Michigan Communicable Disease Reporting Gathering Data through Electronic Laboratory Reporting

Michigan Communicable Disease Reporting: Gathering Data through Electronic Laboratory Reporting 2006 PHIN Conference Poster Abstract MDSS Referrals by Submitter Role 2% 5% 10% Michigan Department Of Community Health M DCH • • Bradley Carlson, MPH Surveillance Systems Coordinator, MDCH Gwen Thompson, MPH Senior Policy Analyst, Altarum Institute Jim Collins, MPH, RS Manager, Surveillance Systems Section, MDCH Electronic laboratory reporting (ELR) using HL7 messaging is a key component of the PHIN functions of ‘Automated Data Exchange’ and ‘Specimen and Lab Result Information Management and Exchange’. As Michigan strives to achieve these functions, the Michigan Disease Surveillance System (MDSS) (Michigan’s NEDSS Solution) has had success, and also faced challenges in implementation of ELR. The Michigan Department of Community Health (MDCH) Bureau of Laboratories (BOL) has been successfully submitting electronic laboratory data in an HL7 format into the MDSS since December of 2004. During 2005, electronic laboratory reports initiated 7,143 case reports that account for 10.3% of all new reports in the MDSS during that time period. Implementation of ELR has also reduced the mean time from lab report to referral into the MDSS when compared with manual data entry (.16 days and 8.45 days respectively). The improvement of the timeliness of reporting and data completeness has not come without some challenges. The MDSS project team worked with the BOL laboratory information management system (LIMS) vendor to improve the format of the HL7 message being produced. Concurrently work was done with the MDSS software vendor to improve processing of a standard HL7 message to incorporate additional information beyond what was being sent in the initial BOL message. Modifying the MDSS to process all information in the incoming HL7 message was critical to the ability to bring on new laboratories. With these improvements in place, MDCH has started outreach with other regional and national laboratories to bring new data sources into the MDSS electronically, via HL7 messaging. This has proven challenging, but we’ve made significant progress with one national laboratory. As many other states are finding, HL7 messages can vary significantly in format, content and coding. Michigan’s current strategy is to work with the laboratories to make modifications to adhere to the accepted HL7 standards. In addition, Michigan is planning to perform some preprocessing and mapping of local codes to SNOMED codes outside of the MDSS system using the Orion Rhapsody software in coordination with products developed as part of the PHIN initiative. We believe this strategy will pave the way for future laboratory integration in a consistent and timely fashion. Michigan will present the successes, challenges and future strategy regarding electronic laboratory reporting into the MDSS. Current Status of ELR: 12% ELR Successes: Software enhancements have been made to the MDSS and the BOL LIMS to address the content and processing of the messages being sent to capture additional data in a more standard and readable format. Future Strategy: Preprocessing of HL7 messages using Orion Rhapsody software Inclusion of other MDCH program areas to reduce burden on the laboratories through the use of Orion Rhapsody to map and parse messages to appropriate program areas • Receiving approximately 15 referrals per day (HL7 2.3.z messages) from the MDCH Bureau of Laboratories (BOL) • The HL7 messages automatically generate a referral within the MDSS • Currently working with Quest Laboratories and Mayo on ELR • Working on installation of PHIN-MS and Rhapsody to process and route messages • Will be ready to begin outreach with other reference laboratories and local hospital laboratories when Rhapsody installation is complete 10% BEFORE MSH|^~\&|COHORT|MDCH REGIONAL LAB - LANSING|NEDSS||20060131090020||ORU^R01|19191|D|2.2|| PID|||||A^PATIENT||19830101|F||||||||||| OBR|1||M06GP001790|670^RNA AMPLIFICATION ASSAY^EPIC|||20060126|20060131||||||20060130|CVX&CERVIX^^^T-83200&UTERINE CERVIX&CERVIX|2404^HARGROVE^TANGANIKA^^^^||||M06GP001790||20060131|||F||^^^^^ROUTINE||||||| ZLR|555 TOWNER, Suite 149^^YPSILANTI^MI^48197^^^^MI161||||^22^Y|||||3350 N. Martin Luther King,Jr. Blvd., PO Box 30035^^LANSING^MI^48909 OBX|1|CE|^^^3010,3020,3050^GENUS (BACT),SPECIES (BACT),PHAGETYPE (BACT)^EPIC||L-2A901^Chlamydia trachomatis^SNM^3010.101,3020.315,3050.104^Chlamydia,trachomatis,RNA DETECTED^EPIC||||||F||||| OBX|2|CE|^^^3010,3020,3050^GENUS (BACT),SPECIES (BACT),PHAGETYPE (BACT)^EPIC||L-10001^No Organism found^SNM^3010.23,3020.54,3050.105^Neisseria,gonorrhoeae,RNA NOT DETECTED^EPIC||||||F||||| OBX|3|CE|^^^3100,,^TEST COMMENT (BACT),,^EPIC||^^^3100.319,.,.^Aptima Combo 2 test used,,^EPIC||||||F||||| OBX|4|CE|^^^3100,,^TEST COMMENT (BACT),,^EPIC||^^^3100.320,.,.^Positive Aptima Combo 2,,^EPIC||||||F||||| OBX|5|CE|^^^3100,,^TEST COMMENT (BACT),,^EPIC||^^^3100.321,.,.^Negative Aptima Combo 2,,^EPIC||||||F||||| 61% MDSS Lab Processing Quest Labs Communicable Disease Program ELR Challenges: MDCH-BOE Admin & General Epidemiology Staff ELR Submitting Laboratory MDCH-STD Program Staff Submitting Laboratory Health Care Provider Local Health Jurisdiction • Processing messages from various laboratories has been a challenge, as the message format and content can vary significantly • The current system was designed to process an HL7 2.3.z message in one standard format Variability in HL7 messages: • Different versions (2.3.z vs. 2.3.1) • Results in different places (NTE segments vs. OBX segments) Electronic Laboratory Reporting Has Greatly Reduced the Referral Time (Time from Laboratory Report to Entry into MDSS) for Cases Based on Laboratory Results • Ordering provider information not available on MDSS interface • Notes in multiple OBX segments • Test comments sent as codes, instead of actual text Rhapsody PHINMS Michigan Bureau of Labs FTP HL7 Conversion HyperSend Code Translation Excel Conversion Excel • Specimen source in different places (NTE segments vs. OBR segments) • Multiple OBXs used instead of NTE segments • Reference Ranges in different places (NTE segments vs. OBX segments) Michigan Disease Surveillance System Excel Time in days from Lab Report to Referral into the MDSS Electronically Reported Lab Result N Mean Median 343 0.19 0 12 0 0 150 0.41 0 2802 0.08 0 36 0.31 0 40 0.45 0 677 0.39 0 Examples of variable messages • Results in NTE segments • Specimen source in test name/NTE segment MSH|^~\&|RD|LABONE^99X9999999^CLIA|XXDOH|XX|20041104085821||ORU^R01|20041104085821178492|P|2.3.1 PID|1||200||LASTNAME^FIRSTNAME||19870728|F||U|||^^^^^^ NK1|1||||^^^^^^ ORC|||||||||||||||||||||Childrens Hsp and Hlth Ctr|3020 Childrens Way^^San Diego^CA^92123-4282|^^^^^858^9665940 OBR|1||W40624236|^^^81094^Chlamydia/gonorrhoeae Amplified DNA^L|||200411020854|||||||200411030910|^^URINE|^GRAN2 GRAFF NANCY R MD|^^^^^^|||||200411032045|||F OBX|1|CE|^^^21715^Specimen Source^L||^^||||||F|||20041103084500|99X9999999^LABONE^CLIA||^Strand Displacement Amplification (SDA) NTE|1||URINE OBX|2|CE|^^^81094^Result^L||L-22201^^||||||F|||20041103084500|99X9999999^LABONE^CLIA||^Strand Displacement Amplification (SDA) NTE|1||POSITIVE for CHLAMYDIA TRACHOMATIS NTE|2||REPORTABLE DISEASE NTE|3||Negative for NEISSERIA GONORRHOEAE OBX|3|CE|^^^21716^Special Information^L||^^DNR||||||F|||20041103084500|99X9999999^LABONE^CLIA||^Strand Displacement Amplificati on (SDA) OBX|4|CE|^^^21717^Report Status^L||^^||||||F|||20041103084500|99X9999999^LABONE^CLIA||^Strand Displacement Amplification (SDA) NTE|1||FINAL 11032004 ARUP Labs Translation Maintenance Code Maps HIV Program Background • The goal of the Michigan Disease Surveillance System (MDSS) is to develop a Public Health Information Network (PHIN) compliant disease information system that implements a NEDSS based logical data model in support of the Michigan Department of Community Health (MDCH) public health surveillance system. • The MDSS has been operational since June 13, 2004, • The system was created with JAVA, HTML, JavaScript, JSP, XML, Oracle Database, CVS, Kodo JDO, Jasper reports, Ant, and HL7. • The system currently has over 900 users in state and local public health as well as healthcare provider and laboratory roles. • MDSS receives disease reports through manual entry, on-line web submission of case referral/intake reports, and importation of HL7 (Health Level 7, an American National Standards Organization approved standards developing organization) laboratory reports (HL7 laboratory reports are in the standard HL7 V2.3 format and include lab test results). • The demographic data contained in each potential case is de-duplicated to ensure the system contains a set of unique patient demographics. • MDSS geocodes all encountered addresses. Geographical Information Systems (GIS) mapping is integrated into case display and summary report screens. Disease Group Foodborne Meningitis Other STD VPD Vectorborne Viral Hepatitis Std Dev 0.85 0 0.81 0.66 1.83 1.08 3.36 Changes requested of MDSS software vendor: The MDSS was designed to receive an electronic laboratory message in the HL7 2.3.z format, however it was discovered that the application was coded to map only fields that were being sent by our state laboratory (MDCH Bureau of Laboratories). To accept messages from other laboratories and gather all of the relevant information, we asked the software vendor to process several additional fields from an HL7 2.3.z message. These fields included: • Race • Ethnicity • Home phone number • Business Phone number • Parent/Guardian information • Units value Changes requested of the Submitting Laboratory: We also worked with the MDCH Bureau of Laboratories and the LIMS software vendor to modify the format of the HL7 messages they were sending. These changes included: • Format of the specimen source and body site fields • Improved format and inclusion of data from Ordering Provider and Facility Name fields • Test Comments to appear in NTE segments instead of multiple OBX segments • Include outbreak name if available • Include race if available • Include ethnicity if available • Include negative tests and results for specimens with an associated positive test (e.g. chlamydia and gonorrhea assays) Conclusion The development of the MDSS and implementation of ELR requires successful collaboration on many levels. The number of partners and their varied abilities has made the transition to electronic laboratory reporting a lengthy process to date. Improvements in the MDSS and advancements in adherence to accepted standards have gone a long way toward improving the timeliness of this transition. Implementation of Orion Rhapsody/Symphonia and its ability to accept varying formats of electronic laboratory data will facilitate the incorporation of additional laboratories and open the door to the inclusion of smaller reference laboratories and hospital clinical laboratories. Manually Entered Lab Result by Submitting Lab Disease Group N Mean Median Std Dev Other 22 1.18 0 1.68 STD 1545 1.03 0 1.94 VPD 1 0 0 -Vectorborne 5 0.6 0 0.89 Viral Hepatitis 724 1.67 1 2.46 Other Manually Entered Laboratory Result Disease Group N Mean Median Std Dev Foodborne 788 2.63 1 5.64 Meningitis 305 4.46 2 10.04 Other 176 3.99 1 6.93 STD 3727 10.47 6 11.51 VPD 54 3.17 1 5.31 Vectorborne 32 3.55 0 8.21 Viral Hepatitis 1284 5.83 1 12.43 Occupation Outbreak name Reference range Abnormal flag/susceptibility result • Test comments • • • • Contact Information Brad Carlson, MPH Surveillance Systems Coordinator Michigan Department of Community Health Surveillance Systems Section 1151 Taylor, Room 211 B Detroit, MI 48202 Phone: (313) 870-2735 carlsonbr@michigan.gov Gwen Thompson, MPH Senior Policy Analyst Altarum Institute 3520 Green Court, Suite 300 Ann Arbor, MI 48105 Phone: (734) 302-4623 gwen.thompson@altarum.org AFTER • Reference range in middle of NTE segments • Structured numeric result formatted incorrectly MSH|^~\&|COHORT|MDCH REGIONAL LAB - LANSING^23D0650909^CLIA|NEDSS||20060810073022||ORU^R01|30529|D|2.2|| PID||926477^^^516^^^516|011954^^^516^^^516||A^PATIENT||19730101|F||B||||||||||||N OBR|1||M06GP014472|670^RNA AMPLIFICATION ASSAY^EPIC|||20060804|20060810||||||20060809|CVX&CERVIX^^^T-83200&UTERINE CERVIX&SNM| ||||M06GP014472||20060810|||F||^^^^^ROUTINE||||||| ZLR||PLANNED PARENTHOOD OF MID-MICHIGAN-YPSILANTI|840 MAUS AVENUE^^YPSILANTI^MI^48198^^^^MI161 ||^33^Y||||||||||||||||3350 N. Martin Luther King,Jr. Blvd., PO Box 30035^^LANSING^MI^48909| OBX|1|CE|21190-4^CHLAMYDIA TRACHOMATIS DNA^LN_2.09^3010,3020,3050^GENUS (BACT),SPECIES (BACT),PHAGETYPE (BACT)^EPIC||L-2A901^Chlamydia trachomatis^SNM^3010.101,3020.315, 3050.104^Chlamydia,trachomatis,RNA DETECTED^EPIC||||||F||||| OBX|2|CE|24111-7^NEISSERIA GONORRHOEAE DNA^LN_2.09^3010,3020,3050^GENUS (BACT),SPECIES (BACT),PHAGETYPE (BACT)^EPIC||L-10001^No Organism found^SNM^3010.23,3020.54,3050.1 05^Neisseria,gonorrhoeae,RNA NOT DETECTED^EPIC||||||F||||| OBX|3|FT|^3100^TEST COMMENT (BACT)^EPIC||^^^1^See note^EPIC||||||||||| NTE|1||Test results obtained using Transcription-Mediated Amplification. For NTE|2||medical/legal concerns, culture is still the accepted specimen testing NTE|3||standard. NTE|4||C. trachomatis and/or N. gonorrhoeae organism viability and/or infectivity NTE|5||cannot be inferred since target RNA may persist in the absence of viabl e NTE|6||organisms. NTE|7||A negative result does not preclude C. trachomatis and/or N. gonorrhoea e NTE|8||infection because results are dependent on adequate specimen collection . MDSS Users by Role 1000 911 900 800 700 831 Average Time from Lab Report Date to Referral into the MDSS 12 10 MSH|^~\&|LAB2|LAB2^99X9999999^CLIA|XXDOH|XX|200308230158||ORU^R01|20030823023900891457|P|2.3.1||||||| PID|1||EM-8.5.1^^^^^LABC||LASTNAME^FIRSTNAME||195304101017|F||U|2808 AVE G^^CANTON^OH^44701||^^^^^000^0000000||||||||||||||||| NK1|1|||||||||||||||||||||||||||||||||||| ORC|||||||||||||||||||||CANTON CLINIC, P.C.|211 W. 33RD ST.^^CANTON^OH^44702|^^^^^308^8652141|211 W. 33RD ST.^^CANTON^OH^44702 OBR|1||EM-8.5.1|^^^164020^HSV I/II, IGG/RFX TYPE II IGG^L|||200308131110|||||||200308141057||^ERNST|^^^^^308^8652141||||||||F||||||||||| OBX|1|SN|5209-2^HERPES SIMPLEX VIRUS 2 AB.IGG^LN^163151^HSV II IgG,Type Spec^L||^1.5|Index|0.0-0.8|H|||F|||20030817|99X9999999^LAB2^CLIA||EIA NTE|1|L|Note: Negative indicates no antibodies Negative <0.9 NTE|2|L|detected to HSV-2. Equivocal may Equivocal 0.9-1.0 NTE|3|L|suggest early infection. If clinically Positive >or=1.1 NTE|4|L|appropriate, retest at later date. NTE|5|L|Positive indicates antibodies detected to NTE|6|L|HSV-2; coinfection with HSV 1 cannot be NTE|7|L|excluded. Average number of days (on the left side of card): 8 Number of Users 600 500 400 300 559 579 544 December 2004 December 2005 August 2006 6 440 ELR Manual entry by Lab Manual entry by Other • Ordering provider information populating interface • Test comments sent as text in NTE segments • LOINC test name added to message 4 207 200 116 121 100 0 74 29 1 4 4 0 152 2 LHJ Users MDCH Users Health Care Provider MDSS Role Type Lab Total Foodborne Meningitis Other STD VPD Disease Category Vectorborne Viral Hepatitis Acknowledgements Michigan Department of Community Health: Melinda Wilkins, Sheryl Conway, Corinne Miller; Altarum Institute: Jim Lee, Andrey Yeatts, Liz Ritter