BioSense Application Training for Public Health

1
BioSense Application Trainingfor Public Health

• Division of Emergency Preparedness and Response
• National Center for Public Health Informatics
• Centers for Disease Control and Prevention

2
Overview

• Purposes of BioSense
• Initial Data, Analysis, and Visualization
• Hospital Data, Analysis, and Visualization
• BioIntelligence Center
• User Support

3
Purposes of BioSense

• Establish an electronic biosurveillance
  infrastructure
• Enhance national preparedness
• Outbreak detection and situational awareness
• Bioterrorist attacks and naturally-occurring
  disease
• Safety net for routine public health surveillance
• Promote use of technology standards

4
Initial Data Sources

• Department of Defense (DoD) outpatient Medical
  Treatment Facilities (n355)
• ICD-9 CM diagnosis codes
• CPT procedure codes
• Veterans Affairs (VA) outpatient medical centers
  and clinics (n849)
• ICD-9 CM diagnosis codes
• CPT procedure codes
• LabCorp
• Reason for test orders (ICD-9 CM)
• Diagnostic test orders

5
Initial Data Syndromes

• Data mapped to eleven syndromes defined by
  multi-agency working group
• Definitions available at http//www.bt.cdc.gov/su
  rveillance/syndromedef/index.asp
• Botulism-like
• Fever
• Gastrointestinal
• Hemorrhagic illness
• Localized cutaneous lesion
• Lymphadenitis
• Neurological
• Rash
• Respiratory
• Severe illness/death
• Specific infection

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Initial Data Analysis
MA1 7-day moving average with a 1 day lag MA3
7-day moving average with a 3 day lag s1
7-day moving standard deviation with a 1 day lag
s3 7-day moving standard deviation with a 3
day lag

• Adapted from Lori Hutwagner (CDC EARS)
• Indicates recent data value changes by comparing
  to a 7-day moving average
• Unit of analysis state or metropolitan area
• C1

7
Initial Data Analysis

• Adapted from Ken Kleinman (Harvard)
• Generalized linear (GLM) model
• 1 year of baseline data
• Individual models run for each syndrome-zip
  code-data source-day
• Includes parameters for day of week, holidays,
  day after holidays, and seasonality with an
  intercept difference for each zip code to
  calculate the expected value
• Calculates deviation of the observed count from
  the expected count
• Calculates the likelihood of observed count using
  the deviation from predicted
• Unit of analysis zip code

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Initial Data Application

• Analytical Home page
• Analytical algorithm results
• Data transmission and receipts
• Consolidated Line Graph
• Graph for each syndrome including data from all
  sources
• Syndrome Specific Views
• Line graphs
• Maps
• Tables (with access to detailed line lists of
  records)
• Sentinel Infection Alerts
• Sentinel Infection Alert records and reports
• BioWatch
• BioWatch negative laboratory test results
• Contact Us
• Contact information
• Training Schedule
• BioSense website
• Help
• In-depth documentation

9
BioSense Real-Time Clinical Connections

• Vision
• Provide health situational awareness for suspect
  illness and possible disease cases before,
  during, and after a health event
• Help confirm or refute the existence of an event
  monitor its size, location, and rate of spread
• Approach
• Real-time delivery of healthcare data to BioSense
  from hospitals, labs, and other sources
• Electronic views, analytics, and reports for
  national, state, and local public health,
  contributing healthcare organizations

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Health Situational Awareness

• Confirm or refute existence of an event
• Environmental signal
• Suspect illness
• Intelligence warning
• Known outbreak/public health event
• Monitor ongoing event and effectiveness of
  response
• Ascertain size of event
• Ascertain rate of spread
• Track efficacy of response efforts
• Monitor for adverse events
• Know when an event has passed

11
BioSense Hospital Recruitment

• Hospitals prioritized by focusing on
• Large metropolitan areas
• Top 5 emergency departments by volume in area
• Existing IT infrastructure, especially ED system
• Health systems with multiple hospitals
• Recommended by local public health

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Hospital Data Patient Populations

• Emergency Department
• Hospital Inpatient
• Ambulatory Care

13
Hospital Data Types

• Foundational demographics, chief complaint,
  discharge diagnoses, disposition, hospital
  utilization
• Clinical vitals, triage notes, working
  diagnosis, discharge summary
• Laboratory orders, microbiology results
• Pharmacy medication orders
• Radiology orders, interpretation results

Phase 1
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Hospital Data Chief Complaint

• Parse actual chief complaint into sub-syndromes
• Phase 1 is simple lookup table
• (eg n v d ? nausea, diarrhea, vomiting)
• 79 sub-syndromes
• Map sub-syndromes to syndromes

15
Hospital Data Diagnosis

• ED diagnosis may be received as
• ICD-9 codes
• Group into standard sub-syndromes
• Map ICD-9 codes into syndromes
• Free text
• Parse into standard sub-syndromes
• Map sub-syndromes into syndromes
• 79 standard sub-syndromes

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Hospital Data Sub-syndromes (n79)

• Botulism-like
• Paralysis
• Speech disturbance
• Dysphagia
• Fever
• Fever
• Septicemia and bacteremia
• Viral infection, unspecified

• GI
• Abdominal pain
• Anorexia
• Diarrhea
• Food poisoning
• Intestinal infections, ill-defined
• Nausea and vomiting

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Hospital Data Sub-syndromes (n79)

• Hemorrhagic
• Coagulation defects
• Gastrointestinal hemorrhage
• Hemorrhage
• Purpura and petechia
• Cutaneous lesion
• Insect bites
• Skin infection
• Lymphadenitis
• Lymphadenopathy

• Neurological
• Alteration of consciousness
• CNS, inflammatory disease
• Convulsions
• Gait abnormality
• Headache
• Meningismus
• Photophobia

18
Hospital Data Sub-syndromes (n79)

• Respiratory
• Asthma
• Bronchitis and bronchiolitis
• Chest pain
• Cough
• Cyanosis and hypoxemia
• Dyspnea
• Influenza-like illness
• Otitis media
• Pleurisy
• Pneumonia and lung abscess

• Respiratory (continued)
• Respiratory failure
• RSV
• Upper respiratory infections
• Hemoptysis
• Rash
• Rash
• Severe Illness and Death
• Coma
• Death
• Shock

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Hospital Data Other Sub-syndromes (Not
Classified Into Syndromes)

• Allergy
• Anemia
• Bites, animal
• Burns
• Carbon monoxide poisoning
• Cardiac dysrhythmias
• Cerebrovascular disease
• COPD
• Dehydration
• Diabetes mellitus
• Dizziness
• Edema
• Falls
• Fractures and dislocation
• Heart disease, ischemic
• Heat, excessive
• Hypertension
• Hypotension

• Injury, NOS
• Jaundice
• Malaise and fatigue
• Mental disorders
• Migraine
• Motor vehicle traffic accidents
• Myalgia
• Neoplasms
• Numbness
• Open wound
• Poisoning by medicines
• Pregnancy, childbirth complications
• Sprains and strains
• Syncope and collapse
• Urinary tract infection
• Visual impairment

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Hospital Data Disease Indicators

• Disease indicators for Phase 1
• Chief Complaint Sub-syndrome
• Chief Complaint Syndrome
• Physician Working Diagnosis Sub-syndrome
• Physician Working Diagnosis Syndrome
• Discharge ICD-9 Diagnosis Sub-syndrome
• Discharge ICD-9 Diagnosis Syndrome

21
Hospital Data Analysis

• Initial CUSUM
• Counts and rates per 1000 visits
• Units of analysis facility, MRA, state
• Patient residence zip code used only for map
• Later data analysis strategy being developed
• Different methods when counts low vs. high with
  automated switching to best method
• Several regression methods being compared

22
Hospital Data Patient ID

• BioSense Patient ID
• Used to uniquely distinguish a patient across all
  visits to a single facility, or across all visits
  to a healthcare system when a common patient
  identification system is used
• Can be used by the healthcare facility to
  associate BioSense patient data to the patients
  medical record
• No personally identifiable information

23
Hospital Data Application

• Chief Complaint/Diagnosis
• Counts for each syndrome and data type for a
  particular day
• Statistical Anomalies
• List of statistical anomalies
• Time Series
• Graph for a disease indicator
• Describe
• Descriptive statistics, create sub-groups
• Patient List
• List of patient visits, including chief complaint
  and diagnosis and demographic information
• Patient Detail
• Clinical and demographic information at the
  analysis visit level for one patient
• Patient Map
• Map distribution of patients based on residence
  zip code

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Access to BioSense

• CDC SDN digital certificate required
• Approval from public health or facility BioSense
  administrator required, including level of access
• A state or MRA view of all facility data within
  that jurisdiction available to public health
  staff
• A facility view of all data for a given facility
  (or facility group) available to hospital staff

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Near-Future Plans

• Develop a better data analysis strategy
• Census data
• National map
• Custom disease indicators and text parsing
• Multiple time series graphs
• Stratified analyses
• Spatial-temporal analysis (SaTScan)
• Additional data types (census, laboratory)
• Signal fusion and dashboard

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BioIntelligence Center

• Initiated June 2004
• Dedicated monitors examine BioSense application
  for data anomalies
• Track anomalies
• Communicate with state and local PH
• Support for state and local personnel
• System troubleshooting and enhancement

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User Support

• Technical Help Desk
• 1-800-532-9929
• Secure Data Network question
• BioSense technical support
• BioSense E-mail Address
• BioSenseHelp_at_cdc.gov
• General questions
• Additional user requests
• Problem reporting
• Suggestion for enhancements
• All feedback!