1. LA County Dept. of Health Services 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

2. LA County Dept. of Health Services 2 Pathology Informatics in Public Health - 18 Aug 06 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

3. LA County Dept. of Health Services 3 Pathology Informatics in Public Health - 18 Aug 06.. and as pioneer of technologies and standards 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 1987  LOINC – cooperative development with extensive pathology/lab medicine involvement - 1994.

4. LA County Dept. of Health Services 4 Pathology Informatics in Public Health - 18 Aug 06 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)

5. LA County Dept. of Health Services 5 Pathology Informatics in Public Health - 18 Aug 06 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.

6. LA County Dept. of Health Services 6 Pathology Informatics in Public Health - 18 Aug 06 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.

7. LA County Dept. of Health Services 7 Pathology Informatics in Public Health - 18 Aug 06 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)

8. LA County Dept. of Health Services 8 Pathology Informatics in Public Health - 18 Aug 06 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.

9. LA County Dept. of Health Services 9 Pathology Informatics in Public Health - 18 Aug 06 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

10. LA County Dept. of Health Services 10 Pathology Informatics in Public Health - 18 Aug 06 Our most important data sources  The astute clinician and the telephone!  Message: If you see something that looks wrong, let public health know.

11. LA County Dept. of Health Services 11 Pathology Informatics in Public Health - 18 Aug 06

12. LA County Dept. of Health Services 12 Pathology Informatics in Public Health - 18 Aug 06 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.)

13. LA County Dept. of Health Services 13 Pathology Informatics in Public Health - 18 Aug 06 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

14. LA County Dept. of Health Services 14 Pathology Informatics in Public Health - 18 Aug 06 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

15. LA County Dept. of Health Services 15 Pathology Informatics in Public Health - 18 Aug 06 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

16. LA County Dept. of Health Services 16 Pathology Informatics in Public Health - 18 Aug 06 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

17. LA County Dept. of Health Services 17 Pathology Informatics in Public Health - 18 Aug 06 80+ reportable diseases (mostly infectious) must (by law) be reported to Public Health

18. LA County Dept. of Health Services 18 Pathology Informatics in Public Health - 18 Aug 06 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.

19. LA County Dept. of Health Services 19 Pathology Informatics in Public Health - 18 Aug 06 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

20. LA County Dept. of Health Services 20 Pathology Informatics in Public Health - 18 Aug 06

21. LA County Dept. of Health Services 21 Pathology Informatics in Public Health - 18 Aug 06 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

22. LA County Dept. of Health Services 22 Pathology Informatics in Public Health - 18 Aug 06 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

23. LA County Dept. of Health Services 23 Pathology Informatics in Public Health - 18 Aug 06 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

24. LA County Dept. of Health Services 24 Pathology Informatics in Public Health - 18 Aug 06 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

25. LA County Dept. of Health Services 25 Pathology Informatics in Public Health - 18 Aug 06 ELR 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 complete  Lab staff time savings.

26. LA County Dept. of Health Services 26 Pathology Informatics in Public Health - 18 Aug 06 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”

27. LA County Dept. of Health Services 27 Pathology Informatics in Public Health - 18 Aug 06 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 www.loinc.org

28. LA County Dept. of Health Services 28 Pathology Informatics in Public Health - 18 Aug 06 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 www.snomed.org

29. LA County Dept. of Health Services 29 Pathology Informatics in Public Health - 18 Aug 06 Data Transformation Hospital Systems 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 compliant HL7 messages PH compliant HL7 messages PH compliant HL7 messages These functions may be performed in the Public Health Department, Data Producing Facility or an Intermediary Filter Code translation Code translations

30. LA County Dept. of Health Services 30 Pathology Informatics in Public Health - 18 Aug 06 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)

31. LA County Dept. of Health Services 31 Pathology Informatics in Public Health - 18 Aug 06 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)

32. LA County Dept. of Health Services 32 Pathology Informatics in Public Health - 18 Aug 06 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

33. LA County Dept. of Health Services 33 Pathology Informatics in Public Health - 18 Aug 06 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

34. LA County Dept. of Health Services 34 Pathology Informatics in Public Health - 18 Aug 06 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

35. LA County Dept. of Health Services 35 Pathology Informatics in Public Health - 18 Aug 06 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.

36. LA County Dept. of Health Services 36 Pathology Informatics in Public Health - 18 Aug 06 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)

37. LA County Dept. of Health Services 37 Pathology Informatics in Public Health - 18 Aug 06 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)

38. LA County Dept. of Health Services 38 Pathology Informatics in Public Health - 18 Aug 06 ELR – current status  Nationwide, many states (and a few local jurisdictions) are now receiving ELR  Most commonly connected – national labs (LabCorp, Quest)

39. LA County Dept. of Health Services 39 Pathology Informatics in Public Health - 18 Aug 06 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

40. LA County Dept. of Health Services 40 Pathology Informatics in Public Health - 18 Aug 06 Potholes in the information superhighway  When you are trying to travel at 186,000 mps, a pothole is a big deal!

41. LA County Dept. of Health Services 41 Pathology Informatics in Public Health - 18 Aug 06 The official salute of the governmental I/T insecurity officer

42. LA County Dept. of Health Services 42 Pathology Informatics in Public Health - 18 Aug 06 The general I/T industry is beginning to recognize this

43. LA County Dept. of Health Services 43 Pathology Informatics in Public Health - 18 Aug 06 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

44. LA County Dept. of Health Services 44 Pathology Informatics in Public Health - 18 Aug 06 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

45. LA County Dept. of Health Services 45 Pathology Informatics in Public Health - 18 Aug 06 Back to biological disease  Gathering diverse data  Looking for patterns  Letting key people know about it

46. LA County Dept. of Health Services 46 Pathology Informatics in Public Health - 18 Aug 06 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

47. LA County Dept. of Health Services 47 Pathology Informatics in Public Health - 18 Aug 06 Conceptual Architectural Overview Public Health Information System Web page Data entry Pharmacy Billing Emergency Department Chief Complaint Clinical Documentation LIS Reference Labs Veterinary / Zoo Labs HIS & other systems Collation, transformation and routing processes PH Compliant HL7 Messages All are Data Producing Facilities (DPFs) Web page Data entry

48. LA County Dept. of Health Services 48 Pathology Informatics in Public Health - 18 Aug 06 Assumptions – Bioterrorism detection

49. LA County Dept. of Health Services 49 Pathology Informatics in Public Health - 18 Aug 06 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

50. LA County Dept. of Health Services 50 Pathology Informatics in Public Health - 18 Aug 06 Key steps  Getting the data  Analyzing the data  Disseminating the findings

51. LA County Dept. of Health Services 51 Pathology Informatics in Public Health - 18 Aug 06 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)

52. LA County Dept. of Health Services 52 Pathology Informatics in Public Health - 18 Aug 06 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

53. LA County Dept. of Health Services 53 Pathology Informatics in Public Health - 18 Aug 06 How would data flow from 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

54. LA County Dept. of Health Services 54 Pathology Informatics in Public Health - 18 Aug 06 Line Listing

55. LA County Dept. of Health Services 55 Pathology Informatics in Public Health - 18 Aug 06 Key steps  Getting the data  Analyzing the data  Disseminating the findings

56. LA County Dept. of Health Services 56 Pathology Informatics in Public Health - 18 Aug 06 Analyzing the data: Syndrome Classification  Standard –Gastrointestinal –Respiratory –Rash –Neurological  Special categories –Influenza like illness –Heat –(Trauma) –Others as needed

57. LA County Dept. of Health Services 57 Pathology Informatics in Public Health - 18 Aug 06 Sample: Syndrome Trend and CUSUM Analysis

58. LA County Dept. of Health Services 58 Pathology Informatics in Public Health - 18 Aug 06 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

59. LA County Dept. of Health Services 59 Pathology Informatics in Public Health - 18 Aug 06 Sample: SaTScan Syndrome Cluster Map

60. LA County Dept. of Health Services 60 Pathology Informatics in Public Health - 18 Aug 06 Over-the-Counter Cough & Cold Medication Sales Multiple Signals For 11/28/03

61. LA County Dept. of Health Services 61 Pathology Informatics in Public Health - 18 Aug 06 Key steps  Getting the data  Analyzing the data  Disseminating the findings

62. LA County Dept. of Health Services 62 Pathology Informatics in Public Health - 18 Aug 06 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.

63. LA County Dept. of Health Services 63 Pathology Informatics in Public Health - 18 Aug 06 Example of daily syndromic report HospitalSyndromeSignalObservedThreshold AGINo1119 ILINo5492 NeuroNo11 RashYes87 Respiratory No5898 OTCNo CoronerNo

64. LA County Dept. of Health Services 64 Pathology Informatics in Public Health - 18 Aug 06

65. LA County Dept. of Health Services 65 Pathology Informatics in Public Health - 18 Aug 06 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

66. LA County Dept. of Health Services 66 Pathology Informatics in Public Health - 18 Aug 06 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

67. LA County Dept. of Health Services 67 Pathology Informatics in Public Health - 18 Aug 06 How well do we cover the population of LA County? Green = well covered Red = poorly covered

68. LA County Dept. of Health Services 68 Pathology Informatics in Public Health - 18 Aug 06 Improving the precision of syndromic categorization  Today – ADT transactions, extract free text chief complaint  Tomorrow - structured observations and impressions from the ED record, and EMR/EHR

69. LA County Dept. of Health Services 69 Pathology Informatics in Public Health - 18 Aug 06 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

70. LA County Dept. of Health Services 70 Pathology Informatics in Public Health - 18 Aug 06 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

71. LA County Dept. of Health Services 71 Pathology Informatics in Public Health - 18 Aug 06 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

72. LA County Dept. of Health Services 72 Pathology Informatics in Public Health - 18 Aug 06 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, 4 th 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.

73. LA County Dept. of Health Services 73 Pathology Informatics in Public Health - 18 Aug 06 Resources  CAP Today – articles, Newsbytes – –www.cap.orgwww.cap.org  www.cdc.gov/phin www.cdc.gov/phin  www.loinc.org www.loinc.org  www.snomed.org www.snomed.org

74. LA County Dept. of Health Services 74 Pathology Informatics in Public Health - 18 Aug 06 Contact us  Raymond Aller, M.D. –raller@ladhs.org 213-989-7208raller@ladhs.org Thank you !!