Transcript Stimulus Bill Update

Information Exchange for Detection
and Monitoring: Clinical Care to
Health Departments
Janet J Hamilton, MPH
Florida Department of Health
Bureau of Epidemiology
www.amia.org
Different data needs from clinical care
for different surveillance activities
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Vitals
Registries – cancer, birth defects etc.
Reportable disease/condition surveillance
Outbreak management
Periodic active surveillance
Emergency situations
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Reportable disease/condition
surveillance
– The traditional core of public health
surveillance
– Learn about every person with a reportable disease
to:
• Identify promptly all cases of diseases or
conditions that require public health intervention;
• Detect outbreaks, changing trends or patterns in
disease occurrence;
• Plan, assess or evaluate control and prevention
interventions.
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Conditions for which clinician case
reporting has been used
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Infectious diseases
Birth defects
Cancers
Occupational diseases
Environmental diseases
Child abuse
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How does PH get needed
information?
• The initial report alone (from either clinician or the
laboratory) often does not have all the information PH
needs for completing follow up and documentation of
individuals with reportable diseases
– PH needs Person, Place, Time (Who, When, Where, What):
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Clinical (and lab) information to confirm the diagnosis
Treatment or medications given to the patient
Where the exposure/event occurred
Denominator present (total exposed/impacted)
Environmental setting
How the patient may have become ill (insect bites, foods
consumed, travel locations, etc.)
• Further prevention actions needed (e.g. exposed family
members needing treatment or vaccine)
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Syndromic Surveillance
• Might better be called pre-diagnostic
surveillance
• Detect events at the community level before
diagnoses are made
• Monitor the progress of larger events once
recognized
• Speed vs completeness
– Data sources: ED or clinic visits, poison control
center calls, EMS run reports, absenteeism, key
words in tweets or search engines, news reports,
blogs
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Defining data management needs
during outbreaks and events
• What data does public health need for
outbreak management and investigation
• What is different about outbreaks?
– Review some examples:
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Anthrax
H1N1
Fungal meningitis
Lots of media attention and need for data
multiple times a day
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Anthrax
2001
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Anthrax 2001 - Challenges
• > 600 suspect cases reported and triaged; only 8 confirmed (7
cutaneous and 1 inhalation)
• Site investigations needed at multiple locations (media outlets, hospital,
USPS distribution center)
• No system available to manage huge volume of data related to
laboratory specimens
– Suspect and Confirmed Cases
– Potentially Exposed people at worksites (> 2500 nasal swabs)
– Environmental specimens at all affected sites (> 1270 specimens)
– > 3,000 “White powder events”
• Need to capture, describe and easily retrieve relationships between
people, sites, specific exposures, environment, courses of prophylaxis,
laboratory results
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H1N1, early on - Challenges
• New, many susceptibles in the population
• Communicable
• Complex contact tracing (home, work, and healthcare
contacts)
• Need for case isolation and quarantine of contacts
• Laboratory diagnosis challenging; esp. initially testing
only available at CDC; public health not prepared to
be the only clinical diagnostic location
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Fungal meningitis - Challenges
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New, unexpected, non infectious
Need specific specialized ID consults for treatment
Long incubation periods
Long courses of treatment
Many exposed
Multiple specimens over time
Detailed clinical record reviews
Changing role of public health for health care
associated infections; patient provider relationships
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Outbreak and event detection needs
• Establish data flow connections; leverage
electronic feeds
– prior to events
– balance between speed of information vs
completeness
– Public health goal: reduce time accessing
and gathering information  patients are
contacted sooner  source of illness is
identified more quickly leading to improved
disease prevention
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Event Monitoring
• ESSENCE ED Chief Complaint
“Meningitis,” Statewide, 9/1-10/26/2012
Note: Visit spike on 10/12-10/13 is due to bacterial meningitis
outbreak
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Dashboard-Morbidity Post-Disaster
Wilma
Landfall
Wilma
Landfall
Wilma
Landfall
Wilma
Landfall
Wilma
Landfall
Earthquake
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Specific Query – Drowning in
those <1-4 yrs old
• Uses that go beyond our typical surveillance purposes.
Other program areas may also benefit.
• Example: Combining ED and Mortality data in one graph
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ESSENCE-FL: Pneumonia and influenza mortality data from
the Office of Vital Statistics, Florida 2003-2010
• Mortality due to the 2009 H1N1 virus was only slightly
increased, however the increases were seen
unusually early in the year
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Further discussion - Where do we
go from here?
• Provider understanding – role of public
health, closing the loop - communicating
results/info to providers
• Clinical data (coded) in EHRs often
insufficient for outbreak management
• How realistic is a public health query /
access / portal into EHRs for use after
an outbreak has been identified or
disease report has been made?
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Case-detection from EHRs?
• Determine where might be more complete than
passive clinician-based reporting
• Not clear how much more timely it would be
• How would you assure a high positive predictive
value?
• Would you put a human in the loop?
• Would you want to wait for the final diagnosis at
discharge?
• If not, how do you detect potential cases before a
diagnosis is entered in the chart?
• Expand conversation beyond infectious
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