Transcript View Slide Presentation - Association for Pathology Informatics

Disease Surveillance –
Applying Pathology
Informatics to Public Health
Raymond D. Aller, M.D.
Contributing Editor, CAP Today and Director,
Bioterrorism Preparedness and Response Section
Acute Communicable Disease Control Program
Los Angeles County Department of Public Health
18 August 2006
LA County Dept. of Health Services
Pathology as a clinical
informatics pioneer
First information systems used in routine
patient care
 First electronic longitudinal patient
records
 First nationwide clinical records
 Comfort and familiarity with building and
maintaining large analytical databases

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LA County Dept. of Health Services
.. and as pioneer of technologies and
standards for PH disease surveillance
– 1975 (SNOP 1965)
 In 1970’s first automatic transfer of coded
data to a PH system (tumor registry)
 HL7 – from glimmer in 1979 to publication
in 1987
 LOINC – cooperative development with
extensive pathology/lab medicine
involvement - 1994.
 SNOMED
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LA County Dept. of Health Services
Clinical Informatics
 Not
about computers or information
technology
 Is about how we acquire, analyze, and apply
clinical information
 We are informaticists
 (Informaticians work with dead information)
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LA County Dept. of Health Services
Keys to success
Use of data produced as a byproduct of clinical care
 Automatic transfer of that data from clinical care
setting, to public health database
 Translation functions to standardize the incoming
vocabularies and codes
 Mechanisms to detect outbreaks designed for both
naturally occurring (epidemics) and malicious
(bioterrorism)
 Informatics is today a key tool in defense against
natural and man-made outbreaks.

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LA County Dept. of Health Services
Objectives
Describe at least 3 types of data from clinical medicine
being used to detect disease outbreaks
 Discuss 4 or more non-technical barriers delaying
connection of clinical data sources to the public
health database
 List at least three types of unique contributions,
critical to PH disease surveillance, that originated in
pathology
 Eliminate excuses as to why his/her laboratory isn’t
pursuing connection with their local PH disease
surveillance system.

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LA County Dept. of Health Services
Types of data from the lab
to public health

First implemented: tumor diagnoses from
surgical path to the tumor registry.
– An entire subject in itself, and I won’t attempt to cover
today

In recent years, I’ve focused on a few other areas,
from clinical lab to PH:
– Transfer of reportable (mostly infectious) disease
information (for case management)
– Antimicrobial susceptibility (de-identified)
– All lab orders (de-identified)
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LA County Dept. of Health Services
Knowing that there is a
problem
 Natural
(epidemic) vs. malicious (bioterrorism)
 Most agents (biological, nuclear, incendiary,
chemical, explosive, radiologic - b-NICER) are
overt
 Biological agents - typically covert
 A major portion of preparation for bioterrorism
is about detection.
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LA County Dept. of Health Services
Detection –
two sides of the coin
 Detecting
the organism (or toxin) itself
– Example – the post office Biohazard Detection
System
– A point of care laboratory assay!
 Detecting
early signs of disease
– Disease reporting by clinicians, labs
– Symptoms and behavior
– Animal diseases
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LA County Dept. of Health Services
Our most important data
sources
 The
astute clinician and the
telephone!
 Message: If you see something that
looks wrong, let public health know.
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LA County Dept. of Health Services
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LA County Dept. of Health Services
The Scope of PH Informatics (1
Vital records: birth and death registries
 Public Health laboratory:

– biological
– chemical/ environmental (potable and recreational water,
milk, etc.)
– newborn screening/ management for genetic and infectious
disorders

Management of chronic conditions (disabilities,
newborn abnormalities, etc.)
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LA County Dept. of Health Services
PH Informatics (2)

Population health and perception measurement,
monitoring - data acquired from:
– Population-based clinical care systems (e.g., Indian Health
Service)
– Telephone and other population surveys



Environmental health
Reportable disease: National electronic disease
surveillance system
Management of communicable disease: Acute
communicable disease, Sexually transmitted diseases,
HIV epidemiology, Tuberculosis, Immunization registry
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LA County Dept. of Health Services
PH Informatics (3)







Lead poisoning case management
Electronic laboratory reporting:
Syndromic surveillance
Alerting and partner communications
Strategic national stockpile inventory and warehouse
management
Countermeasure response administration (mass prophylaxis)
Education and training of medical professionals and the public
– Tracking/managing that training (learning management)

Emergency management information systems:
– Coordination with other first responders, such as fire, police
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LA County Dept. of Health Services
Public Health Informatics
 Today’s
talk
– Encourage reporting of disease by clinicians
– Electronic laboratory reporting
– Syndromic surveillance
 Other
areas of interest to pathology, will
not be discussed today
– Lab information systems – PH, veterinary
– Many others
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LA County Dept. of Health Services
How do we detect
disease?




Reportable disease
– Clinician – paper (underreporting)
– Infection control practitioners – web entry
– Electronic reporting from labs
– Automatic reporting from clinical systems
Symptoms
– Emergency departments (symptoms, volume - Reddinet)
– 911 calls, ambulance dispatch, nurse call lines
Byproducts of care
– Ambulatory diagnoses, lab orders (Biosense)
Behavior
– Purchase of over the counter medications
– School or work absenteeism
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LA County Dept. of Health Services
80+ reportable
diseases
(mostly infectious)
must (by law) be
reported to
Public Health
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LA County Dept. of Health Services
Reportable diseases
• In the past, handwritten paper form via mail or fax
• Reporting is slow, and rates are often abysmal (5% or less)



Improved by use of a web-based system
However, findings diagnostic of many of these diseases
(e.g., hepatitis B) are stored in hospital, laboratory and/or
clinic computers
Automatic electronic transfer of these cases to public
health (e.g., Electronic Laboratory Reporting) has been
shown to greatly improve the reporting rate.
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LA County Dept. of Health Services
Web-facilitated reporting
Web-visual Confidential Morbidity Report
(Web-vCMR)
 Now called the Community Reporting
Module
 Anywhere with internet access
 Security: digital certificate on your
workstation, plus username/password

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LA County Dept. of Health Services
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LA County Dept. of Health Services
From manual to automatic
 When
a reportable diagnosis is
recorded in an EMR/EHR
– Automatically report - or –
– Pop-up question to clinician –
• OK to report?
 Recognizing
patterns in the EMR
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LA County Dept. of Health Services
Electronic Lab Reporting
(ELR)
Software on the laboratory information system
automatically selects from all laboratory results,
those which are reportable to public health
 In other cases, ALL results transferred to a filtering
system, that selects reportables
 These may be enhanced by other findings of public
health importance

– Antimicrobial susceptibility testing
– Syndromic indications

ELR commonly doubles the reporting rate
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LA County Dept. of Health Services
Key characteristics of ELR




Unbroken (no manual steps) electronic linkage between
the database of the laboratory’s information system and
the database of the public health disease reporting
system.
– HL7 format
– Flat file format
For a very small lab, web entry
Types of data that may be sent: immunology,
microbiology, tumor diagnoses
Systems the data is sent to: communicable disease
reporting systems, syndromic surveillance systems,
tumor registries
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LA County Dept. of Health Services
Why Electronic Lab Reporting?
 Community/clinician
reporting rates abysmal
(often less than 5%)
 Laboratories typically have much better
administrative organization
 Positive laboratory findings more definitive
than a clinical impression
 Even without ELR, labs often achieve 50% or
better reporting rates.
 ELR permits close to 100% reporting rates
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LA County Dept. of Health Services
ELR Benefits to the Lab
to PH as soon as available –
compliance with <24-hour reporting law
 Every case that meets criteria is sent
automatically
 Some states now mandate electronic
reporting
 HIPAA disclosure records complete
 Lab staff time savings.
 Results
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LA County Dept. of Health Services
ELR Implementation
Format – HL7 v2.3.z, v2.3.1, now v2.5 target
 Security – sFTP, VPN
 Important to capture patient address and phone
(for PH followup) – may require additional data
from ADT system, etc.
 Codes converted from local to standard

–
–
–
–
Result names standardized – LOINC
Result values standardized – SNOMED
Specimen source – HL7 table, SNOMED
Appropriate tests/results to send – “Dwyer/Sable tables”
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LA County Dept. of Health Services
LOINC
Logical Observation Identifier Names and Codes
 In ELR, used for test names
 Published beginning in 1994
 Freely available – copyright but royalty free
 Now mandated by Federal government for all
governmental healthcare programs (VA, DOD, IHS).
 The standard for reporting of public health data.
 Future standards for physicians office systems
 www.loinc.org

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LA County Dept. of Health Services
SNOMED
Systematized Nomenclature of Medicine
 In ELR, used for organism names
 Under development since the late 60’s
 Encompasses all areas of clinical medicine
 Mandated for all medical records in the UK
 Also used by many organizations (Kaiser) and
countries
 Licensed for use throughout the United States.
 www.snomed.org

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LA County Dept. of Health Services
Data Transformation
These functions may be performed
in the Public Health Department,
Data Producing Facility or an
Intermediary
Hospital
Systems
PH compliant
HL7 messages
Public
Health
Information
System
PH compliant
HL7 messages
Public
Health
Information
System
PH compliant
HL7 messages
Public
Health
Information
System
Format converter
Text handling
Filter
De-identification
Collation
(of “non-reportable” findings)
Routing
Code
translation
Code
Codetranslation
translations
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Web page
Data entry
LA County Dept. of Health Services
To Do a LOINCing
 Download
lab’s test dictionary
 Test name, test code, units, method,
specimen type
 Done by Public Health staff or outside
services (probably not the lab)
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LA County Dept. of Health Services
Getting from internal test codes
to standard LOINC codes

Today –
– Laborious, mostly manual process to match description,
units, method, etc. to appropriate code
– Some vendors (e.g. 3M) have a suite of automated tools

Tomorrow –
– Vendors (instruments, kits, reference labs) supply the
appropriate codes
– Statistical assessment of a high-volume HL7 data stream
(e.g., mean and SD of results)
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LA County Dept. of Health Services
What Data is Transmitted?
 Now:
Reportable diseases
– Supporting lab findings – liver enzymes and
bilirubin on cases of positive hepatitis serology
 Soon:
Lab orders that may help define
syndromes
 Future: Antimicrobial susceptibility testing –
on ALL organisms
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LA County Dept. of Health Services
Syndromic Surveillance
using lab data
 Real-time
public health surveillance using
data that is routinely collected for other
purposes
 Not to identify individuals, but to detect
atypical patterns of symptoms, orders,
findings
– Therefore, data can be de-identified
 Real
time transmission, analysis, and alerts
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LA County Dept. of Health Services
Lab Order Defined
Syndromes
Blood cultures: fever
 Stool cultures: GI
 Sputum cultures: respiratory
 CSF cell counts: meningeal (e.g., West Nile)
 This is a nascent area – may be better to get ALL
orders, as we learn what constitutes a useful
pattern
 The BioSense – LabCorp experience

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LA County Dept. of Health Services
Antimicrobial
Susceptibility Testing
 Antimicrobial
resistance is an increasing
problem in all communities
 Traditional – collect antibiograms from
hospitals
 Late 90’s – commercial services such as TSN
collected susceptibility data from labs
 Alternative – collect raw susceptibility results
from labs, perform calculations at public health.
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LA County Dept. of Health Services
Cost of disease reporting
from labs

Cost of manual reporting –
– 0.50 to $5 per case

Interface
– Initial – license fees, implementation, personnel time
– Ongoing –
• Direct link - maintenance fees
• Intermediary - monthly use fee.
– LA County has arranged to reimburse hospitals for
costs (see next slide)
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LA County Dept. of Health Services
For once, a funded mandate
LA County has HRSA/NHBPP grant
funding to reimburse hospitals for their
out-of-pocket expenses (e.g., vendor
fees) in establishing data feeds
 We have already purchased lab interface
modules for several hospitals
 We also provide data conversion (LOINC)

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LA County Dept. of Health Services
ELR – current status
 Nationwide,
many states (and a few
local jurisdictions) are now
receiving ELR
 Most commonly connected –
national labs (LabCorp, Quest)
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LA County Dept. of Health Services
Mandatory use of
electronic lab reporting
 Still
voluntary in most jurisdictions
 Some now require by law/regulation
– New York State
 Or
for certain tests –
– Blood lead - California
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LA County Dept. of Health Services
Potholes in the information
superhighway
 When
you are trying to travel at
186,000 mps, a pothole is a big deal!
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LA County Dept. of Health Services
The official salute of the
governmental I/T
insecurity officer
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LA County Dept. of Health Services
The general I/T industry is
beginning to recognize this
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LA County Dept. of Health Services
What is the biggest threat to
our informatics preparedness
for biosecurity?
 The
information insecurity officer
– Fingerpointing
– “Finding a way to get to NO”
– The security Luddite
– Forces expensive, error prone and
unsafe workarounds
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LA County Dept. of Health Services
5 I/T syndromes hazardous
to the public’s health
The security Luddite
 The perfect: enemy of the good
 Governmental bureaucracy

– Counterproductive hiring policies
– Inhibitory purchasing procedures
– Impossible contracting procedures
The vaporware merchant
 Judgments based on Insufficient data

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LA County Dept. of Health Services
Back to biological disease
 Gathering
diverse data
 Looking for patterns
 Letting key people know about it
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LA County Dept. of Health Services
Current Data Sources

Disease reports – diagnosed or suspected
–
–
–
–

Telephone reports
Paper reports
VCMR
Labs
Syndromic
–
–
–
–
–
Sixteen hospital emergency departments
Over-the-counter pharmacy sales
Reddinet©
Biosense
Coroners service
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LA County Dept. of Health Services
Conceptual Architectural Overview
All
Pharmacy
Billing
Emergency
Department
Chief
Complaint
are Data Producing Facilities (DPFs)
LIS
Clinical
Documentation
PH Compliant
HL7 Messages
Collation, transformation and
routing processes
Web page
Data entry
HIS & other
systems
Veterinary /
Zoo Labs
Pathology Informatics in Public Health - 18 Aug 06
Reference
Labs
47
Public
Health
Information
System
Web page
Data entry
LA County Dept. of Health Services
Assumptions –
Bioterrorism detection
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LA County Dept. of Health Services
Syndromic Surveillance
Presenting complaints are automatically
categorized into a particular syndrome
 Syndrome counts are tracked over time
 Statistical increase in syndrome counts triggers
a signal
 To detect major trends from baseline patterns,
not individual cases

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LA County Dept. of Health Services
Key steps
 Getting
the data
 Analyzing the data
 Disseminating the findings
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LA County Dept. of Health Services
Getting ED chief complaint
data
• Data use agreement – hospital – PH
– May take months to get signoff


Automatic electronic connection from hospital
admitting/hub system to PH information system
– 12 hours of technical work, but months to get there.
– sFTP, VPN, or even (+/-) encrypted eMail
De-identified – send only age, sex, date/time, chief
complaint, zip code, disposition (+diagnosis if rapidly
available)
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LA County Dept. of Health Services
Where do we pull data
from?
 Now
- ADT transactions (HL7 A04/8)
to extract free text chief complaint
 Future –
– Emergency department systems
– structured observations, impressions
and orders from the EMR/EHR
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LA County Dept. of Health Services
How would data flow from
clinics?
automatic – no ongoing
manual intervention
 One possible source – walk-in and
same-day patients’ reason for visit
 A future possible source –
electronic medical records systems
 Completely
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LA County Dept. of Health Services
Line Listing
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LA County Dept. of Health Services
Key steps
 Getting
the data
 Analyzing the data
 Disseminating the findings
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LA County Dept. of Health Services
Analyzing the data:
Syndrome Classification

Standard
–
–
–
–

Gastrointestinal
Respiratory
Rash
Neurological
Special categories
–
–
–
–
Influenza like illness
Heat
(Trauma)
Others as needed
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LA County Dept. of Health Services
Sample: Syndrome Trend and
CUSUM Analysis
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LA County Dept. of Health Services
Investigation and Daily
Report I

Investigation
—Review counts and proportions
one day increase or continued increase?
coincidence with high profile public event?
—Review line lists
similar chief complaints within and across the
hospital, age and gender clustering?
Unusually severe and high volume?
coincident with traditional disease reports?
—Review complementary systems
—Call ED, review charts, follow-up patients
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LA County Dept. of Health Services
Sample: SaTScan
Syndrome Cluster Map
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LA County Dept. of Health Services
Over-the-Counter Cough & Cold Medication Sales
Multiple Signals For 11/28/03
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LA County Dept. of Health Services
Key steps
 Getting
the data
 Analyzing the data
 Disseminating the findings
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LA County Dept. of Health Services
Reporting the data
 Generate
summary report, hospitals
coded
 7 days per week
 Send to key public health staff, to
the LAC Terrorism Early Warning
group, as well as to each
participating hospital.
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LA County Dept. of Health Services
Example of daily
syndromic report
Hospital Syndrome Signal
A
GI
No
ILI
No
Neuro
No
Rash
Yes
Respiratory No
OTC
No
Coroner
No
Observed
11
54
1
8
58
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Threshold
19
92
1
7
98
LA County Dept. of Health Services
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LA County Dept. of Health Services
What have we found in LA
County?
Onset of 03-04 flu season
 Diarrhea outbreak Feb 21 ‘04 – rotavirus
 Cluster of respiratory distress Mar 3, ‘04
 Cluster of rash – Oct 15, 04
 “rule out smallpox” – varicella contacts
 Summer surge in viral meningitis – ‘03
 Retrospective analysis for West Nile meningitis

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LA County Dept. of Health Services
Syndromic surveillance:
others findings
Early detection of flu in NYC, Utah, others
 Case finding for measles, varicella outbreaks
 Cryptosporidium, Milwaukee, 2001 (OTC)
 Diarrhea following blackout – NYC, Aug 2003
 Asthma, respiratory distress, SD County, Nov. 2003/4
 Heat-related illness // Cipro sales after anthrax
 Fireworks // Dog bites/rat bites // Overdoses
 West Nile virus spraying // Suicide attempts
 Carbon monoxide poisoning – Pennsylvania, 2003
 Diarrheal outbreaks: norovirus, rotavirus – NYC, 2002

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LA County Dept. of Health Services
How well do we cover the
population of LA County?
Green = well
covered
Red = poorly
covered
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LA County Dept. of Health Services
Improving the precision of
syndromic categorization
– ADT transactions, extract
free text chief complaint
 Tomorrow - structured observations
and impressions from the ED
record, and EMR/EHR
 Today
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LA County Dept. of Health Services
Public Health and RHIOs
Regional Health Information Organizations
 Focused on clinical data sharing, but serves
many needs
 Often, PH may be the first to connect multiple
hospitals in a community – albeit for a limited
data set
 Public Health is very interested in several of the
data types flowing in an established RHIO.
 One of the best examples is the
Regenstrief/Indiana RHIO

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LA County Dept. of Health Services
Public Health Davies
Award
To recognize outstanding achievement in using
informatics to improve the public’s health
 Pennsylvania disease reporting system
 S. Dakota Vital Records
 Utah – Immunization registry
 Indian Health Service
 North Carolina ED surveillance
 2006 Awardees to be announced this fall
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LA County Dept. of Health Services
Key Points about
surveillance







Avoid manual work by labs and hospitals
Rapid detection of nasty disease, tracking slower public
health menaces
Implementation requires expert and experienced technical
support
Not a panacea, but gives some reassurance.
This is a process that can easily take months – or years
HIPAA compliant
Need to add more data sources
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LA County Dept. of Health Services
How can your lab
contribute?

Talk with your local and state public health
agencies
–
–
–
–

Are they ready to receive ELR and ED data?
If not, encourage them!
Monthly national ELR call, first Tuesday 10a PDT
Monthly national ED/SS call, 4th Thursday, q other
month
Talk with your LIS vendor
– What software module(s) are available for this activity?
– We in LA County have had extensive discussions with
Misys, Meditech, Cerner, McKesson, some
discussions with others – all have useful tools

Please let us know if we can be of assistance.
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LA County Dept. of Health Services
Resources
 CAP
Today – articles, Newsbytes –
– www.cap.org
 www.cdc.gov/phin
 www.loinc.org
 www.snomed.org
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LA County Dept. of Health Services
Contact us
 Raymond
Aller, M.D.
– [email protected] 213-989-7208
Thank you !!
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LA County Dept. of Health Services