Reporting public health cases in real time

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IBM, the Center for Disease Control and Prevention, and the New York State Department of Health are piloting a projectto connect public health data with electronic health records (EHR) – which currently reside across disparate systems – to make access for health care professionals instantaneous. This access and compatibility, via an clinical document architecture (CDA) template, will help those providers, as well as other city and state services quickly react to and prevent the spread of disease.
The following interview with Shannon Kelley, Director of Programs, Office of Health Information Technology and Transformation, New York State Department of Health, discusses the progress and implications of the project.
IBM Research: What’s the current state of public health case reporting in New York?
Shannon Kelley, Director of Programs, Office of Health Information Technology and Transformation, NY Dept. of Health

Shannon Kelley: Currently, laboratories (in New York and elsewhere) submit test results to the Electronic Clinical Laboratory Reporting System (ECLRS) when they have reportable conditions among New York state residents. 

Communicable Disease Electronic Surveillance System (CDESS) transfers laboratory reports from ECLRS to trigger public health case investigations conducted by Local Health Departments (LHDs) in the identification, treatment, and prevention of communicable diseases. CDESS also provides LHDs the capability to forward a case to another county to investigate as appropriate and the capability to collect supplemental forms for specific diseases. Providers may mail paper reports to LHDs for those diseases that do not need laboratory confirmation (e.g. Lyme disease diagnosed by Erythema chronicum migran rash) and these are entered into CDESS.

IBM Research:
Why were you interested in pilot testing the project to create templates for public health case reports that could work with electronic health record, and what were your results?
SK: Since 2006, New York has been investing in technology, operational capacity, and collaborative governance structures and processes to support the adoption of EHR technology, and to mobilize state-wide health information exchange to improve the quality, safety, efficiency, and affordability of health care.
Our department of health’s Universal Public Health Node (UPHN) is the state’s strategic initiative to transform the health information exchange for public health. The UPHN streamlines how providers interact with the many public health information systems that currently exist – to decrease reporting burdens, promote bidirectional information exchange, and advance public health priorities.
This CDA pilot opportunity with IBM and the CDC was well-aligned with our vision for health care transformation by utilizing healthcare IT (HIT) to drive clinical and public health practice improvements. 
As part of this pilot, our partner EHR vendor and Forms Manager vendor successfully created a CDA document according to the existing template requirements, which could be transported over secure lines to NYSDOH. The department was able to receive and review the CDA document – completing
the correct transport between the Forms Manager and NYSDOH. 
From a public health perspective, the CDA document can be manually viewed in a viewer as an initial report from a provider. It will require more collaboration among EHR vendor, form manager vendor, and public health to integrate CDA document with public health applications.  
IBM Research: How does this have the potential to help public health officials serve their populations better?
SK: Electronic transfer of a CDA from a provider’s EHR to public health offers the ability to improve timeliness of communicable disease reporting. This would let the local health departments to begin their investigation earlier; make appropriate control recommendations to the providers; and offer preventive measures to contacts.
For example, measles lab work results can take seven to 10 days to come back from a commercial laboratory; however, control measures of vaccine administration must be completed within three days of exposure. If public health officials know about a suspected case, lab results can be facilitated and received more quickly so that cases can be prevented.

IBM Research: What are the barriers to implementing this approach today?  
SK: Here’s the piloted CDA approach:
  • Use a CCD (Continuity of Care Document) – a patient summary commonly implemented in EHR systems – to extract data about an identified case from the EHR and make the information available for use in a Reporting Form.
  • Either automatically, or at a healthcare provider’s instigation, activate this Reporting Form to open for a user of the EHR system. The Reporting Form will display the information delivered by the CCD and allow the EHR user to insert more information.
  • A qualified person using the EHR would have the responsibility of making the decision to report the case to the Public Health Agency.
  • By an automated method, the information from the Reporting Form would be formatted as a specific type of CDA (for the pilot, the CDA would follow the requirements for reporting a case of pertussis) and transmitted to the Public Health Agency (PHA).
 That’s how the information transfer should work, but a few barriers remain:
  • The PHA would have to gather requirements for the triggering of the Reporting Form and the data needed for reporting for each type of reportable disease (though there may be some diseases where a positive lab result is all the information that is needed).
  • PHA will have to develop
    a way to populate disease surveillance system databases from CDA data.
  • Cost and time involved in implementing new procedures and perhaps new technology at the EHR system and at the PHA.
  • Different EHR systems may extract different kinds of data to create the CCD (mentioned in the first bullet above about the CCD approach); this may result in different kinds of data being reported to the PHA. 

IBM Research: Where would you like to see this collaboration go moving forward? 

Going forward, we expect that NYSDOH will be closely involved in national initiatives to develop and implement standardized approaches to electronic public health reporting from EHR systems to local and state public health program areas. Consensus around common core data elements and reporting structures for communicable diseases and other public health use case is essential to realizing a more efficient public health response system.
Availability of harmonized IT standards for public health offer great promise to alleviate the administrative burdens that presently reduce the timeliness, completeness and actionability of data. Once there are standards for EHRs to build to (and incentives for the vendors to do so), we will use our health information exchange infrastructure to transition to a fully electronic reporting system that integrates data from the provider or EHR source to the NYSDOH program application.
Bidirectional data flow is also important, so the ability to generate automated acknowledgements of data received or requests for additional data is also important to reducing unnecessary outreach to providers.

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