Missouri ESSENCE Training Public Health Event Detection and Assessment (PHEDA) Program Office of Emergency Coordination Missouri Department of Health and Senior Services (573) 751 -6161 http: //www. dhss. mo. gov/ESSENCE/ ESSENCE@dhss. mo. gov
What is ESSENCE? • Electronic • Surveillance • System for the • Early • Notification of • Community-based • Epidemics
What is ESSENCE? • Developed by Johns Hopkins University and Department of Defense • Automated surveillance tool • Analysis & reporting of pre-defined syndrome groups • Data mining ability • Web based
Purpose of ESSENCE Our mission is to help state and local partners respond to public health events by providing information and tools for early event detection and situational awareness -- Public Health Event Detection & Assessment Program
What is syndromic surveillance? • Utilization of nontraditional data sources to detect health events earlier than possible with traditional methods like laboratory-confirmed diagnoses 1. Early event detection 2. Situational awareness
What is early event detection? • Analysis of time-sensitive data for the purpose of detecting outbreaks as early as possible • ESSENCE will “flag” a syndrome group whose number of visits was higher than expected to detect anomalies as early as possible
What is situational awareness? • ESSENCE can be used during ongoing health events to track impact in terms of time, geography, and demography – Example: carbon monoxide poisonings following an ice storm – Injuries related to falls following and ice storm – Injuries related to activities dealing with flooding conditions
Missouri ESSENCE Users • Johns Hopkins University has said that “ESSENCE is only as good as the people who monitor it” • We agree: that’s why we want professionals from all different points of view to be able to access ESSENCE • We have granted access to 200+ users and are in the process of training everyone who is interested
Who is eligible for ESSENCE access? • Any public health authority – Local public health agency – Missouri DHSS • Any staff from a hospital that sends data to DHSS and that are displayed in ESSENCE – Usually infection control staff – Anyone concerned with communicable disease or overall ED trends
Where do ESSENCE data come from? • ESSENCE was acquired by DHSS in order to utilize the electronic emergency department (ED) data sent to DHSS under 19 CSR 10 -33. 040 • This Rule requires that 85 out of about 120 hospitals with ED’s send data to DHSS for the purpose of syndromic surveillance • 83 of those hospitals are currently loaded in ESSENCE (See Map) – Represents approximately 90% of all ED visits in MO
Where do ESSENCE data come from? • Utilizes data from the “Hospital Information System” that each hospital maintains for its own purposes, like billing and patient records • Put into the HL 7 format by each hospital and sent to DHSS • Each have their own methodology and criteria • No special data entry required: use data already being entered into hospital’s information system
How do hospital data get to DHSS? • Two defined structures are used for transfer of data from hospitals to DHSS: HL 7 version 2. 3. 1 messages & ASCII flat file – Note: Both structures are pre-processed and placed in a single Oracle database prior to being loaded into ESSENCE • Hospitals using HL 7 messages may send their data either as real-time messages or into a batched file (submitted on a daily basis) • The real-time messages connect to DHSS using our virtual private network (VPN) for security purposes. Files of HL 7 messages and ASCII flat files are transmitted using FTP, also using our VPN
Data Loading • DHSS processes data and loads into ESSENCE each day – Including weekends and holidays • Approximately 8, 000 ED visits per day with some variability based on time of year • Data are presented to public health authorities and hospital staff via the Missouri ESSENCE website – Available 24/7 but only loaded once per day
Data Displayed in ESSENCE • Patient data are unduplicated and de-identified • Data are displayed within pre-defined syndrome groups & are also available for data mining using custom queries • All available ED data are loaded – Varies by hospital, but some hospital data date back to January 1, 2004
What patient level data are displayed? • • • Admission date and time Hospital name Zip code (patient) County (patient) Age group Age Sex Chief complaint Category (Rash, GI, etc. ) • Discharge diagnosis (ICD 9 code, if available) • Discharge disposition (chief complaint, working diagnosis, final diagnosis) • Medical Record Number • County (hospital) • Zip Code (hospital)
ED Chief Complaints are Clustered in Broad Syndrome Groups • • Respiratory (cough, pneumonia, influenza) Gastrointestinal (vomiting, diarrhea) Neurological (meningitis, altered mental status, dizzy) Fever Rash (vesicular rash, chicken pox) Botulism-like (weakness, blurred vision, speech) Shock/Coma (syncope) Hemorrhagic Illness (blood)
How is ESSENCE used by other jurisdictions? • Early event detection • Monitoring for disease outbreaks following planned events • Assessing effects of natural disasters or severe weather • Rumor control • Good to know that no alerts have been generated Source: Johns Hopkins University Applied Physics Lab
How is ESSENCE used in MO? • Office of Emergency Coordination staff review ESSENCE Alert List each working day – Staff use internal protocols to review ESSENCE alerts, or flags, and determine whether further investigation is needed – Only about five flags a month are investigated further, coordinated through local health departments
How is ESSENCE used in MO? • Aid in surveillance efforts – Work with Bureau of Environmental Epi on carbon monoxide, hypothermia, and hyperthermia case finding • Monitor communities affected by Department of Natural Resources-issued Boil Water Orders – For those orders associated with bacteriological and/or turbidity findings • Create situational awareness reports
How is ESSENCE used in MO?
How is ESSENCE used in MO? • Special projects – Working with partners in St. Louis County on flu assessment – Compared ESSENCE “Influenza-like Illness” cases to lab-confirmed cases during previous flu seasons – Interesting findings
2006 -2007 Flu Season Statewide CDC Week
2007 -2008 Flu Season Statewide CDC Week
Two basic functions of ESSENCE 1. Early event detection: Alert Lists – Detecting flagging events within syndrome groups 2. Situational awareness: Query Portal – Querying all ED visits to obtain more information about a known health event or other phenomenon – Example: Looking for cases associated with GI outbreak – Example: Tracking number of ED visits due to dog bites
Active Surveillance vs. Traditional Disease Tracking Methods Johns Hopkins Applied Physics Laboratory
ESSENCE Statistics • Flags are generated when data from the past ninety days are selected and loaded into the database • Specially developed algorithms look for anomalies in the data, which can be used to detect possible outbreaks at the hospital or community level • ESSENCE retains all data indefinitely, which can be mined using the Query Portal for historical or research purposes
Statistical Algorithms for Alert Detection • Exponentially Weighted Moving Average (EWMA) – Predicts based on smoothing of data for previous weeks – Most recent three days have highest weight • Autoregression – Predictions on past several weeks of data – Adjusts for the day of week and holiday trends • Sat. Scan – Used to detect geographic clusters by comparing number of cases within overlapping circles Source: Johns Hopkins University Applied Physics Lab
Flagging Events Variability Based on Algorithms
ESSENCE Alert List Statistics • Alert List Time Series Page displays basic stats • Shows the count and the expected frequency • Detection levels – Red flag: p ≤ 0. 01 – Yellow flag: p value between 0. 01 and 0. 05
ESSENCE Alert Tips • Treat each Alert review as a mini-hypothesis test • Aggregating “all ages” makes reviewing the Alert List easier – Can go back and see if Alert “sticks” for an individual age group • Look for trends that persist over more than one day especially those that increase in subsequent days
ESSENCE Alert Tips • Rare syndromes more likely to flag for “mundane” complaints – See many stroke victims in “Bot-Like” and many seizures in “Neuro” • If a known event is occurring, such as a chemical leak, a botulism outbreak, etc. more likely to be concerned about this syndrome group
ESSENCE Alert Tips • Gastrointestinal Syndrome – Use “NVD” subsyndrome that contains Nausea, Vomiting, Diarrhea if you want to examine GI further • Does not contain duplicates • These cases more likely to be associated with a communicable disease – Does not work 100% of the time • Some hospitals classify nearly every GI visit as “Abdominal Pain” so this does not help there
ESSENCE Alert Investigation • Each hospital or community may develop their own process and criteria for determining which ESSENCE Alerts require further investigation – Recommend drilling down to patient list for each day’s data of concern to see if the alert is still of concern
ESSENCE Alert Investigation • May use internal information/contacts to investigate – Reportable disease figures – Numbers of tests ordered – What colleagues tell you • Other times you need more info: need to initiate an official Alert Investigation
Who Can Initiate a Flag Investigation? • We rarely hear of a local community initiating an official ESSENCE Investigation • PHEDA initiates most official investigations – About 5 per month (flu season) • Missouri ESSENCE Policies and Procedures state that anyone may initiate a flag investigation – Individuals at the local, regional, and hospital level know things we don’t!
How are ESSENCE communications accomplished? • All contact with hospitals is coordinated through their local public health agency – Or at least with the permission of the agency • LPHAs and hospitals are often familiar with each other and comfortable discussing communicable disease issues • Ensures LPHAs are kept in the loop on health concerns
How do I respond to an ESSENCE Investigation? • May use internal resources only – Communicable disease reports – Local active surveillance – Local knowledge • May ask hospital infection control for help – Lab confirmed cases or lab tests ordered – Pull patient records (next slide show Med Rec No) • Similar symptoms beyond what our chief complaints show • Other commonalities
Medical Record Number • ESSENCE unduplicates using Medical Record Number • Med Rec No can be used by hospitals to obtain patient records • MOHospital. Name. ERCC_01049308 -0805601578 Hospital Name Patient ID Encounter ID
ESSENCE Statistics • ESSENCE groups data into syndrome groups but retains all ED data for analysis • ESSENCE can compute produce reliable statistical findings “on the fly” – Query of “GI” syndrome by region, zip code, or hospital will show whether a flag is present • This can be run for previous day’s data even before Alert List has generated – Query of the keyword “insect bite” by region, zip code, or hospital will show the number of visits PLUS whether that number was higher than expected
ESSENCE Query Tips • ESSENCE can query by syndrome, subsyndrome, or keyword • Syndrome examples: GI, Respiratory, Rash • Subsyndrome examples: NVD (nausea, vomiting, diarrhea), ILI, Asthma, Cough, Malaise, Disseminated Intravascular Coagulation • Keyword queries: free text query of the chief complaints field
ESSENCE Query Tips • If there is a syndrome or subsyndrome available, use it rather than “thinking up” a query • Avoid combining syndromes or subsyndromes if possible, will pull one record per syndrome group – Record for someone with Fever & Cough will appear in both the Fever and Respiratory Syndrome group – Not a real duplicate, just inconvenient – If you must pull records this way, refer to Excel Deduplication Tutorial at: http: //www. dhss. mo. gov/ESSENCE/Training. html
ESSENCE Query Tips • Keyword queries can be tricky, but very useful • Need to refer to instructions listed on the page • Use “or” rather than “and” to get more results – Can narrow down later • Example: To detect hypothermia cases use keywords ^therm^, or, ^cold exposure^ – Using hypothermia does not pick up misspellings or entries that mistakenly list “hyperthermia” – Just keyword “cold” gets everyone with a cold, which doesn’t help
What else can ESSENCE do? • Can pull a full ED log by day for a particular hospital • Can examine historical trends – Put any date range back to January 1, 2004 and see what data are available – Better to use % than counts as data have been added continuously over time • Can see Hospital usage patterns by residents of different counties, zip codes
What else can ESSENCE do? • Can query to search for conditions of interest that do not fit into specific syndrome groups, like “animal bite” for weekly reports – Can Bookmark this query if it is something you need to do routinely
What else can ESSENCE do? • Can find cases associated with a known event • Chemical exposure event at a factory – Searched all ED visits for hospitals located in/around affected county, found cases split between two smaller hospitals • Because workers may live other places, did not search by residence – Did not know what keywords to search for, so selected all ED visits • Viewed patient list to see TOX EFF NONMED SUBST NOS, TOXIC EFF GAS/VAPOR NOS, and name of company affected to acquire a tally of ED visits due to the event (n=124)
Chemical Exposure Event at a Factory
Future Plans • Acquiring novel data sources for ESSENCE – Non-mandated hospitals in Missouri – Over-the-counter drug sales data from 248 Missouri pharmacies – Missouri Poison Center – Ambulance/EMS data • Real-time data analysis of continuous-feed facilities
Online Resources • http: //www. dhss. mo. gov/ESSENCE/ – Training and Technical Support • User Guide and Quick-start Guide – Information for Public Health Authorities – Information for ESSENCE Hospitals – Laws, Regulations, Manuals • Copy of 19 CSR 10 -33. 040 & our Policies and Procedures – Contact Information
ESSENCE Demo with Examples • ESSENCE System Status Page • Alert List by Region and Hospital – Configuration options – Bookmarks • Spatial Alerts • Overview Portal • Query Portal – Syndrome-based queries – Subsyndrome-based queries – Free text queries • Custom reports: Matrix Portal • Weekly percent: Influenza -like Illness
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