APC Surveillance Tools Building a Public Health Community of Practice for Biosurveillance &

2. APC Surveillance Tools Building a Public Health Community of Practice for Biosurveillance & Syndromic Surveillance for Epidemiological Investigation APC Road Show Covington, KY April 26-27, 2010

3. Learning objectives: At the end of this session, participants will be able to: • Identify the primary purposes of syndromic surveillance and how it can benefit public health and other stakeholders in a public health community of practice. • Understand why syndromic surveillance is needed and how it fits into the broader surveillance picture. • Describe and understand some key concepts for integrating syndromic surveillance in LHD operations • Explore key APC resources for building syndromic surveillance into LHD practice.

4. Building a Public Health Community of PracticeA Biosurveillance Resource Compendium

5. Why should public health get involved in automated surveillance? • Primarily, it is now a key element tying public health to healthcare reform. • Secondarily, it is also a required public health component for healthcare providers to achieve “meaningful use” of electronic medical record systems. (along with immunization registries and health alert integration)

6. The context for syndromic surveillance in public health… • Healthcare reform is focused on improving: • Poor quality of care, errors resulting in more deaths annually than highway accidents, breast cancer or AIDS • Consumer empowerment • Presence of disparities in insurance, access to care and in health outcomes • Rapidly increasing costs of healthcare • Surveillance is the law-of-the-land as well as presidential directives for preparedness and broader healthcare. Electronic health information is a key element of priority HHS program already underway!

7. More context for syndromic surveillance… • 12-06: Pandemic and All-Hazards Preparedness Act (PAHPA) • Broad implications for HHS’s preparedness and response activities • Establish quadrennial National Health Security Strategy and support new programs (e.g., includes advanced development of medical countermeasures and surveillance) • 11-07: Homeland Security Presidential Directive 21 (HSPD-21) • Establishes biosurveillance capability for early warning of a biological attack or disease outbreak w/ ongoing “near real-time” updates • Plus 3 other core components

8. Syndromic surveillance purpose: • Syndromic surveillance is defined as "the timely collection, analysis, and investigation of health-related data that precede diagnosis." • Syndromic surveillance is used to: • Detect changes in community health status, especially for the early detection of outbreaks • Trace disease patterns over time • Describe patterns of disease in geographic locations and demographics at any time

9. Syndromic surveillance • The system groups acquired data into sets of symptoms that define syndromes and sub-syndromes such as : • Respiratory • Influenza-like illness • Gastrointestinal • Neurological • Based on traditional sources: • Outpatient ICD-9 codes • Emergency room chief complaints • Based on non-traditional sources: • School absenteeism • Over the counter (OTC) sales

10. Partner participation benefits: • Early awareness is preparedness • Consider potential for pandemic, bioterrorism, etc. • Supports infection prevention goals • Shows community patterns (MRSA and HAI’s) • Provides situational awareness when outbreaks are in process – H1N1 • Enhances public image of provider • Fosters collaboration with others and public health on health problem solving

11. Key steps to a Successful Syndromic Surveillance Program • Establish common ground – build program around users/providers and other stakeholders within community, not just public health • Define objectives and benefits to all stakeholders – avoids confusion, delays and disappointment • Clearly define what syndromic surveillance is • Also define what syndromic surveillance isn’t • Determine requirements and system strategy • Traditional (clinician-based) –SYRIS, EMSystems, others • Automated ( “data-mining”) – EARS, ESSENCE, RODS, other • Make sure to also capture organizational and operational requirements, not just epi-surveillance and technical

12. More Keys to a Successful Program • Assess readiness • Human resource – project management critical! • Funding – scale steps with available funding but show progress • System support/training • Agency/stakeholder support • Infrastructure and system options – in-house or service provider? • HIPAA/security • Pace the progress • Define technical and program requirements • “Sail the right ship”; realistically match milestones to resources with continuous improvement • Manage the project • Lead the team by continuously assessing and revisiting expectations

13. Other Important Considerations for LHD leading the program • How large, complex and diverse is your community? • The greater your community’s size, complexity and diversity, the more vulnerable you may be to various covert threats and the more important it then becomes to consider and establish a syndromic surveillance capability. • Where does your community stand today in terms of emergency preparedness and healthcare reporting/surveillance? • Have public health or other community leaders completed comprehensive threat and readiness assessments? • If so, what findings seem applicable to the consideration of a syndromic surveillance system? • Is it an appropriate focus for your agency to provide a syndromic surveillance system?

14. What is biosurveillance? • Consists of two major surveillance methodologies: • 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 as well as environmental conditions and other data sources, to use as baselines comparisons, and to support the accuracy and reliability of the biosurveillance findings. • Early event detection, case detection and situational awareness - the use of an automated system to evaluate case and suspected 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 an imminent public health incident of significance.

15. What is a public health community of practice? • People, organizations, resources and practices working together to share information in an effective, efficient way – working towards separate but related solutions. • Partners: • Hospitals and physicians • Schools, school-based clinics and daycares • EMS providers, law enforcement and other first responders • Long-term care facilities and mental health care providers • Public information officers and the media • Academics, vendors, subject-matter experts, insurance providers

16. Also including… • Resources and practices: • Surveillance data and systems • And their accompanying response protocols • Networks, IT assets and solutions, including: • Applications • Databases • Forums • Medical facilities and laboratories • Governance models – RHIOs, HIEs

17. Syndromic Surveillance for Epidemiological Investigation Response Protocols for Disease Detection

18. What is a response protocol? • Clear guidelines to review and summarize large amounts of data daily • Approaches or steps to review data and analyze the anomalies in data • A methodology to prompt inquiries or interventions that need to be completed in a time frame depending on degree of urgency

19. Why response protocols are needed: • A standard framework can help distinguish statistical anomalies from more important public health events • Can translate to time and cost savings for LHD in: • Investigating alerts • Reduce time to initiate intervention • Systems development

20. Response protocols framework: • Anomaly identification & detection • Anomaly characterization • Validation of anomaly • Assessing public health significance of findings • Other factors of importance

21. Anomaly detection – use of algorithms: • Systems use statistical algorithm to determine if actual case counts exceed expected counts for syndromes • Healthcare providers send information on unusual disease clusters and incidence that system can evaluate

22. Anomaly detection – across jurisdictions • Helps epidemiologists spot suspicious disease clusters • Detection should occur at multiple levels to discover anomalies that may be missed in a single jurisdiction

23. Anomaly characterization – descriptive epidemiology • Anomaly should be described fully w/ respect to person, place, and time (descriptive epidemiology) • Use geographic and demographic information • Clinical data should be evaluated and summarized • More information may be needed to fully characterize

24. Anomaly validation – expected? Anomalies: expected or unusual? • Seasonal or temporal (e.g. ILI) • Environmental causes • Disease trends • Corroborate data sources • Holiday, day-of-week effects • Same pattern prior year?

25. Assessing public health significance of findings Public health significance? • Extent of variance from usual frequency distribution • Atypical from known patterns • Magnitude, continuity of increase given syndrome group • Sustained for multiple days?

26. Other factors of importance • Unique attributes of the data stream to assess: • Lag time between occurrence of an event and time it is available to the system for detection of anomaly • Clinical value of the data; prompt evaluation following alerts is critical • One data stream or source may be chosen as primary indicator of change and other data sources as secondary • Compare anomaly w/ other surveillance systems

27. Key considerations in drafting response protocols: • Agency size • Experience • Training • Degree of risk • Time pressures • Data quality (lag time) • Jurisdiction • Department level

28. Final thoughts on applying APC surveillance tools • Syndromic surveillance systems have broad, major benefits • A community of public health practice engages many to be successful • LHD should assess community-level health problems • General guidelines are helpful, but may not be sufficient • Response protocols require effective communication • Staff experience key factor in protocol development • Findings and response should be shared broadly and promptly • One plan does not fit all

29. Now Let’s Explore the Tools! • Building a Public Health Community of Practice A Biosurveillance Resource Compendium • Syndromic Surveillance for Epidemiological Investigation Response Protocols for Disease Detection

30. QUESTIONS -Bill Stephens, MS, APC Manager, Tarrant County Public Health wfstephens@tarrantcountytx.gov (817) 321-4730 -Kay Sanyal-Mukherji, MPH, Workforce Development Specialist ksanyal-mukherji@tarrantcountytx.gov (817) 321-4883

31. References and resources to learn more: • Book: “Handbook of Biosurveillance,” M. Wagner et al., Elsevier, May, 2006. Details: www.elsevier.com/wps/find/bookdescription.cws_home/707451/description • Useful Websites and pages: • American Health Information Community: www.hhs.gov/healthit/community/background/ • CDC Biosense: www.cdc.gov/biosense/ and CDC PHIN: www.cdc.gov/phin/ • CDC syndromic surveillance resources: www.cdc.gov/epo/dphsi/syndromic.htm • Johns Hopkins Applied Physics Lab (ESSENCE developer): www.jhuapl.edu/ • HIMSS HIT Dashboard: www.hitdashboard.com/ • HIPAA and decision tool: www.hipaa.org and www.hhs.gov/ocr/hipaa/decisiontool/ • Health Level 7: www.hl7.org/ • Homeland Security Presidential Directive 21: www.fas.org/irp/offdocs/nspd/hspd-21.htm • Mirth project (open source HL7 interface engine): www.mirthproject.org/ • Office of the National Coordinator: www.hhs.gov/healthit/onc/mission/ • PAHPA: www.hhs.gov/aspr/conference/pahpa/2007/pahpa-progress-report-102907.pdf • Regenstrief Institute: www.regenstrief.org/ • University of Pittsburgh’s RODS Lab (RODS developer): https://www.rods.pitt.edu/site/ • Southwest Center for Advanced Public Health Practice (APC): www.texasapc.net • Tarrant County Public Health: www.tarrantcounty.com/eHealth/site/default.asp