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$: eCR Now...Public Health Informatics is the application o\൦ informatics in areas of public health, including surveillance, reporting, and health promotion. Public health informatics,$
eCR NowA Webinar Describing the Effort to Scale Electronic Case Reporting (eCR) Nationwide for COVID-19

April 28, 2020

Presenter

Presentation Notes

Electronic Case Reporting (eCR) is the automated generation and transmission of case reports from electronic health records (EHRs) to public health agency surveillance systems. The value of eCR is several fold, including more complete, accurate data in near real-time for case management, contact tracing, situational awareness and reporting, connecting with lab results, as well as helping to coordinate isolation and other response measures.

PresentersJohn W. Loonsk, MD, FACMI Adjunct Associate Professor, Johns

Hopkins Bloomberg School of Public Health & Consulting Chief Medical Informatics Officer, Association of Public Health Laboratories

Laura A. Conn, MPH eCR lead, Public Health Informatics Office, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention

Steven R. Lane, MD, MPH, FAAFP Clinical Informatics Director, Privacy, Information Security & Interoperability Sutter Health, Clinical Professor, Family & Community Medicine University of California San Francisco

Catherine Staes, RN, MPH, PhD, FACMI Professor & Director, Nursing Informatics, College of Nursing, University of Utah

Presenter

Presentation Notes

This presentation will focus on eCR as part of AMIA's COVID-19 Webinar Series and explore the “eCR Now” initiative to rapidly deploy eCR capability for COVID-19. Presenters will discuss the informatics opportunities and challenges with implementation of eCR and discuss ways, among other things, that FHIR and CDA technology standards and eHealth Exchange and Carequality policy frameworks can be leveraged to provide eCR functionality across various EHRs nationwide.

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Health Informatics is the science of how to use data, information, and knowledge to improve human health, including the execution of scientific research, the delivery of health care services, and the promotion of public

health. AMIA is the multi-disciplinary, inter-professional home for 5,400+ health informatics experts.

AMIA | COVID-19 Webinar Series | Public Health Informatics

Presenter

Presentation Notes

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Working Groups of AMIA

AMIA

Clinical Research

Translational Bioinformatics

Clinical Informatics

Public Health Informatics

Consumer Informatics

Intensive Care InformaticsKnowledge Discovery and Data

MiningKnowledge Representation and

SemanticsNursing Informatics

Open SourceStudent

PharmacoinformaticsPrimary Care Informatics Public Health Informatics

Regional Informatics ActionVisual Analytics

Natural Language Processing

Biomedical Imaging InformaticsClinical Decision SupportClinical Information SystemsClinical Research InformaticsConsumer and Pervasive Health InformaticsDental InformaticsEducation EvaluationBioinformaticsEthical, Legal and Social IssuesGenomics and Translational Global Health InformaticsPeople and Organizational Issues

AMIA | COVID-19 Webinar Series | Public Health Informatics 4

Presenter

Presentation Notes

AMIA members advance health and wellness by implementing and evaluating informatics interventions, innovations, and public policy across settings and patient populations, adding to our collective understanding of health in the 21st century through peer-reviewed journals and scientific meetings.

The Globe of Health Informatics & COVID-19

5AMIA | COVID-19 Webinar Series | Public Health Informatics

10-9 10-6 10-3 100 103 106 109

DNASmall

Molecules Disease Patient Practice Population Global

TBI

Clinical

Public Health

Consumer Health

CRI

Analysis of Coronavirus

Development of Therapeutics and symptom identification

Treatment of patients via EHRs & Information Exchange

Tools for contact tracing and for study of transmission

Presenter

Presentation Notes

One way to think about informatics is through scales. We tend to think of patients as an n of 1 or 10 to the 0 power. Practices are usually measured in panels of a thousand, populations are in the millions, and globally we’re talking billions of patients. On the other end of the scale, we have thousands of diseases, millions of small molecules and billions of lines of DNA. When we apply the scope of health informatics to this scale, it helps articulate the various, overlapping boundaries of the five main areas of informatics: TBI professionals use informatics tools and methods that link biological entities (genes, proteins, and small molecules) to clinical entities (diseases, symptoms, and drugs)—or vice versa. CRI professionals leverage IT and data systems to manage information related to clinical trials and also involves informatics related to secondary research use of clinical data. Clinical informatics experts focus primarily on information systems that impact patient care and manage information related to their diseases and symptoms – and they do so at the practice level. Public Health Informatics is the application of informatics in areas of public health, including surveillance, reporting, and health promotion. Public health informatics, and its corollary, population informatics, are concerned with groups rather than individuals. Consumer informatics professionals analyze consumers' needs for information; studies and implements methods for making information accessible to consumers; and models and integrates consumers' preferences into health information systems. Finally, we can also think about policies on this scale: And perhaps the policy response to the coronavirus best exemplifies why the globe of health informatics is so important. Across all scales from genomic to disease to patients/consumers, practices, populations and the entire globe, informatics and AMIA members have a role to play. This background on AMIA and the informatics community is the impetus behind our….

To highlight how our members and the broader informatics community is addressing this global pandemic we are launching the AMIA COVID-19 Webinar Series.We will look at the pandemic through a health informatics lens and is designed to share informatics responses to the COVID-19 pandemic. Panelists will share their specific domain expertise, including clinical informatics, public health informatics, translational bioinformatics, clinical research informatics, and consumer health informatics. We will also have special emphasis webinars covering topics related to global health, telemedicine, and public policy during the COVID-19 pandemic. These webinars are open to all at no cost.

Presenter

Presentation Notes

From front-line informaticians and public health informaticists, to clinical and bioinformatics researchers, AMIA's members are uniquely positioned to leverage data and evidence in the fight against COVID-19. Panelists will share their specific domain expertise, including clinical informatics, public health informatics, translational bioinformatics, clinical research informatics, and consumer health informatics. We will also have special emphasis webinars covering topics related to global health, telemedicine, and public policy during the COVID-19 pandemic. The first webinar of the AMIA COVID-19 Webinar Series will be an overview of Public Health Informatics issues, including shifts in the regulatory landscape and new legislation developed by the US Congress. We will focus on the key health informatics policy issues to watch and discuss additional steps that may be needed to address this ongoing epidemic.

● Several additional webinars are being planned to highlight members of AMIA and the wider informatics community

● Visit AMIA.org/COVID19

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https://www.amia.org/covid19

John W. Loonsk MD, FACMIConsulting Chief Medical Informatics Officer, Association of Public Health Laboratories

Adjunct Associate Professor, Johns Hopkins Bloomberg School of Public Health

Agenda

• Introduction• Electronic Case Reporting (eCR) and COVID-19• How eCR works• eCR Now

• eCR Now Element #1 Rapid Implementation of COVID eCR• eCR Now Element #2 HL7 FHIR App• eCR Now Element #3 Trust Frameworks

• COVID eCR evaluation opportunities• Questions and Answers


cdc.gov/coronavirus

eCR Now: A Webinar Describing the Scaling of Electronic Case Reporting (eCR) Nationwide

Laura A. Conn, MPHeCR Lead, Health Scientist, CSELS, CDC

American Medical Informatics Association (AMIA)COVID-19 Webinar Series

April 28, 2020

Introduction

COVID-19 is now a reportable condition in all jurisdictions With widespread community transmission of the virus, SARS-

CoV-2, reporting individual cases to public health is challenging Need for Health IT tools to

– Decrease provider and healthcare facility burden in reporting– Improve case-based surveillance for state, regional, and federal

situational awareness

What is Electronic Case Reporting (eCR)?

The automated generation and transmission of case reports from electronic health records (EHRs) to

public health agencies for review and action

Value of Electronic Case Reporting (eCR)

Automatic, complete, accurate

data in real-time

Supports reporting and situational

awareness, case management, contact tracking, connecting

lab results, and coordinating isolation

and other response actions

Diminishes healthcare provider burden and

meets public health needs

Healthcare receives information back

from public health

eCR Incubated by Digital Bridge

Digital Bridge is a collaborative of healthcare, public health and HIT industry partners to solve information exchange challenges

– Goal: To ensure our nation’s health through a bidirectional information flow between health care and public health

An incubator, cultivating projects that meet the goal of effective information sharing First project: advance a nationally scalable, multi-jurisdictional approach

to electronic case reporting (eCR)– Initial implementation successful at small number of sites– Transitioned for operations to CDC, APHL and CSTE in Summer 2019

Current Implementers

Texas Utah NYC & NY State

California Multi-State

19 State/Local Public Health Agencies

https://www.eclinicalworks.com/wp-content/uploads/2014/12/nyc-health-logo.png

eCR for COVID-19

Rapidly expanded to include COVID codes and use existing infrastructure used for routine public health reporting

Over 130,000 case reports identified and sent from seven eCR implementations since January 27, 2020

Confirmed cases have been identified from case reports Receipt of electronic case reports confirmed faster and more complete

than manual reporting and Electronic Laboratory Reports

Electronic case reporting (eCR)The automated identification of reportable health events in electronic health records and

their transmission to state and local public health authorities

for review and action.


eCR - an Informatics Problem for the Ages

1. Public health “reporting burden”2. “Public health is a black hole for data”3. Variable state reporting laws and conditions4. States will not accept data except as specified by law5. EHRs want a single interface6. Individual disease program funding lines7. Connecting lab and epidemiologic data8. Case definitions change during outbreaks9. Public health agency roles change during public heath emergencies10.Poor public heath funding interspersed with boluses that must be

spent immediatelyAMIA | COVID-19 Webinar Series | Public Health

Informatics 18

Setup

Provider(EHR)Provider

(EHR)Provider(EHR)Provider

(EHR)Provider(EHR)

Existing eCR Infrastructure

Public Health Agency

Patient residence


Where care was provided

eICR

RR

eICR

RR

APHL Platform (AIMS)

CSTE / CDC Decision

Support Engine

(RCKMS)Provider(EHR)Provider

(EHR)Provider(EHR)Provider

(EHR)Provider(EHR)

TermsRCKMS - Reportable Conditon Knowledge Management SystemeRSD – Electronic Reporting and Surveillance Distribution System

Possible Policy AgreementseHealth Exchange, APHL participation agreement, and Carequality (*coming)

HL7 StandardseICR - Electronic Initial Case Report CDA v1.1RR - Reportability Response CDA v1.0

eICR

RR

eICR

RR

Health Information Exchange (HIE)

and / oreHealth Exchange / Carequality* Trust

Framework with / or without

DirectTrust

eRSD

Triggering Set-Up


eCR Now• Electronic case reporting (eCR) is a critical tool for COVID-19

and other outbreak management needs• Automated case reporting from EHRs to state and local public health

agencies (PHAs)• Minimizes healthcare provider burden and meets core public health needs• Supports case management, contact tracing, situational awareness and

reporting, connecting lab results, coordinating isolation and other response measures

• Case reporting is a legally requirement in every state and territory

• eCR is operating well now for COVID-19, but there were a limited number EHRs with eCR capabilities when COVID-19 began

• We need more implementations of eCR NowAMIA | COVID-19 Webinar Series | Public Health

Informatics 20

eCR Now Elements

1. Cohort-based COVID-19 rapid eCR implementations for provider sites that have eCR enabled EHRs

2. A new eCR Now FHIR app that non-eCR enabled EHRs can rapidly implement to automate COVID-19 eCR

3. Extension of the existing eHealth Exchange policy framework through a developing Carequality eCR implementation guide


Steven Lane, MD, MPH

Clinical Informatics Director, Privacy, Information Security & InteroperabilitySutter Health

@emrdoc1https://www.linkedin.com/in/steven-lane-md/

https://www.linkedin.com/in/steven-lane-md/

eCR Now -Element #1

Rapid Implementation

Cohorts

Background

• While some EHR vendors had implemented an eCR technical solution, eCR was just moving from Digital Bridge pilots to APHL/CSTE/CDC operational ramp-up when COVID-19 appeared.

• The eCR team worked with Epic to develop an accelerated implementation plan for COVID-19 case reporting. What had previously taken 2-3 months was reduced to 3-4 days.

• There now have been over 130,000 COVID-19 electronic case reports transmitted to public health agencies since the onset of the pandemic.

• We have completed two cohorts of health systems in California and are now moving out of California and to a third.

• Here is how we are doing it…


Approach• Leveraged Epic interoperability Regional User Groups (RUGs)

• History of successful collaboration • Trusting, non-competitive relationships

• Made the case for:• Doing the right thing for community/public health• Reducing clinician and staff burden• Replacing legally required paper-based reporting• Getting information / feedback from public health back into patient’s chart• Saving lives

• Established cohorts of the (many) willing

• Challenged the participants to do eCR Now


Success

• Built on the foundation of original four Digital Bridge pilots

• Developed a culture of cooperative collaboration

• Held daily stand-up meetings to address common progress and issues

• Herded cats, celebrated success, invited innovation

• Starting our third cohort now; a fourth is planned

• Established the Sutter Health Challenge - a bottle of fine wine for any cohort participant that beats our implementation record!


2/14 1st report

3/14 - 3/16IM triggers lab results and orders

4/7IFH live

4/15 Sutter Health

live

4/17 OCHIN and CCHS live

1/27 IM and HM trigger

Dx/Problems

3/20HM triggers lab results

3/23UC Davis

live

Total case reports by date and new implementation milestones


COVID-19 eCR Reporting Metrics

• Intermountain, UT (since 1/27) – 106, 069

• Houston Methodist, TX (since 1/27) – 13,693

• UC Davis, CA (since 3/23) – 347

• Institute for Family Health, NY (since 4/7) – 140

• Sutter Health, CA (since 4/15) – 8,377 – 8,149 were reportable

• OCHIN, 19 states (since 4/17) – 8,200 – 5,530 were reportable

• Contra Costa Health Services, CA (since 4/17) – 589

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Reports sent to more than one Public Health Agency = 847


COVID-19 eCR Reporting @ Sutter Health

29

3 Day Implementation:4/13-15

Go-live @ 5 pm

0

200

400

600

800

1000

1200

1400

Problem List Results Total Problem and Results


COVID-19 eCR Implementation Sites


Current implementation cohort members• Washington Hospital Healthcare System (CA)• UCLA (CA)• MemorialCare (CA)• Community Medical Center (CA)• University Of Utah• Group Health Cooperative of South Central Wisconsin (WI)• PeaceHealth (WA)• Northwest Permanente, PC (WA, OR)• Memorial Healthcare System (FL)• Novant Health (GA, NC, SC, VA)Future cohorts forming now


Opportunities

• Working with Epic to advance a nationwide approach to rapidly onboardall US healthcare organization customers

• Working with Carequality to finalize a new eCR Implementation Guide to a llow participation by any provider organization that has s igned on to utilize the national interoperability framework

• Encourage a ll EHR vendors to develop triggering and report generation capabilities based on the Digita l Bridge s tandard

• Encourage a ll state and local health jurisdictions to accept eCR in lieu of manual case reporting

• Advance the future option of eCR via FHIR


eCR Now Elements

1. Cohort-based COVID-19 rapid eCR implementations for provider sites that have eCR enabled EHRs

2. A new eCR Now FHIR app that non-eCR enabled EHRs can rapidly implement to automate COVID-19 eCR

3. Extension of the existing eHealth Exchange policy framework through a developing Carequality eCR implementation guide


eCR Now FHIR App – Element 2

• A FHIR app that can be rapidly implemented to automate COVID-19 eCR in otherwise non-enabled EHRs

• Connect COVID-19 electronic case reporting to existing infrastructure to confirm case reports and route to appropriate public health surveillance systems

• Immediately implement in as many EHRs as possible, based on API that is “in the wild” without waiting for EHR software releases

• Initial version of eCR Now app for COVID-19 and source code will be available May 1 for EHR sandbox implemenation and testing

• Encourage EHR companies to test in HL7 FHIR Virtual Connectathon May 13-15


eCR Now - FHIR Reporting App

eCR Now COVID-19 and full eCR option Backend Services App Reporting Services in

FHIR API

DescriptionExpedited delivery of app to provide automated COVID-19 eCR for EHRs that don’t have it. App can be used subsequently for full eCR.

Planned roll-out of app with fully automated launch, trust services, and other reporting functions

Advance FHIR Common Reporting Functions into FHR API – all EHRs must report

Timing App / source code available May 1 Projected for 2021 Longer term objective

Output HL7 CDA electronic Initial Case Report (eICR) Ver 1.1 HL7 FHIR electronic Initial Case Report Version 1.0 and other FHIR payloads

Multiple FHIR payloads

Operations

• Fully manages triggering with eRSD input• Automated behind the scenes process• “SMART on FHIR App launch” for patient and

encounter context• App launch by auto pages, CDS Hooks, etc. • Followed by system access for triggering and eICR

loading or refresh tokens• Backend can be centrally hosted by EHR• Direct or XDR transport

• Full backend services app• Trust services for chronic

surveillance• FHIR Subscription triggering• CQL engine connection

• Minimized app services• Possible CQL engine services

Query Data• Argonaut 1.0.0 (R2) based on FHIR Version 1.0.2• USCore 2.0.0 (STU 2) based on FHIR Version 3.0.1

• FHIR Release 5• USCore

• TBD


Catherine Staes, PhD, MPH, RN, FACMI, FAMIA (EIS)Professor & Director, Nursing Informatics, College of Nursing, University of Utah

Twitter handle @StaesCatherineEmail: [email protected]

COVID-19 eCRevaluation

opportunities

Acknowledgements:

Shan He, IntermountainGoldie MacDonald, CDC

Big questions

Does the current eCReffort for COVID-19….

• meet healthcare system needs to:• efficiently report needed data (avoid ‘one-offs’ & manual work)• receive guidance from public health (in reportability response)• access population level information to make clinical and business decisions

• meet public health needs to:• efficiently receive and manage growing volume of data (avoid ‘one-offs’ & manual work)• efficiently provide reports to the community & governmental agencies

• daily updates: cases/hospitalizations/deaths/geographic

• support public health investigation and control efforts: • Case management (isolation), contact tracing, outbreak management in high risk settings, etc

38

state

local


Healthcare ProviderIntermediary Service

(AIMS)


EHR

Trigger Codes

eICR Generation

RCKMS

… multiple components to evaluate

Reportable?

Yes

eICR

RR Parsing

match?

RR

Author reporting rules

ParsingService

Yes

eICR

RR

Surveillance Information

System

eICR

RR


(AIMS)


EHR

Trigger Codes

eICR Generation

RCKMS

… accurate, timely, complete, cost effective

Reportable?

Yes

eICR

RR Parsing

match?

RR


ParsingService

Yes

eICR

RR


System

eICR

RR

1.How well are reporting rules represented as computable logic?

2.Are trigger codes aligned with EHR workflow and data?

3.Is content accurate & complete?

4.Is case detection accurate (PPV/sens) & complete?

5.Can the person-based data be automatically integrated and linked with event-based data (labs, immunizations)?


(AIMS)


EHR

Trigger Codes

eICR Generation

RCKMS

… efficient and effective for decision making

Reportable?

Yes

eICR

RR Parsing

match?

RR


ParsingService

Yes

eICR

RR


System

Information for action


eICR

RR


Presenter

Presentation Notes

Information for action available for public health control work and the community, but not yet realized as specific guidance to clinicians in the RR. It will be nice to figure out how to route this to the relevant individuals for review and action as appropriate. Knowledge management issue.

Bigger questions

• How can the processes implemented for COVID-19 support and enhance surveillance for other conditions and future waves of COVID-19?

• COVID-19 is just one of over 60 conditions reportable in a given state or city. • We shouldn’t be building just for COVID-19, but developing systems that support both

routine and emergent infectious disease control needs

• How well does eCR support Information for Action : • the ongoing systematic collection, collation, analysis and interpretation of data;

• and the dissemination of information (to those who need to know)

• in order that action may be taken based on knowledge.


Strategy for evaluation

Leverage Digital Bridge Evaluation Plan & prior work*

CDC Foundation & CDC working with stakeholders to:

• Refine evidence-informed logic model • Articulate eCR components/outcomes, update indicators

• Document eCRthree-day implementation to:• Identify crucial components:

• pre-work needed, steps in the process, maintenance activities

• Consider health care organization, public health entity, & EHR vendor

43

• Multisite Evaluation Plan: https://digitalbridge.us/wp-content/uploads/2018/10/Digital-Bridge-eCR-Implementation-Evaluation-Plan-final-report.pdf• Mulitsite Evaluation Report: https://ecr.aimsplatform.org/cms/resources/blocks/digital-bridge-ecr-evaluation-report-12-32019.pdf


Presenter

Presentation Notes

How were the core elements of eCR initiated and implemented in participating sites? What were the facilitating and inhibiting factors related to initiation and implementation? How did sites address inhibiting factors? To what extent were sites able to develop and implement the core components of the Digital Bridge approach to eCR successfully? To what extent are electronic case reports accurate, complete, and timely? To what extent is the information in the electronic initial case report (eICR) complete and accurate? What were the costs associated with the initiation and implementation of eCR in sites? To what extent did eCR improve (or hinder) surveillance functions in sites? What are the strengths and weaknesses of the Digital Bridge approach to eCR for digital information exchange and use? To what extent does eCR add value to health care and public health practice in sites?

https://digitalbridge.us/wp-content/uploads/2018/10/Digital-Bridge-eCR-Implementation-Evaluation-Plan-final-report.pdf

https://ecr.aimsplatform.org/cms/resources/blocks/digital-bridge-ecr-evaluation-report-12-32019.pdf

How can you participate in these activities?

• Volunteer to review logic model and provide recommendations

• Participate in a stakeholder exercise to review and rate the indicators used previously to prepare for future evaluation that speaks to priority interests and needs

• Implement eCR……. and evaluate your eCRimplementations using vetted indicators/metrics for comparison

• https ://ecr.aimsplatform.org /

• [email protected]


https://ecr.aimsplatform.org/

mailto:[email protected]

Audience Q&A

AMIA’s 2020 Virtual Clinical Informatics Conference Webpage: https :/ / www.amia.org/ cic2020

Clinical and Health Informatics Practitioners… CIC is YOUR conference.


https://www.amia.org/cic2020

ecr now...public health informatics is the application o\൦ informatics in areas of public health,...

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