2003 Model Practice Application (Public)

Communicable Disease Prevention/Public Health Preparedness

Kansas City Health Department

Building strong public-private partnerships is becoming increasingly important in public health and is often essential for enhancing many public health initiatives. In 2002, the Kansas City (Missouri) Health Department (KCHD) collaborated with Cerner Corporation to develop and implement an automated electronic communicable disease reporting system, known as HealthSentry™. This system captures laboratory and physician ordering information from 22 metropolitan area healthcare systems, standardizes the data, and delivers reports to KCHD daily. HealthSentry can also alert health department staff by pager if potential agents of bioterrorism have been found. A benefits analysis of the first six months of data found significant improvements in the timeliness and completeness of disease reports, compared to conventional reporting mechanisms. HealthSentry also identified areas of considerable underreporting.

Successful partnerships between KCHD, Cerner, other local and state health departments, and the contributing laboratories are key to the continuing success of HealthSentry. Heightened concerns about bioterrorism and newly emerging pathogens have forced public health organizations to re-evaluate the methods presently used to report diseases. Currently, most healthcare providers and laboratories notify public health by telephone, fax, or mail. Timeliness and completeness of reporting vary widely between reporting sites and can impair the ability to detect or respond to a large outbreak or bioterrorist event. Underreporting is another major concern with traditional disease surveillance strategies; even severe diseases can sometimes go unreported. HealthSentry was developed to help meet the challenge of linking public health organizations to reliable clinical data without burdensome manual data collection and reporting.

The city of Kansas City, Missouri, is located on the Missouri-Kansas border and serves a diverse population from both sides of the state line. Within the six-county, bi-state area, there are 22 acute-care hospitals, two regional reference laboratories, and eight local health departments. The multi-jurisdictional nature of Kansas City often poses challenges for these local health departments in conducting communicable disease surveillance activities. Since KCHD is the largest health department in the area and the majority of the hospitals are located within the city limits, it often acts as a centralized reporting site as well as the "clearinghouse" for the majority of the communicable disease reports for the metropolitan area. Reports received by KCHD are sorted and forwarded to the appropriate jurisdiction for investigation. Receiving well over 40,000 disease reports annually, KCHD found conventional reporting mechanisms were becoming too cumbersome, and the department desired more timely and accurate reporting. This could be provided by HealthSentry.

Data from clinical laboratories in the Kansas City area are uploaded via a virtual private network (VPN) to the HealthSentry data warehouse every night.. Automated processes at the data warehouse map results to a common nomenclature, de-duplicate the data, and conduct error checking. Incoming data are automatically monitored to determine whether a result warrants alerting public health officials. A single case of plague coming into the system would trigger alerts to the appropriate public health officials. After processing, two summary reports are delivered to KCHD through a VPN. One report provides trending information on orderable procedures (non-patient identifiable) and the other report includes results from microbiology tests (includes patient demographic information). GIS maps using ARC-IMS showing the zip codes of residence of patients with reportable isolates are delivered to KCHD via the same VPN secure internet connection.

KCHD has a long history of successful collaborations with a variety of community agencies, both public and private, that have resulted in metro-wide public health initiatives. Shortly after the anthrax events in fall 2001, KCHD’s Health Director, along with the CEO of Cerner Corporation, began discussions on ways to more effectively link health care providers with public health. HealthSentry was planned, developed, and executed in Kansas City within three months and has been a tremendous success.

The HealthSentry system consists of three groups of participants – the healthcare providers and laboratories (data contributors), the HealthSentry clearinghouse, and the public health organizations. Four non-affiliated healthcare organizations of varying size participate in the system. The participating Kansas City metropolitan area laboratories use the Cerner PathNet® Laboratory Information System (LIS) (Cerner Corporation, Kansas City, Missouri) to document clinical microbiology results and provide daily laboratory orders and results electronically to Cerner for automated cleansing, de-duplication, standardization, and error checking. The resulting data are delivered daily to the Kansas City Health Department. Participating healthcare organizations also have the option to receive the summary reports for their facility to assist with internal disease surveillance issues. To date, more than two million patient encounters have been processed and filtered by HealthSentry for reportable disease analysis and trending.

The HealthSentry implementation in Kansas City began in January 2002. Meetings between Cerner, KCHD, and local health care providers were conducted to establish the framework for the system. The clinical sites participating in HealthSentry are diverse, representing publicly and privately owned organizations, including urban and suburban hospitals of all sizes. Large core labs that serve as reference labs to physician offices and clinics are key participants. HealthSentry involved legal agreements, technical implementation, installation, and training.

For some time, KCHD has been exploring methods of electronic laboratory reporting (ELR) to enhance its disease surveillance activities. Three ELR technical approaches are currently available, and each has associated costs and maintenance requirements. The “local message” approach requires each healthcare provider to standardize, filter, and de-duplicate the data before sending it to public health. This can entail a significant amount of technical support and staff time from both the healthcare provider and public health agency and must be continually updated. The “public health translation” approach requires the installation of message translation software at public health facilities. This approach places the burden of effort on public health organizations and requires them to make new investments in technology and personnel. The “data clearinghouse” approach involves an intermediary organization (i.e., Cerner Corporation) that receives, cleanses, and aggregates the data and distributes standardized reports to public health. KCHD chose last option, which takes the technical burden off both the healthcare provider and public health agency.

As a Kansas City-based company, Cerner felt it was of great importance to assist with bioterrorism preparedness and disease prevention initiatives within its local community. KCHD entered into a partnership with Cerner to help develop, pilot test, and refine HealthSentry. Cerner paid for all HealthSentry developmental and supplemental costs. Additionally, KCHD and the contributing healthcare facilities will receive HealthSentry free of charge through 2007. Additional public health agencies are using various grant funds to implement HealthSentry in their respective cities and/or states.

A benefits analysis of the first six months of data was evaluated and found significant improvements in the timeliness and completeness of disease reports compared to conventional reporting mechanisms. As of September 30, 2002, results from 526,058 patients were reviewed by the system, with 948,842 unique clinical encounters. Patients whose results were reviewed by the system reside in a large region, encompassing much of Missouri and Kansas, as well as parts of Iowa and Nebraska. Patients whose data was reviewed by HealthSentry for reportable events represent the diverse population of Kansas City.

Reports received through both conventional and electronic reporting between March 29, 2002 and September 2, 2002 were evaluated for data completeness and timeliness. No changes on the part of the health care providers that would optimize the electronic reporting were requested. Disease reporting in Kansas City, Missouri, requires that public health officials know the name of the testing facility and the age, date of birth, race, sex, address, and telephone number of the patient. Upon receipt of the initial conventional or electronic report, KCHD documented whether each of these required data elements was provided and documented the date on which conventional reports were received. Timeliness was determined by comparing this date with the date on which a reportable pathogen was first posted to the HealthSentry system.

During the early stages of this work, a few confounding issues that reflect the challenges of semi-discrete reporting were identified. These provided an opportunity for greater communication between KCHD, the contributing laboratories, and Cerner to work toward the most efficient solution.

For example, a laboratory technician entered a report with the word "No" on one line, followed by "Bordetella pertussis" on the next line, with the intent of negating the positive result. This type of data-entry error led to a few false-positives propagating into the HealthSentry clearinghouse during the first few weeks of operation and has been an issue for other electronic reporting systems. After this issue was recognized, context-sensitive logic was added, in which a reportable isolate preceded by "No" or "Not" was flagged as a potential false positive by the system. Such reports were shaded to clearly distinguish them from true positives.

Nonetheless, other false positive scenarios reflecting incorrect usage of the LIS were identified that do not lend themselves to clear context sensitive logic. As a further solution to false positive issues, KCHD now receives the full text of microbiology reports. Review of these reports allows public health officials to verify a result without contacting the health providers and often provides additional useful contextual information for the isolate report (i.e., colony counts, serotyping information).

Both of these situations further underscored the importance of strong collaboration between all parties involved. Without commitment, open communication, cooperation, and interaction among all public and private participants, HealthSentry would not have been such a success. Though some challenges were identified, KCHD found that the data clearinghouse approach to ELR offers many benefits, including ease and speed of implementation for the healthcare providers and public health as well as improved timeliness and completeness of the data received.

KCHD found that it worked best to have a dedicated epidemiologist or disease investigator assigned to monitor and process the daily reports from HealthSentry. This allowed for easier tracking of trends and a consistent method of capturing the data necessary for evaluation. An additional two to three individuals cross-trained in the use of HealthSentry were necessary to offer back-up support when the workload was extremely heavy or when the dedicated staff member was on vacation or out on sick leave.

It was also essential to have appropriate, internal information technology (IT) support to deal with internal firewall issues so that VPN connections could work properly. Though Cerner Corporation was able to troubleshoot and resolve issues specific to HealthSentry, KCHD had to rely on its own IT staff to deal with internal network issues.

All end-users of the system needed training the tools utilized by HealthSentry. However, the reporting applications (Business Objects and ArcIMS) provided are fairly simple to use and require limited technical skill.