BioSense - University of Pittsburgh

Report
TUTORIAL T6
Theory and Practice of Outbreak Detection
John W. Loonsk, M.D.
Associate Director for Informatics
Centers for Disease Control and Prevention
AMIA Annual Meeting
Saturday, November 8, 2003 8:00 - 4:30 pm
TM
Outline
• The Public Health Information Network
• Setting and goals
• National Electronic Disease Surveillance
System
• Preparedness needs for event
management and response
• BioSense goals and objectives
TM
Program Specific Reports and Summaries
HARS
STD*MIS
TIMS
MMWR Weekly Tables
NNDSS
EIP Systems
MMWR Annual Summaries
PHLIS
Statistical Surveys for
Chronic Diseases,
Injuries and Other Public
Health Problems
CDC
Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc.
State Health
Department
HARS
STD*MIS
TIMS
NETSS
EIP Systems
PHLIS
Reporting by
Paper Form,
Telephone
and Fax
Data
Sources
Physicians
Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc.
Chart
Review
City/County Health
Department
HARS
STD*MIS
TIMS
NETSS
EIP
Systems*
PHLIS
Lab
Reports
*EIP Systems (ABC, UD, Foodnet)
STD*MIS (Optional TIMS (Optional
at the Clinic)
at the Clinic)
TM
CDC and Other
Federal Organizations
Traditional Public
Health Reporting
• Many reporting steps are
still manual
• Time latency of data is high
• Each PH – data source
“connection” is done
independently
• Little sharing of technology
and infrastructure
• Rapid analysis possibilities
reside at only one level of
public health
State Health
Departments
Local Health
Departments
Hospital or
Health Plan
TM
Public Health Information Network - Vision
To transform public health by coordinating
its functions and organizations with
information systems that enable:
• real-time data flow
• computer assisted analysis
• decision support
• professional collaboration
• rapid dissemination of information to
public health, clinical care and the
public
TM
What is PHIN?
Gartner – a multi-organizational business
and technical architecture
• Technical standards
• Data standards
• Specifications to do work
Is also a process
• Commitment to the use of standards
• Commitment to participating in development
and implementation of specifications
TM
TM
Health Department
ODA
Data
Reporting
Detection
Algorithms
Unified Person
(Patient)
Integratable
Data
Repositories
Registry
Content
Delivery and
Knowledge
Management
Directory of
PH Involved
Personnel
PH Logical
Data Model
(Derivative of
HL7 RIM)
Communications
and alerting
HL7…
Integratable
Data
Repositories
Data
Exchange
Messages
Integration
Services
Reporting, GIS
and Analysis
Strong Security
PKI or VPN
Web
Services
TM
Public Health Information Network – “Live Network”
“Live” Exchange of and Access to Specific Data
for Interoperable Systems – Messages and Storage
Specific Data Content – Vocabulary and Implementation
Guides (LOINC, SNOMED, etc.)
Data Structure – Data Models (PHLDM, HL7 etc.)
Transport / “Handshake Between Information Systems” - ebXML
Encryption / Security – HTTPS, PKI
Connectivity – Continuous Internet Connectivity
TM
PHIN Coordinated Functions
• Detection and monitoring – support of disease and
threat surveillance, national health status indicators
• Analysis – facilitating real-time evaluation of live data
feeds, turning data into information for people at all
levels of public health
• Information resources and knowledge management reference information, distance learning, decision
support
• Alerting and communications – transmission of
emergency alerts, routine professional discussions,
collaborative activities
• Response – management support of recommendations,
prophylaxis, vaccination, etc.
TM
Public Health Information Network
Early Event Detection
BioSense
Surveillance
NEDSS
Secure
Communications
Epi-X
Analysis &
Interpretation
BioIntelligence
Analytic Technology
Information
Dissemination & KM
CDC Website
Health alerting
Federal Health
Architecture &
Consolidated
Health Informatics
PH Response
Lab, Outbreak
Management, Vaccine
administration, etc.
TM
NEDSS Base System
• Internet technology for
routine public health
surveillance
• Manages electric
laboratory reporting for
more cases, more
complete cases, sooner
• Helps connect clinical
care infrastructure with
public health
• Integrates multiple,
problematic single
disease systems
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Public health involves many
organizations sharing
information and working
together
Health
Department
Investigation
Team
Ambulatory
Care
Vaccination
Center
• Have needs and requirements
for each other’s information
systems
CDC and
Other
Federal
Organizations
Early Detection
Sources
RX
Pharmaceutical
Stockpile
• Clear case for use of specific
standards to protect the
public’s health
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Health
Department
Early event detection is
important
Investigation
Team
• Has been the focus of a lot of
recent informatics attention to
public health
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
Early Detection
Sources
RX
Pharmaceutical
Stockpile
• BioSense is important new
initiative for early detection
Public
• Benefits of early detection
come from an early and well
integrated public health
response
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Health
Department
Investigation
Team
•
•
•
•
•
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
After a possible event has
been identified, integrated
systems are needed for:
Early Detection
Sources
RX
Pharmaceutical
Stockpile
Possible case management
Case demographics
Tracking of symptomology
Travel history
Related environmental events
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Health
Department
Investigation
Team
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
Public health response
begins with trained public
health professionals and
systems that support:
Early Detection
Sources
RX
Pharmaceutical
Stockpile
• Contact tracing to determine
conveyance; person-person,
vector-person, place (plane,
building, etc.) to person
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Initial communications are
needed to heighten
watchfulness, but maintain
calm for a likely false
alarm:
Health
Department
Investigation
Team
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
Early Detection
Sources
RX
Pharmaceutical
Stockpile
• Secure
• Selective access
• Interactive
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
For most BT
pathogens, tests done
in public health labs are
central to confirmation:
Health
Department
Investigation
Team
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
Early Detection
Sources
RX
Pharmaceutical
Stockpile
Public
• Lab Information
management systems
to support standard
result reporting
• Clinical tests
• Environmental tests
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Public health action
requires systems for
supporting:
Health
Department
Investigation
Team
Vaccination
Center
•
•
•
•
CDC and
Other
Federal
Organizations
Ambulatory
Care
Early Detection
Sources
RX
Pharmaceutical
Stockpile
Stockpile management
Vaccine administration
Quarantine management
Prophylaxis and
treatment support
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
Having identified a true
event, the rapid
communication of
information to the public,
the clinical care community
and public health is critical
Health
Department
Investigation
Team
CDC and
Other
Federal
Organizations
Ambulatory
Care
Vaccination
Center
Early Detection
Sources
RX
Pharmaceutical
Stockpile
• Information specific to role
• Message geared to
audience
Public
TM
Public Health
Lab
Law Enforcement and
First Responders
Hospital or
Health Plan
After the event, lengthy
follow-up management
needs to occur:
Health
Department
Investigation
Team
Vaccination
Center
• Adverse events
tracking
• Vaccination “take”
recording
• Exposure registries
CDC and
Other
Federal
Organizations
Ambulatory
Care
Early Detection
Sources
RX
Pharmaceutical
Stockpile
Public
TM
0 - specimen
Clinical Site
Local
Responders
(police, fire, etc.)
26
Person
Hospital
22
Clinic
FBI
4.5
4.1q
6.1
Other
Federal
Agencies
23 32
33
4.1r
42
25
24
16
17
17
2.2
2N
1
State and Local
Public Health
Departments
2.1
2P
44
6P
6N
50
48
30
5
4P
3
4N
6.2
6.13
45
38
40
4.12 4.3
35
28
36
8
15
39
4.2
8
14
8
14
15
Other Federal
Response
Team
43
14
14
State/Local
Response
Team
13
Contractor
Response
Team
15
Centers For
Disease Control
and Prevention
(CDC)
4.4
4.13
Regular Lab
(non-LRN)
6.12
16
49
51
8
9
8
46
7
38
21
15
19 29
18
31
27
47
4.11
37
6.11
12
CDC Response
Team
27
Treatment/Intervention
Center
41
LRN Labs (may be
separate or
combined A/B/C)
10
11
10
20
Affected Community
Public Health Partners Messaging Information Flows
TedKlein
Contaminated Bldg.
TM
LRN Lab Result Reporting
• Application for
Laboratory Response
Network labs
• Produces standard HL7
lab result message
• Being used to support
BioWatch initiative
• Also can support other
lab result reporting for
response
TM
Outbreak Management System
• Manages possible cases,
cases in outbreak
• Meta-data driven rapid
data input
• Supports contact tracing
for people, vectors and
locations
• Works on single pc, in
multi-user LAN,
synchronizes with state
or CDC
TM
Vaccination Administration Support
• PVS initiative provided
infrastructure for national
vaccine administration
support
• CDC system and
compliant state systems
• Included “take” recording
and active surveillance
• Converting to support
vaccination and
prophylaxis
administration for other
possible agents
TM
Public Health Information Network - Process
1.
Capture the business requirements that support the
public health mission
2.
Identify relevant industry standards - technical and
data
3.
Develop specifications based on standards that are
concrete enough to do work
4.
Fund through the specifications
5.
Develop “transitional software” that implements the
specifications now
6.
Encourage partners and private sector to implement
the specifications
7.
Support conformance testing
TM
Public Health Information Network
• Bioterrorism Functions and Specifications
accepted as PHIN Version 1.0 Standards
• Were attached to over 1 billion in BT supplement
(CDC and HRSA) and will be this year
• Gartner Group independent technical review
• ASTHO – NACCHO – CDC Data Standards
Working Group
• ASTHO – NACCHO – CDC Technical Standards
Working Group
TM
Today’s Environment
TM
BioSense - Setting
The third piece of the recent national Bioterrorism
initiatives:
BioShield - rapid development of new vaccines and
therapeutics against biological threats
BioWatch - deployment of environmental air samplers
in key locations to detect releases of
certain biological agents
BioSense - enhanced capability to rapidly detect
Bioterrorism by accessing and analyzing
diagnostic and pre-diagnostic health data
for bioterrorism indicators
TM
BioSense
Initiative
• Support the advancement of early detection
• Data acquisition, infrastructure for near real-time
reporting and analytics
• Promote the use of national standards and develop
requisite specifications
• Increase the sharing of approaches and technology
• Insure integration with other public health systems
System
• National “safety net” – help support BioWatch cities
• An implementation of identified standards
• A platform for the implementation and evaluation of
different analytic approaches
TM
CDC and Other
Federal Organizations
Traditional Public
Health Reporting
• Many reporting steps are
still manual
• Time latency of data is high
• Each PH – data source
“connection” is done
independently
• Little sharing of technology
and infrastructure
• Rapid analysis possibilities
reside at only one level of
public health
State Health
Departments
Local Health
Departments
Hospital or
Health Plan
TM
CDC and Other
Federal Organizations
Early Detection
Sources
Ambulatory
Care
Hospital or
Health Plan
State and Local
Health
Departments
BioSense
• Near real-time data
access
• Analysis capabilities at
local, state and
national levels
• Sharable outbreak
detection algorithms
and analytic
capabilities
• National coverage
TM
BioSense - Principles
• Early event detection is critical for Bioterrorism
management and response
• The most useful tools will be dual use;
Bioterrorism capable and regularly exercised for
“routine” public health activities
• Systems should minimize reporting burden manual reporting of data has limited roles
⁻ prospectively around major events
⁻ retrospectively after major occurrences
• Both diagnostic and pre-diagnostic (syndromic)
data exist in electronic form in many yet
untapped health-related data stores
TM
BioSense - Principles
• Where available, early event detection data
based on the diagnostic skills of clinical
personnel should be emphasized and certainly
integrated
• Data stores are aggregated locally, regionally,
nationally, and in cross organizational
databases that can be actively leveraged for
public health purposes
• Real-time data acquisition and analysis
technologies are still not broadly implemented
• Needs for analytic capabilities at the local,
state, and national levels
TM
BioSense Principles
• Many pre-diagnostic data sources still need
to be rigorously evaluated
• Consequence management is a major issue
• As much as possible let public health users
control alerting and notifications
• Coordinate multiple data sources to facilitate
signal evaluation, reduce false alarms and
minimize end-user burden
• Support comparative analysis and
interpretation by public health professionals
TM
BioSense Principles
• Data should be securely managed for public
health use with jurisdictional access controls
• Be sensitive to patient confidentiality – reported
data will not include patient names or medical
record numbers – but strive for linkage
• Support public health investigation through
supplemental electronic queries for information –
bidirectional infrastructure; reporting and query
• Build on national standards and investments
 Public Health Information Network (PHIN –
required for BT cooperative agreement
spending) (fully aligned with national and
industry standards - CHI, NCVHS, Federal
Health Architecture…)
TM
BioSense Principles
• Early event detection needs to connect to the
people and systems for public health
response
• Systems and evaluation should consider the
continuum for:
1. Initial detection
2. Subsequent case identification
3. Quantification of event magnitude to help
shape public health response
4. Data exchange and integration with
outbreak management and response
systems
TM
Beyond Early Detection Systems
• Case management – possible cases, symptomology,
travel history, possible environmental events and
demographics
• Investigation and confirmation – integration of clinical
lab results, environmental results
• Contact tracing – person-person, person-place,
conveyance (plane, home, etc.)
• Response coordination – quarantine, stockpile
dispensation, accelerated vaccination, prophylaxis
• Adverse events and follow-up management –
exposure registries, vaccination “take” recording,
adverse reactions to treatment
TM
National and
Regional Data
Sources
BioSense System I
City / State
Recipients
National labs
test requests & results
DoD and VA
sentinel clinical data
Analysis and Visualization
Clinical lab orders
Nurse Call
Line Data
Lab Response Network
(including BioWatch)
Over-the-counter
drug sales
TM
National and
Regional Data
Sources
BioSense System II
(proposed)
City / State
Recipients
National labs
test requests & results
DoD and VA
sentinel clinical data
Analysis and Alerts
Regional clinical
networks
Nurse Call
Line Data
Electronic Investigation
Lab Response Network
(including BioWatch)
Over-the-counter
drug sales
(others)
State and Metropolitan
Surveillance and
Response Systems
TM
BioSense
• Secure access for
authorized public
health officials
• Reported data will not
have direct patient
identifiers
• Agree not to attempt to
re-identify outside of
authorized public
health investigation
TM
BioSense
• Entry page
• Representation of
jurisdiction
• Geographic
representation of
unusual data (as
per Harvard
algorithm)
TM
BioSense
• Single page for
representation of all
“health indicators”
• Challenge to
represent different
sources, different
scales, possibly
significant signals
TM
BioSense
• Highly configurable
display
• Data parameters;
demographics, data
sources, region (to zip
code level)
• Graphing and display
parameters; day of
week adjustment,
“normalization”
methods
TM
BioSense
• Specific category
display
• Includes added
details of actual
counts
• Display challenges
of multiple data
sources and scales
TM
BioSense
• Time shift allows for
the relative reorientation of
individual graphs to
emulate varying
latencies
TM
BioSense
• Alternative
geographic
visualization of
“normalized” data
and actual counts
TM
BioSense
• Data drill down into
“count” data to the
level of counts per
zipcode
• Next step drill down
to individual records
will also be
available
TM
BioSense
• Developing dynamic
display capabilities
• Example here is for
ICD diagnoses that
may be
representative of
possible SARS
cases
TM
BioSense
• Another data source is
the BioWatch
environmental
sampling data
• Expect that positive
results will initiate calls
• Presents location of
collectors, opportunity
for follow-up mapping
and presentation of
other relevant data
• Indicates when testing
is actually being done
TM
BioSense
• Using same lab
specimen logging and
result reporting system
to allow for electronic
reporting of Category A
results
• Uses federal standards
for lab result messages
(HL7, LOINC,
SNOMED, PKI,
ebXML)
TM
BioSense
• Drill down on results
to allow for
individual record
display
TM
BioSense
• Alternative display
capabilities for
results including epi
curves, etc.
TM
BioSense
• Analytic workbench
• Exposes additional
data analytic
capabilities of SAS
for working data
TM
BioSense System Infrastructure
and Analytics
Analytics
• Multiple analytic and display
algorithms
• Data source evaluation
Infrastructure
• COTS technology for:
• Spatial display
• Time series presentation
• Data standards
• Data acquisition
TM
TM

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