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Re-purposing The Electronic Medical Record For Public Health

Re-purposing The Electronic Medical Record For Public Health. Sylvain DeLisle MD, MBA VA Maryland Health Care System and University of Maryland. Parade to Promote Sale of War Bonds, Philadelphia, September 28, 1918. Overall Objective.

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Re-purposing The Electronic Medical Record For Public Health

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  1. Re-purposing The Electronic Medical Record For Public Health Sylvain DeLisle MD, MBA VA Maryland Health Care System and University of Maryland

  2. Parade to Promote Sale of War Bonds, Philadelphia, September 28, 1918

  3. Overall Objective • To find out if a comprehensive EMR can contribute to the early detection of an infectious disease epidemic

  4. Case Detector EMR Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  5. Case Detector CPRS Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  6. CPRS: Provider Interface

  7. CPRS: Free-text data entry

  8. CPRS: Structured data entry

  9. CPRS: Structured data entry

  10. CPRS is really VISTA

  11. Data Extraction: “MDE”

  12. SQL: Data Transformation Sequences

  13. SQL: Primary Warehouse

  14. Case Detector CPRS Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  15. Case Detector SQL Database Data Extractor VISTA /CPRS Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  16. Case Detector SQL Database Data Extractor VISTA /CPRS Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  17. Focus on ILI • We focused on influenza-like illness (ILI) as a syndrome that may indicate an event of public health significance • Anthrax • Plague • SARS • Influenza

  18. ILI Case Definition • Positive influenza culture or antigen OR • Any two of the following (<= 7 days duration) • Cough • Fever or chills or night sweats • Pleuritic chest pain • Myalgia • Sore throat • Headache AND • Illness not attributable to a non-infectious etiology

  19. Gold Standard Detector: Manual Case Review • VA Maryland Health Care System (VAMHCS) and the Salt Lake City VA (SLCVAMC) • Study period: 10/01/03 to 3/31/04 • 15,377 (of 253,818) random sample, ER and selected outpatient clinics • All ILI cases and a 10% subsample of the records were re-reviewed by a MD, discordant pairs were adjucated by a panel of three MDs • Found 280 cases

  20. ICD-9-based ILI Detectors • Compared “respiratory” ICD-9 groupings from • BioSense (CDC) • Essence (DoD) • Optimized (VA)

  21. Structured Parameters-based Case Detectors • Vitals: Temp >38, RR > 22, HR > 100 • Orders/dispense for Rx: expectorants, antibiotics, antitussives, decongestants, anti-emetics, antidiarrheals • Order/results for tests: CBC, Diff, Strep. screen, Sputum cultures, Gram stain, Respiratory serologies, Influenza cultures/antigens, Chest/sinus XRays or CT scans

  22. ILI Case DetectorRetained parameters • “Cold remedies” • Fever >= 38ºC

  23. “Cold Remedies” CN101 opioid analgesics like ”codeine" OR CN900 CNS medications, other acetaminophen/diphenhidramine, OR MS102 non-salicylate NSAIS (does not include antirheumatics) , OR NT100 decongestants, nasal, OR NT200 anti-inflammatories, nasal, OR NT400 antihistamine, nasal, OR NT900 nasal and throat, topical, use “other throat lozenge" only, OR RE200 decongestants, systemic, OR RE301 opioid-containing antitussives/expectorants, OR RE302 non-opioid-containing antitussives/expectorant, OR RE501 antihist/decongest, OR RE502 antihist/decongest/antitussive , OR RE503 antihist/decongest/expectorant , OR RE507 antihist/antitussive, OR RE508 antihist/antitussive/expectorant , OR RE513 decongest/antitussive/expectorant , OR RE516 decongest/expectorant , OR RE599 cold remedies, OR AH102 antihistamines, ethanolamine, OR AH104 antihistamines, alkylamine

  24. TEXT-based ILI Case Detectors • Examine the text of all clinical encounter notes on the day of an index visit • Used modified NegEx algorithm (Wendy Chapman)

  25. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc

  26. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc

  27. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc Negation?

  28. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc Negation?

  29. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc Negation?

  30. TXT ILI Case DetectorsNegEx Mumbo jumbo fever nonsense trivia blabla etc Negation?

  31. Which One Should We Use?

  32. Case Detector SQL Database Data Extractor VISTA /CPRS Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  33. Time Series:VAMHCS, Jan 1999 – Dec 2004 80 70 60 50 Number of ILI Cases 40 30 20 10 0 1999 2000 2001 2002 2003 2004

  34. ILI Cases VAMHCS 2002-2003 70 60 50 40 Number of ILI Cases 30 20 10 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

  35. Case Detector SQL Database Data Extractor VISTA /CPRS Outbreak Generator Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  36. Outbreak Generator for Baltimore • Age-structureddeterministic epidemicmodel generates the number of new infections in each age group, each day, for each zip code • Stochasticmetapopulation spatialmodel determines how the outbreak will extend in space-time • Stochasticclinical features algorithm determines which of these infections will be recognized cases at the VA, and the severity, clinical profile and outcome for each recognized case

  37. ILI Cases VAMHCS 2002-2003 70 60 50 40 Number of ILI Cases 30 20 10 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

  38. ILI Cases VAMHCS 2002-2003 70 60 50 40 Number of ILI Cases 30 20 10 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

  39. ILI Cases VAMHCS 2002-2003 70 60 50 40 Number of ILI Cases 30 20 10 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

  40. Case Detector SQL Database Data Extractor VISTA /CPRS Outbreak Generator Outbreak Detector Outbreak Detector Case Valid? N Y N Outbreak Valid? Y Y N Outbreak Sign.? Escalate PHS Stop

  41. ILI Cases VAMHCS 2002-2003 70 60 50 Number of ILI Cases 40 30 20 10 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

  42. BIOSENSE (Current)

  43. Fixed Threshold (p-value)

  44. Optimized Threshold

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