In August, I attended the Public Health Informatics Conference in Atlanta, GA. I attended many great presentations, and one term I heard a lot was “eCR,” which stands for electronic case reporting. eCR essentially means that an electronic health record can send incidents of reportable cases, like certain sexually transmitted infections and other diseases, directly to public health surveillance systems. Electronic case reporting can take the place of the manual reporting methods that we’ve relied on in the past—for example, post cards or faxes for each individual case—which then frees up time and resources.

In this episode, I learn about the Chicago Department of Health’s eCR demonstration project with Dr. Marion Tseng, Health Systems Integration Program (HSIP) Fellow, and her mentor, Cristal Simmons, who is a Senior Epidemiologist. We talked about the challenges of transmitting data electronically when electronic health records and public health surveillance systems don’t have the same data fields, and how informatics plays the role of “translator” between these systems. Cristal and Marion also discussed the importantance of partnerships in this work, as well as the improved data quality and increased efficiency eCR could mean for the Sexually Transmitted Infections (STI) program at their agency.

I am very grateful to Marion and Cristal for informing me (and listeners) about eCR!

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From left to right: Cristal Simmons, Marion Tseng and I at the Public Health Informatics Conference in Atlanta, GA.

INTRO

JESSICA

Public health informatics is the science and the art of taking raw data and turning them into useful information for health policies and programs. It takes all those data out there and turns them into knowledge of how people can live healthier lives. But how does this process work? My name is Jessica Hill, and I work at the Public Health Informatics Institute in Atlanta, Georgia. This podcast is my quest to learn about informatics and how it’s made people’s lives better, how has it made my life better and, really, why does it matter. So I’m ready. Inform Me, Informatics.

Hi, this is Jessica Hill. I recently attended the Public Health Informatics Conference in Atlanta, Georgia. I attended a ton of great presentations and I learned a lot about current happenings in informatics. One term I heard a lot was eCR or electronic case reporting. eCR essentially means that an electronic health record can send incidents of reportable cases directly to a public health surveillance system. No postcards, no faxes. Dr. Marion Tseng from the Chicago Department of Health gave a presentation about a pilot project she conducted around electronic case reporting, and I thought it was really interesting. So interesting, in fact, that I went to her after the presentation and asked if she’d be willing to sit down with me and record a podcast. I’m very grateful that Marion said yes, and her mentor, senior epidemiologist Cristal Simmons, also agreed to be a guest. Before we dive in further, I want to share some terms with you that you’ll hear throughout the discussion. So eCR, that stands for electronic case reporting. That’s what this demonstration project was about. This specific type of reporting was for STIs or sexually transmitted infections. That term is used pretty much interchangeably with STDs, sexually transmitted diseases. You’ll also hear us talk about EHRs. That’s electronic health records.

You should also know that I-NEDSS is an acronym for the Illinois’ National Electronic Disease Surveillance System. So that’s the specific system that the State of Illinois uses to track reportable diseases including the STIs as chlamydia and gonorrhea. Finally, the Chicago Department of Public Health partnered with the Alliance of Chicago, which is a network of community health centers. Alliance of Chicago supports essentially hosted EHR systems for users in 10 community health centers in that city, as well as others nationwide. In 2014, these 10 clinics reported over 10% of the chlamydia and gonorrhea cases in the city for that year. So this demonstration project was conducted with one such clinic which reports about 10 to 11 cases per week. Oh, one more thing. Marion’s position is funded by a fellowship called the Health Systems Integration Program, or the HSIP fellowship, which is administered through a partnership between CDC, CSTE, and NATO. One note on the audio quality. We realized this interview may sound like it’s happening in a tunnel, but it’s just that the air conditioning in the room where we recorded impacted the sound quality. Our apologies, and we hope it’s not too distracting. Cristal started the conversation by explaining the background for why her department was interested in eCR?

CRISTAL

Well, first of all, we chose gonorrhea and chlamydia because those are the two conditions that have the highest morbidity in the city of Chicago, or reportable conditions. The way our system works, for a case to be reported, it needs a laboratory report and a case report. And the case reports… And this is something that Marion discussed in her presentation. Traditionally, the case reports come in as pieces of paper that the practitioner or the healthcare provider, or even a clerk will fill out. And it gives the demographics about that particular case. They fill out a piece of paper, and they send it to the Chicago Department of Public Health, our surveillance unit. And because we have maybe 40,000 cases of gonorrhea and chlamydia a year, you can imagine that that’s 40,000 pieces of paper that our staff, and at this point, I believe we have maybe five or six people, have to manually type that into the I-NEDSS system.

JESSICA

And is that happening right now?

CRISTAL

That’s happening right now.

JESSICA

The 40,000 pieces of paper? Wow.

CRISTAL

Exactly. And we are traditionally backlogged by six months. So what that means is that we are six months behind in understanding the morbidity of gonorrhea and chlamydia in the city of Chicago. What we wanted was a way to improve that to get that record into our hands faster. And we knew that if the data can come in electronically, that would be a faster way. One, it would get the data in faster, but also it would reduce the amount of paper that our staff have to enter in. And they can save that time to enter in paper from the smaller clinics that don’t have the capacity to send it in electronically. So that was the background. We also were just interested in informatics programs or projects that would enhance the capacity of the I-NEDSS system.

JESSICA

And when you say I-NEDSS, could you let me know what that is?

CRISTAL

Yes, I’m sorry. So I-NEDSS is the State of Illinois’ Surveillance System. So that’s what we use, the City of Chicago, we use that to manage our surveillance data. So we have a partnership with the Illinois Department of Public Health. The project really enhanced our staff’s workflow, but it also provided an opportunity for the State of Illinois to improve their electronic system, to add additional functionality to their electronic system. So that was some of the thoughts behind why we wanted to develop this project in the first place. It also was a value add for the Alliance because they would be able to offer this additional service to their clients, which are the federally qualified health centers. Because then they could say to their clients, “If you use our electronic system, you will no longer have to complete those pieces of paper. Those reports will go electronically to the health department, and that’s one less step that you have to do, thus improving your functionality and your efficiency.”

JESSICA

Next, Marion told us how she made the project happen.

MARION

I was very happy to be able to work on this project because I think, really, health systems integration is really collaboration between primary care services and public health practice. And this project is the perfect example that this idea is realized in the current world. So for our eCR project, we developed and built an application which sits on Alliance of Chicago’s electronic health record system database. And what this application does is it screens cases within the EHR database with laboratory-test-positive chlamydia and gonorrhea cases every day. And this application will extract the information that’s required by the public health departments, and then send these electronic case reports to the I-NEDSS system we use at the public health department.

JESSICA

So when you say you built an application that sits on the EHR, did that mean having to work with the EHR vendor to actually write the application?

MARION

So for this project, we work with the Alliance of Chicago, and we also work with a software developer who’s our technical consultant on this project. And they are really the people who write the codes and build the application and sets on the database. So we quickly learned through the process that EHR data fields are not created equal to public health reporting data fields. And so some of the fields are more straightforward, such as date of birth, or gender, or sex. Some of the challenges we encounter, for example, are pregnancy status. There was no such pregnancy status field in the EHR. So we had to write in logic statements to determine the pregnancy status of this patient.

JESSICA

For this project, the City of Chicago Department of Health served in a kind of translator role between the clinics’ EHR, the city’s STI program, and the state surveillance system. The idea is that whenever a case of chlamydia or gonorrhea was documented in the EHR, then the eCR application would send this information directly to the state surveillance system. The city also uses that surveillance system to follow up on specific cases. However, as Marion is describing the fields in the EHR and the fields in the state system didn’t always match up. They didn’t map one-to-one. So the team had to work to find those discrepancies and then modify the eCR app to account for them and enable the data to be electronically transferred. I asked Marion to describe a specific example of this informatics as a translator role.

MARION

The application return medication from a section within the EHR called Medication List. And then there’s a field in the public health reporting form is asking the treatment date. So at first, this application looks at the medication start date. That’s in this Medication List section within the EHR. However, we quickly learned that, well, sometimes provider prescribe refills for some of the cases. And for these cases that receive refills in their EHR, on the Medication List, the medication start date happened in the past. And because this patient may have multiple chlamydia or gonorrhea infection incidents throughout the years. So we decided to tweak this application so that, currently, the application will look at not only the start date in the medication list section, but it will also look at a prescription date that will contain the most recent prescription that’s received by this patient. So then we learned that, in order to develop this application to be able to return the most current and correct information from EHR, we have to understand fully how the EHR users use their system and their clinical workflow.

JESSICA

And that was just one example of the kind of mapping Marion and her team needed to do in order for the data to be sent from the EHR directly to the State’s I-NEDSS surveillance system. This process was repeated over and over and over until the I-NEDSS system successfully received all the necessary data for each case of chlamydia and gonorrhea. Cristal also explained that, in some cases, the state was willing to modify its own system to accommodate the data sent by the eCR. After the team built the application, then they needed to test to see, well, is this working? They needed to know if the data captured through eCR were the same or different than data captured through the regular paper-based reporting process. So they put together an evaluation plan. Marion explained the evaluation approach and evaluation findings.

MARION

So in order to assess the data quality, we look at three variables in the case reports. So we look at the treatment information, race, and ethnicity. And we look at the completeness of these three fields among the case reports. So in this evaluation process, we look at 510 cases that were reported from health center A where we tested this application for. And for these 510 cases, we compared two sets of different reports. The first set was the electronic case report that’s generated by this application pulled directly from these 510 cases’ EHR. And then we also look at the same 510 cases. We look at their closed surveillance reports that’s in our surveillance system, in the I-NEDSS system. What we found out, first of all, for the treatment information field, for the reports that’s pulled by the eCR, I think it’s around 20% of them had incomplete treatment information. And in contrast, when we look at reports in the I-NEDSS system, which are reported through the traditional methods, over 70% of them had incomplete treatment information.

JESSICA

Were the findings similar for the other fields of race and ethnicity?

MARION

Yeah, so for race and ethnicity, the numbers are even higher than what we saw in the treatment information. So when we were comparing these two sets of reports, one is directly pulled by the eCR application through the patient’s EHR, and the other is the traditionally submitted and completed surveillance reports in I-NEDSS. And we found out that among these 510 cases, in the traditional surveillance reports that’s in I-NEDSS, around half of them had no race and ethnicity information. But then, in contrast to the reports that’s pulled by the eCR application, only about roughly 0.1% of them had no race or ethnicity information. So, again, that’s another example that eCR definitely will improve the data quality of the surveillance reports.

CRISTAL

This was really a true collaboration of the Health Department and our state counterpart as well as the Alliance. We also pulled in our STI Program. And we were just really working to make this happen. I’m very happy with the collaboration. There were a few issues that we had to wrestle with, but it was a good wrestle. And we really worked hard to make sure we came up with a product that was very robust. We had a great technical partner, very interested in expanding it to other, not only just other health centers, but other disease groups, perhaps hepatitis. So there’s opportunity for this to go beyond just the STD disease groups. So we’re just excited about just all of the possibilities for this.

JESSICA

Do you think that, eventually, all reportable cases for STIs will come electronically?

CRISTAL

We’re hoping to pull syphilis in too. There’s another opportunity for syphilis. In the back of my mind, I’m thinking about it. We’re not ready to put it out there yet. Syphilis is so complicated that we would rather work on hepatitis first. But, you know, we think that maybe syphilis might come through, yes.

JESSICA

Do you think your STI project will be able to use this more timely and more complete data to inform their outreach efforts for either prevention or public health messaging?

CRISTAL

That’s what I hope. Yeah, yeah. Once we can just ingrain it into our surveillance activities, because our systems are linked and, in fact, we’re developing another system that will pull in surveillance and case management data. That’s another project that informatics is working on, case reports coming in, it will then be available to our other HIV and STI case management staff as well. So it’s all one big web. So that’s one of our hopes, that they’ll be able to utilize that data too.

JESSICA

What are the next steps for the health department based on this project?

CRISTAL

Okay, during this project, we were actually working with our STD program because we have to help them change or adapt their workflow to make sure that they are ready to receive these results electronically. They are very familiar with going into I-NEDSS to retrieve electronic lab data. But the fact that now they won’t be receiving paper… Or they’re used to type it in the data, but now a case report will be coming in electronically. So when we started this project and, you know, we were telling them about it, I told them, you know, I went through the workflow, and it opened their eyes about some changes that they will have to do to the workflow. So before we decide to go live, and we’re ready, we feel confident with the data quality, we feel confident that everything is working, but I don’t want to turn it on until… We don’t want to make that, “Okay, send it to production,” until we actually go back to our staff and review this process with them, make sure they are ready and understand the changes to the workflow, to see if they’ve accommodated it, if they make changes to what they do. Because we don’t want this data to sit in the EMR…I mean, in the I-NEDSS system, and they’re not aware. So that’s the next step, really, to make sure that they are aware of a project, to see if they’ve adjusted their workflow and are ready for it. Because that’s the other role of informatics. We spend a lot of time going through workflows because it’s one thing to develop the system and the system will work and it’s beautiful, but if the health department won’t use it, then it’s a waste of time.

JESSICA

Thanks again to Cristal Simmons and Marion Tseng from the Chicago Department of Health for taking the time to speak with me while we were still at the Public Health Informatics Conference. Thank you. I know time is super valuable, but I learned a lot about eCR through this story, and I’m so grateful you were willing to share it with us on the podcast.

This podcast is a project of the Public Health Informatics Institute and the Informatics Academy. Wanna learn more? Check us out at phii.org. You can also find us on Facebook or follow us on Twitter, @phinformatics. Our theme music is called Carnivale Intrigue and was composed by Kevin Macleod. Finally, many thanks to our production team, especially Kyle Dix (welcome to the team, Kyle!) and Piper Hale, our producer and editor extraordinaire. I’m Jessica Hill and you’ve been informed.

BUTTON

JESSICA

That’s a smash.

PIPER

That’s a smash.

[LAUGHTER]

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