Using EMRs to capture public health “syndromic surveillance” data

The certification requirements for an HHS-Certified Electronic Health Record (EHR) are in the process of being defined explicitly by the National Institute of Standards and Technologies (NIST). These are the “test questions” that will be asked of EHR vendors in order deem them as Certified.

As of now, no EHR is Certified. The ONC-Authorized Certification and Testing Bodes have yet to be announced – to date, CCHIT and Drummond have expressed their interest in becoming ONC-ACTBs. However, these testing bodies aren’t the ones who come up with the “test questions” – they are more like proctors of an exam. The exam questions are defined by the feds, and are the NIST specifications.

The specific criteria come from the Interim Final Rule put forward by the Office of the National Coordinator for Health IT (ONC). These, in turn stem from the Meaningful Use proposal that was published simultaneously, and (after the 60 day comment period, which closed March 15th) is in the process of becoming finalized – we anticipate that the final rule on Meaningful Use to be published late May or early June.

The Meaningful Use specifications stem from a set of Health Outcomes Policy Priorities, from which are derived Care Goals, and (for each of these goals) are Objectives and Measures.

One of the five Health Outcomes Policy Priorities is to “improve population and public health.” Under this Policy Priority, there is only one Care Goal: to “communicate with public health agencies.” And for this Care Goal, there are two Objectives: (1) the capability to submit electronic data to immunization registries, and actual submission where required and accepted; and (2) the capability to provide electronic syndromic surveillance data to public health agencies, and actual transmission according to applicable law and practice.

This second objective, “providing syndromic surveillance data,” is a term seldom used by practicing physicians, though it is used in Public Health realms. What is meant by this, exactly?

The Centers for Disease Control (CDC) defines “syndromic surveillance” as “surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response. Though historically syndromic surveillance has been utilized to target investigation of potential cases, its utility for detecting outbreaks associated with bioterrorism is increasingly being explored by public health officials.”

In other words, the intent is to capture clinical syndromes in as real-time a way as possible from EHR data in order to detect disease outbreaks, and especially early evidence of bioterrorism. It is a use of anonymized EHR data for the public health interest – a topic we have commented on previously.

Given this population-based orientation to “syndromic surveillance,” the NIST guideline for this piece of capability in EHR Certification testing is confusing. The guideline measures an EHR’s ability to “electronically record, retrieve and transmit public health syndromic information to public health agencies” – as if entry of such data is done by clinicians in their charting. In fact, the collection of “reportable illnesses” to public health agencies is generally done based on reports, rather than a specific encounter.

The only thing that is individual-patient-based is the reporting of specific diagnoses (like tuberculosis, etc.) at the time the diagnosis is made – and perhaps the electronic reporting of these Infectious Disease Report forms to the local public health agency is what is meant by the NIST guideline. However, again, the CDC definition of “syndromic surveillance” is population-based reporting – which can be assessed by reports rather than by specific submission of Infectious Disease Reports

Historically, in a paper-based world, the only thing that public health agencies have had to go on are the Infectious Disease Reports submitted by health practitioners (when we remember to fill them out) and by laboratories (which automatically report certain positive lab tests, like positive tuberculosis cultures from sputum samples). However, with EHRs, direct access to clinical data as patient encounters occur allow for a more consistent and more real-time capture of such information (which is likely the hope of the ONC in their Meaningful Use objective). The challenge for EHR vendors is to create a system that can capture and report such items automatically, without interrupting the workflow of the clinician. More clarification from the NIST about exactly what is intended here (their language is quite vague) would certainly be welcomed.

Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.