The Florida Department of Health is at the forefront of electronic communicable disease reporting with Merlin, the Bureau of Epidemiology’s web-based reporting system. Development on Merlin started 3 years ago with the vision of a central statewide database that would serve as the single gateway for mandatory communicable disease reporting and data analysis as part of the Florida Department’s bioterrorism preparedness. Merlin has been live for a year and a half receiving real-time data from all 67 counties, has 10 reports for analysis of morbidity data, and extended data for hepatitis, bacterial meningitis, and childhood lead poisoning. The Merlin system was an important tool during the anthrax event last October, enabling investigating epidemiologists to review the case electronically by accessing the central Merlin database from multiple locations around the state. Additional screens are being published soon for the Perinatal Hepatitis B Prevention program and Enhanced Analysis tools that will enable users to run risk factor frequencies. The Merlin Project Team has successfully worked with both the Bureau of Environmental Epidemiology and the Bureau of Immunization to incorporate data entry screens for these other program areas. Plans are currently in development to design an outbreak module for Merlin and connection to one pilot hospital infection control department.
Merlin is available for data entry 24 hours a day, 7 days a week through the Department of Health intranet. The programming, or business rules, of reportable disease surveillance are built into the system to assure accurate and complete reporting with minimum data requirements for saving and reporting a case. Checking criteria on the case definitions for surveillance is required when entering a case of reportable disease to keep cases out of the system that do not meet the case definition. Diseases of importance, or red flags, can be monitored on a real-time basis from the database from the time of data entry. Lag time between either date of laboratory result, date of diagnosis, date the case was reported to the county health department, or date the case was entered to the date reported to the Bureau of Epidemiology can easily be assessed and analyzed.
The Florida Department of Health’s Epi Com project addresses the need to coordinate communications in the public health system, between state agencies and between public health officials in the event of bioterrorism or an outbreak. The development of this secure communication tool will strengthen bioterrorism preparedness efforts by facilitating the sharing of preliminary information about disease outbreaks and other health events among public and private healthcare professionals across the state. The Florida Epi Com project will collect reports of unusual disease occurrence in the state, automatically notify users of incidents, and allow direct access to Merlin for authenticated users. Epi Com will also allow for notification to be sent in the event of any unusual case being entered into Merlin.
The current capacity for mandatory reporting of disease conditions is supported by Florida statute and administrative rule. The statute specifies that diseases and any outbreak diagnosed or detected by clinicians or laboratories listed in the administrative rule are reportable by law to the Department of Health. Bioterrorism agents or diseases that have been determined to be a potential bioterrorism event are covered in the administrative rule including smallpox, brucellosis, plague, etc. The statute differentiates between diseases that need to be reported immediately by phone and diseases that should be reported within 72 hours of diagnosis.
The state of Florida is under mandate to complete electronic laboratory reporting receipt of results from our central state laboratory and Lab Corp. Development of electronic transfer of results from clinical laboratories into Merlin is underway. This will enable the Florida Department of Health to move from a paper-based laboratory result system where cases are entered into Merlin manually to automatically loading the results into Merlin, directly onto county task lists to initiate investigation.
The Bureau of Epidemiology of the Florida Department of Health (FDOH) is developing Epi-com, a secure, web-based outbreak communication/information network. When completed, the system will have the capacity to connect more than 800 key public health partners that may play a pivotal role in the recognition of and intervention in disease outbreaks including those related to a real or potential bioterrorist attack. The key partners include county health departments, state health offices, hospital emergency and infection control departments, clinical laboratories, major primary care providers, and a variety of responder groups.
The proposed network will have a basic design that is similar to that of the CDC’s Epi-X. An internet web-site will be created for the exchange of information among members. A user authentication system (such as password protection) will protect the security of data transmission. Members will use the web-site to communicate all levels of individual case, cluster, laboratory information or other data that they fell may be related to a potential outbreak or for which they are seeking medical or epidemiologic assistance. Communication of confidential data will be protected through access restriction and other security measures. Members reading notices may respond with elucidating comments, guidance, their own anecdotal reports or criticisms. Users will also be assigned access levels; not all users will be eligible to all information on the system. For example, if a clinical laboratory were to provide information about a positive botulism test result, that information would be available only to limited categories of users, such as the county health department director and epidemiologist of the patient’s residence and the state health department’s epidemiology staff. The network also contains a step-down communications system to locate and inform key public health and response officials using pagers, telephones and other devices.
The Epi-Com network will include features such as the collection of hospital surveillance data, access to a variety of FDOH epidemiologic, bioterrorism and other public health information, connectivity to several specialized FDOH surveillance systems, and allow access to Merlin, the state’s web-based disease reporting and analysis system. The Bureau of Epidemiology will also provide an editing interface between the Florida network and the CDC Epi-X to which the system will be connected so that posting of nationwide interest can be easily migrated to the national system.
The Epi-Com will provide a very practical method of collecting hospital surveillance data, which is a key function for bioterrorism surveillance. Participating hospitals will designate a member of the emergency department staff to evaluate the ER log at the end of the shift, looking for significant increases in attendance for certain syndromes. If those increases are evident, the designated ER representative will post a notice on the Epi-Com network. The network will be monitored regularly by county health department and DOH Bureau of Epidemiology staff. In later versions, programs may be introduced for the electronic evaluation of this anecdotal surveillance information.
Electronic laboratory reporting (ELR) planning and management in Florida has been, and remains, a joint venture between the bureaus of the Division of Disease Control (Epidemiology, HIV/AIDS, TB, STD); the Division of Environmental Health, Bureau of Environmental Epidemiology; the Division of Information Resource Management (now Information Technology); and the Office of Planning, Evaluation, and Data Analysis. Managers of those programs recognize that Implementation of electronic laboratory reporting (ELR) is vital to enhancing disease intervention in Florida. The current (reporting) process does not provide a reliable and timely procedure for receiving lab reports. Labs around the state currently submit state-mandated reports in different formats via U.S. mail, telephone, facsimile, or courier. As a result, the FDOH receives large amounts of written or printed data that must be entered manually into state and county computer systems. Realizing the need for electronic transmission of laboratory results, a stakeholder group consisting of representatives from each of the bureaus that would benefit from ELR was convened in the fall of 1999. The Division of Information Resource Management, identifying ELR as a top priority, used state funds to schedule a series of Joint Application Development Sessions (JADS) to discuss the development and implementation of electronic laboratory reporting in Florida. The IRM engaged the services of a software development/ business systems company to facilitate the development of the plan. Representatives from the DOH cooperating organizations participated in day-long joint applications development (JAD) meetings that were held weekly for two months. The contractor’s summary report (following) describes the process and product of those sessions (see attachment 2).
In September of 1999, representatives from Florida's Division of Disease Control met to determine and document critical information system needs. Electronic transmission of lab results was identified as a need for several bureaus. The Bureau of Tuberculosis and Refugee Health, the Bureau of STD Control and Prevention, the Bureau of HIV/AIDS, and the Bureau of Epidemiology all expressed a need for progress in the area of electronic reporting. Later, it was determined the Bureau of Environmental Epidemiology within the Department of Environmental Health could also benefit from electronic reporting.
…The group researched ELR efforts in other states and brought in representatives from the New York Department of Health, and Tennessee's Department of Health, two states that have made progress with their ELR initiatives. Dr. Daniel Jernigan, a key representative from CDC, attended a JAD session early in the project and provided valuable insight on ELR at a national level. Dr. Jernigan has been involved for the duration of this JAD project via email and telephone and has provided input as various issues have been discussed. Representatives from two large labs, LabCorp and Quest Diagnostics, also attended a session to express their interests and discuss their ELR capabilities.
Identifying a standard format and coding scheme was one of the key factors in defining a proposed ELR solution. As part of this research, private hospitals and other state health departments were contacted to determine what methods of reporting were in use. The outcome revealed that most states were still using a paper-based system and have not implemented a common format or coding scheme. Personnel at other state health departments did indicate that they were hoping to pursue an initiative like ELR and have not yet budgeted time or money for such efforts. Private hospitals in Florida indicated that their labs are using internal laboratory information systems with local sets of codes to indicate test names and results.
As a result of this research, the group recommended adopting HL7 as the primary and desired format for electronic lab reports, and designing one alternate format for reporting entities that find HL7 formulation too costly. Also, the group recommended adopting LOINC and SNOMED where applicable, and designing an alternate set of codes for situations where the standard is not applicable. Adopting these industry standards will increase the integrity of laboratory test data and also the efficiency of querying, interpreting, and sharing it.
The proposed model, as a result of this preliminary project, includes a mechanism that accepts electronic lab reports in a specified format and forwards data to the appropriate bureaus and county health departments using their desired formats. The need to manually enter the reports into one or more computer systems is alleviated. Reporting entities can schedule routine data deliveries on a daily basis and the results would be posted to the state and counties that same day. Timely receipt of lab reports with little required user intervention is one of the main benefits once the system is established.
Both the Department of Health and participating labs will realize cost savings with the implementation of ELR because postage and delivery fees would be essentially non-existent. Established computer networks can be utilized to transfer the data between destinations, and security techniques can be applied to ensure privacy. Manual entry of data and handling of paper forms would be reduced to only those labs that could not provide the data in the defined format. The JADs group identified the expected benefits of ELR to be as follows:
- More timely reporting of positive results.
- Improved data integrity and quality.
- A common central reporting point reduces confusion.
- Streamline reporting procedure for labs.
- Increased number of lab reports.
- Improved monitoring of lab reporting.
- Reduced initial and redundant data entry.
- Easier interpretation of results because of standard formats and codes.
- Cost savings in telephone use, facsimiles, postage fees, and manpower.
- Increased opportunity for data sharing and system integration."
A principle product of the ELR/JADs was the consensus acceptance of data flow diagram that represents the electronic transmission of laboratory data through a new data management system. The diagram below describes, at a high level, the model for electronic laboratory reporting in Florida. Labs will submit reportable results to the Department of Health and the Cloverleaf integration broker at the FDOH will determine the format for transmission to the appropriate program office, county health department (CHD), or other report destinations.
Laboratory reports that are submitted electronically should be formatted using the industry standard HL7 format. LOINC codes will be used to identify the type of test performed, and SNOMED codes will be used to indicate the result. Although these coding standards are robust, they cannot address every desired test and result imaginable. The organizations that maintain the LOINC and SNOMED codes are effective at maintaining a comprehensive list but cannot forecast every new test and result definition. They are amenable to additions on a request basis and prefer establishing new codes to the use of local codes. These standards depend on user input to remain current. If current LOINC and SNOMED codes do not address a specific need for a lab report then the reporting lab will substitute a local code and description or use a state-defined alternative.
The integration broker component will provide key functions for processing electronic reports; Cloverleaf has been selected as the Department standard integration broker. This tool is an any-to-any mapper that allows for excellent flexibility in accepting and managing electronic files. The messaging capabilities of Cloverleaf can be utilized to address several business needs.
*Arrows indicate the direction of data flow. Arrows are labeled indicating what type of data follows that specific path.
Quest/Labcorp through agreement with CDC, transmit HL7 messages to CDC Router.
Reporting Entity – This is any origination point of a lab report. Private and public labs would qualify as reporting entities. Reporting Entities such as laboratories and hospitals, send laboratory test results directly to DOH in HL7 format.
CDC Router accepts HL7 test results and routes Florida test to DOH Cloverleaf Integration Broker
Labs and hospitals unable to send HL7 messages will enter test results into DOH developed Web interface. Web reporting application will route messages to the DOH Cloverleaf Integration Broker
HL7, LOINC, SNOMED are DOH Standards for Electronic Laboratory messaging.
Quality Assurance checks at CDC. Before routing to DOH Cloverleaf Integration Broker reject reports have been cleared or removed by CDC.
Quality Assurance checks at Integration Broker. Before routing to individual Program databases rejected reports have been cleared or removed per protocol to be developed by DOH.
DOH Cloverleaf Integration Broker and application interfaces. Transformation of data from originating sources delivered to applicable program databases.The integration broker accepts, interprets, and forwards the lab results to the appropriate destinations.
Message Repository-Holding area for message processing.
Data Quality Summary- Information collected on the quality of data submitted to the integration broker is shared both with the provider and with the program areas for quality improvement.
NEDSS Base System-Messages are routed through NEDSS Base system and then to the individual program components.
Lab results sent electronically to applicable program databases.
Receiving database for electronic lab results
Receiving databases for electronic lab results with Disease Control.
Note: this model has been updated from that developed in the ELR/JADs. The update includes a link from the Cloverleaf engine to the CDC NEDSS "base system." It is possible that FDOH program managers will elect NOT to employ the NEDSS base system (which could happen if Merlin were used as the base system) in which case design of another data flow diagram will be required