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• 2004 Article
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Building
a Better Biosurveillance System
by Eric Skjei
Article originally
printed in CAP Today –
February, 2004
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The advantages of computerizing a public health reporting system that is still
largely manual are so compelling that they've spawned a number of initiatives
to do so. These projects, organized under the Public Health Information Network,
are enjoying renewed attention not only because of the specter of bioterrorism
but also because of new infectious and communicable disease threats, such as
SARS.
In a process being duplicated in urban regions around the country, software and
hardware, phone lines, and virtual private networks are first complementing and
then replacing fax, phone, and traditional mail or courier-based reporting systems.
The result: Diseases and threats are identified and responded to more quickly,
and more such cases are picked up in the first place.
In Florida, for example, the state Department of Health implemented a pilot project
more than a year ago that was designed to pull laboratory data for infectious
or communicable diseases from the state laboratories and pass the data electronically
to appropriate caseworkers, in this instance those working with sexually transmitted
diseases. Before the pilot project was launched, reporting was done via hard
copy only.
"We've been pretty successful," says Janet Firestone, integration program
manager and data administrator for the state's Department of Health. "We've
reduced the lag time in getting caseworkers access to the data from four to 10
days down to under 72 hours." In many cases, she adds, that notification
takes place even sooner, within 24 hours of the time the tests are done.
This depends heavily on rules that operate automatically in the system's software. "Once
we get the test in, our integration broker applies certain user-defined rules
to it," Firestone says. "We look for circumstances relevant to that
test-for example, is the child under a certain age, is the test positive for
a specific STD, and so on." Cases that fit the profile may generate an e-mail
alert to the caseworker, who then investigates further. In one recent instance,
the caseworker showed up at the hospital and began the process of getting treatment
for an infant even before the child was discharged. "That made us real happy-IT
people don't get to save too many babies," Firestone says.
The next step in the project is to bring in a laboratory that does not operate
within the state system. To this end, she has gained the participation of Integrated
Regional Laboratories in Fort Lauderdale, whose medical director is James Robb,
MD. Dr. Robb is also vice president for medical affairs at MDS Laboratory Services,
U.S.
Dr. Robb and Firestone point to the value of incorporating data communication
and exchange standards in making an interlaboratory project like theirs a success.
"We're using the HL7 format, which is standard with the CDC, as the message
standard, and we're working with Dr. Robb's laboratory staff so we can do a crosswalk
on the local laboratory test codes and the national standards, which are LOINC
codes for the tests and SNOMED codes for the lab results," Firestone explains.
Without this step, the process can become unmanageable. "Every laboratory
uses its own local codes," she notes. "For us to figure out which tests
need to go into which program areas, we need to know what those tests are and
have a standard way to identify them. That's where standards like HL7, LOINC,
and SNOMED CT come in."
Once the new process is in place, reacting to requests to add a new test or result
becomes straightforward. "We had a request in the middle of last week from
our infectious disease people indicating that they would like to receive positive
tests for influenza," Firestone says. "It's not bioterrorism, but for
public health it's very important."
Because influenza had not until that point been a reportable disease, Firestone's
lab had not been filtering out state laboratory data for it. "Within a day
and a half we were able to modify our system so we could pull that test out of
the file that we get from the state laboratory, and now we're reporting that
electronically to our infectious disease people so they have access to that data
within 24 to 36 hours of the time the tests are completed," she says.
Adds Dr. Robb: "This is exactly what we want to carry on to a regional,
national, global level, where you can use coding that will take that information
and rapidly alert back when you have a proper constellation of symptoms, age
groups, and data, including lab, radiology, and clinical data. And it will throw
up warning signs in the proper facility, even hopefully at some point with the
physician and his or her Palm Pilot."
Firestone notes that alternative mechanisms must still exist to circumvent the
standard procedures when the need to act urgently is paramount. "There are
certain cases and circumstances that will continue to bypass this process," she
says. "If Dr. Robb were to get a lab test in and find he's got a positive
for anthrax, our basic alerting system will continue to work. But he has protocols
in place that he will continue to follow that say, for example, When you get
one of these tests, you pick up the phone and you call somebody at the state
department of health or the CDC now."
Linking private and public labs to build better Public Health Information Networks
is going on all across the country, with different regions advancing at different
paces, Firestone says.
"We participate in a monthly conference call with a lot of other places
that are trying to implement this process," she reports, "and they
have all implemented pieces or parts of it, or they are in different stages of
implementation." In New York, private labs are supplying HIV data to state
health officials, and the PHIN group there is hoping to enlist the help of the
national reference laboratories.
Los Angeles County has been working with Visual CMR (Confidential Morbidity Report),
a disease-tracking and case-management system, and is seeing "great results," says
Robert Gregory, managing director of Atlas' new Public Health division. David
Dassey, MD, deputy chief of Los Angeles' Acute Communicable Disease Control,
and others designed the system in the late '90s, and Atlas created the software.
It was deployed by the L.A. County Department of Health and Human Services in
May 2000 and has been operating ever since.
"The county has found it to be a huge boon to its efficiency in terms of
its ability to gain a great deal of data about what's happening in the field
and its ability to investigate and resolve incidents and outbreaks on a much
quicker timeline," Gregory says. What might have taken a month now takes
a week.
The vision of a national electronic disease surveillance system is not all that
new to the CDC, explains Gregory. "Originally, they referred to it as the
NEDSS [National Electronic Disease Surveillance System] program. About a year
and a half ago, CDC began to use the term Public Health Information Network,
PHIN, which has now become the new label for the emerging mandate that the CDC
is putting forward to create a national network of interconnected public health
departments and other public health entities."
"
PHIN is basically a series of guidelines that the CDC has been finalizing for
some time," Gregory says.
The PHIN standards are directed to state and local health departments, which
still must determine what specific IT solutions to deploy. "The standards
don't dictate exactly what each system should be," Gregory says. "They
provide a framework that emphasizes open technologies that can communicate easily,
in particular HL7 3.0 RIM, which is an emerging standard for HL7 messaging that
will include public health-specific messaging, and ebXML as the transfer layer,
an electronic business XML standard that will allow for secure standard message
passing using HL7."
The Atlas system, Gregory says, was designed by L.A. County to address its local
needs, to handle exactly the kind of case management and workflow that's needed
to make sure public health nurses out in the field are doing the investigation
and analysis, and that all followups are done to ensure information is correct
and up to date. "But the system also complies with the standards as they
exist today for PHIN, and we are working to ensure continuing compliance," he
adds.
Atlas recently expanded that system by bringing San Diego County online. "We
have had additional conversations with others in California as well as with several
prospects throughout the United States," Gregory says.
Larger integrated health delivery networks or academic medical centers also are
interested in the case investigation possibilities of Atlas Visual CMR within
their own health systems, Gregory says.
At the same time, Atlas is approaching private-sector laboratories it has worked
with on the LabWorks side of the equation, he says. LabWorks is an order-entry
solution that outreach programs use. To make this strategy workable, Atlas is
establishing a centralized data-brokering capability through its data center
in Agoura Hills, Calif. The center will receive incident reports that come out
of any laboratory information system enrolled in the program.
"
We'll take those incident reports, filtered to determine that they are in fact
reportable incidents, and then broker them to the appropriate local health department
that is supposed to receive that report by statute," Gregory says. "We
call this the public health information link, or PHIL."
L.A. County has been receiving electronic transmissions of reportable disease
incidents from Kaiser Permanente Reference Laboratories in southern California.
Kaiser's reports constitute 40 percent of all the communicable disease reports
that L.A. County Public Health receives; they're transmitted using LOINC standard
encoding. At CAP TODAY press time, Atlas was planning to add incident reporting
from Kaiser to San Diego County within a few weeks, using PHIL.
Atlas has begun to deploy a Web-based CMR system in Los Angeles County. It's
a Web-based reporting module that physicians and other health care providers
can use to file reports, by way of a Web browser. They are able to log on to
a secure system administered by the county that provides them with a Web-based
form that is virtually indistinguishable from the paper form they're used to
using. They complete it online, submit it electronically, and receive an instant
electronic response from the server, which functions as a receipt to show their
compliance.
Cerner Corp. has, with the cooperation of local clinical laboratories, operated
an automated reporting system for the Kansas City (Mo.) Health Department for
18 months now. It has already demonstrated significant improvements in the speed
and completeness of reporting over the older, manual system it is intended to
eventually replace. So successful has the first phase of this project, dubbed
Health Sentry, been that it is now slowly being expanded to the state level.
"
The key benefits observed were that not only was the speed of reporting improved,
but there were a lot of underreported diseases that we were able to capture and
deliver to the health department," says Mark Hoffman, PhD, genomic solutions
manager for Cerner Corp.
Dr. Hoffman and colleagues reported in the October 2003 issue of Emerging Infectious
Diseases that notification of chlamydia cases arrived two days earlier, invasive
group A streptococcal disease cases arrived 2.3 days sooner, and salmonellosis
cases arrived 2.7 days sooner. "Data were more complete for all demographic
fields, including address, age, sex, race, and date of birth. Two hundred fourteen
cases reported electronically were not received by conventional means," they
wrote.
The health department receives three types of reports daily. "The electronic
reports are usually available for download around midday," says Tiffany
Wilkinson, assistant division manager for communicable disease prevention and
public health preparedness, Kansas City Health Department. "These can then
be reviewed to monitor for disease trends. The data from the reports can also
be exported to allow for uploading into our existing surveillance system."
The first report is an isolate report that includes all the available reportable
disease information from the contributing laboratories. The laboratory results,
along with available demographic data, are provided, Wilkinson says.
The second report is a laboratory orders report. "That report assists in
identifying actual lab orders before the results even come back," Wilkinson
explains. "So regardless of the results, whether they're positive or negative,
we can monitor the ordering patterns within the hospitals. For example, examining
the number of stool specimens ordered may give insight a little bit sooner as
far as potential foodborne illness outbreaks or something else that's going on
within the community."
The final report is a full-text document. "It's very common for laboratories
to report things differently," Wilkinson says. "And because the templates
they use aren't necessarily standardized across facilities, the addition of this
full-text report allows us to see the information on a more detailed basis for
microbiology orders." This report also provides, in some cases, additional
information such as colony counts and serotyping information, as well as information
on whether the result has been reported and who it was reported to.
The Cerner-operated data clearinghouse takes the reportable results from all
the contributing laboratories and translates them into a standardized nomenclature.
The clearinghouse maps these results to common codes, aggregates the information,
and delivers the encrypted reports through a secure shell network.
"
What we do is download these reports and cull through them based on a set of
criteria that we've developed," says Karen Miscavish, an epidemiology specialist
at the health department. "We go back a week at a time, picking up all the
isolates, further sort them by diseases that are reportable in our area, and
then we compare that with our existing surveillance system so we're not entering
duplicates or anything like that." Information received on people who reside
outside the department's jurisdiction is forwarded to the correct agency. "And
we do that basically every single day," says Miscavish.
Eric Skjei is a writer in Stinson Beach, California
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