Pathology and PH - the informatics intersection

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					          Pathology and Public Health:
          A View of the Informatics
          Intersection


      Raymond D. Aller, M.D.
Director, Automated Disease Surveillance Section
Los Angeles County Department of Public Health



                 10 April 2008

                      Los Angeles County Department of Public Health
                Commonalities

        Pathology
         – The study of disease
         – Emphasizes data, process
        Public Health
         – The detection and prevention of
           disease
         – Emphasizes data, process



10 April 2008             2     Los Angeles County Department. of Public Health
                The diversity of public
                health ….
    Improving the public’s health, in a variety of
    ways
    Takes the population point of view, rather than
    the individual patient
     – About assessing, protecting, and improving the
       public’s health
     – Not about using public funds to provide medical
       care to individual patients
    Registries, early warning systems, e-Notification
    Ascertain – act - assure
10 April 2008           3     Los Angeles County Department. of Public Health
                The diversity of pathology

        Surgical pathology – individual diagnoses via
        personal service
        Clinical pathology – assuring usefulness of a
        variety of diagnostic and monitoring assays
        Forensic pathology – why and how did they
        die?
        Pathology and labs produce a lot of
        information important to protecting the
        public’s health.


10 April 2008             4     Los Angeles County Department. of Public Health
                For each subspecialty, a
                different way we can
                support public health …
        Surgical pathology
         – Tumor diagnoses
         – Other findings of PH importance
         – Research findings: asbestos
        Clinical pathology
         – Infectious diseases, toxic exposures, etc
         – Population patterns – antimicrobial susceptibilities,
           rate of test orders, meta-surveillance of epidemic
           disease
        Forensic pathology
         – Infectious diseases, toxins, etc.
         – Injury and violence prevention data

10 April 2008                 5      Los Angeles County Department. of Public Health
                And there are many other
                places where pathology
                and PH interact …
        Public health labs
        Discoveries that impact public
        health policy
        Cross-fertilization of personnel
        Etc…




10 April 2008           6     Los Angeles County Department. of Public Health
                Surgical pathology to the
                tumor registry
   Automated transfer of tumor diagnoses to the cancer
   registry
   First automated transfer of SNOMED-coded diagnoses: 1977
   … it has taken a LONG time for others to pick up this model.
   Recent projects to make this a more widespread practice:
   NAACCR volume 5 2007
   Complicated by the one-blob-of-text model of surgical
   pathology reporting
   A whole lecture in itself.


10 April 2008              7     Los Angeles County Department. of Public Health
                  Electronic Lab Reporting
                            (ELR)
        Software on the laboratory information system
        automatically selects from all laboratory results,
        those which are reportable to public health
        In other cases, ALL results transferred to a filtering
        system, that selects reportables
        These may be enhanced by other findings of public
        health importance
         – Antimicrobial susceptibility testing
         – Syndromic indications
        ELR commonly doubles the reporting rate

10 April 2008                 8      Los Angeles County Department. of Public Health
                Benefits of fully automated
                Electronic Lab Reporting
        More rapid transmittal of required reports
        More complete reporting
        Savings in lab staff time
        More accurate transmission
        Assured regulatory compliance (“HIPAA”)




10 April 2008           9    Los Angeles County Department. of Public Health
                Coroner/Medical Examiner
                Data to Public Health
        Alert PH to serious infectious diseases
        Trauma: epidemiology, intervention, policy
        A diversity of other diseases
        Direct transmission of case reports from
        Coroner’s case management system, to public
        health epidemiology systems
         – Best if fully automated (sometimes hard to accomplish
           with under-resourced medical examiners offices)



10 April 2008                10     Los Angeles County Department. of Public Health
  Two different categories of data
Identified disease cases                      Findings in large populations
 Case reports from
  Infection control
practitioners, nurses                                     Emergency department




                                              Syndromic
 physicians, others vCMR                                    chief complaints
                                Public
 Tumor diagnoses
                                Health
                               Disease
                              Surveillance       ELR
  Coroner’s cases                                              Lab orders
                        ELR
                                             RODS
Diagnostic laboratory
                                    ELR                    Over the counter
      findings
                                                             medications
                                    Antimicrobial
                                       results

10 April 2008                       11       Los Angeles County Department. of Public Health
                         Data Transformation
                           These functions may be performed
       Hospital
                           in the Public Health Department,
       Systems
                           Data Producing Facility or an
                                                                                                                                     Public
                           Intermediary
                                                                                                                   PH compliant      Health
                                                                                                                   HL7 messages   Information
                                                                                                                                    System
    Format converter




                                                              (of “non-reportable” findings)
                                                                                                                                     Public




                                                                                               De-identification
                                                                                                                   PH compliant      Health
                                         Routing
                                                                                                                   HL7 messages   Information
       Collation                                                                                                                    System


                                                                                                                                     Public
                                                                                                                   PH compliant      Health
     Text handling                        Filter                                                                   HL7 messages   Information
                                                                                                                                    System


                   Code translation
                    Code translation
                     Code translations                                                                                            Web page
                                                                                                                                  Data entry
10 April 2008                                      12         Los Angeles County Department. of Public Health
                 How is clinical lab data
                 conveyed to public health?
         LIS+ – extract reportables,          sFTP, VPN,
           apply LOINC/SNOMED                 Hypersend,
                                              SCP, AtC, etc.
                                                                        PH
                                       RHIO                             ELR
                                                                        System
         LIS – HL7                 Provider-Lab Link
         of all results
                             Edge server –
                             Filtering, translation

10 April 2008                 13       Los Angeles County Department. of Public Health
                   Data we gather in public health
      Diagnoses of individual “reportable” diseases
        – Fax, mail, manual entry
        – Web-based entry by providers
        – Electronic lab reporting
        – Build a longitudinal database: vCMR
        – Follow up on cases by nurses, epidemiologists, physicians
      Symptoms in populations
        – Emergency department (ED) chief complaints (50% of visits in LA
          County
        – Nurse call complaints
        – Parse free text – syndromes – look for patterns
      Behavior of populations
        – Purchases of over the counter medications
      Many other data sources
        – Coroners
        – Ambulance services
        – Reddinet – ED volumes (95% of EDs)
10 April 2008                      14      Los Angeles County Department. of Public Health
                In the near future…

        Complete Emergency Department record
         – (our first such interface has been bogged in a hospital
           legal department for 30 months)
        Ambulatory clinical and hospital records (EHRs,
        EMRs)
         – When a physician records a reportable diagnosis in an
           EMR, why can’t that be immediately transmitted to
           public health?
        Granular hospital records (e.g., ICU systems)



10 April 2008                 15     Los Angeles County Department. of Public Health
                Uses of additional lab data
                (using de-identified data)
        Ordering patterns
         – A doubling in rates of blood cultures, or
           spinal taps, might be indicative…
        Antimicrobial susceptibility patterns
        (MRSA, other MDR bugs) – community-
        wide antibiogram
        Result patterns
         – What might a sudden spike in ALT values
           indicate?
        Your thoughts?

10 April 2008                 16     Los Angeles County Department. of Public Health
                Data from clinical practice is
                being applied to public health
    Byproduct – no added work to gather data
    Automated – reliable, fast (as it occurs, not days later)
    Relevant – lab results, patient complaint, temperature
    – not billing data or massaged diagnosis codes
    Translation – accept data as it comes, provide
    translation function centrally (don’t insist that
    hospital/provider re-do their systems in order to
    connect to public health)
    Informatics is today a key tool in defense against
    natural (epidemics) and man-made (bioterrorist)
    outbreaks.


10 April 2008             17    Los Angeles County Department. of Public Health
                Real-time population health
                surveillance
      Most frequently used application:
      – Syndromic Surveillance
      Major improvement: coordination of data feeds
      through robust, secure, accessible data center.
      LA County: Number of EDs reporting has increased
      – started in 2000, 9 at 18 months ago, 17 in July 06, 28 by
        July 07, and 35 by Dec. 07
      – Data received and analyzed 7 days per week, report sent
        to approx. 105 public health staff and hospital partners.
      Also monitors various aspects of health status
      – case finding
      – health assessment – for example, the impact of the
        summer heat wave, assessing the flu season

10 April 2008                18     Los Angeles County Department. of Public Health
                ED Coverage Rate By Zip Code




10 April 2008           19   Los Angeles County Department. of Public Health
                Syndromic Surveillance

        Presenting complaints are automatically
        categorized into a particular syndrome, by
        word search
        Syndrome counts are tracked over time
        Statistical increase in syndrome counts
        triggers a signal
        To detect major trends from baseline
        patterns, not individual cases

10 April 2008           20   Los Angeles County Department. of Public Health
                Analyzing the data:
                Syndrome Classification
        Standard
        – Gastrointestinal
        – Respiratory
        – Rash
        – Neurological
        Special categories
        – Influenza like illness
        – Heat
        – (Trauma)
        – Others as needed
10 April 2008              21      Los Angeles County Department. of Public Health
                Los Angeles County Novel
                Surveillance Program
        Current LAC novel surveillance systems
         – ED chief complaint data syndromic (28 hospitals, 44%
           of total ED visits in the County)
         – Emergency Department Volume data through Reddinet
         – Coroner’s Database
         – Over the counter pharmacy
         – Nurse call/advice lines
        LAC systems in development
         – School absenteeism (currently passive)
         – 911 calls
         – Automated electronic surveillance

10 April 2008                 22      Los Angeles County Department. of Public Health
10 April 2008   23   Los Angeles County Department. of Public Health
10 April 2008   24   Los Angeles County Department. of Public Health
                Daily PHS summary




10 April 2008         25   Los Angeles County Department. of Public Health
                Labs/Hospitals and EDs
                connected
        30

        25

        20
                                           Labs/hospitals
        15
                                           ED s
        10

         5
                                             Note: in 2002, we brought
         0                                   the Kaiser regional lab
                                             live, serving 7 hospitals.

                  ly
                  01

                  02

                  03

                  04

                  05

                  06
               Ju
               20

               20

               20

               20

               20

               20
            07
         20




10 April 2008          26   Los Angeles County Department. of Public Health
                How do I get my lab
                connected?
        Talk with your local public health department
         – Are they ready to receive data?
         – What format/coding do they want?
         – In the US, we are moving toward standardization on
           HL7 version 2.5.1
        Talk with the vendor of your lab’s Laboratory
        Information System
         – How to install their public health interface module?
         – Does it match the specifications of your local PH?
         – Or do they have a way of sending out all results in HL7
           2.3.1+
10 April 2008                 27     Los Angeles County Department. of Public Health
                How are the LIS vendors
                doing?
    Our knowledge is based mainly on working with the 80 largest
    labs in LA
    Largest commercial labs provide HL7, some LOINC/SNOMED
    Modules with filtering and translation available from Sunquest
    and SoftLab
    Basic HL7 output (requires external filtering and translation)
    from Meditech, Cerner
    Don’t yet have a response from McKesson
    Haven’t yet worked with Orchard, Schuylab, Siemens, GE,
    Aspyra, Compromed, Fletcher-Flora, Psyche, OmniTech,
    OmniLab, Seacoast, NetLims, many others ….

10 April 2008               28     Los Angeles County Department. of Public Health
                   What about PH labs?
       A unique set of testing types
        –   Clinical
        –   Environmental
        –   Newborn screening
        –   Etc.
       A unique set of regulations (e.g., Calif. PHLT
       licensure)
       Sometimes a name does make a difference
        – LIMS tend to originate in pharmaceutical, research,
          industrial settings
        – LIS tend to have come from the clinical realm
        – Several installations of “LIMS” in the PH space have been
          problematic
             • E.g., one widely purchased product lacks a patient table… it
               can handle specimens, but tying them to a patient is a
               “custom” modification

10 April 2008                        29       Los Angeles County Department. of Public Health
                The latest religion?
        A number of folks in PH believe that open
        source will be the panacea.
        Others believe it will be an important addition
        to our toolkits.
        A few open source projects are underway –
        including a laboratory information system,
        developed for use in PHLs in Minnesota and
        Iowa, that is now operational in Vietnam
        Open-source EMRs are now being used in a
        number of resource-poor countries.

10 April 2008              30    Los Angeles County Department. of Public Health
                How else can we help PH?

        Pathologists and laboratorians have
        a valuable skill set
         – Much pathology training also prepares
           one for Public Health
         – Not necessary to have specialized PH
           training to make a worthwhile
           contribution to public health



10 April 2008             31    Los Angeles County Department. of Public Health
                  How can we contribute?

        On contract or salary
         –   Director of the public health laboratory
         –   Communicable disease (infection control)
         –   Informatics
         –   As Health Officer
        As a volunteer
         – Especially in a third world context
        Bring your ideas to a roundtable at the CAP-
        08 meeting: the pathologist practicing public
        health


10 April 2008                  32     Los Angeles County Department. of Public Health
                Questions? Follow up?

                Raymond D. Aller, M.D.
                raller@ph.lacounty.gov

        I look forward to hearing from you.




10 April 2008             33   Los Angeles County Department. of Public Health