1. 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

2. How We Learned to Stop Worrying and Love the NBS

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

4. 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

5. 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)

6. 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.

7. Milestones May 2003 – CHESS live in Central Office
November 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.

8. 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.

9. Revolution
First part - Revolution

10. “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.

11. 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

12. 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.

13. 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…

14. 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.

15. 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.

16. 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

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

18. Evolution

19. 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.

23. 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

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

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

29. Future Perspectives

30. 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