Biosurveillance/BioSense Evaluation Project

1. Biosurveillance/BioSense Evaluation Project Project OverviewPresented at the PHIN 2008 ConferenceAtlanta, GA – August 24-28, 2008 Walter G. Suarez, MD, MPH President and CEO, Institute for HIPAA/HIT Education & Research President, Public Health Data Standards Consortium

2. Background • Current public health surveillance and investigation often involves manual reporting of cases to public health agencies and phone calls to healthcare providers for more detailed information • The timeliness, completeness, and breadth of coverage of these manual processes can be problematic, especially during a public health emergency • With increasing amounts of healthcare and health-related data in electronic form, the progressive adoption and use of electronic health records and the move towards interoperable health information exchanges (HIEs) at the local, regional, state and national level, there are now significant opportunities to leverage health IT and HIE to better support public health functions including preparedness and disease surveillance.

3. CDC Preparedness Goals

4. Project Objectives • Overall: • Assess the impact of disease surveillance, including BioSense, on public health practice • Specifically: • Assess current public health disease surveillance program(s) and system(s) • Document current resources, data flows, data content, standards, formats and analysis tools used in disease surveillance • Evaluate methods and processes used to detect, respond/manage, and monitor a public health event • Assess the current data, system and resource gaps, barriers and issues • Review disease surveillance performance evaluation and improvement activities • Assess the BioSense program (for states/organizations participating in BioSense)

5. Project Objectives • What are we really attempting to do? • Opportunity to move forward the bi-directional inter-relationship between Electronic Health Records and Public Health Information Systems • Help give shape to the future of the integration between public health and clinical practice to improve the quality of health care

6. Core Concepts • Biosurveillance (ASTHO) • Well established public health surveillance methods and sources used for the tracking, monitoring, and reporting of health-related information, such as epidemiologic investigations of infectious disease outbreaks or environmental conditions, are needed to ensure a broad coverage of data sources, to use as baselines comparisons, and to support the accuracy and reliability of the biosurveillance findings. • Early event detection and situational awareness, the use of an automated system to evaluate case and suspect case reporting along with statistical surveillance and data visualization of pre-diagnostic and diagnostic data to support the earliest possible detection of events that may signal a public health emergency, is an essential component for near real-time detection of natural or man-made health events. • BioSense • National program intended to improve the nation’s capabilities for near real-time biosurveillance and health situational awareness through access to existing health data from healthcare organizations.

7. Core Concepts • Syndromic Surveillance • Surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response. Though historically syndromic surveillance has been utilized to target investigation of potential cases, its utility for detecting outbreaks associated with bioterrorism is increasingly being explored by public health officials. • Situational Awareness • The ability to know what’s going on; accomplished by monitoring the extent of disease or disease indicators over time and geographically, especially in an emergency context. Emphasis is placed on monitoring after the initial upswing of the epidemic curve.

8. BioSurveillance/BioSense Evaluation Project • Phases of the Project: • Year 1 (2007) State Assessments • Year 2 (2008) Functional Requirements Development • Year 3 (2009) Prototype/Pilot Development

9. Phase 1 Strategy • Purpose: • Conduct a series of state site-visits and interviews with key public health informants subject-matter experts to gather information necessary to achieve goals of the project • Approach: • Identify and select three states • Within each state, approach three organization types (state public health, local public health, private sector entity) • Select three core condition ‘topics’ to focus interviews • Develop and test standard interview instrument • Pre-site visit preparation; site-visit interviews; post-visit follow-up

10. Selection of States • Minnesota: • 5.2 million; 87 counties; 91 local public health agencies (city, country, multi-country) • BioSense: no operating BioSense site yet • Wisconsin: • 5.6 million; 72 counties; 109 local public health agencies (city, country, multi-country) • BioSense: Aurora Health Care – largest health care provider in state; 14 hospitals (103 clinics) • Indiana: • 6.3 million; 92 counties; 94 local public health agencies (city, country, multi-country) • BioSense: State of Indiana (includes 70 hospitals)

11. Selection of States Higher Degree of State Decentralized Disease Surveillance Functions Higher Degree of State Centralized Disease Surveillance Functions

12. Selection of Entities Within States • Minnesota: • Minnesota Department of Health • Did not do local public health or private sector organization • Wisconsin: • Wisconsin Division of Public Health • Milwaukee Department of Health • Aurora Health Care • Indiana: • Indiana Department of Health • Marion County (Indianapolis) Health Department • Indiana Medical Center/Wishard Health Services (EMS)

13. Selection of Conditions • Focus on real-situation public health events in the states within the last 3-4 years • Provide opportunity to do a ‘walk-through’ of the various stages of the event as they occurred • Allow cross-state comparisons • Included two acute conditions and one chronic condition • Criteria: • Conditions represent high priority area for state • Recent public health event experienced by state with condition • High incidence (and prevalence for chronic condition) in state • Conditions selected: • Acute respiratory condition – Pertussis • Acute GI condition – E. Coli • Chronic condition - Diabetes

14. Interview Instruments • Development • Project team served as instrument development group • Identified core dimensions to cover • Prepared initial draft of instruments • Organized sections and question flow • Added probes and interviewer notes • Reviewed and revised several times • Tested instrument

15. Interview Instrument Dimensions • Section 1 - Basic Organization Information • Structure, budget, divisions and programs • Section 2 - Overview of surveillance programs • Description of program • Biosurveillance information systems and infrastructure • Management and operating resources, procedures, policies, practices • Systems, applications, connectivity, standards (data, format, terminology), interoperability • Purpose and goals • Data flows and methods used for collecting/receiving/reporting • Internal and external actors (send, receive, use data) • Data types (demographics, clinical, environmental, financial) • Data analysis tools • Outputs (who uses data, what are the uses given to data, data sent back to data providers) • System performance (usefulness, timeliness, reliability, flexibility, stability, acceptability) • Benefits and challenges, system and outcome gaps

16. Interview Instrument Dimensions • Section 3 – Event Detection, Response, Management and Monitoring (condition-driven) • ‘Walk-through’ event • Methods used to identify and detect event • Methods used to respond and manage event • Timeline for event detection and response • Methods for monitoring event (post identification/confirmation of first case) • Section 4 – Health Information Exchange/Sharing of Data Across Systems • Who, what, when, why, how • Exchanges within (internal) organization • External exchanges of data (local public health, private sector, other states, federal agencies, others) • Use of local HIEs (RHIOs)

17. Interview Instrument Dimensions • Section 5 - BioSense • Description of local program/participation • Features, relationship to program • Program outcomes and performance • Ability to detect, respond, manage alerts • Level of situational awareness provided • Usefulness, timeliness, reliability, flexibility, stability, acceptability • Benefits and Issues/Challenges

18. Sample Interview Instrument