Deepthi Rajeev, MS, MSc

1. Evaluating the Impact of Electronic Disease Surveillance Systems On Local Health Department Work Processes Deepthi Rajeev, MS, MSc Department of Biomedical Informatics University of Utah 10/28/2009

2. Steps in the Reporting Process Laboratories, hospitals, doctors: • Identify condition • Recognize that it is reportable • Collect data and transmit clinical and laboratory information to public health Health Departments: • Receive clinical and laboratory reports • Trigger an investigation if indicated • Implement control measures to prevent further exposure and transmission

3. Problems for local health departments • Manual reporting process (fax) • Insufficient data in initial case report • Manual triage of initial case report • Time consuming, but not quantified • Reports belong to other jurisdictions • Duplicate reporting • Lack of shared information

4. NETSS NETSS Electronic health record Lab information system Former Reporting Process in Utah Reporting entities Local Health Dept Phone Manual entry Fax Fax State Health Dept Fax Manual entry Physician Infection Preventionist Others * No interface to receive electronic information * No shared public health records

5. NEDSS Lab system Electronic health record Electronic health record New Reporting Process in Utah Intermountain Healthcare HL7 (RT-CEND) Local Health Dept Manual entry Other reporting entities Fax Fax Phone State Health Dept Fax Physician Manual entry Infection Preventionist Others RTCEND= electronic transmission of case reports NEDSS = shared public health records

6. Issues to consider • Will the new electronic systems impact workflow? • Who will be affected? • Will the impact be positive or negative?

7. Research Objectives • Identify metrics to monitor impact on workflow as new systems are developed and implemented • Collect baseline data

8. Salt Lake Valley Health Dept • 8000+ reports per year • Reports from Laboratories, • Hospitals, Clinics, State Health • Department, other local Health • Departments, Community, Jail… • Formats: Fax, Phone call, Email, • Mail Study Location

9. Methods to select metrics • Observation Study - observed tasks performed by various personnel at SLVHD • Interviewed SLVHD personnel - Triage nurse, data entry, nurse, nurse manager • Documented workflow associated with processing a case report and validated workflow • Identified tasks that were frequent, important, and measurable • Identified metrics to measure the selected tasks

10. Timestamps for timeliness evaluation Onset of disease Time to diagnose case Case detected (date of lab results or diagnosis) Reporting Time Reported to public health Time until case is triaged Start triage process Goal: shorten this time interval Time to review (establish jurisdiction and reportable condition status) + time for initial data entry Entry in surveillance database Time until case is investigated Investigation starts Time until case investigation is completed Investigation ends

11. SLVHD workflow Forward to state health department Stop Start • Does the report have all the information required to identify: • if the condition is reportable? • if SLVHD is the responsible health department? Triage Report Archive Case Information Review and assign case classification Initial Data Entry Identify if the report belongs to a new case or is an update to an existing case Investigation and implementation of control measures Assignment

12. Metrics for Triage Process • Relevance of the reports received: • # (%) of reports with new information including: • new unique (non-duplicate) cases • updated information • # (%) of duplicate reports • # of out-of-county cases • Follow-up: • # of phone calls to gather additional information • Type of additional information required • # of times data required was obtained • # of times forwarding of reports to data entry was delayed • Time to review a report and determine that condition is reportable and relevant for Salt Lake County

13. Metrics for Data Entry Process • Time required to identify whether information on a newly arrived report has previously been reported (i.e., new or existing case) • Time required to enter data into the computer • Number of reports entered each day and week

14. Baseline data collection

15. Methods • Direct observations at Salt Lake Valley Health Department • July 6 - 13, 2009 • Data collection form • Extracted timestamps from NEDSS that were collected as part of routine work processes

16. Date Collection Form

17. Distribution of Reports Received 380 reports received for 33 different diseases Out-of-County reports (n=86) New unique reports for Salt Lake County (n=172) Duplicate reports (n=72) 76% reports from Utah Department of Health Updated information (n=50)

18. Number of reports triaged by day

19. Incomplete Reports Of 380 reports, • 105 reports (32%) required additional information • 99 phone calls made • 63 reports (60%) were held for additional information and not forwarded to data entry immediately

20. Details on Missing Data

21. Time to Triage Reports • Average 3 mins 31 sec / report • 3 mins 30 sec for SLVHD cases • 3 min 38 secs for Out-of-county cases • Total time to triage cases (before forwarding to data entry) : 12:20:40 (hh:mm:ss) • ~ 26% FTE

22. Interval between Report and Triage Date

23. Time for Initial Data Entry Observed 29th - 30th June 2009 • 62 reports entered • Time to identify if report already exists • in NETSS: 12 seconds/ report • in NEDSS: 35 seconds/report • Time to enter data • in NETSS: 49 seconds/ report * • in NEDSS: 3 min 9 seconds/ report *During study, only part of the data was entered in NETSS (NEDSS was the main system in use)

24. SLVHD Timeliness Onset of disease Time to diagnose case 7 days Case detected (date of lab results or diagnosis Reporting Time 6 days Reported to public health Time until case is triaged 1 day Start triage process Goal: shorten this time interval Time to triage 0 days Entry in surveillance database Time until case is investigated 7 days Investigation starts Time until case investigation is completed Investigation ends

25. Next Steps • Develop an ongoing monitoring system to evaluate impact of surveillance systems on workflow • Issues: • Is this feasible with the existing infrastructure?

26. Acknowledgements • CDC- Utah Public Health Informatics Center of Excellence (Grant # 8P01HK000030) • Rui Zeller • Andrea Price • Jon Reid • Catherine Staes • Ilene Risk • Richard Kurzban • Mary Hill • Kris