Division of Acute Disease Epidemiology Five Years with the NEDSS Base System in South Carolina: Revolution, Evolution, and Future Perspectives Claire Youngblood, MA Division of Acute Disease Epidemiology South Carolina Department of Health and Environmental Control Columbia, SC

How We Learned to Stop Worrying and Love the NBS

Acknowledgements Eric Brenner, MD Jason Collins Dan Drociuck, MT Many hardworking DHEC people

Revolution Evolution Future Perspectives Rollout to Regions Rollout to Providers Electronic Lab Reports Evolution A few numbers CHESS outside the box Future Perspectives Upcoming projects Where we want to go Presentation outline

Carolina’s Health Electronic Surveillance System Make sure that everyone knows what CHESS is. South Carolina’s Implementation of CDC’s NEDSS Base System (NBS)

South Carolina’s CHESS Team Physicians Nurses Epidemiologists Programmers Data Analysts Data Entry Trainers Healthcare Providers Laboratory Staff CHESS is a complex system, and requires people in many different roles to keep everything running as it should.

Milestones May 2003 – CHESS live in Central Office November 2003 - CHESS Deployment Complete for All Health Districts December 2004 – Last record entered in NETSS July 2006 – First External Deployment April 2007 – First Electronic Lab Report in CHESS A brief timeline of major events.

Electronic Lab Reports (ELR) Contains lab data automatically transmitted from lab databases to CHESS Loaded at the end of each day Contains no clinical information Often received by DHEC before the ordering provider Brief overview of what ELRs are.

Revolution First part - Revolution

“This thing makes me cuss.” -Anonymous Regional User Moving from a centralized system like NETSS to CHESS required a huge change in the way that regional health department staff performed daily tasks. Nurses and other professionals, who were already very busy and had their own way of doing things, were suddenly asked to learn a new and very different system.

SC Disease Report Card The South Carolina disease report card. These are still distributed to all healthcare providers and are submitted to local health departments for entry into CHESS (unless the provider is actually using CHESS) but until CHESS was rolled out it was often the only record that a staff member saw

Why Give This Up? Simple interface Portable Cheap Easy to edit No passwords Convenient in rural health departments Prior to CHESS, all actual data entry for NETSS was done in the Central Office. Regional staff did the majority of their work on paper, and rarely saw aggregate data that they did not compile themselves. From the point of view of regional staff, this was not necessarily a bad thing.

Revolution Rewards Increased communication between regions and central office Faster response More complete data Ability to follow patients over time Closer connection to CDC case definition Data entry from lots of sources For both regional staff and central office purposes, CHESS did have a lot to offer. Records could be shared between regional and central office staff for the first time Data was entered and avialable much fasster. The data are now far more complete than ever before. It is much easier to follow patients with certain chronic conditions, such as hepatitis over long periods of time. It is in some ways easier to make a connection between a report and the CDC case definition, although this requires very careful training. Data entry workload is shared across a large number of users – fewer bottlenecks. This can also be a problem though…

Revolution Costs Data entry from lots of sources Changes in infrastructure Training needs Changes in interaction More hands-on computer work The message here is “be careful what you wish for.” Adding so many data entry people makes it impossible to get completely consistent data entry. Locations also have to change their infrastructure and process to fit CHESS into a routine that they may feel already works very well. Training and RETRAINING become a constant need, and just providing written materials and updates is not enough. New users must be brought up to speed, some users must be retrained as their job duties evolve, and we must have a way to update users quickly and consistently when there are changes to the system. We also had to change the fundamental way that we interact with one another. Central office staff suddenly had much more direct oversight of regional activities in disease surveillance – a young epidemiologist in the central office was suddenly telling an experienced regional nurse that her investigation needed improvements. Work that was once reviewed by only one or two people could be evaluated by many. This made careful two-way communication very important. All staff also had to get used to using the system on a daily basis.

Provider Deployment Challenges Site visits Fitting CHESS into each office Education: initial and ongoing Corporate policy Providing feedback Staff turnover “What’s in it for us?” As CHESS is rolled out to providers, a new set of challenges emerge. It is necessary to make site visits to providers, in order to make sure that CHESS is appropriate and will be used. CHESS must be made to fit with each office’s routine Trainers are required to provide initial and ongoing training, Some hospitals must work within a complex bureaucracy of their own. Providers want feedback, and that is not available in the current version of the NBS – no organization level security. Staff turnover is higher among provider staff than at the health department. The big question – not always easy to answer.

ELR Challenges Funding – Hospitals like the idea, but don’t want to spend the money Getting vendors to meet the standard Keeping LOINC/SNOMED codes updated Auditing procedures to ensure that all reportable conditions are included Complex reporting rules

Ongoing Process Challenges Records without Jurisdiction Records without Program Area Disease specific process requests Legacy Data Ad-hoc reporting needs

Evolution

Users 26 Users in Central Office 40 Regional Users 42 Provider Facilities 234 Provider Users 11 ELR Reporting Facilities NETSS: Data was entered by ONE user. CHESS: Data is entered by >350 users.

ELRs Since April 2007, more than 33,500 ELRs have been received 16,865 Total Investigations 10,990 (>65%) Investigations with Labs 6,423 (>38%) Investigations with ELR as first observation

CHESS Uses Beyond Notifications Annual Report Detailed Statistics for Vaccine Preventable Disease Grant Enhanced Influenza Surveillance Outbreak Details Comorbidity Studies

CHESS Uses Beyond Notifications Hospital Infections Disclosure Act EARS Analysis of CHESS Data Pass-through for STD/HIV Data Rabies Post Exposure Prophylaxis Tracking Email Notification Geographic analysis platform for disease tracking

Future Perspectives

2013? Web or ELR reporting from all labs and providers. Integration of all reportable diseases into a single system (TB, HIV/AIDS, STDs…) Integration with outbreak management Integration of case report forms Integration with CDC case definitions Contact tracing Greater flexibility with fields. GIS incorporated into the system