Cleaning up the clutter in disease reporting
It’s no secret why laboratories and physicians have had such
an "abysmal" track record reporting diseases to the Los Angeles County
Department of Health Services.
"It’s been the shame of this department and many other health
departments around the country that we have separate forms for various
reportable diseases, each of which must be sent to different offices,"
says David Dassey, MD, deputy director of the county’s Acute Communicable
Disease Control, or ACDC, to which reports are sent.
The legendary bureaucracy at LA County’s health department was
created because tuberculosis, sexually transmitted diseases, AIDS,
and communicable diseases receive individual federal funding, and
the departments that track those diseases developed their own information
and reporting systems. But health care providers, having had to
use seven different forms, often failed to report the 83 diseases
California law mandates. "Even for serious diseases such as hepatitis
A and pertussis, the number of cases reported may be only 25 percent,"
Dr. Dassey says.
But clean up the internal bureaucracy and remove the human element
in reporting, and the picture looks different. In February, Kaiser
Permanente Regional Reference Laboratories became the first lab
in the county to electronically transmit test results of suspected
communicable diseases, eliminating the need to fax thousands of
lab reports to ACDC each year. The link with Kaiser Permanente is
the start of what LACounty is doing as part of a Centers for Disease
Control and Prevention initiative.
In 1995, the CDC awarded grants to state and local governments
to improve their surveillance of infectious diseases by upgrading
information systems and using technology to shore up reporting.
LA County used about $200,000 of its CDC grant to develop and refine
the required software.
Before building the interface with Kaiser, however, ACDC had to
revamp its old communicable diseases reporting system, which was
replete with errors and redundancies. In the past, reports of communicable
diseases were mailed or faxed to 12 different sites, where clerks
entered the data on terminals that couldn’t alert them that a patient
had already been entered into the system. Each time a patient with
hepatitis B or C was retested, the public health department would
register a new case of hepatitis, resulting in egregious overreporting
of some chronic diseases, Dr. Dassey says. And because the old system
didn’t track the progress of staff as they investigated disease
outbreaks, cases often lingered unresolved, or staff waited until
cases were closed before even entering them.
ACDC contracted with Atlas Development Corp., of Woodland Hills,
Calif., to create an electronic reporting system that allows health
care providers to call in or fax disease reports to a central location.
Called Visual CMR (for Confidential Morbidity Report), the system
is on a wide-area network, so staff now has access to all the data
in the system. This means that new test results for a patient can
be attached to previous ones without a duplicate record being created.
Supervisors can also now monitor the status of a disease investigation
and be alerted to overdue work, making staff more accountable for
their handling of cases. And, with a simple query, Visual CMR can
generate epidemiological reports to help public health staff identify
clusters or outbreaks of, for example, salmonella.
With the new system, says Dr. Dassey, "staff can quickly identify
clusters of diseases so they can probe deeper into underlying causes
and start preventive measures. Before, we only performed that kind
of analysis annually because of the difficulty of extracting data
from the old system."
Visual CMR also has a feature that provides outbreak alerts to
staff at any time via e-mail, pager, cell phone, or wireless device.
This feature, called ARNOLD (for Advanced Results Notification and
Online Delivery), notifies staff, too, when key information is missing
from a record and will automatically print a letter to be sent to
the lab or physician requesting additional data.
Although it would appear that Visual CMR’s return on investment would be significant,
Dr. Dassey says he can’t cite cost and labor savings because the data in the
old system aren’t reliable enough to make comparisons. "We did discover, however,
that under the old system it took an average of 30 days from the time a disease
was diagnosed to the time it was entered as a new record," Dr. Dassey says.
"So things can only get better."
Kaiser Permanente, which reports 40 percent of LA County’s
communicable diseases, was the logical choice for the laboratory
pilot project. Ann Vannier, MD, pathologist and director of microbiology
at Kaiser Permanente Regional Reference Laboratories in Southern
California, estimates that, with a yearly volume of 225,000 chlamydia
tests and about 90,000 tests for hepatitis C, her department will
save $10,000 in staff costs each year by eliminating the manual
handling of communicable disease and sexually transmitted disease
reports to LACounty Public Health.
Forging a strong relationship with the public health department
is also to Kaiser’s advantage, says Dr. Vannier. "When the health
department detected an outbreak of Legionella in 1998, they
asked if we had seen an increase in the isolation of the organism.
Such an alert guides us in looking for various organisms in our
patients." Kaiser’s staff also helps the county in its work. "When
there was an outbreak of Alcaligenes this year in LACounty,
we were able to send some of our previous isolates to the health
department for use in molecular fingerprint comparison." Kaiser’s
collaboration with local and state public health departments was
especially helpful in dealing with the threat of anthrax and other
potential bioterrorist agents in California.
Complying with HIPAA regulations and satisfying Kaiser’s conservative
confidentiality committee were among Dr. Vannier’s primary concerns
in establishing an electronic interface with ACDC. To maintain the
security of the lab data, ACDC installed at Kaiser an Atlas LabWorks
workstation and a DES3 Cryptocom modem that allows a one-way transfer
of Kaiser’s lab data directly into the county’s Visual CMR.
"We never have to touch Kaiser Permanente’s network," says Irene
Culver, project manager for the Enhanced Surveillance Project. "And
the modem provides great security with 168-bit encryption." The
"beauty" of the Visual CMR software, she says, is that "an interface
can be built to link to any information system that a lab uses."
ACDC funded the eight-month project with $27,000, which included
the cost of the hardware, and Kaiser spent an estimated additional
$10,000 to develop and deploy the interface. Because Kaiser’s lab
information system didn’t include all of the patient demographic
data ACDC requires, the HMO’s IT staff had to integrate it with
other Kaiser patient information systems. The lab also had to configure
its data so files could be downloaded using HL7 transmission standards.
(The conversion to HL7 benefited Kaiser internally by making it
easier for the lab to communicate with other Kaiser Permanente groups
throughout the country.)
Kaiser wanted to ensure that physicians have the opportunity to
be in touch with the patient before the public health department
might contact the patient, so the lab delays downloading test results
to ACDC by 23 hours. "This is in compliance with the 24-hour reporting
requirement for most communicable diseases, more efficient for the
health department, and in effect faster than the manual method of
reporting," Dr. Vannier says. The laboratory transmits about 300
lab results of communicable diseases to ACDC each week.
So successful has been the electronic transfer of lab results
that Kaiser asked to download sexually transmitted disease reports
also—about 100 per week—which ACDC for now transmits
internally to the STD department. "Ultimately, we want all the LA
County public health departments to have one face with the laboratory
via one electronic form with separate modules for the different
diseases," Dr. Dassey says.
That shouldn’t be a tough sell to the other disease-tracking departments.
Electronic interfaces with labs lead not only to better reporting
but also to streamlining staff. Kaiser’s electronic transmission
of hepatitis B and C results alone has eliminated the work of at
least 1.5 clerical full-time equivalent employees, according to
LA County Health Department’s dozen hospital laboratories and
the Public Health Laboratory are next to receive electronic interfaces.
Dr. Dassey has also received inquiries from Unilab and other commercial
labs interested in electronic reporting. Now that the laboratory
interface has been field-tested at Kaiser, Stephen Atlas of Atlas
Development Corp. estimates it will take other labs a maximum of
six weeks to configure their data and software to report electronically
"All they have to do is filter out nonreportable diseases and
modify their HL7 messaging format to meet the specifications set
by the Centers for Disease Control," Atlas says.
ACDC has allocated $10,000 to $15,000 to assist each lab with
the development cost and will pay the minimal cost for the hardware.
"In the next two to three years, we hope to add three to four more
labs," says project manager Culver.
Although Atlas’ LabWorks can translate labs’ internal test result
codes into LOINC and SNOMED, Dr. Dassey is looking for laboratory
partners that have already mapped their codes to the universal identifiers.
"As long as labs keep current with these standards, they should
be able to send their data anywhere without making changes to it,"
Dr. Dassey says.
To get more health care providers to report their patients’ communicable
diseases, ACDC will pilot Internet reporting for 10 infection control
practitioners this month. If physicians are receptive to Web-based
reporting, ACDC plans to offer the option to the more than 30,000
physicians in the county, provided the physicians have Internet
access in their offices and the measures to secure the Web site
aren’t too costly for the county or too onerous for the users.
For now, however, Dr. Dassey would be happy with better reporting
by labs. "At least if I get the lab report, I can call the doctor
and ask for her impressions," he says.
Anita Slomski is a writer in Evanston, Ill.