Missouri ESSENCE Training

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Missouri ESSENCE Training

• Public Health Event Detection and Assessment
• (PHEDA) Program
• Office of Emergency Coordination
• Missouri Department of Health and Senior Services
• [phone]
• http//www.dhss.mo.gov/ESSENCE/
• ESSENCE_at_dhss.mo.gov

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What is ESSENCE?

• Electronic
• Surveillance
• System for the
• Early
• Notification of
• Community-based
• Epidemics

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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

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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

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What is syndromic surveillance?

• Utilization of nontraditional data sources to
  detect health events earlier than possible with
  traditional methods like laboratory-confirmed
  diagnoses
• Early event detection
• Situational awareness

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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

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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

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Missouri ESSENCE Users

• Johns Hopkins University has said that ESSENCE
  is only as good as the people who monitor it
• We agree thats 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

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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

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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 EDs 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

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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 HL7 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 hospitals information system

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How do hospital data get to DHSS?

• Two defined structures are used for transfer of
  data from hospitals to DHSS HL7 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 HL7 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 HL7 messages and ASCII flat
  files are transmitted using FTP, also using our
  VPN

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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

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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

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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)

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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)

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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

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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

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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

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How is ESSENCE used in MO?
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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

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2006-2007 Flu Season Statewide
CDC Week
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2007-2008 Flu Season Statewide
CDC Week
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Two basic functions of ESSENCE

• Early event detection Alert Lists
• Detecting flagging events within syndrome groups
• 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

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Active Surveillance vs. Traditional Disease
Tracking Methods
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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

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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
• SatScan
• Used to detect geographic clusters by comparing
  number of cases within overlapping circles
• Source Johns Hopkins University Applied Physics
  Lab

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Flagging Events Variability Based on Algorithms
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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

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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

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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

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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

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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
  days data of concern to see if the alert is
  still of concern

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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

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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 dont!

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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

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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

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Medical Record Number

• ESSENCE unduplicates using Medical Record Number
• Med Rec No can be used by hospitals to obtain
  patient records
• MOHospitalNameERCC_01049308-0805601578

Patient ID
Hospital Name
Encounter ID
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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 days 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

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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

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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.go
  v/ESSENCE/Training.html

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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 doesnt help

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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

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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

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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 (n124)

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Chemical Exposure Event at a Factory
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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

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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

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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