LA County Dept. of Health Services Disease Surveillance – Applying Pathology Informatics to Public Health Raymond D. Aller, M.D. Contributing Editor, CAP

LA County Dept. of Health ServicesLA County Dept. of Health Services

Disease Surveillance – Disease Surveillance – Applying Pathology Applying Pathology

Informatics to Public HealthInformatics 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 Health18 August 2006

LA County Dept. of Health ServicesLA County Dept. of Health Services2Pathology Informatics in Public Health - 18 Aug 06

Pathology as a clinical Pathology as a clinical informatics pioneerinformatics 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


.. and as pioneer of technologies and .. and as pioneer of technologies and standards for PH disease surveillancestandards for PH disease surveillance

SNOMED – 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 1987LOINC – cooperative development with

extensive pathology/lab medicine involvement - 1994.


Clinical InformaticsClinical 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)


Keys to success 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.


ObjectivesObjectives

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.


Types of data from the lab Types of data from the lab to public healthto 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)


Knowing that there is a Knowing that there is a problemproblem

Natural (epidemic) vs. malicious (bioterrorism)Most agents (biological, nuclear, incendiary,

chemical, explosive, radiologic - b-NICER) are overtBiological agents - typically covertA major portion of preparation for bioterrorism is

about detection.


Detection – Detection – two sides of the cointwo 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


Our most important data Our most important data sourcessources

The astute clinician and the telephone!

Message: If you see something that looks wrong, let public health know.



The Scope of PH Informatics (1)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.)


PH Informatics (2)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


PH Informatics (3)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


Public Health InformaticsPublic Health InformaticsToday’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


How do we detect How do we detect disease?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


80+ reportable

diseases

(mostly infectious)

must (by law) be

reported to

Public Health


Reportable diseasesReportable 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.


Web-facilitated reportingWeb-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



From manual to automaticFrom 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


Electronic Lab Electronic Lab Reporting (ELR)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


Key characteristics of ELRKey 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


Why Electronic Lab Reporting?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


ELR Benefits to the LabELR Benefits to the Lab

Results 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 completeLab staff time savings.


ELR ImplementationELR 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”


LOINCLOINC

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


SNOMEDSNOMED

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


Data Transformation Data Transformation

HospitalSystems

Public Health

Information System

Public Health

Information System

Public Health

Information System

Web page Data entry

Format converter

De-identification

(of “n

on

-rep

orta

ble

” find

ing

s)

Collation

Text handling

Routing

PH compliantHL7 messages



These functions may be performed in the Public Health Department, Data Producing Facility or an Intermediary

Filter

Code translationCode translationCode translations


To Do a LOINCingTo Do a LOINCing

Download lab’s test dictionaryTest name, test code, units, method,

specimen typeDone by Public Health staff or outside

services (probably not the lab)


Getting from internal test codes Getting from internal test codes to standard LOINC codesto 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)


What Data is Transmitted?What Data is Transmitted?

Now: Reportable diseases– Supporting lab findings – liver enzymes and

bilirubin on cases of positive hepatitis serologySoon: Lab orders that may help define

syndromes Future: Antimicrobial susceptibility testing –

on ALL organisms


Syndromic Surveillance Syndromic Surveillance using lab datausing 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


Lab Order Defined Lab Order Defined SyndromesSyndromes

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


Antimicrobial Antimicrobial Susceptibility TestingSusceptibility Testing

Antimicrobial resistance is an increasing problem in all communities

Traditional – collect antibiograms from hospitalsLate 90’s – commercial services such as TSN

collected susceptibility data from labsAlternative – collect raw susceptibility results from

labs, perform calculations at public health.


Cost of disease reporting Cost of disease reporting from labsfrom 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)


For once, a funded mandateFor 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)


ELR – current statusELR – current status

Nationwide, many states (and a few local jurisdictions) are now receiving ELR

Most commonly connected – national labs (LabCorp, Quest)


Mandatory use of Mandatory use of electronic lab reportingelectronic lab reporting

Still voluntary in most jurisdictionsSome now require by law/regulation

– New York StateOr for certain tests –

– Blood lead - California


Potholes in the information Potholes in the information superhighwaysuperhighway

When you are trying to travel at 186,000 mps, a pothole is a big deal!


The official salute of the The official salute of the governmental I/T governmental I/T insecurity officerinsecurity officer


The general I/T industry is The general I/T industry is beginning to recognize thisbeginning to recognize this


What is the biggest threat to What is the biggest threat to our informatics preparedness our informatics preparedness for biosecurity?for biosecurity?

The information insecurity officer– Fingerpointing– “Finding a way to get to NO”– The security Luddite– Forces expensive, error prone and

unsafe workarounds


5 I/T syndromes hazardous 5 I/T syndromes hazardous to the public’s healthto 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


Back to biological diseaseBack to biological disease

Gathering diverse dataLooking for patternsLetting key people know about it


Current Data Sources 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


Conceptual Architectural OverviewConceptual Architectural Overview

Public Health

Information System

Web page Data entry

Pharmacy

Billing

EmergencyDepartment

ChiefComplaint Clinical

Documentation

LIS

Reference Labs

Veterinary / Zoo Labs

HIS & othersystems

Collation, transformation and routing processes

PH CompliantHL7 Messages

All are Data Producing Facilities (DPFs)

Web page Data entry


Assumptions – Assumptions – Bioterrorism detectionBioterrorism detection


Syndromic SurveillanceSyndromic 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


Key stepsKey steps

Getting the dataAnalyzing the dataDisseminating the findings


Getting ED chief complaint Getting ED chief complaint datadata

• 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)


Where do we pull data Where do we pull data from?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


How would data flow from How would data flow from clinics?clinics?

Completely 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


Line ListingLine Listing


Key stepsKey steps



Analyzing the data: Analyzing the data: Syndrome ClassificationSyndrome Classification

Standard– Gastrointestinal – Respiratory– Rash– Neurological

Special categories– Influenza like illness– Heat– (Trauma)– Others as needed


Sample: Syndrome Trend and Sample: Syndrome Trend and CUSUM Analysis CUSUM Analysis


Investigation and Daily Investigation and Daily Report IReport I

Investigation—Review counts and proportions

one day increase or continued increase? coincidence with high profile public event?

—Review line listssimilar 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


Sample: SaTScan Sample: SaTScan Syndrome Cluster MapSyndrome Cluster Map


Over-the-Counter Cough & Cold Medication SalesMultiple Signals For 11/28/03


Key stepsKey steps



Reporting the dataReporting the data

Generate summary report, hospitals coded

7 days per weekSend to key public health staff, to the

LAC Terrorism Early Warning group, as well as to each participating hospital.


Example of daily Example of daily syndromic reportsyndromic report

Hospital Syndrome Signal Observed Threshold

A GI No 11 19

ILI No 54 92

Neuro No 1 1

Rash Yes 8 7Respiratory No 58 98

OTC No

Coroner No



What have we found in LA What have we found in LA County?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


Syndromic surveillance: Syndromic surveillance: others findingsothers 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


How well do we cover the How well do we cover the population of LA County?population of LA County?

Green = well covered

Red = poorly covered


Improving the precision of Improving the precision of syndromic categorizationsyndromic categorization

Today – ADT transactions, extract free text chief complaint

Tomorrow - structured observations and impressions from the ED record, and EMR/EHR


Public Health and RHIOsPublic 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


Public Health Davies Public Health Davies AwardAward

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


Key Points about Key Points about surveillancesurveillance

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


How can your lab How can your lab contribute?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.


ResourcesResources

CAP Today – articles, Newsbytes –– www.cap.org

www.cdc.gov/phinwww.loinc.orgwww.snomed.org


Contact usContact us

Raymond Aller, M.D.– [email protected] 213-989-7208

Thank you !!

Documents

LA County Dept. of Health Services Disease Surveillance – Applying Pathology Informatics to Public Health Raymond D. Aller, M.D. Contributing Editor, CAP