSense system with the cost
and benefits of operating other similar state, local, and private surveillance
systems, we
• identified from CDC’s fiscal year 2009 budget and planning documentation
the agency’s expected cost and projected benefits of operating the
BioSense system;
• reviewed cost and benefits information related to the use of the BioSense
system and available information on cost and benefits reported for other
surveillance systems used by hospitals and state and local public health
organizations; and
• discussed with the BioSense users selected for our second objective the
cost of and benefits realized from using data provided by the BioSense
system.

8

Page 14

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

To determine the views of federal, state, and local public health officials and
hospitals on the usefulness of BioSense data versus local surveillance data, we
selected and interviewed officials of organizations that conduct syndromic
surveillance using BioSense, other systems, or BioSense together with other
systems. These organizations include:
• the three federal agencies that have access to the BioSense system—CDC,
the Department of Defense (DOD), and the Department of Veterans Affairs
(VA); and
• three state and five local public health departments and two hospitals
• state public health departments in Arizona, Georgia, and North Carolina;
• local public health departments in Dallas, El Paso, and Tarrant counties
in Texas; Maricopa County in Arizona; and the East Metro Health District
in Georgia; and
• Gwinnett Medical Center in Lawrenceville, Georgia, and a Tenet
Healthcare hospital in El Paso, Texas.

9

Page 15

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

• To select these organizations, we obtained from CDC the program office’s
list of BioSense users from the most recent month at the time of our
request—October 2007.
• According to CDC, there are more than 500 users of the BioSense
system, and they are located throughout 150 hospital, federal, state, and
local facilities, including CDC.
• We selected organizations from different geographic areas that use
BioSense and other syndromic surveillance systems.
• We sorted users by state to identify a subset of organizations from a
wide geographic dispersion.
• From that subset, we selected states with varying numbers of BioSense
users.
• From those states, we selected a final set of states with high, midrange,
and low numbers of BioSense users, based on the average number of
users across the selected states.
• We then selected local health departments in municipalities with populations
that varied from large to small.
10

Page 16

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

• From among the BioSense users we selected, we further identified
organizations that also use BioSense and other commercial or locallydeveloped systems based on literature research and our knowledge of the
syndromic surveillance system user population.
• We also included in our selection BioSense facilities that have not opted to
use the data provided by the system.
• We discussed with the selected users the usefulness of BioSense data as
compared with data from other similar systems.
To supplement our discussions with selected users, we met with officials from two
public health associations to obtain their views on the usefulness of BioSense and
of syndromic surveillance systems in general. We held discussions with officials
from:
• the Association for State and Territorial Health Officials, and
• the Council for State and Territorial Epidemiologists.
We also interviewed public health officials from four other state and local
jurisdictions at a meeting arranged for us by the National Association of City and
County Health Officials.
11

Page 17

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

In addition, we asked the federal, state, local, and hospital representatives with
whom we spoke to identify any lessons they had learned from developing and
implementing other similar surveillance systems.
Our selection of BioSense users does not provide a statistically-valid sample;
therefore, the information provided by the organizations we selected cannot be
generalized across the entire BioSense user population.

12

Page 18

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

To identify annual and long-term cost and timeline estimates and performance
indicators and benchmarks for implementing the initial design of BioSense, we
reviewed and assessed CDC’s relevant program management and budget
justification documentation for the program.
To evaluate CDC’s plans for implementing the redesigned BioSense program and
related system, we obtained CDC’s draft plan for and other documentation relevant
to implementing the redesigned BioSense program. We evaluated the costs,
schedule, and performance components addressed in this documentation against
criteria established by federal guidance to determine if CDC followed best practices
to develop these components of its plan.2
• We analyzed CDC’s documented cost estimates for implementing the
redesigned program, as well as documentation describing the practices that
cost estimators followed to estimate costs of the program.
• We assessed CDC’s estimated time frames for completing the strategic
activities described in the plan.
2
Executive Office of the President, Office of Management and Budget, Planning, Budgeting, Acquisition, and Management
of Capital Assets, Circular No. A-11, Part 7 (Washington, D.C.: June 2008). See also, U.S. Government Accountability
Office, Cost Assessment Guide: Best Practices for Estimating and Managing Program Costs, Exposure Draft, GAO-071134SP (Washington, D.C.: July 2007).

13

Page 19

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

• We reviewed CDC’s documented approach for developing performance
measures described in the plan and compared it to the Office of
Management and Budget’s (OMB) guidance and industry practices to
determine if the agency’s documented approach was consistent with federal
and industry guidance.3

3

Executive Office of the President, Office of Management and Budget, Guide to the Program Assessment Rating Tool,
(Washington, D.C.: January 2008); Thomas Wettstein and Peter Kueng, "A Maturity Model for Performance Measurement
Systems," Management Information Systems 2002--Incorporating GIS and Remote Sensing (Southampton: WIT Press,
2002),113-122; and Karen J. Richter, Ph.D., Institute for Defense Analyses, CMMI® for Acquisition (CMMI-ACQ) Primer,
Version 1.2 (Software Engineering Institute, May 2008).

14

Page 20

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Scope and Methodology

We supplemented our documentation reviews with interviews of officials from
CDC’s BioSense program office to obtain additional information about the
development of current and future plans for BioSense. We did not independently
verify CDC’s cost or timeline estimates for the program.
We conducted this performance audit from October 2007 to August 2008 at CDC’s
headquarters in Atlanta, Georgia, in accordance with generally accepted
government auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe that the
evidence obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.

15

Page 21

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results in Brief

The cost and benefits of using data from the current BioSense system and other
similar syndromic surveillance systems are difficult to measure and compare. The
state and local public health and hospital officials with whom we spoke stated that
documenting the cost and benefits of using syndromic surveillance systems such
as BioSense is difficult and that they do not develop or track cost or benefits of
using these systems.
Federal, state, and local public health and hospital officials expressed mixed views
on the usefulness of BioSense data as compared with the usefulness of other
similar systems’ data. While they stated that they find the data from the BioSense
system useful in varying degrees, about half of them stated that they rely on other
systems as their primary tool for syndromic surveillance. Officials from two public
health associations differed in their views on the usefulness of nationwide
surveillance overall and BioSense in particular. While an official from one of the
associations noted that other methods of conducting syndromic surveillance were
more useful than electronic syndromic surveillance systems, officials from the other
association stated that establishing a national syndromic surveillance system is
essential. Further, preliminary results of a study on the use of syndromic
surveillance systems conducted for CDC reiterated public health and hospital
officials’ views of the usefulness of BioSense data.
16

Page 22

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results in Brief

Although CDC identified annual and long-term costs for the initial implementation of
the BioSense program, these estimates did not reflect the cost of implementing the
redesigned program and its related system. CDC subsequently developed a draft
plan for the redesigned program with high-level cost estimates based on program
officials’ professional judgment. Best practices require cost estimates to be welldocumented, comprehensive and accurate, and credible before they can be
considered to be reliable. However, CDC’s cost estimates for the program are not
reliable because they are only partially documented, are not comprehensive and
accurate, and are not credible.
According to program officials, CDC is in the strategic planning phase of the
redesigned program and is only able to provide high-level cost estimates during
this phase. Program officials stated that they intend to reflect more accurate and
refined estimates as the program plans evolve and the technical and performance
requirements of the program are better defined. Until program officials are able to
define the information needed to develop cost estimates that are comprehensive
and accurate, CDC will not be positioned to provide reliable cost estimates for
implementing the BioSense program.
17

Page 23

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results in Brief

CDC also identified annual and long-term timeline estimates for the initial
implementation of the BioSense program. However, the timelines were not relevant
to the goals of the redesigned program. While CDC has developed timeline
estimates for implementing the redesigned BioSense program, they are not
reliable. Best practices for reliable timeline estimates include, among other things,
the identification of resources to complete each task, establishment of a critical
path, and analysis of risks to the schedule. However, the agency has not assigned
resources to activities, established a critical path, or analyzed risks to the schedule
to ensure that its estimates are reliable.
According to BioSense program officials, the redesigned program is in the early
stages of planning, and they have not yet completed tactical plans that would
identify resources needed to complete tasks and a critical path for the schedule.
Until program officials consider these components, CDC will not be positioned to
provide reliable timeline estimates for its plans to fully implement the BioSense
program.

18

Page 24

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results in Brief

CDC established performance measures and benchmarks for the initial design of
the BioSense program. However, the performance measures defined in the
business case were not focused on intended results of the redesigned program.
OMB directs agencies to define meaningful annual and long-term performance
measures to gauge the intended results of carrying out a program or activity early
in the program to allow time for stakeholder review. Additionally, industry experts
describe the need for performance measures to be developed with stakeholders’
input early in a project’s planning process to provide a central management and
planning tool and to monitor the performance of the project against plans and
stakeholders’ needs.
CDC’s plan for the redesigned BioSense program describes a need to develop
outcome-based performance measures. However, program officials stated that
they do not intend to complete development of performance measures until the end
of 2009. Until BioSense program officials develop these measures, they will lack an
effective management and planning tool for gauging the success of the program
against plans and against federal, state, and local partners’ use of the BioSense
system for responding to public health events.
19

Page 25

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results in Brief

We are recommending that the Director of the Centers for Disease Control and
Prevention instruct the Director of the National Center for Public Health Informatics
to take the following three actions while in the planning phase of the redesigned
BioSense program:
• develop reliable cost estimates for the program that are well-documented,
comprehensive and accurate, and credible;
• develop reliable timeline estimates for implementing the program; and
• develop performance measures that address all phases of the program and
focus the success of the program on CDC’s federal and state partners’ use
of the system for responding to public health events.
We received oral comments on a draft of this briefing from BioSense program
officials, including the Director of CDC’s National Center for Public Health
Informatics. The officials generally agreed with the information included in the draft
and provided additional information and technical comments which were
incorporated into the briefing as appropriate.

20

Page 26

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

Historically, disease outbreaks have been recognized based either on accumulated
case reports of diseases by local public health departments or by clinicians and
laboratorians who alert public health officials about potential disease outbreaks.
Complete responsibility for disease surveillance is shared among health care
providers, including public health officials from 59 state and territorial health
departments; more than 3,000 county, city, and tribal health departments; multiple
federal agencies, including CDC; and more than 180,000 public and private
laboratories.
• States take the lead in conducting disease surveillance and supporting local
emergency response efforts through a public health infrastructure that is
made up of state and county, city, and tribal health departments—i.e., local
health departments. State health departments are responsible for collecting
surveillance information from local health departments, coordinating
investigations and response activities, and sharing disease surveillance
data with CDC.

21

Page 27

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

Local health departments are responsible for conducting the initial investigations
into reports of diseases. Initial response to a public health emergency is generally a
local responsibility that could involve multiple local health departments in a
geographical region, with state health departments providing additional support
when needed.
The federal government’s role in disease surveillance traditionally has been to
collect data from state and local health departments and perform nationwide
analyses of the aggregated state and local data using surveillance systems. CDC
uses information and communications systems to share disease surveillance
information with state and local health departments and provides funding and
technical expertise to support surveillance at the state and local levels.

22

Page 28

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background
For nearly 10 years, federal, state, and local public health organizations, private
companies, and academic institutions have been developing systems for collecting
and analyzing electronic surveillance data from sources such as hospital
emergency departments, clinical laboratories, and pharmacies. These systems are
intended to better support efforts to detect disease outbreaks through electronic
syndromic surveillance and to more efficiently communicate information to public
health officials. For example:
• The University of Pittsburgh and Carnegie Mellon University developed the
Real-time Outbreak and Disease Surveillance (RODS) system in 1999.
• DOD developed the Electronic Surveillance System for the Early Notification
of Community-based Epidemics (ESSENCE) in 1999. A civilian version of
the system is available, at no charge, to any health department that wants
to use the system locally.
• According to CDC, about 20 states have developed electronic surveillance
systems.
CDC officials stated that, as tools to share information more quickly and efficiently
become available, the roles of federal, state, and local public health agencies in
conducting disease surveillance are likely to evolve.
23

Page 29

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

According to BioSense program officials, the initial vision for the program was to
provide real-time health data to federal, state, and local public health organizations
and participating hospitals in order to:
• provide health situational awareness by enabling public health officials at
the federal, state, and local levels to monitor the size, location, and rate of
an outbreak;
• support early event detection by enabling public health officials to detect a
potential public health emergency at the earliest possible time; and
• assist public health officials in responding to a disease outbreak or other
emergency.
A key component of the program is the BioSense system—an electronic
information system which CDC developed to provide data and analytical tools for
public health and other health organizations to use in conducting syndromic
surveillance.

24

Page 30

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The system is made up of (1) the hardware and software that enable BioSense to
collect relevant data from public health organizations and hospitals and (2)
software that analyzes the collected data and provides the analyzed data and
analytical tools via a Web-based application for use by public health and hospital
officials who conduct syndromic surveillance activities.
The current system collects site-specific data directly from (1) state and local public
health departments that collect hospital data from within their jurisdictions and (2)
hospital, DOD and VA facility, health department, and laboratory data sources. The
collected data are stored in a central CDC data repository.

25

Page 31

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

To provide data to the system, facilities must electronically store and maintain the
data, and they must establish data-sharing agreements with CDC. As part of these
agreements, CDC provides to facilities, at minimal or no charge, the hardware and
software needed to collect and translate the facility’s data into a standard format to
enable transmitting the data to BioSense.
According to CDC, the agency has agreements with and the system currently
collects data from about 570 hospitals, 320 DOD military treatment facilities, 860
VA hospitals and outpatient clinics, and other data sources that provide public
health officials with the information needed to conduct syndromic surveillance, such
as patients’ reasons for seeking medical attention, over-the-counter drug sales,
prescription drug information from clinicians, and clinical laboratory test requests
that could indicate disease outbreaks.

26

Page 32

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The BioSense data analysis software aggregates and analyzes the electronic data
collected from these facilities to identify disease syndromes within state and local
jurisdictions. The system then displays graphical views of the presence of
syndromes across time and geographical locations in the form of charts, graphs,
and maps via a Web-based application. BioSense users can access the application
via the Internet at no charge.
• The views displayed by the BioSense Web-based application can be
accessed by public health and health care professionals, such as public
health epidemiologists and hospital infectious disease clinicians, who use
the system to facilitate their ability to track the outbreak, treatment, and
spread of diseases within their own jurisdictions.4
• CDC reports that there are more than 500 users of the BioSense system,
and that they are located throughout 150 hospital, federal, state, and local
facilities, including CDC.

4
Users can access data for neighboring jurisdictions or other locations only with additional approval from the other
jurisdictions involved and from CDC.

27

Page 33

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The following graphic provides an overview of the current BioSense system.

28

Page 34

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

According to program officials, the current BioSense system
• collects data directly from medical facilities or local public health
departments, VA and DOD facilities, or from state public health departments
that have already collected the local health department and hospital data
within their jurisdictions; the collected data are analyzed and stored in a
central CDC data repository;
• is not integrated with other federal public health information technology
initiatives, such as CDC’s electronic disease surveillance system; and
• was designed and developed with limited collaboration between CDC and
state and local public health stakeholders.
In June 2005, we reported on federal agencies’ progress in implementing public
health information technology initiatives. We noted that public health officials said
they did not find the BioSense system useful because of limitations in the data
being collected.5

5

GAO, Information Technology: Federal Agencies Face Challenges in Implementing Initiatives to Improve Public Health
Infrastructure, GAO-05-308 (Washington, D.C.: June 2005).

29

Page 35

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

In 2006, an independent contractor evaluated the BioSense program and identified
about 50 management weaknesses that increased program risks, including the lack
of a clear, consistent vision and supporting plans to guide and constrain the scope
of the program.
During the third quarter of fiscal year 2007, a new director that CDC hired to lead
the National Center for Public Health Informatics initiated efforts to redesign the
BioSense program.6
• According to BioSense officials, the redesigned program includes a new
strategy that emphasizes increased collaboration with state and regional
public health officials by providing more opportunities for stakeholder
training and holding round-table meetings with stakeholders to gain a better
understanding of their needs.
• BioSense officials stated that, as part of the program’s redesign, they intend
to address all of the weaknesses identified by the contractor’s evaluation
that are relevant to the new strategy.
6

The BioSense program is managed by the National Center for Public Health Informatics within CDC.

30

Page 36

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

• The officials also told us that they plan to reengineer the BioSense system
to reflect the redesigned program’s new mission to “provide a system that
comprehensively monitors the health care system of the United States for
evidence of acute health threats to the public.”
Program officials intend for the redesigned BioSense system to:
• collect and analyze already-aggregated data from states and health
information exchanges, rather than collect site-specific data from individual
data sources as the current system does;
• store results of the analyzed data in a central data repository at CDC (the
data collected from state and health information exchanges will remain with
their original sources);
• include enhanced, user-customizable data analysis tools to allow users to
easily tailor the application to better detect disease outbreaks and
emergencies within their own jurisdictions;

31

Page 37

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

• allow states to share data and views across jurisdictions by building regional
data-sharing collaboratives;
• incorporate case detection technology for use in catastrophic as well as
routine public health capacities; and
• be integrated with other public health information technology components,
such as CDC’s electronic notifiable disease surveillance systems and
electronic laboratory reporting, the Department of Homeland Security’s
(DHS) National Biosurveillance Integration System (NBIS),7 and with the
planned Nationwide Health Information Network (NHIN).8
According to program officials, Web-based analytical tools and data views will still
be available to BioSense users via the Internet.
7
The National BioSurveillance Integration System is a federal effort to combine multiple data streams from sectorspecific agencies—those with medical, environmental, agricultural, and intelligence data—to give DHS situational
awareness that is intended to allow earlier detection of events and to assist response activities.
8
The Nationwide Health Information Network is a critical portion of the HHS Office of the National Coordinator for
Health Information Technology’s agenda intended to provide a secure, nationwide, interoperable health information
infrastructure that will connect providers, consumers, and others involved in supporting health and health care. It is
planned to be a “network of networks” built out of state and regional health information exchanges and other networks
to support the exchange of health information by connecting these networks.

32

Page 38

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The following graphic provides an overview of CDC’s initial proposal for the
redesigned BioSense system.

33

Page 39

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

In May 2008, BioSense program officials developed a draft plan that outlined a
vision for implementing the redesigned BioSense program within a four-year
timeframe.9 The draft plan articulates four strategic goals for the redesigned
program along with strategic-level activities for accomplishing the goals. The four
strategic goals are:
• sponsor regional collaboration and health information exchanges,
• pursue open collaborative development,
• transition to a federated data model,10 and
• expand case detection technology.
BioSense program officials intend for the four goals to be accomplished by the end
of 2012 and stated that they will continue to update the plan and incorporate more
tactical and operational planning details throughout 2008 and 2009.

9

Centers for Disease Control and Prevention National Center for Public Health Informatics, BioSense Strategic Plan, FY
2008 – 2012, Version 6 (Draft); (Atlanta, Ga.).

10

A federated data model supports data sharing across a large community despite having data stored in different geographic
locations. Use of this model would be expected to enable the public health community to store data locally, in state and local
public health departments, while enabling CDC and other organizations to access and analyze that data.

34

Page 40

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The plan describes 2008 as a transitional year during which CDC will continue to
support ongoing initiatives and work to expand collaboration with its stakeholders.
• Program officials incorporated into the new strategy for BioSense ongoing
initiatives, such as proof-of-concept efforts for evaluating technology
solutions for a federated data model and case-detection, and linked the
outcomes of these initiatives to the new program goals.

35

Page 41

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

BioSense program funding covers costs for the program office, including staff,
equipment, and contractor support to develop, implement, maintain, and support
the BioSense system. It also covers extramural activities, such as stakeholder
round-table meetings, and research grants and cooperative agreements with
universities and other public health researchers to evaluate the usefulness of the
system for supporting early event detection, situational awareness, and emergency
response. CDC reported spending about $184 million on the program from 2003
through June 2008.

36

Page 42

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Background

The following graphic illustrates the evolution of the BioSense program and
system since the initiation of the system’s development.

37

Page 43

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Costs and Benefits
Costs and benefits of using data from BioSense and other syndromic surveillance
systems that public health officials rely on are difficult to measure and compare.
The state and local public health and hospital officials with whom we spoke stated
that documenting costs and benefits of using syndromic surveillance systems such
as BioSense is difficult and that they do not develop or track the costs or benefits of
using these systems. Factors limiting the ability to compare the costs and benefits
of operating BioSense with other surveillance systems include:
• Some of the systems in use, including BioSense, are provided to state,
local, and hospital users at very low or no cost and require little investment
by users.11 Therefore, any additional data provided by these systems are
beneficial. Without a need to justify a substantial investment in the systems,
these organizations have not tracked costs or benefits.
• Costs of developing and implementing systems can vary widely depending
on the approach used to acquire, maintain, and monitor surveillance data.
11

Three organizations in our review reported that the only cost for using surveillance systems was staff time for using the
systems, which is performed in combination with other activities. Most state and local users in our review used federal or
state grant funding to cover system costs.

38

Page 44

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Costs and Benefits
• Implementation of syndromic surveillance systems varies widely in scope by
the type and volume of data collected, size of the jurisdiction, and number of
data providers. BioSense is the only national system that centrally supports
federal, state, and local public health and hospital users and that evaluates
nationwide data to provide a national view of the country’s health. In
contrast, DOD and state and local public health departments’ systems are
intended specifically for use within their jurisdictions, such as within military
bases or state and local public health districts.
• System costs and benefits are difficult to track within the wide range of
response activities that are undertaken during outbreaks. Syndromic
surveillance activities are conducted as a component of a wide range of
emergency response activities, including activities such as identifying
available hospital beds and identifying specific patients, and it is difficult to
segregate the costs of specific tasks from the overall response effort.
Consistent with other public health officials’ experiences in using syndromic
surveillance systems, BioSense program officials have not widely reported actual
quantifiable benefits of using the BioSense system.
39

Page 45

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
Views on the usefulness of data provided by the BioSense system as compared
with the usefulness of other similar systems’ data are mixed. The federal agencies
that use the BioSense system for syndromic surveillance reported mixed views on
the usefulness of the data provided by the system.
• BioSense program officials stated that CDC’s epidemiologists and infection
control analysts find the data provided by the BioSense system useful for
detecting and monitoring potential events that could have a nationwide
impact on public health and for notifying local public health officials about
potential outbreaks in their jurisdictions. Program officials reported that, in
2007, BioSense data were useful in identifying ten local public health
events.
• Among these events, one of them was detected by CDC personnel
using data from BioSense before it was detected by the local health
department.
• DOD and VA officials stated that their departments’ public health personnel
do not rely on data provided by the BioSense system to conduct syndromic
surveillance activities.
40

Page 46

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
• DOD officials told us that they use ESSENCE because it provides the ability
for users to monitor the local populations for which they are responsible—
i.e., populations within military installations—whereas the current version of
BioSense presents aggregated information at the state level. Therefore, the
results of the BioSense system do not provide information that DOD can act
on within its jurisdiction.
• VA officials stated that their public health personnel do not regularly rely
on data provided by BioSense or any other system to conduct syndromic
surveillance activities. They told us that they use the civilian version of
ESSENCE more often than BioSense, though both systems are
occasionally monitored.
• Both DOD and VA officials stated that ESSENCE allows them more
flexibility in evaluating and viewing data than BioSense does.

41

Page 47

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
Epidemiologists and infectious disease personnel at state and local public health
organizations and hospitals use data from the BioSense system, other similar
systems, and manual techniques for conducting syndromic surveillance. Many
organizations operate multiple syndromic surveillance systems simultaneously,
allowing access to multiple sources of data that help them identify and respond to
emergencies.
• For example, one county public health department we visited used a
“dashboard” that employs BioSense, ESSENCE, and RODS to conduct
syndromic surveillance.
Of the ten organizations and hospitals we contacted—five local public health
departments, three state health departments, and two hospitals—eight reported
that they use data provided by the BioSense system.
All but one of the eight state and local public health departments and hospitals that
use the BioSense system reported that they also use other electronic syndromic
surveillance systems. The following table identifies these users and the systems.

42

Page 48

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
Organization

BioSense

ESSENCE a

RODS

State-developed
system

Locallydeveloped
system

Manual
analysis

Local public health departments
Maricopa County, AZ

X

Gwinnett County, GA

X

Tarrant County, TX

X

El Paso, TX

X

X

X

X

X
X

X

X

State public health organizations
Arizona

X

Georgia

X

X

North Carolina

X

X

X

X

Hospitals
Tenet Healthcare, El Paso, TX

X

Total

8

X
1

4

4

1

2

Source: GAO analysis based on data provided by state and local public health organizations and hospitals.

a

The civilian version of ESSENCE is used by state and local health departments.

43

Page 49

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
The users we interviewed at the public health departments and hospitals expressed
mixed views about the usefulness of the data provided by the BioSense system.
• Seven of the eight users we interviewed stated that they use the data for
situational awareness and that the system was useful for this activity.
Although some users stated that they use BioSense for early event
detection, they found that the system was only somewhat useful for this
activity because it does not provide sufficient health-related data for event
detection within their jurisdiction.
• Six of the eight BioSense users we interviewed stated that they use the data
either weekly or daily. Three of these users stated that the BioSense system
is their most important electronic syndromic surveillance tool; two of these
users stated that BioSense is the only tool that they use for syndromic
surveillance.12
• Three of the seven users who also use other electronic syndromic
surveillance systems stated that the BioSense system is less important to
their overall syndromic surveillance efforts because the other systems they
use better enable them to evaluate and view data based on specific needs
of their jurisdictions.
12

One of the two users stated that, although other tools were used at the facility, they were not used specifically for
syndromic surveillance.

44

Page 50

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
The users we interviewed stated that deficiencies in the data provided by the
BioSense system limited their ability to use the data to conduct syndromic
surveillance in their jurisdictions:
• Limited data about health within jurisdictions—Seven of the users we
interviewed indicated that the BioSense system would be more effective if
its analysis included data from more hospitals in the jurisdiction. For
example, one local health department stated that the BioSense system
analyzes and provides its users with data for only seven of the 27 hospitals
within its jurisdiction.
• Limited flexibility to query data on multiple symptoms—Three of the users
we interviewed explained that the BioSense system does not provide the
ability to query and report on multiple symptoms or to tailor the system to
detect emerging threats specific to their jurisdictions. Users stated that this
type of system flexibility—which is available in other systems such as
ESSENCE and RODS—enables public health officials to more accurately
identify health conditions that have more than one symptom, such as
influenza, and to detect and monitor new illnesses as they appear within
their own jurisdictions.
45

Page 51

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
• Inability to access patient-level data—Five users we interviewed cited the
inability to access patient-level data as a significant limitation of the
BioSense system. According to these users, the BioSense system does not
provide these data, while other systems, such as ESSENCE, can be
enabled to allow access to data about specific patients. Without this ability,
local health officials may be limited in their ability to quickly identify an
infected patient in their local areas.13
While these users expressed mixed views about the usefulness of the data
provided by the BioSense system and stated that the system does not yet fully
address their needs, when asked if BioSense helped them to better respond to
emergencies, six of them stated that the data provided by the BioSense system
was useful for this purpose. According to four of these users, the system provides
an additional data resource for confirming data provided by the other syndromic
surveillance systems that they use.

13

In their comments on a draft of this briefing, BioSense program officials stated that individual patient-level data are available
from application-level views provided by the BioSense system.

46

Page 52

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
Of four additional local public health officials with whom we spoke at a meeting
arranged by the National Association of County and City Health Officials, three
stated that their organizations use the BioSense system on a very limited basis
because their locally-developed systems provide access to more, better, or more
detailed data, and allow more flexibility in using the data. The one other
organization does not use any electronic system for syndromic surveillance, but
instead relies on manual data analysis because the hospitals within its jurisdiction
do not provide electronic data to be processed by any electronic surveillance
system.

47

Page 53

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
Additionally, the public health experts from the two associations with whom we
spoke offered differing views on the usefulness of the BioSense system and other
similar electronic syndromic surveillance systems.
• The Council for State and Territorial Epidemiologists official with whom we
spoke stated that surveillance for disease and outbreak detection has been
accomplished primarily by astute clinicians and physicians within a jurisdiction,
and that communication support is more important for detecting outbreaks
across jurisdictions than syndromic surveillance systems. Some capabilities
developed through the BioSense program, such as the data-viewing tools and
the collection of real-time hospital data, have been very useful, and the
BioSense system has been shown to be helpful in monitoring cases of disease
outbreaks, such as influenza.

48

Page 54

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
•

On the other hand, the Association for State and Territorial Health Officials
representatives with whom we spoke believe that establishing a national
syndromic surveillance system is essential and there is no question about the
need to have such a system. They pointed out that a national system such as
BioSense should be made up of multiple systems instead of a single system,
build on existing local and state capabilities, and include local and state health
officials as integral partners in its design. While these officials had concerns
with the initial design of BioSense, they stated that they are pleased with
CDC’s new plans.

49

Page 55

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
In October 2006, CDC funded four institutions to conduct evaluations of syndromic
surveillance systems. The results of the studies are intended to be used together to
evaluate the usefulness of the BioSense system at the federal, state, and local
levels of public health for supporting early event and situational awareness
activities.
Preliminary results for one of the studies were published in 2007.14 Initial case
studies for this evaluation focused on a large salmonella outbreak and a tornado in
Georgia, the 2006-2007 influenza season, and a wildfire in south Georgia and north
Florida. The study is to be completed in November 2008. The preliminary results of
the evaluation reiterated the views of the users we contacted and found that:
• Among the four events, the utility of syndromic surveillance was greatest for
monitoring the influenza season.
•

In most instances, BioSense was not used because of the lack of local realtime hospital data from local hospitals and the inflexibility of the system.

14

James W. Buehler, M.D., Alexander P. Isakov, M.D, M.P.H., Michael J. Prietula, Ph.D.,Donna J. Smith, M.A., Ellen A.
Whitney, M.P.H., Preliminary Findings from the BioSense Evaluation Project (Rollins School of Public Health, School of
Medicine, and Goizueta Business School, Emory University, Atlanta, Ga.; 2007).

50

Page 56

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
•

Syndromic surveillance systems used first were those that were developed
locally to support state and local public health and health care practices and
relationships.

In addition to BioSense system users, officials at BioSense facilities who do not use
the system offered several explanations for not doing so.
•

•

An official we spoke with at one hospital said that they had never used the
system because they use the state’s system; they stated that they rely on
relationships with state and local public health departments for conducting
surveillance and use the state-level system, which was designed to meet
specific needs of their jurisdiction.
Officials at one local health department stated that they had accessed the
BioSense system only once during the past year. The department uses
ESSENCE, RODS, and manual analysis to conduct syndromic surveillance.
These officials stated that they do not use BioSense because the system lacks
adequate data for their jurisdiction and because BioSense does not provide
the flexibility available in ESSENCE and RODS, such as allowing users to
perform multiple queries on the data or to customize views of the data
analyzed by the systems.
51

Page 57

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
Usefulness of BioSense
State and local public health and hospital officials we interviewed identified lessons
they had learned from their experiences in developing, implementing, and
sustaining syndromic surveillance systems to ensure the systems are useful. They
reported learning that:
• Systems should be developed incrementally. Officials with experience in
developing or implementing state and local systems emphasized that systems
should be developed incrementally based on users’ needs and lessons
learned from each increment.
•

Systems must be sustainable at the local level. Initiatives to develop and
implement systems must build in support for IT infrastructure, installation and
maintenance, and staff training.

•

Stakeholder communication and involvement in determining requirements is
critical. The development and implementation of syndromic surveillance
systems must involve frequent, effective communications with stakeholders
while defining, documenting, and sharing project requirements.
These experiences provide valuable lessons that BioSense program officials could
apply to their approach for reengineering the system to help ensure that the data
provided by the system are useful for BioSense stakeholders.
52

Page 58

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
OMB has made developing accurate life-cycle cost estimates a priority for agencies
in properly managing their portfolios of capital assets, including information
technology, that have an estimated life of two years or more.15 In addition, the draft
Cost Assessment Guide, which we developed based on best practices, defines
characteristics of reliable cost estimates for federal agencies’ information
technology programs.16 The guide describes reliable cost estimates as those that
are well-documented, comprehensive and accurate, and credible.
• Well-documented cost estimates are those that include source data and
their significance, clearly detailed calculations and results, and explanations
of why particular methods and references were chosen. The data used to
estimate the costs can be traced to their source documents.
• Comprehensive and accurate cost estimates have enough detail to ensure
that cost elements are neither omitted nor double counted, and all costinfluencing assumptions are detailed in the estimates’ documentation.

15

OMB Circular A-11, Part 7.
GAO-07-1134SP.

16

53

Page 59

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
• Cost estimates are credible when limitations of the analysis are discussed,
assumptions made about the costs are varied, and outcomes are
recomputed to determine how sensitive they are to changes in the
assumptions. Risk analyses are also performed to determine the level of
risk associated with the estimate. The estimate’s results are cross-checked,
and an independent cost estimate is developed to determine whether other
estimating methods produce similar results.
By addressing these characteristics, program officials should be better able to
define reliable cost estimates that are comprehensive and accurate and that can be
easily and clearly traced, replicated, and updated. Additionally, program officials
should reliably estimate costs before proceeding too far into development or
production to reduce the risk that the program will not be able to meet its
established cost targets.

54

Page 60

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
CDC identified cost estimates for the initial BioSense in its fiscal year 2009
business case that was submitted to OMB in September 2007.17 Program officials
estimated the total cost for the program through 2013 to be $369 million. However,
these estimates did not reflect the cost of implementing the redesigned program
and its related system.

17

OMB requires agencies to submit business cases through OMB Exhibit 300’s for major information technology programs
to establish cost, schedule, and measurable performance goals.

55

Page 61

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
In May 2008, CDC included in its plans for the redesigned program cost estimates
for completing the strategic activities that are intended to provide an operational
program by 2012.18 Program officials report the total estimated cost of
implementing the redesigned program from 2009 through 2012 to be about $314
million. The estimates cover costs of completing each of the strategic activities,
such as federating existing data sources, developing case detection
methodologies, and supporting research and development for real time
surveillance. According to program officials, the estimates also cover the costs of
existing BioSense operations including the program office’s staff, travel,
transportation, and contractor support.

18

According to program officials, CDC’s cost estimates reflect the agency’s plan to complete the development and
implementation of the redesigned BioSense program and its related system by 2012 rather than 2013, as its previous plans
reflected.

56

Page 62

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
CDC’s cost estimates for implementing the redesigned BioSense program are only
partially documented. Specifically, the documentation for the estimates consisted
only of explanations of the methods and references chosen to compute the
estimates. According to an official with CDC’s Financial Management Office, the
initial cost estimates for the redesigned BioSense program were developed based
on program officials’ professional judgment.19 As professional judgment estimates,
the official did not believe that the agency was required to develop or maintain
supporting documentation.

19
CDC defines its professional judgment estimates as informal estimates provided to Congress. According to CDC
officials, the agency provides professional judgment estimates without regard to the competing priorities that the
agency, the President, and their advisors must consider as budget submissions to the Congress are developed.

57

Page 63

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
Additionally, the cost estimates for BioSense are not comprehensive and accurate
because the estimates were developed without considering all cost elements.
According to program officials, the estimates do not include the cost of technology
required to support new methods for measuring performance of the system, such
as tools for simulating emergency response scenarios to estimate the impact that
use of the BioSense system has on the time required to respond to health threats.

58

Page 64

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Cost Estimates
Finally, the cost estimates do not meet the criteria for credibility as defined in our
cost estimation guide. The BioSense cost estimators did not vary major
assumptions to determine whether and to what extent outcomes are sensitive to
changes in the assumptions. Program officials did not conduct risk and uncertainty
analyses to determine the level of risk and the extent to which the actual costs may
vary from the initial estimates. Additionally, the cost estimates for BioSense have
not been independently reviewed and verified to determine if other estimating
methods would produce similar results.
Program officials stated that the cost estimation activities were conducted in the
early planning phases of the redesigned program and that they intend to refine cost
estimates for a more accurate reflection of the cost to fully implement the BioSense
program and its related system as the program requirements are defined in more
detail.20 Until program officials develop well-documented, comprehensive and
accurate, and credible cost data, CDC will not be able to reliably estimate the cost
of fully implementing BioSense.
20

BioSense program officials stated that they intend to use the refined estimates for the preparation of future congressional
budget submissions.

59

Page 65

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Timeline Estimates
Our draft Cost Assessment Guide identifies best practices for estimating project
timelines and schedules, which include
•
•

defining, sequencing, and estimating the duration for each activity;
assigning resources (e.g., labor, material, and overhead) to all activities;

•
•

identifying the critical path for all activities;
identifying float time—the amount of time a task can slip before affecting
the critical path—between activities; and

•

conducting a schedule risk analysis using statistical methods to determine
the amount of time to reserve for contingencies.

By following these practices, program officials should be better able to define
reliable timeline estimates that can be used to identify when problems or changes
may occur and the impact they may have on the success of the program. Further,
according to OMB guidance,21 reliable timeline estimates should be defined before
program officials proceed too far into development or production to reduce the risk
that the program will not be able to meet its time frames and to reduce the risk of
undesirable outcomes.
21

Executive Office of the President, Office of Management and Budget, Memorandum on Conducting Acquisition
Assessments with Guidelines for Assessing the Acquisition Function (Washington, D.C.: May 21, 2008).

60

Page 66

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Timeline Estimates
CDC’s fiscal year 2009 OMB business case for the initial BioSense program
identified annual and long-term timelines and milestones for meeting program goals
through fiscal year 2013. CDC also reported the goals and the status of the
program’s efforts to meet the goals for fiscal years 2006 and 2007. For example,
the business case identified a milestone to support research related to BioSense
algorithms, bioterrorism, and pandemic flu in 2006 and reported that the program
had met that milestone.

61

Page 67

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Timeline Estimates
In its draft plan for the redesigned program, CDC defined the timelines for
completing the program’s strategic activities and goals within a four-year time
frame, as shown in the following table.22 According to BioSense program officials,
these timelines were defined based on experiences and knowledge gained from
implementing prior and ongoing pilot projects.23
Strategic activities

Strategic goals

Timeline

Expand state and local partnerships with the CDC and develop
regional collaboratives for real time surveillance

2008 - 2010

Support linkages between public health and health information
exchanges for real time surveillance

2009 - 2012

Pursue open collaborative
development

Pursue open source collaborative development

2009 - 2012

Transition to a federated data model

Federate existing state and local real time surveillance data sources

2009 - 2010

Expand case detection technology

Refine and deploy BioSense case detection technologies

2009 - 2012

Enhance incentives for clinical providers to transmit data to public
health

2009 - 2011

Sponsor regional collaboration and
health information exchanges

Source: CDC’s National Center for Public Health Informatics
22

According to program officials, CDC’s timeline estimates were developed to support completion of the development and
implementation of the redesigned BioSense program and its related system by 2012 rather than 2013, as its previous
plans reflected.

23

CDC officials described an additional activity, support for research to develop innovative and promising technologies for
real time surveillance, as a cross-cutting activity that supports each goal from 2009 through 2012.

62

Page 68

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Timeline Estimates
While program officials have defined timelines for the program’s strategic-level
activities, they have not completed the detailed plans needed to estimate reliable
timelines for implementing the redesigned program.
• While the strategic activities were defined and sequenced, resources have
not yet been assigned to the activities, a critical path for the program’s
schedule has not been identified, float time between activities has not been
determined, and a schedule risk analysis has not been performed to plan for
contingencies.

63

Page 69

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Timeline Estimates
BioSense program officials stated that the program is still in the early stages of its
redesign and that they have recently begun to develop tactical-level plans that
include the detailed information needed to define more specific timelines for
completing the program’s strategic activities. In this regard, they drafted a
document that reflects timelines for completing specific activities in fiscal years
2008 and 2009 and stated that they intend to finalize a detailed tactical plan for the
program by September 30, 2008.
Until the program completes detailed plans that define the steps and resources
needed to accomplish the plan’s strategic activities, identify the schedule’s critical
path, and perform a schedule risk analysis, CDC will not be positioned to provide
reliable timeline estimates that can be used to identify when problems or changes
may occur and the impact they may have on CDC’s plans to fully implement
BioSense by 2012.

64

Page 70

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Performance Measures
OMB directs agencies to define and select meaningful annual and long-term
outcome-based performance metrics that measure the intended result of carrying
out a program or activity.24 Additionally, industry experts describe the need for
performance measures to be developed with stakeholders’ input early in a project’s
planning process to provide a central management and planning tool and to
monitor the performance of the project against plans and stakeholders’ needs.25
According to the Software Engineering Institute, performance measures are
effective mechanisms for providing credible evidence of a program’s progress.26

24

OMB, Guide to the Performance Assessment Rating Tool.

25

Thomas Wettstein and Peter Kueng, “A Maturity Model for Performance Measurement Systems,” and Karen J. Richter,
Ph.D., Institute for Defense Analyses, CMMI® for Acquisition (CMMI-ACQ) Primer, Version 1.2.

26
GAO, Veterans Benefits Administration: Progress Made in Long-Term Effort to Replace Benefits Payment System, but
Challenges Persist, GAO-07-614 (Washington, D.C.: April 2007).

65

Page 71

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Performance Measures
In the fiscal year 2009 business case for BioSense, program officials identified
performance measures for the initial implementation of the program and reported
the status of the program in meeting benchmarks for 2006 and 2007. For example,
a decrease in the time required to update BioSense after receipt of data from data
providers was identified as a performance measure with a benchmark to reduce the
time from an average of 2.81 hours in 2006 to no more than 2 hours in 2007.
However, the performance measures defined in the business case were not
focused on intended results of the redesigned program.

66

Page 72

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Results
BioSense Plans: Performance Measures
CDC’s draft plan for the redesigned BioSense program describes a need to
develop outcome-based performance measures that focus the success of the
program on federal, state, and local partners’ use of the BioSense system. They
stated that new performance measures for the redesigned system are to be
included in the program’s plan by the end of calendar year 2009.27 However, it is
important to complete the development of performance measures early in the
planning phase of the program to provide an essential planning tool that can be
utilized throughout all phases of the development and implementation of BioSense.
Unless BioSense program officials develop outcome-based performance measures
based on stakeholder input during the planning phase of the program, they will lack
an effective management and planning tool needed to monitor the performance of
the program against plans and stakeholders’ needs throughout all phases of the
program.

27

In commenting on a draft of this briefing, BioSense program officials stated they intend for federal, state, and local
partners to be engaged in the development of outcome-based performance measures early in the detailed planning
process, beginning in November 2008.

67

Page 73

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Conclusions

The costs and benefits of using data from the current implementation of the
BioSense system and other similar systems are difficult to measure and compare,
and state and local public health and hospital officials with whom we spoke do not
document or track costs and benefits of using these systems. Additionally, these
officials expressed mixed views on the usefulness of BioSense data as compared
to the usefulness of data from other systems.
BioSense program officials have developed initial high-level cost and timeline
estimates for completing the implementation of a redesigned BioSense program
and related system that are intended to address weaknesses of the initial
implementation of the program and improve the usefulness of the system for CDC’s
stakeholders. However, program officials have not yet reliably estimated costs and
timelines for fully implementing the redesigned BioSense and for managing the
development and implementation of the program. Additionally, program officials do
not expect to complete the development of performance measures before the end
of calendar year 2009, which increases the risk that they will not be able to
effectively monitor the performance of the program against plans and stakeholders’
needs throughout all phases of development and implementation.
68

Page 74

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Conclusions

Until BioSense officials develop reliable cost and timeline estimates and outcomebased performance measures, CDC’s plans for the redesigned program and its
related system will lack key components needed to effectively manage the program
throughout all phases of the program. Further, the agency will lack management
and planning tools needed to effectively gauge the success of the BioSense
system’s performance toward improving federal, state, and local partners’ abilities
to respond to public health events. Moreover, the agency remains at risk that it will
perpetuate weaknesses identified in the agency’s initial implementation of the
program and related system and will continue to spend money on a program that
does not provide intended results or meet stakeholders’ needs.

69

Page 75

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Recommendations for Executive Action

To ensure that CDC defines reliable plans for effectively managing the
development and implementation of the redesigned BioSense program and its
related system throughout all phases of the program, we are recommending that
the Director of the Centers for Disease Control and Prevention instruct the Director
of the National Center for Public Health Informatics to take the following three
actions while in the planning phase of the program:
• develop reliable cost estimates for fully implementing the program that are
well-documented, comprehensive and accurate, and credible;
• develop reliable timeline estimates for implementing the program; and
• with stakeholder input, develop outcome-based performance measures that
address all phases of the program and that focus the success of the
program on CDC’s federal, state, and local partners’ use of the system for
responding to public health events.

70

Page 76

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix I: Briefing Slides

Agency Comments and Our Evaluation

We received oral comments on a draft of this briefing from CDC’s BioSense
program officials, including the Director of the National Center for Public Health
Informatics. The officials generally agreed with the information included in our draft
briefing and provided additional information and technical comments related to the
program, which we have incorporated as appropriate.
BioSense program officials acknowledged areas of deficiencies in the initial design
of the BioSense system and stated that the current managers of the program, with
extensive user engagement through BioSense roundtable meetings, had identified
the shortcomings detailed in our briefing. They stated that they are consequently
taking steps to reconfigure the system and to address these problems, as outlined
in the draft BioSense Strategic Plan and as described in this briefing.

71

Page 77

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix II: Comments from the Department
of Health and Human Services

Appendix II: Comments from the Department
of Health and Human Services

Page 78

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix II: Comments from the Department
of Health and Human Services

Page 79

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix II: Comments from the Department
of Health and Human Services

Page 80

GAO-09-100 CDC’s Redesigned BioSense Program

Appendix III: GAO Contact and Staff
Acknowledgments

Appendix III: GAO Contact and Staff
Acknowledgments
GAO Contact

Valerie C. Melvin, (202) 512-6304 or [email protected]

Staff
Acknowledgments

In addition to the contact named above, key contributions to this report
were made by Teresa Tucker (Assistant Director), Heather A. Collins, Neil
J. Doherty, Amanda C. Gill, Nancy E. Glover, Franklin D. Jackson,
Mohammad S. Khan, and Lee A. McCracken.

(310931)

Page 81

GAO-09-100 CDC’s Redesigned BioSense Program

GAO’s Mission

The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO’s
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

Obtaining Copies of
GAO Reports and
Testimony

The fastest and easiest way to obtain copies of GAO documents at no cost
is through GAO’s Web site (www.gao.gov). Each weekday afternoon, GAO
posts on its Web site newly released reports, testimony, and
correspondence. To have GAO e-mail you a list of newly posted products,
go to www.gao.gov and select “E-mail Updates.”

Order by Phone

The price of each GAO publication reflects GAO’s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO’s Web site,
http://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional information.
Contact:

To Report Fraud,
Waste, and Abuse in
Federal Programs

Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: [email protected]
Automated answering system: (800) 424-5454 or (202) 512-7470

Congressional
Relations

Ralph Dawn, Managing Director, [email protected], (202) 512-4400
U.S. Government Accountability Office, 441 G Street NW, Room 7125
Washington, DC 20548

Public Affairs

Chuck Young, Managing Director, [email protected], (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548