Pathology and PH - the informatics intersectionLos Angeles County Department of Public HealthLos Angeles County Department of Public Health Pathology and Public Health: A View of the

Los Angeles County Department of Public HealthLos Angeles County Department of Public Health

Pathology and Public Health:Pathology and Public Health:A View of the Informatics A View of the Informatics IntersectionIntersection

Raymond D. Aller, M.D.Director, Automated Disease Surveillance SectionLos Angeles County Department of Public Health

10 April 2008

Los Angeles County Department. of Public HealthLos Angeles County Department. of Public Health10 April 2008 2

CommonalitiesCommonalities

Pathology– The study of disease– Emphasizes data, process

Public Health– The detection and prevention of

disease– Emphasizes data, process


The diversity of public The diversity of public health ….health ….

Improving the public’s health, in a variety of waysTakes the population point of view, rather than the individual patient– About assessing, protecting, and improving the

public’s health– Not about using public funds to provide medical

care to individual patientsRegistries, early warning systems, e-NotificationAscertain – act - assure


The diversity of pathology The diversity of pathology

Surgical pathology – individual diagnoses via personal serviceClinical pathology – assuring usefulness of a variety of diagnostic and monitoring assaysForensic pathology – why and how did they die?Pathology and labs produce a lot of information important to protecting the public’s health.


For each subspecialty, a For each subspecialty, a different way we can different way we can support public health …support public health …

Surgical pathology– Tumor diagnoses– Other findings of PH importance– Research findings: asbestos

Clinical pathology – Infectious diseases, toxic exposures, etc– Population patterns – antimicrobial susceptibilities,

rate of test orders, meta-surveillance of epidemic disease

Forensic pathology– Infectious diseases, toxins, etc.– Injury and violence prevention data


And there are many other And there are many other places where pathology places where pathology and PH interact …and PH interact …

Public health labsDiscoveries that impact public health policyCross-fertilization of personnelEtc…


Surgical pathology to the Surgical pathology to the tumor registrytumor registry

Automated transfer of tumor diagnoses to the cancer registryFirst automated transfer of SNOMED-coded diagnoses: 1977… it has taken a LONG time for others to pick up this model.Recent projects to make this a more widespread practice: NAACCR volume 5 2007Complicated by the one-blob-of-text model of surgical pathology reportingA whole lecture in itself.


Electronic Lab Reporting Electronic Lab Reporting (ELR)(ELR)

Software on the laboratory information system automatically selects from all laboratory results, those which are reportable to public healthIn other cases, ALL results transferred to a filtering system, that selects reportablesThese may be enhanced by other findings of public health importance– Antimicrobial susceptibility testing– Syndromic indications

ELR commonly doubles the reporting rate


Benefits of fully automated Benefits of fully automated Electronic Lab Reporting Electronic Lab Reporting

More rapid transmittal of required reportsMore complete reportingSavings in lab staff timeMore accurate transmissionAssured regulatory compliance (“HIPAA”)


Coroner/Medical Examiner Coroner/Medical Examiner Data to Public HealthData to Public Health

Alert PH to serious infectious diseasesTrauma: epidemiology, intervention, policyA diversity of other diseasesDirect transmission of case reports from Coroner’s case management system, to public health epidemiology systems– Best if fully automated (sometimes hard to accomplish

with under-resourced medical examiners offices)


Two different categories of dataTwo different categories of data

PublicHealth

Disease Surveillance

Identified disease cases Findings in large populationsCase reports fromInfection control

practitioners, nursesphysicians, others

Diagnostic laboratoryfindings

ELR

vCMR

Antimicrobialresults

Emergency departmentchief complaints

Over the countermedications

RODSS

yndromic

ELR

Lab ordersELR

Tumor diagnoses

Coroner’s cases


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 “non-reportable” findings)

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


How is clinical lab data How is clinical lab data conveyed to public health?conveyed to public health?

LIS+ – extract reportables,apply LOINC/SNOMED

LIS – HL7of all results

Edge server –Filtering, translation

PHELRSystem

sFTP, VPN,Hypersend,SCP, AtC, etc.

RHIO

Provider-Lab Link


Data we gather in public healthData we gather in public healthDiagnoses of individual “reportable” diseases– Fax, mail, manual entry– Web-based entry by providers– Electronic lab reporting– Build a longitudinal database: vCMR– Follow up on cases by nurses, epidemiologists, physicians

Symptoms in populations– Emergency department (ED) chief complaints (50% of visits in LA

County– Nurse call complaints– Parse free text – syndromes – look for patterns

Behavior of populations– Purchases of over the counter medications

Many other data sources– Coroners– Ambulance services– Reddinet – ED volumes (95% of EDs)


In the near future…In the near future…

Complete Emergency Department record– (our first such interface has been bogged in a hospital

legal department for 30 months)Ambulatory clinical and hospital records (EHRs, EMRs)– When a physician records a reportable diagnosis in an

EMR, why can’t that be immediately transmitted to public health?

Granular hospital records (e.g., ICU systems)


Uses of additional lab data Uses of additional lab data (using de(using de--identified data)identified data)

Ordering patterns– A doubling in rates of blood cultures, or

spinal taps, might be indicative…Antimicrobial susceptibility patterns (MRSA, other MDR bugs) – community-wide antibiogramResult patterns– What might a sudden spike in ALT values

indicate?Your thoughts?


Data from clinical practice is Data from clinical practice is being applied to public healthbeing applied to public health

Byproduct – no added work to gather dataAutomated – reliable, fast (as it occurs, not days later)Relevant – lab results, patient complaint, temperature – not billing data or massaged diagnosis codesTranslation – accept data as it comes, provide translation function centrally (don’t insist that hospital/provider re-do their systems in order to connect to public health)Informatics is today a key tool in defense against natural (epidemics) and man-made (bioterrorist) outbreaks.


RealReal--time population health time population health surveillancesurveillance

Most frequently used application: – Syndromic Surveillance

Major improvement: coordination of data feeds through robust, secure, accessible data center.LA County: Number of EDs reporting has increased – started in 2000, 9 at 18 months ago, 17 in July 06, 28 by

July 07, and 35 by Dec. 07 – Data received and analyzed 7 days per week, report sent

to approx. 105 public health staff and hospital partners.Also monitors various aspects of health status– case finding– health assessment – for example, the impact of the

summer heat wave, assessing the flu season


ED Coverage Rate By Zip CodeED Coverage Rate By Zip Code


Syndromic SurveillanceSyndromic Surveillance

Presenting complaints are automatically categorized into a particular syndrome, by word searchSyndrome counts are tracked over timeStatistical increase in syndrome counts triggers a signal To detect major trends from baseline patterns, not individual cases


Analyzing the data: Analyzing the data: Syndrome ClassificationSyndrome Classification

Standard– Gastrointestinal – Respiratory– Rash– Neurological

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


Los Angeles County Novel Los Angeles County Novel Surveillance ProgramSurveillance Program

Current LAC novel surveillance systems– ED chief complaint data syndromic (28 hospitals, 44%

of total ED visits in the County)– Emergency Department Volume data through Reddinet – Coroner’s Database– Over the counter pharmacy– Nurse call/advice lines

LAC systems in development– School absenteeism (currently passive)– 911 calls– Automated electronic surveillance




Daily PHS summaryDaily PHS summary


Labs/Hospitals and EDs Labs/Hospitals and EDs connectedconnected

0

5

10

15

20

25

30

2001

2002

2003

2004

2005

2006

2007

July

Labs/hospitalsED s

Note: in 2002, we broughtthe Kaiser regional lab live, serving 7 hospitals.


How do I get my lab How do I get my lab connected?connected?

Talk with your local public health department – Are they ready to receive data?– What format/coding do they want?– In the US, we are moving toward standardization on

HL7 version 2.5.1Talk with the vendor of your lab’s Laboratory Information System– How to install their public health interface module?– Does it match the specifications of your local PH?– Or do they have a way of sending out all results in HL7

2.3.1+


How are the LIS vendors How are the LIS vendors doing?doing?

Our knowledge is based mainly on working with the 80 largest labs in LALargest commercial labs provide HL7, some LOINC/SNOMEDModules with filtering and translation available from Sunquest and SoftLabBasic HL7 output (requires external filtering and translation) from Meditech, CernerDon’t yet have a response from McKessonHaven’t yet worked with Orchard, Schuylab, Siemens, GE, Aspyra, Compromed, Fletcher-Flora, Psyche, OmniTech, OmniLab, Seacoast, NetLims, many others ….


What about PH labs?What about PH labs?A unique set of testing types– Clinical– Environmental– Newborn screening– Etc.

A unique set of regulations (e.g., Calif. PHLT licensure)Sometimes a name does make a difference– LIMS tend to originate in pharmaceutical, research,

industrial settings– LIS tend to have come from the clinical realm– Several installations of “LIMS” in the PH space have been

problematic• E.g., one widely purchased product lacks a patient table… it

can handle specimens, but tying them to a patient is a “custom” modification


The latest religion?The latest religion?

A number of folks in PH believe that open source will be the panacea.Others believe it will be an important addition to our toolkits.A few open source projects are underway –including a laboratory information system, developed for use in PHLs in Minnesota and Iowa, that is now operational in VietnamOpen-source EMRs are now being used in a number of resource-poor countries.


How else can we help PH?How else can we help PH?

Pathologists and laboratorians have a valuable skill set– Much pathology training also prepares

one for Public Health– Not necessary to have specialized PH

training to make a worthwhile contribution to public health


How can we contribute?How can we contribute?

On contract or salary– Director of the public health laboratory– Communicable disease (infection control)– Informatics– As Health Officer

As a volunteer– Especially in a third world context

Bring your ideas to a roundtable at the CAP-08 meeting: the pathologist practicing public health


Questions? Follow up?Questions? Follow up?

Raymond D. Aller, [email protected]

I look forward to hearing from you.

Documents

Pathology and PH - the informatics intersectionLos Angeles County Department of Public HealthLos Angeles County Department of Public Health Pathology and Public Health: A View of the