Code Orange: Managing health information in a crisis

Although much has been written about managing the Severe Acute Respiratory Syndrome (SARS) crisis, the focus has been on health care professionals and patient care. Little if anything has been written on the impact of the crisis on technical infrastructures, information management and modes of communication.

Managing health information during a crisis is not unlike managing other forms of information. Essentially, the challenges are centred on sending and receiving information. Channels of information have proved vitally important in combatting epidemics, outbreaks and terrorist attacks in the past. We have seen, for example, how the efficient use of helped fight smallpox in the early 1900s, Legionnaires’ Disease in the 1970s, HIV/AIDS in the 1980s and ebola in the 1990s. While not as significant as vaccines or antibiotics, proper information management was pivotal in the containment of deadly outbreaks. Information shared between researchers and among medical facilities, and information disseminated to the public (e.g., promoting better hygiene) played vital roles in combating deadly outbreaks throughout history.

Close to the centre of much of the SARS crisis was the University Health Network (UHN) in Toronto. UHN is an umbrella organization consisting of three hospitals — Toronto General, Toronto Western and Princess Margaret – and is a teaching partner of the University of Toronto. SARS affected its 10,000 affiliated staff and health care professionals in a number of ways, and posed challenges for the provision of key information systems services including communications and access.

How UHN Coped with SARS

Once provincial health authorities determined that there was a significant public health threat, UHN declared a Code Orange emergency, indicating an external disaster. From an information management/technology perspective, says Matt Anderson, UHN’s CIO, disaster planning has always centred on anticipating system crashes. “With SARS, downtime procedures did not apply. Health information and business systems were functioning normally, but there was no one around to receive and disseminate information.”

Hospitals were closed to all visitors and non-essential staff, entrances were strictly controlled and screening stations were set up. Little was understood about this new disease; particularly how it was being spread. Hospitals such as those within UHN feared that emergency wards would admit patients with SARS without realizing it. The movement of patients and all other individuals associated with hospitals had to be monitored and controlled. Staff, patients and the public required up-to-date information, patient care remained a priority and information had to be shared with health authorities within the city, the province and the federal government.

The direction of UHN’s technical infrastructure, operations and patient flow seemed to turn 180 degrees overnight and was subsequently modified daily throughout the crisis as the situation developed. In the initial three weeks of the crisis, a disaster model took shape.

Week 1

UHN’s Shared Information Management Services (SIMS) department implemented three significant functions to ensure the proper collection and dissemination of information throughout the organization:

Command Centres

Four command centers staffed with resources from designated UHN departments were set up at each hospital site, as well as within SIMS. To provide UHN with the essential channels for communicating with internal and external stakeholders, the information systems department established five phone lines, a central phone number, PCs with Internet access, a dedicated e-mail address, fax machines and phone conference capabilities. Each Corporate Command Centre fielded an overwhelming number of e-mails and phone calls from staff asking questions about procedures and policies – in most cases presenting unique patient/staff situations. The communications approach consisted of 8 a.m. teleconferences with the Chief Operating Officers of each UHN hospital, 9 a.m. site team briefings by phone and by e-mail, and 3 p.m. UHN-wide teleconferences on daily screening and policy updates.

Patient and Staff Entrance Screening

Images that may have been shown most frequently on television during the SARS crisis were those of people being turned away at the screening stations that were set up at designated hospital entrances. The patient and staff entrance screening process actually existed largely as a paper process, aided by a screening template that was provided and changed daily by the Provincial Operations Committee (POC). Thousands of screening forms were photocopied every day until a screening database was put in place several weeks into the crisis.

Operational Patient Information (SARS Stats Form)

A template was developed in-house to collect and aggregate information including the number of SARS and suspected SARS cases, number of new SARS cases, hospital bed occupancy percentage, number ambulatory visits, number of operating rooms open and other data. The template proved challenging to implement because of the diversity of methods needed to collect the required data. At the Toronto Western Hospital, this was not difficult because one person was made responsible and the information was collected in a central location. However, the much larger Toronto General assigned several people to data collection and the data was located in several different areas.

Weeks 2 and 3

By the second and third weeks of the crisis, it became apparent that there was a tremendous need among health care providers for information on procedures, policies and news on research into the disease. The requirement was particularly acute since many of them were unable to come to work due to the Code Orange directives. UHN utilized four existing tools as part of its communication approach:

Web Mail

The need for information, especially for telecommuters, resulted in a 300 per cent increase in the use of e-mail among hospital staff. To accommodate the influx of users on the system, UHN set up two more servers and distributed incoming Internet e-mail to one or the other using a simple filtering method that directed traffic according to user name.

Voice Mail

Voice mail became another essential tool for communication for both patients and staff. Additional voice mailboxes were set up to accommodate the increased number of patient calls and detailed announcements were created daily to inform staff and patients.


Throughout the crisis, UHN’s Intranet and the Internet provided both staff and external clients with daily and hourly updates. This capability also presented a challenge, as resources were required to keep the information current.

Tom Talks

As UHN’s President and Chief Executive Officer (, Tom Closson communicated with staff during the crisis through an e-mail process called Tom Talks. Tom Talks had existed before SARS, as an occasional method of informing staff about issues facing the hospital, including budget updates and media stories. During the SARS crisis, daily and sometimes hourly messages were sent to staff informing them about recent developments and procedure changes and to provide a general morale booster. Tom Talks messages proved to be the most effective method of reaching staff. Other methods that were tried but not used included mass voice mail, which overloaded the telephone system, and video messages via the Intranet, which slowed down internal servers.

Lessons Learned UHN learned many lessons during this crisis, including:

Maintain consistency in messages

It was difficult to ensure consistent messages among more than 10,000 staff. Media rumours affected morale and had to be countered with accurate information provided by senior management. Aside from responding to media reports, those at the centre of the crisis response at UHN were bombarded with staff e-mails and phone calls asking about procedures and protocols. There was never much time to develop corporate-wide messages. However, UHN learned a valuable lesson in maintaining consistent messaging, achieving it through top-down, centralized conveyance of information via CEO e-mails and other modes. Similarly, in the flow of incoming information was also centralized in order to ensure consistency.

Use a variety of methods of communication

UHN learned that a variety of modes supported by the existing infrastructure were necessary. However not all were successful. Voicemail tended to overburden, and analog telephone systems proved impractical for mass messaging. Streaming video taxed server space; however this could be helped by increasing system memory. Since the virus kept people away from work, the UHN concluded that more personal means of communication (e.g. Tom Talks) were effective. Thus a balance was struck between keeping people informed and maintaining the infrastructure.

Leverage existing tools

Prior to SARS, the Tom Talks e-mail series had a huge impact on UHN staff satisfaction, and during the crisis the messages proved a primary success factor for the organization. Tom Talks was an existing tool that was leveraged effectively to disseminate information to staff while boosting morale. Other tools that were leveraged included remote access to the Intranet. In the aftermath of the crisis, electronic scheduling was identified as another important tool. Prior to SARS, two of the three UHN hospitals used paper-based systems that depended on staff being physically present to administer them.

Share and coordinate the flow of information During the crisis, UHN felt like they were operating in a vacuum. Information flowed slowly, and differences in system architectures among other organizations prevented information from being shared from one hospital to the next. Recommendations are already being presented on this issue in various reports.

Conclusion: Validating the Model

Not long after SARS was no longer deemed a threat, Ontario faced a new challenge when much of the province was plunged into darkness in August 2003. The blackout of 2003 was another Code Orange disaster for provincial health care facilities. During this crisis, UHN was prepared as it utilized its newly developed disaster model. Once again, command centres were established, and attention was devoted to maintaining consistency of messaging and utilizing the same channels that proved successful during SARS. “In the end,” says Anderson, “the disaster validated our disaster plan.”

Robert Randall ([email protected]) is a senior consultant with The Intoinfo Consulting Group, a management and information consulting firm located in Ottawa. Michael Caesar ([email protected]) is a project manager in patient care management systems with the Shared Information Management Services department at the University Health Network.


Further information on the management of health information can be sourced through the following links: American Health Information Management Association

A proposed model for managing health information during a crisis is described in a presentation by Toronto’s St. Michael’s Hospital to the SARS Commission in October 2003, accessible through the following link:

In the aftermath of the SARS crisis in Ontario, federal and provincially sponsored commissions and reports have been produced and can be found online at the following locations:

SARS (Campbell) Commission

Learning from SARS – Renewal of Public Health in Canada

An example of a Tom Talks message can be accessed through the following link:

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