Upload
lexiss
View
33
Download
1
Tags:
Embed Size (px)
DESCRIPTION
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. - PowerPoint PPT Presentation
Citation preview
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 ObjectiveOverall Objective
• To find out if a comprehensive EMR can contribute to the early detection of an infectious disease epidemic
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
EMREMR
Outbreak DetectorOutbreak Detector
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
CPRSCPRS
Outbreak DetectorOutbreak Detector
CPRS: Provider Interface
CPRS: Free-text data entry
CPRS: Structured data entry
CPRS: Structured data entry
CPRS is really VISTA
Data Extraction: “MDE”
SQL: Data Transformation
Sequences
SQL: Primary Warehouse
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
CPRSCPRS
Outbreak DetectorOutbreak Detector
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Outbreak DetectorOutbreak Detector
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Outbreak DetectorOutbreak Detector
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
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
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
ICD-9-based ILI Detectors
• Compared “respiratory” ICD-9 groupings from
– BioSense (CDC)– Essence (DoD)– Optimized (VA)
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
ILI Case DetectorRetained parameters
• “Cold remedies”
• Fever >= 38ºC
“Cold Remedies”CN101 opioid analgesics like ”codeine" OR CN900 CNS medications, other acetaminophen/diphenhidramine, ORMS102 non-salicylate NSAIS (does not include antirheumatics) , ORNT100 decongestants, nasal, ORNT200 anti-inflammatories, nasal, ORNT400 antihistamine, nasal, ORNT900 nasal and throat, topical, use “other throat lozenge" only, ORRE200 decongestants, systemic, ORRE301 opioid-containing antitussives/expectorants, ORRE302 non-opioid-containing antitussives/expectorant, ORRE501 antihist/decongest, ORRE502 antihist/decongest/antitussive , ORRE503 antihist/decongest/expectorant , ORRE507 antihist/antitussive, ORRE508 antihist/antitussive/expectorant , ORRE513 decongest/antitussive/expectorant , ORRE516 decongest/expectorant , ORRE599 cold remedies, ORAH102 antihistamines, ethanolamine, ORAH104 antihistamines, alkylamine
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)
Mumbo jumbo fever nonsense trivia blabla etc
TXT ILI Case Detectors
NegEx
Mumbo jumbo fever nonsense trivia blabla etc
TXT ILI Case Detectors
NegEx
TXT ILI Case Detectors
NegEx
Negation?
Mumbo jumbo fever nonsense trivia blabla etc
TXT ILI Case Detectors
NegEx
Negation?
Mumbo jumbo fever nonsense trivia blabla etc
TXT ILI Case Detectors
NegEx
Negation?
Mumbo jumbo fever nonsense trivia blabla etc
TXT ILI Case Detectors
NegEx
Negation?
Mumbo jumbo fever nonsense trivia blabla etc
Which One Should We Use?
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Outbreak DetectorOutbreak Detector
1999 2000 2001 2002 2003 2004
0
10
20
30
40
50
60
70
80
Number of ILI Cases
Time Series: VAMHCS, Jan 1999 – Dec 2004
ILI Cases VAMHCS 2002-2003
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
0
10
20
30
40
50
60
70
Number of ILI Cases
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Outbreak DetectorOutbreak Detector
Outbreak GeneratorOutbreak Generator
Outbreak Generator for Outbreak Generator for Baltimore Baltimore
1. Age-structured deterministic epidemic model generates the number of new infections in each age group, each day, for each zip code
2. Stochastic metapopulation spatial model determines how the outbreak will extend in space-time
3. Stochastic clinical 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
ILI Cases VAMHCS 2002-2003
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
0
10
20
30
40
50
60
70
Number of ILI Cases
ILI Cases VAMHCS 2002-2003
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
0
10
20
30
40
50
60
70
Number of ILI Cases
ILI Cases VAMHCS 2002-2003
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
0
10
20
30
40
50
60
70
Number of ILI Cases
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Outbreak Outbreak DetectorDetector
Outbreak GeneratorOutbreak Generator
ILI Cases VAMHCS 2002-2003
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
0
10
20
30
40
50
60
70
Number of ILI Cases
BIOSENSE (Current)
Fixed Threshold (p-value)
Optimized Threshold
Improved ICD-9 Codesets
Adding Structured Parameters
Adding Text Analysis
Optimizing for Positive Predictive Value
Surveillance for Febrile_ILI
• EMR data can significantly enhance automated Case detection of ILI compared to the use of ICD-9 codes alone
• Whole-system simulation and is required to evaluate and calibrate the performance of alternative single-case detectors
Conclusions (1)
• For influenza surveillance, case-detection algorithms should aim for high positive predictive value, and target ILI cases who are febrile
Conclusions (2)
StoStopp
YY
NN
OutbreakOutbreakValid?Valid?
OutbreakOutbreakSign.?Sign.?
Escalate PHSEscalate PHS
Case DetectorCase Detector
Outbreak DetectorOutbreak Detector
YY
CaseCaseValid?Valid?NN
YY
NN
Outbreak DetectorOutbreak Detector
Outbreak GeneratorOutbreak Generator
Data ExtractorData Extractor
SQL DatabaseSQL Database
VISTAVISTA/CPRS/CPRS
Bob Sawyer
Shawn LoftusBrett South
Ericka Kalp
Sylvain DeLisle
Trish Perl
Steve Altman, Raju Vatsaval
Jill Anthony
Shobha PhansalkarBrett South
Matt SamoreGary SmithHolly Gaff
Hongzhang ZhengZhilian MaFang TianPaul Sun“Vibrio”