Information Exchange for Detection and Monitoring: Clinical Care to Health Departments Janet J Hamilton, MPH Florida Department of Health Bureau of Epidemiology

Different data needs from clinical care for different surveillance activities Vitals Registries – cancer, birth defects etc. Reportable disease/condition surveillance Outbreak management Periodic active surveillance Emergency situations

Reportable disease/condition surveillance –The traditional core of public health surveillance –Learn about every person with a reportable disease to: Identify promptly all cases of diseases or conditions that require public health intervention; Detect outbreaks, changing trends or patterns in disease occurrence; Plan, assess or evaluate control and prevention interventions.

Conditions for which clinician case reporting has been used Infectious diseases Birth defects Cancers Occupational diseases Environmental diseases Child abuse

How does PH get needed information? The initial report alone (from either clinician or the laboratory) often does not have all the information PH needs for completing follow up and documentation of individuals with reportable diseases –PH needs Person, Place, Time (Who, When, Where, What): Clinical (and lab) information to confirm the diagnosis Treatment or medications given to the patient Where the exposure/event occurred Denominator present (total exposed/impacted) Environmental setting How the patient may have become ill (insect bites, foods consumed, travel locations, etc.) Further prevention actions needed (e.g. exposed family members needing treatment or vaccine)

Syndromic Surveillance Might better be called pre-diagnostic surveillance Detect events at the community level before diagnoses are made Monitor the progress of larger events once recognized Speed vs completeness –Data sources: ED or clinic visits, poison control center calls, EMS run reports, absenteeism, key words in tweets or search engines, news reports, blogs

Defining data management needs during outbreaks and events What data does public health need for outbreak management and investigation What is different about outbreaks? –Review some examples: Anthrax H1N1 Fungal meningitis Lots of media attention and need for data multiple times a day

Anthrax 2001

Anthrax Challenges > 600 suspect cases reported and triaged; only 8 confirmed (7 cutaneous and 1 inhalation) Site investigations needed at multiple locations (media outlets, hospital, USPS distribution center) No system available to manage huge volume of data related to laboratory specimens –Suspect and Confirmed Cases –Potentially Exposed people at worksites (> 2500 nasal swabs) –Environmental specimens at all affected sites (> 1270 specimens) –> 3,000 “White powder events” Need to capture, describe and easily retrieve relationships between people, sites, specific exposures, environment, courses of prophylaxis, laboratory results

H1N1, early on - Challenges New, many susceptibles in the population Communicable Complex contact tracing (home, work, and healthcare contacts) Need for case isolation and quarantine of contacts Laboratory diagnosis challenging; esp. initially testing only available at CDC; public health not prepared to be the only clinical diagnostic location

Fungal meningitis - Challenges New, unexpected, non infectious Need specific specialized ID consults for treatment Long incubation periods Long courses of treatment Many exposed Multiple specimens over time Detailed clinical record reviews Changing role of public health for health care associated infections; patient provider relationships

Outbreak and event detection needs Establish data flow connections; leverage electronic feeds –prior to events –balance between speed of information vs completeness –Public health goal: reduce time accessing and gathering information  patients are contacted sooner  source of illness is identified more quickly leading to improved disease prevention

Event Monitoring ESSENCE ED Chief Complaint “Meningitis,” Statewide, 9/1-10/26/2012 Note: Visit spike on 10/12-10/13 is due to bacterial meningitis outbreak

14 Dashboard-Morbidity Post-Disaster Wilma Landfall Earthquake

15 Specific Query – Drowning in those <1-4 yrs old Uses that go beyond our typical surveillance purposes. Other program areas may also benefit. Example: Combining ED and Mortality data in one graph

ESSENCE-FL: Pneumonia and influenza mortality data from the Office of Vital Statistics, Florida Mortality due to the 2009 H1N1 virus was only slightly increased, however the increases were seen unusually early in the year 16

Further discussion - Where do we go from here? Provider understanding – role of public health, closing the loop - communicating results/info to providers Clinical data (coded) in EHRs often insufficient for outbreak management How realistic is a public health query / access / portal into EHRs for use after an outbreak has been identified or disease report has been made?

Case-detection from EHRs? Determine where might be more complete than passive clinician-based reporting Not clear how much more timely it would be How would you assure a high positive predictive value? Would you put a human in the loop? Would you want to wait for the final diagnosis at discharge? If not, how do you detect potential cases before a diagnosis is entered in the chart? Expand conversation beyond infectious