CDC Surveillance Strategy: Improving Data Collection
and
Use in CDC Public Health Surveillance
Brian Lee, MPH
Chief Public Health Informatics Officer
Office of Public Health Scientific Services
Public Health Dynamics Lab Seminar Series
Tuesday, January 13, 2015
Centers for Disease Control and Prevention
Office of Public Health Scientific Services
Agenda
•
•
Surveillance Strategy Background and Overview
Major Initiatives




•
•
•
National Notifiable Disease Surveillance System
National Syndromic Surveillance Program (BioSense)
Electronic Laboratory Reporting
Electronic Mortality Reporting
Policy Initiatives
Innovation Initiatives
Conclusion
Office of Public Health Scientific Services (OPHSS)

The primary focus for OPHSS is about putting data and
information into the hands of public health decision makers at the
right time, right place to take action

Values
• Science
• Customer Service
• Innovative yet practical

OPHSS Office of the Director and Two Centers
• National Center for Health Statistics
• Center for Surveillance Epidemiology and Laboratory Services
Office of Public Health Scientific
Services
National Center
for Health Statistics
Center for Surveillance,
Epidemiology,
and Laboratory Services
Division of Vital Statistics
Division of Epidemiology, Analysis,
and Library Services
Division of Health Care Statistics
Division of Health Interview
Statistics
Division of Health and Nutrition
Examination Surveys
Division of Health Informatics
and Surveillance
Division of Scientific Education
and Professional Development
Division of Laboratory Programs,
Standards, and Services
CDC Strategic Directions
Improve
health
security at
home and
around the
world
Better prevent
the leading
causes of
illness, injury,
disability, and
death
Health
Care
Public
Health
Strengthen public health/
health care collaboration
6
Timely, high quality, actionable data is central to
fulfilling the 10 essential functions of public health
7
CDC Director’s Charge: Surveillance Strategy
•
The Strategy should lay out a plan to address 4 key issues:
 Improve availability and timeliness of surveillance data to CDC
programs, STLT agencies, and other stakeholders (public data)
 Advance effective use of emerging information technology
including electronic health records, mobile technologies, and
cloud computing
 Identify and amend or retire ineffective or unnecessarily
redundant CDC surveillance systems
 Maximize the effectiveness of available agency resources
devoted to surveillance and the performance and coordination of
our surveillance systems.
FY 2014 Omnibus Appropriations
•
•
Signed by President on Friday January 17, 2014
Report language: Congress requested
•
“…the Director of CDC is directed to work with State and local
health officials to submit a report to the House and Senate
Appropriations Committees no later than 180 days after
enactment of this act…
•
Due Date to Congress:
July 17, 2014
FY 2014 Omnibus Appropriations (continued)
•
Opportunities for consolidating the various data collection
systems in CDC including:
 opportunities and costs
 advantages and barriers
 projected timeline to such a consolidated data reporting system,
along with recommendations for adoption
 full consideration of a single Web-based data collection
information technology platform
•
The Surveillance Strategy will, in part, respond to the
Congressional request
FY 2015 Omnibus Appropriations
•
“The agreement commends CDC for its surveillance strategy,
and expects CDC to continue to take steps to modernize and
improve this strategy across all CDC-wide public health
programs. CDC is urged to expeditiously improve
standardization and commonality of programs across all CDC
systems, which would reduce duplication, tackle workforce
and informatics challenges at CDC, and State and local public
health agencies, and reduce the burden of participation in
surveillance.”
FY 2015 Omnibus Appropriations
•
“The agreement recognizes the efforts by CDC to develop a
plan for a single Web-based data collection IT platform for
public health. A significant need exists for an agile, cloudbased, and flexible IT platform to reduce the reporting
burden on State public health departments, and create
economic efficiencies. The agreement directs CDC to
continue to work with State and local health officials to
develop a timeline for a cloud-based and flexible IT public
health data reporting platform for CDC programs.”
What Are The Challenges?
•
CDC > 120 surveillance systems or activities
•
Silos often function, but at a cost
 interconnections, interdependencies and efficiencies not realized
 local/state health departments with a plethora of systems and
requirements
Technology
•
 slow adoption of new technologies
 insufficient workforce with the right skills in right places
•
Challenges in addressing emerging Health Information Policy issues
related to:
 electronic health records
 meaningful use standards
 interoperability requirements
13
What are the Opportunities?
 Decreased manual reporting from traditional data sources
to more automated data use and analyses from novel
sources
 Improved interoperability among jurisdictions and data
systems
 More novel partnerships/collaborations to overcome
limited public health informatics resources
 A revolution in analytics, visualization and communication
on public health data and
information
14
Goal 1: Enhance the accountability, resource use,
workforce and innovation for surveillance at CDC and
in support of STLT agencies
•
CDC Surveillance Leadership Board
 Guidance and assessments of progress toward achieving CDCs
broad strategic goals on surveillance
 Primary goal is to make recommendations to Senior Leadership
and the Director regarding strategies and cross cutting agency
gaps and opportunities on surveillance.
•
CDC Health Information Innovation Consortium (CHIIC)
 foster and promote creative solutions to surveillance challenges
in CDC programs and STLT agencies
Goal 2: Accelerate the utilization of emerging tools
and approaches to improve the availability, quality,
and timeliness of surveillance data
•
•
Strategic HIT vendor engagements
Support for innovative projects
 Small project awards (25-50K), technical support
 Guided by CHIIC
 Assist existing systems with more rapid innovation as well as
developing new approaches
Goal 3. Improve surveillance through cross-cutting
initiatives
•
•
•
•
Initiative 1. Modernize National Notifiable Diseases
Surveillance System (NNDSS)
Initiative 2. BioSense Enhancement Initiative
Initiative 3. Accelerate Electronic Laboratory Reporting
Initiative 4. Accelerate Electronic Mortality Reporting
Vision
The right data and information…
…in the right hands
…at the right time
…in the right format
To take effective public health action
18
Vision
Efficient systems that put the
right data and information…
…in the right hands
…at the right time
…in the right format
To take effective public health action
efficient
quality
access
timely
analysis
actionable
decision support
19
Modernizing the National Notifiable Disease
Surveillance System

Assuring a common language
 Using HL7 language for all reports to CDC

Developing a state-of-the art platform
 Improving data exchange services

Providing technical assistance to States
 Supporting Program Implementation
20
NMI
• 4 Message Mapping Guides (MMGs)* vetted and ready for testing.
• Generic v2, STDs, congenital syphilis and hepatitis.
• 2 MMGs under development (mumps, pertussis)
• CDC/CSTE/APHL developed TA plan; completed capacity and readiness assessment
with 14 states.
*MMGs: Summarize the data elements in messages that are shared among state and federal public health entities and enable reporting
jurisdictions to map the data from state public health surveillance information systems to CDC case notification variables.
NNDSS Data Flow from the States via DHIS to
CDC Programs – Current State
States
Labs
OMB
Approved
Data Collection
Requirements
CDC Programs
Secure Transport
Clinical
Facilities
Providers
NNDSS/DHIS
SDN
NETSS
Surveillance
information
system(s)
PHINMS
NBS
PHINMS
HL7
Programs
Programs
Programs
Common Data
Store (CDS)
NETSSified
Data
Database(s)
Full complement of data
received at CDC is not
provided to CDC Programs
NETSS Process
HL7
NBS
Integration
Engine and
Other Tools
MMWR
Process
Secure
Transport
Manual Reconciliation
NETSS
Annual MMWR Data
Reconciliation
MMWR
Report
MMWR Data
Reconciliation
Manual Reconciliation with
States/Jurisdictions
NNDSS Data Flow from the States via MVPS to
CDC Programs – Future State – Phase I
States
Labs
OMB
Clinical
Facilities
Providers
Approved
Data Collection
Requirements
NNDSS/DHIS
Secure Transport
PHINMS
HL7
Surveillance
information
system(s)
PHINMS
NBS HL7
CDCP-MVP
Reporting
and Data
Provisioning
Database(s)
HL7
MMWR
Process
Integration
Engine and
Other Tools
MMWR
Report
Secure
Transport
Ongoing Reconciliation
CDC Programs
Message Monitoring and
Reconciliation
HL7
Data
Programs
Programs
Programmatic
Analysis
Full complement of data
received by CDC is provided
to CDC Programs:
• Flat file view
• Relational view
Standards increase:
• Consistency
• Analytic Capability
• Efficiencies of Scale
Ongoing Reconciliation
Improving the BioSense System: National Syndromic
Surveillance Program



Improving data access, quality, representativeness
and timeliness
Enhancing the capabilities and technology
supporting syndromic surveillance data collection,
processing, and provisioning
Strengthening the National Syndromic Surveillance
Community of Practice to promote data sharing and
further the science and practice of syndromic
surveillance.
24
BioSense Enhancement
• Increase in participation of State level facilities
• 1,929 facilities participating
• Jurisdiction participation in MERS-related surveillance
• 15 jurisdictions total (9 states, 6 large metropolitan cities)
• 822 facilities currently represented due to voluntary participation
• Successful in reacting to a new incident (MERS), collecting data and overall
collaboration with participating jurisdictions.
• New contract this fall will expand our national and local options
• Analytics, tie in to EOC is a focus
Enable jurisdictions to implement and support
standards-based electronic data exchanges
 Increase the number of laboratories sending
reports electronically
 Improve ELR processing and us at health
departments
 Collaborate with laboratories and their laboratory
information management systems (LIMS) vendors
to improve ELR content quality and completeness
ELR Performance Objective
By 2016, 80% of laboratory reports to public health agencies (CDC, States)
will be received as electronic laboratory reports.
Estimated National Status of ELR
4000
3500
3000
2500
2000
ELR Projected Target
April 2014
2,691
2,793 2,855
2,966 2,996
3,133
3,227
2,378
62%
67%
77%
73%
80%
54%
1500
1000
500
0
2011
2012
2013
% of Volume
2014
2015
Labs Sending ELR
(10,470 Total Labs)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2016
*Anticipated results
27
% of Lab Report Volume Received via ELR
April 2014
National Total = 67%
NH
AK
WA
VT
MT
ND
OR
ID
SD
Chicago
MI
PA
IA
HI
OH
NE
NV
IL
UT
CO
KS
MA
RI
CT
NY
WI
WY
CA
ME
MN
IN
MO
NJ
DE
WV
VA
New York City
Philadelphia
DC MD
KY
NC
TN
AZ
Los Angeles County
OK
NM
SC
AR
MS
AL
GA
LA
TX
N=57 Jurisdictions
FL
0%
Total of 2
(1 state, 1 territory)
<25%
Total of 5
(5 states)
25–49%
Total of 11 (8 states, 2 cities)
50–74%
Total of 17 (15 states, 2 cities)
≥75%
Total of 21 (19 states, 2 cities)
Not Specified
Total of 2
Houston
PR
(2 states) (both states receive ELR)
28
Improve the timeliness of Electronic Death Reporting
 Creation of state-based network of enhanced electronic death
registration systems (EDRS)
 Improve physician participation with EDRS
 Improve quality of cause-of-death information on death
certificates
 Transmit specific deaths of interest/concern to State Public
Health to the state epidemiologists within 1 day of registration
 Report to NCHS 80% of all deaths occurring in a state within 10
days of the date of death
29
Where are we now?
Proportion of U.S. Mortality Records Received
Within 10 Days of the Date of the Event by Year
100
90
80
70
60
50
40
29.1
30
20
10.6
17.6
14
10
0
2011
2012
2013
Years
Target
2014 (Jan-Jul)
Proportion of 2014 Mortality Records Received (during January – July) within 10 days of
the Date of the Event by Registration Area
NH
WA
VT
MT
OR
NYC
MN
ID
NY
SD
WY
PA
IA
IN
IL
NJ
OH
WV
KS
VA
KY
MO
NC
AZ
OK
NM
TN
AR
SC
MS
AL
GA
LA
TX
AK
FL
HI
1 None
2 0%-29%
PR
VI
GU
3 30%-49%
AS
MP
4 50%-79%
5 80%+
CT
RI
DE
CO
CA
MA
MI
WI
NE
NV
UT
ME
ND
MD
DC
NVSS based P&I Mortality Surveillance will Replace
existing 122 Cities System
Mortality Surveillance Projects and Partnerships
 Rare Vaccine Preventable Disease Mortality Surveillance
and Validation
• CDC / National Center for Immunization and Respiratory
Diseases (NCIRD)
 Respiratory Syncytial Virus (RSV) Mortality Surveillance
• CDC / NCIRD
 Suicide Surveillance
• NIH / National Institute of Mental Health
 Pneumonia and Influenza (P&I) Mortality Surveillance
• CDC / Influenza Division
Surveillance Strategy Initiatives and their Relationship with
PublicHealth
Health
Reporting
Sources
Departments
CDC
Health
Departments
Sources
Lab
Clinicians
Patients
Healthcare facilities
-electronic messaging,
phone, fax, paper, mail,
interview
Lab data
(including
ELR),
vaccinations
(including
VXU), epi,
clinical
- Receive data
- Route messages/data
- Process and use by one or
more surveillance
NND
information systems
Notifications
-Manual data entry of nonelectronic data
- Receive NND messages
- Validate, parse NND
messages
- Provision NND data to CDC
programs
- CDCP
- Extract data and send
(Create message mapping
guides)
NMI
ELR, EDR, Syndromic
Surveillance
SURVEILLANCE
STRATEGY
INITIATIVES
CDC
Technical Assistance
34
Policies
•
HIT Policy Committee
 CDC now has ex officio seat on the committee
•
Report to Congress on Data systems
 Transmitted to Congress
•
CDC Surveillance Leadership Board
 Evaluate key strategic decisions/actions
 Recommendations to the director, senior leadership
CDC Surveillance Leadership Board
•
•
Lead by Chesley Richards (Deputy Director for PHSS)
Deputy Directors
 Rima Khabbaz, Robin Ikeda, Judy Monroe
•
Offices, Centers, Institutes






OD: Jim Seligman
OID: Beth Bell, Denise Cardo, Gail Bolan
ONDIEH: Judy Qualters, Dan Sosin, Rod McClure
OPHPR: Sonja Rasmussen
NIOSH
CGH
Upcoming Issues for the SLB
•
Strategic, enterprise wide recommendations and decisions
 Data standards—approaches to use of common standards to
reduce burden on STLT agencies
 Funding opportunities and announcements—requirements that
allow flexible investments STLT agencies in common platforms
 Use of data platforms vs silo’ed systems—policies and
investments that move us further toward platforms
How to Shift CDC’s Culture of Innovation?
1. Connect the
Innovators to the
Early Adopters
2. Support the
Early Adopters
to the Early
Majority
3. Shift time for
adoption curve
Roger’s Diffusion of Innovation
Innovation Activities
•
•
•
CDC Health Information Innovation Consortium (CHIIC)
Strategic HealthIT Vendor Forum
CDC Surveillance Strategy Innovation Project Awards
CDC Heath Information Innovation Consortium
Mission
•
Identify and accelerate emerging tools and approaches to
improve the availability, quality and timeliness of
surveillance data as well information and data of use for
public health, improving the information that surveillance
needs.
Mission
C/I/Os
OPHSS
Funding
STLT
Projects
Insight &
Tools
Partners
&
Vendors
Coordination &
Connection
Rapid Assessment
& Novel Projects
Validated Learning
Goals
•
Collect enhancement ideas – identify potential projects
 Identify obstacles, potential paths around
•
•
•
•
Share validated learning with peers
Encourage reuse and interoperability
Provide attention and focus on smaller, yet valuable
surveillance innovations outside of major initiatives
Convene quarterly forums, collaborate online
 Open to outside partners
 Not just informatics
CHIIC Structure
•
•
Sponsored by OPHSS Chief Public Health Informatics Officer
Advisory Board of 4 Innovation Subject Matter Experts
 Influence project review and award process
 Develop focus areas and identify potential projects
•
Quarterly Public Forum
 In person / webinar / teleconference sessions to encourage
collaborative use of innovative projects
 Share validated learning from projects in use across CDC and
STLT
•
•
•
Interactive web site community on phconnect.org
Not governance
Complement to existing innovation groups
Example Innovation Forums
•
May – 33 participants from 9
centers
 mHealth Apps
•
August – 100 participants from
14 centers
 Google Glass
•
November – 130 participants
from every center and 7 STLT
 Mortality Analysis and
Visualization
Vendor Forum Mission
•
Systematically engage surveillance vendors regarding health
IT and informatics that can advance surveillance practice and
systems.
Goals
•
•
Connect public health with vendors groups who provide
tools, services, systems, functionality and more
Open and transparent forum for multiple programs within
CDC to meaningfully discuss requirements and needs of
public health
Vendor Forum Structure
•
•
•
•
Co-sponsored with the Office of the National Coordinator for
Health IT (ONC)
Started in August 2013 to address needs of Electronic Health
Record (EHR) Meaningful Use
Expanded to address broader HealthIT topic
Monthly Public Webinar
 CDC and STLT public health need
 HealthIT Developer perspective
•
Interactive web site community on phconnect.org
Example Vendor Forums
•
February – 122 attendees
 Syndromic Surveillance Messaging Specification
•
June – 144 attendees
 ELR Snapshot Processing
•
October – 1000+ attendees, 20+ EHR vendors
 4 special sessions on US Ebola Response
 Implementing CDC clinical algorithm guidance within EHR
 Support from Medical Care Task Force
Surveillance Strategy Innovation Projects Goals
•
Identify and accelerate emerging tools and approaches to
improve public health surveillance.
•
Foster and promote creative solutions to surveillance
challenges faced by CDC public health programs and STLT
partners.
•
Share results and lessons learned across public health
community.
Surveillance Strategy Innovation Projects Goals
•
•
•
Advance innovation on a specific area related to data
collection, transport, storage, analysis, visualization, or
availability
Improve effectiveness or efficiency of existing surveillance
systems by leveraging emerging information technologies
Explore and answer a distinct question and provide
validated learning
 if successful, provide insights or tools that can be generalized to
other surveillance systems or activities; or
 if unsuccessful, provide lessons learned that can be applied to
future projects (i.e., failure can still be useful)
•
Be independently valuable, but extensible (i.e., accretive)
Surveillance Strategy Innovation Projects Goals
•
•
Share lessons learned in an easily found and reused
structure
Upon project completion, each project will share:





Program perspective of problem that is being tested
Context of the project and its stakeholders
Results and what was learned
Opportunities for reuse within other programs
Potential enhancement areas for add-on work
Surveillance Strategy Innovation Projects Structure
•
•
•
•
•
•
•
Sponsored by OPHSS to support surveillance strategy
Annual process, first class in 2014
Total portfolio - $250k
Short duration - ~3 months
Multiple small projects vs. one medium sized project
Independently valuable, but extensible (i.e., accretive)
Portfolio of small projects needing $20-50k





Extensions
Evaluations & Assessments
Experiments
Prototypes / Pilots
Minimum Viable Products
Innovation Small Project Awards
•
Share results of project





Context of the project and its stakeholders
Program perspective
Opportunities for reuse within other programs
Potential enhancement areas for add-on work
Something indexable (e.g., blog post, article, video, etc.)
2014 Project Impact
Project
Impact
Tracking Population Movement in
Emergencies Using Mobile Phone Network
Data (CGH)
Data Collection
Data Visualization
Denominator Determination
Early Hearing Detection & Intervention
(EHDI) Interoperability Pilot Site Project
(NCBDDD)
EHR Data Standards
Data Quality
Development of Data Technical Standards
and Gap Analysis and for the Paul
Coverdell National Acute Stroke Registry
30 day Follow-Up Data (NCCDPHP)
Data Collection
Data Quality
Improved Analysis
Emerging Infection Program Web Service
(NCEZID)
Reusable Software
Shared Services
Synthetic Patient Dataset for the
Determination of Ventilator-Associated
Events in Electronic Health Record
Systems (NCEZID)
Synthetic Data
Healthcare Interoperability
Data Quality
2014 Project Impact
Project
Impact
STD Analysis and Visualization Tool
(SAViT) (NCHHSTP)
Data Visualization
Reduced Development Time
Evaluation
Dietary supplement imaging in the National
Health and Nutrition Examination Survey
(NCHS)
Data Quality
Reduced Interview Time
NCHHSTP Mobile Atlas (NMA)
(NCHHSTP)
Mobile Data Visualization
Evaluation
National Antimicrobial Resistance
Monitoring Service (NARMS) WATCHPublic Access to Data on Antibiotic
Resistance in Foodborne Pathogens
(NCEZID)
Data Visualization
Open Data
Policy Engagement
2015 Project Priority Areas
•
•
Improve effectiveness or efficiency of existing surveillance
systems by leveraging emerging information technology,
and/or novel approaches
Advance innovation on a specific area related to:





Interoperability and Reuse
Analysis & Visualization
Standardization & Vocabulary
Data Access & Open Data
Privacy & Security
2015 Project Ideas
•
•
EIP / NCIPC Collaboration on preventing opioid overdoses
HHS Entrepreneur Program – Data Analytics Entrepreneurin-Residence
 Mortality Reporting Modernization
 Based in Atlanta, working with NCHS
 Connected to HHS cohort of 9 projects with CMS, FDA, ACL,
ACF, ONC
Resources
•
•
Web site - http://www.cdc.gov/ophss/chiic/index.html
Community site - http://www.phconnect.org/group/chiic
Concluding Thoughts

Population health improvement needs data that
 Triangulates health problems to produce an accurate
picture
 Helps us understand where solutions are needed
 Advances our knowledge on interventions that work
 Provides ongoing feedback on success

Many opportunities to address health, prevention
 Data
 Evidence for community/population interventions
 Joint work together
Success on the Surveillance Strategy Will…
• Reduce the burden on public health agencies
• Increase the range of data and tools for local public health
decision makers
• Set the stage for strengthening, consolidating and improving
our surveillance activities and systems
60
Final Example
•
•
•
•
NOWCAST: Chikungunya in the
Americas
PLOS One article on Chikungunya
by Michael Johansson (NCEZID) et
al
Interactive visualization available
through cdc.gov using free 3rd
party components and
consultation with OADC and CSELS
Data set available through
cdc.CDC.gov
CDC.gov link
Questions
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention
Office of Public Health Scientific Services