The NBS: Digital Public Health Reporting A Brief History 2010 1997 January, 1997 1 st ELR Information Public Health Meeting January, 1999 2 nd ELR Information

The NBS: Digital Public Health Reporting

A Brief History

2010

1997

January, 19971st ELR Information Public Health Meeting January, 1999

2nd ELR Information for Public Health Meeting

October, 1999NEDSS Launched March, 2000

Construction of NBS Begins

January, 2003NBS Launched into Production

May, 2006Public Health ASP Offering Launched December, 2006

16th State in Production with NBS

May, 2010Ability to build disease modules at the state

February, 2005NBS User Group Launched

The NBS continually evolves to meet the challenges of public health surveillance.The NBS continually evolves to meet the challenges of public health surveillance.


Utilization in the United States

NBS is implemented in 16 states and is used by over 1,000 public health practitionersNBS is implemented in 16 states and is used by over 1,000 public health practitioners

The NBS: Digital Public Health ReportingThe NBS: Digital Public Health Reporting and H1N1 Flu

At the Intersection of Policies, Standards and Technologies


An Agent for Change in Public Health Surveillance

1997 2010Paper-Based Web-Based

‘Data Islands’ and ‘One-Off’ Solutions

Integrated and Interoperable

Manual Entry Electronic Messaging

Centralized Data Entry and Access

Distributed Data Entry and Access

Home Grown Standards-Based

The NBS has facilitated the movement from paper to digital surveillance.The NBS has facilitated the movement from paper to digital surveillance.


Addressing Public Health Issues

The NBS: Digital Public Health Reporting and H1N1 Flu

The NBS: Digital Public Health ReportingThe NBS: Digital Public Health Reporting and H1N1 Flu

“Real World” Usage

TX: Responding to H1N1

SC: Empowering Providers

AL: Bidirectional Avenues of Collaboration

ID: Efficiency Through ELR

VA: Analysis/Visualization


What We Now Know About H1N1

Source: Centers for Disease Control and Prevention



Standards Based Surveillance

• Let’s Go Back to April 2009

– What will be the “source of truth” for data related to H1N1?

– At what level are we going to track the disease?

– What questions need to be captured?

– How are we going to analyze our data?

– How will we notify CDC of disease occurrence?

– How can we share our work with other public health departments?



Responding to H1N1

• Identify: Early recognition that the “swine flu” emerging in Texas was actually Novel Influenza A

• Collect: Immediate need was to develop a mechanism to capture data

• Disseminate: Share information based on analysis of data collected using data warehouse

• Adapt: Adjust surveillance based on disease trends and public health outcomes

• Control: Surveillance to document the existence and potential for development of severe sequelae



Before Electronic Laboratory Reporting

• Workload: Labor intensive and prone to error

• Timeliness: Reporting delays; dependency on fax, mail and phone

• Accountability: “Lost in bottom of the drawer”

• Completeness: Difficult to analyze the completeness of reporting



NBS > Point of Care Reporting to Public Health

Public Health Data Repository

Integrated Data Repository

Electronic Laboratory Reporting to Public Health:

1. Salmonella is detected in a specimen submitted for a patient with symptoms of a Foodborne illness

2. County public health practitioner receives the electronic laboratory report and begins an investigation

3. State public health practitioner analyzes received ELRs NEDSS Base

System

Laboratory

2

31

SecurePortal

Laboratory Information System

Analysis



0

200

400

600

800

1000

1200

Jan

Feb

Mar

Apr

May Ju

nJu

l

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Month and Year ELR Received

Nu

mb

er o

f E

LR

s R

ecei

ved

Progress with ELR

Between 1/2007 and 6/2010, the number of lab reports received via ELR increased from ~22/month to ~500/month.

Between 1/2007 and 6/2010, the number of lab reports received via ELR increased from ~22/month to ~500/month.

2008

9/07Mayo

5/08ARUP

4/08Quest

11/08St. Lukes

2007 2009

5/09IBL

H1N1 results

Time period 7/09 – 10/10, includes H1N1 results from Idaho Bureau of Laboratories


2010

<2007LabCorp

3/10Interpath


Percentage of reportable disease lab reports received via ELR, 2007–2009*

*Does not include STDs

3% ELR

97% Non- ELR 25% ELR

75% Non- ELR

40% ELR

60% Non- ELR

~1,000 lab reports

~1,200 lab reports (20%

increase)


Increased ELR between 2007 and 2009 led to a 40% statewide reduction in data entry time (from 195 hrs/yr to 120 hrs/yr) = more time for prevention and control activities.

Increased ELR between 2007 and 2009 led to a 40% statewide reduction in data entry time (from 195 hrs/yr to 120 hrs/yr) = more time for prevention and control activities.

Efficiency Through ELR


Improvements in Timelines and Completeness

• Timeliness.

– Since implementation of the NBS and ELR, disease reporting timeliness has increased• Example: Elapsed time between PHD receiving reports and reporting to the state has

decreased from 5.0 days (95% C.I., 3.6-6.3) to 3.4 days (95% C.I., 2.7-4.8)

• Completeness

– Completeness varies by public health jurisdiction, but the percentage of required fields completed in the NBS in 2009 was between 88% and 100%:• 99.8% basic demographic fields (e.g., age, sex)

• 98.7% onset and diagnosis date

• Race and ethnicity are least likely to be complete (67%)



Bidirectional Avenues of Collaboration

State Health Department

Local Health Departments

• Resource intensive processing of morbidity/laboratory reports

• Lost Investigations• Limited local staff development

• Limited feedback on investigations• Lack of analytic capabilities• Inability to monitor disease trends

Paper Business Process = Disconnected




• Electronic receipt of laboratory and morbidity reports

• Timely investigations and interventions

• Real-time, electronic feedback to field staff • Continual feedback on investigations

• On demand analysis capabilities• Access to multi-year data sets for trend

analysis

Digital Business Process = Connected

Local Health Departments

State Health Department




Paper-Based Digital

Prepare

Paper files received at state level Electronic or paper files received

Files manually sorted/saved according to jurisdiction.

ELR process consumes, translates, and loads messages into the NBS

Sorted files prepared to be sent to local jurisdiction with investigation form.

Paper files keyed in by State

Review

Files sent to jurisdiction by mail Messages appear in the dashboard accessible according to user’s permissions

Indicate records needing follow-up and begin investigation

Records reviewed within NBS, electronically stamping records not needing further follow-up

Respond

Investigation completed and mailed to State and state manually enter records into data silo

Create Investigation. Once completed, create a notification to state for review.

Weekly flat files transmitted to CDC State level electronically reviews investigations for transmission to CDC



Paper Based Approach to Disease Reporting



NBS > Point of Care Reporting to Public Health

National Center for

Public Health Data Repository

Business Process

Provider to Public Health:

1. Infection Control Nurse at a hospital enters a patient’s lab report directly in the NBS to alert public health to a positive finding for Tuberculosis

2. Public health practitioner receives the laboratory report within their dashboard and follows up with the Infection Control Nurse for additional information

3. Upon investigation, CDC is electronically notified of a confirmed case of Tuberculosis

NEDSS Base System

Provider

Interoperability

2

31

SecurePortal

Interoperability



Empowering Providers


GA

NC

Examples of Provider Based Disease Reporting

SC

NBS facilitates private – public joint surveillance.NBS facilitates private – public joint surveillance.

Provider Site

The NBS: Digital Public Health Reporting VA: Analysis/Visualization

Centralized database and analytic tools enhance use of reportable disease data

• All health departments have a database for analysis

• Data is available for analysis sooner because it is in the database sooner

• Working from the same database results in consistent and reliable statistics

• Opportunity for more integrated analysis

• Information is used in decision making when it is readily available

• Once a report is developed it can be shared by all users (and across states)

• Users collaborate to find solutions and build skills


You mean you want to be able to use the data?• Easy-to-use queries encourage non-epidemiologists to run reports• Datamarts support queries and analysis by power users

– Disease specific datamarts provide access to all relevant fields– Data from multiple ODS tables are combined, including administrative data – “Flattened” data structures simplify use – Data transformations simplify analysis – Exportable files support analysis through other tools (Aberration detection, geospacial

mapping, SAS, Logi-XML)• Reports prioritize action

– Identify cases needing investigation when many reports are received – Identify potential clusters from review of linelists

• Evaluation of workflow improves use of resources • Analysis to evaluate data quality and completeness

– improve surveillance strategies – support data improvement – ensure appropriate interpretation

• Incorporation of legacy data in a datamart to support historical analysis


We collect data to guide public health action We need robust tools to analyze and visualize the data

• Need more access to disease-specific data

• Need more capacity for graphic presentation of data

• Need more capacity for ad-hoc analysis by users

• Need more ability to incorporate statistical calculations, including rates

Do we build the capacity in NBS or

build interfaces with other tools and applications?

Documents

The NBS: Digital Public Health Reporting A Brief History 2010 1997 January, 1997 1 st ELR Information Public Health Meeting January, 1999 2 nd ELR Information