1. Local health department electronic reportable disease surveillance practice and costs, North Carolina, 2009 OR: Proving it out E. Samoff MPH PhD, A. T. Fleischauer MSPH PhD, L. DiBiase MS, M. Davis MPH, A. Waller ScD, P. D. M. MacDonald MPH PhD This research was carried out by the North Carolina Preparedness and Emergency Response Research Center (NCPERRC) which is part of the UNC Center for Public Health Preparedness at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health and was supported by the Centers for Disease Control and Prevention (CDC) Grant 1PO1 TP 000296. The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. Additional information can be found at http://cphp.sph.unc.edu/ncperrc/ North Carolina Preparedness & Emergency Response Research Center (NCPERRC)

2. Background All states now use an electronic disease surveillance system What we know – Increase speed of initial notification to public health and number of cases reported – Facilitate data capture and review What we don’t know – Does electronic disease surveillance improve public health surveillance practice? – Support public health interventions? – Is electronic disease surveillance more efficient or cost- effective? – Improve population health?

3. Background Project: To evaluate North Carolina’s electronic disease surveillance system Project objectives – Describe workforce resources used for electronic disease surveillance system – Describe impact on case reporting and surveillance practice – Identify best practices for electronic disease surveillance

4. Background North Carolina Electronic Disease Surveillance System (NC EDSS) – Highly customized off-the-shelf Maven system – Implemented in 2008 – All reportable diseases except syphilis and HIV Case data entered by – LHD staff – Laboratories via ELR (≈ 33% of cases) – State staff System offers additional surveillance capacities

5. Methods Random sample: 30/100 counties Interviews – NC Electronic disease surveillance system (NC EDSS) lead Staff # and hours Use of NC EDSS system Use of surveillance data – CD Nurse Case management Use of NC EDSS system Cost – $29/hour ($60,552/yr) salary

6. Methods NC EDSS system data – All VPD, STD, and other CD cases – Number of cases – Timeliness: % reported to state within 30 days – Accuracy: % of cases returned by state to LHD – Currently ignored cases: % of cases never handled >45 days old

7. Methods Composite score for indicators of good reporting practice: – Assigned 1 point each for: – Timeliness (>79% of completed cases submitted to state in <30 days) – Accuracy (<17% of cases returned to LHD for corrections) – Ignored cases (<1% of total cases ignored after 45 days) High/low comparison: High (2/3 points) vs. Low (0/1 points) County size: Small: 107,427

8. Results: Respondent Profile May-August 2010 28 counties Broad geographical distribution Broad population distribution – 8,888-923,944 population – 10 small, 8 medium, 10 large

9. Results: Cases Total number of cases reported: 10,809 Smaller Larger

10. Results: Staff using electronic disease surveillance Total staff using NC EDSS – 136 employees, 34.5 FTEs – average 4.8 employees, 1.2 FTEs per county Type of staff – CD nurses/supervisors – Administrative staff – DIS – Laboratory personnel

11. Results: Staff time 69% of employees using NC EDSS spent <12 hours per week of their work time on the system 69% 10% 21%

12. Results: Staff expenditure (FTEs) Smaller Larger

13. Results: Cases reported per FTE Average of 68 cases reported per FTE per month Smaller Larger

14. Results: Salary cost per case reported Smaller Larger

15. Results: Salary cost per case reported Smaller Larger

16. Results: Impact on case reporting and surveillance practice NC EDSS leads: – 68% (19/28): Reported changes in case management – 89% (17/19): Improvement CD nurses: – 57% (12/21): Reported changes in case management – 75% (9/12): Improvement Because – Increased timeliness – Easier to know what to do/ask – Easier to access case-patient data – More thorough documentation

17. Results: Impact on case reporting and surveillance practice Counties using >5 NC EDSS capacities are more likely to – Report using surveillance data for decisions about public health program management – Report providing surveillance data to policy- makers – Report including surveillance data in annual reports – Report using data from extended surveillance form for disease intervention

18. Results: Reporting performance rank Rank based on – Timeliness (>82% submitted to NC DPH within 30 days) – Accuracy (<17% of cases returned to LHD) – Incomplete cases (<1% cases incomplete longer than 45 days Small Medium Large             Rank=0

19. Mean cost per case by reporting practice rank

20. Mean cost per case by rank and county size Small Medium Large

21. Good surveillance costs less. How do we get there? Practices associated with high reporting performance Can look at incoming cases daily (P=.11) 6 staff or fewer using NC EDSS (P=.02) Use surveillance data for program evaluation (P=.13) >5% of cases=Not a case (P=0.22)

22. Limitations FTE data are reported by interviewee – Not verified by electronic system – Based on current user lists Does not represent multi-county LHDs as well Interviewer bias

23. Conclusions Resources used per case reported differs across state – Good surveillance costs less Perceived improvement in case management and disease surveillance Electronic surveillance system is supporting key surveillance activities Daily use of electronic surveillance system by a focused user group supports good reporting practice

24. Acknowledgements UNC Gillings School for Global Public Health Pia MacDonald MPH PhD Carol Gunther-Mohr MA Meredith Davis MPH Lauren Dibiase MPH Heidi Soeters MPH Erika Samoff MPH PhD UNC School of Information and Library Science Stephanie W. Haas PhD Carolina Center for Health Informatics / UNC Dept of Emergency Medicine Anna Waller ScD Amy Ising MSIS CDC/NC Division of Public Health Aaron Fleischauer PhD

25. Contact Erika Samoff erika.samoff@unc.edu NC PERRC cphp.sph.unc.edu/ncperrc