Capstone Project of a Community Surveillance System in Kentucky: Evaluation of the Community Surveillance System and the HealthSIS system (Emergint technology Inc.) used in the Northern Kentucky Health Department and St. Elizabeth Hospital
Abstract . 4
Surveillance Systems Overview 5
Disease Surveillance: Responsibilities and Procedures . 6
Project Goals .. 8
Emergint, Inc. (HealthSIS) .. 9
Monthly Log .. 11
Emergent: Health Department and St. Elizabeth Interface .. 12
Performance Issues at St. Elizabeth’s Hospital 13
Questions Regarding Performance Issues at St. Elizabeth’s Hospital . 14
Performance Issues at the Kentucky Department of Health 15
Possible Solutions for Performance Issues .. 16
Using DCTS Computer Software 18
Conclusion and Recommendations .. 19
Works Cited 21
Appendix A .. 22
Abstract
The surveillance systems for hospitals are crucial for monitoring data related to health information. In order to determine that the system is working efficiently for the facility, it is necessary to periodically evaluate and make needed recommendations for modifications. Assurance of system functioning in the HIE space for access of retrieval of data results in safety, effectiveness, and quality patient care. The Center for Disease Control and Prevention has guidelines that focus on simplicity, flexibility, acceptability, positive predictive value, sensitivity, timeliness, and representativeness. The workflow of a health information management system interfaces with public health information systems to monitor community standards for care and by maintaining optimum communication and appropriate information exchange between all parties concerned, the stakeholders for patient care on every level benefit. The capstone project will evaluate the information systems at St. Elizabeth’s Hospital and determine recommendations for improvement.
Project Introduction
This project was completed with the assistance of the Department for Public Health (Frankfort), Independent District Health Department (Florence), St. Elizabeth Medical Center (Edgewood), and Northern Kentucky University, College of Informatics. The time period for the evaluation was from May 2016 to August 2016. A review of the surveillance systems at St. Elizabeth’s Hospital and the Department for Public Health were conducted in order to familiarize the appraiser with the capabilities of the software. The information technology staff for both entities cooperated in the evaluation. In the course of the evaluation, answers were sought to specific questions regarding the functioning of the software, requirements for additions, reasons for errors, and so on.
The origin of the project ideas was based on a request by the Northern Kentucky Health Department for the participation of end-users in order to conduct a case study for informational databases. In order to understand the databases, site visits to the Health Department and the facility of St. Elizabeth’s Hospital were required. Exposure to Health Level Seven (HL-7) international standards for the transfer of administrative and clinical data was necessary. The opportunity allowed comparison of HealthSIS and traditional paper processes. The Kentucky Department for Public Health in Frankfort, the Northern Kentucky Independent District Health Department in Florence, and the St. Elizabeth Medical Center in Edgewood have surveillance systems that required evaluation for functionality and performance issues. It is necessary for nformation technology departments to understand the system and whether their requirements need to be programmed in a particular language in order to translate from code. This allows the HealthSIS system to decipher the coded computer transmissions into their database.
Surveillance Systems Overview
Surveillance computer systems perform systematic handling of health care information by collecting, reviewing, analyzing, interpreting, and broadcasting the health status of a population (WHO.int). The prevention of disease and avoiding injuries is beneficial for all public health and the actions of officials are aided by computer programs and software specifically designed for that purpose. Data is provided by passive and active acquisition of information through reporting efforts of physicians, health care facilities, and local and states departments of health.
The Kentucky Electronic Public Health Record System (KY-EPHRS) is the basis of disease surveillance is the state, integrating health data from numerous sources (Division of Epidemiology and Health Planning Department for Public Health Commonwealth of Kentucky 2). It is the initial reporting center of disease for health care facilities and local health department. Based on the information provided, the staff determines if there is need for more in-depth investigation. If warranted, the data is forwarded to the state department for confirmation and if proven to be valid, is sent on to the CDC. More than $9 million was awarded to the state of Kentucky to promote an electronic health information exchange to support the evaluation and dissemination of validated data. Providers showing they are using electronic health records in a meaningful fashion to support the health information exchange began receiving incentive payments in 2011.
Disease Surveillance: Responsibilities and Procedures\
The process of surveilling the incidences of a disease is crucial for programs operating for prevention and control. Passive surveillance depends on physicians and other initial contacts
Figure 1. Reportable diseases and conditions for the state of Kentucky (Division of Epidemiology and Health Planning Department for Public Health Commonwealth of Kentucky 26-27)
In order for public health agencies to perform efficiently in the detection and tracking of hazards to the health of the community, the performance of ten essential services are necessary. They form a basis for instruments dealing with the National Public Health Performance Standards Program (CDC.gov, 2016). The necessary services include: 1) identification and solutions to health issues by monitoring health status, 2) diagnosis of health issues and community hazards followed by investigation procedures, 3) dissemination of information to educate the population concerning health problems, 4) creation of partnerships in the community to recognize and solve health issues, 5) creation of policies and development of action plans to promote community health, 6) enforcement of health regulation for protection of community health, 7) establish services that place patients with required health services, 8) provide an effective and efficient health care network, 9) conduct periodic evaluations of health care providers and health networks, and 10) conduct research into solutions for present health issues (Figure 2).
Project Goals
The following were the goals of the evaluation of the surveillance systems of St. Elizabeth Hospital and the Northern Kentucky Health Department:
Emergint, Inc. (HealthSIS)
HealthSIS is a software program developed and marketed by Emergint, Inc., a leader in the field of designing, developing, and integrating disparate computer systems (INC.com). As a service to their customers, Emergint also supplies development of full lifecycle systems and services for supporting and consulting. The vision of the company is to allow integration of large amounts of information from system not able to communicate with one another. In the past, Emergint has shown excellent performance in the technical domain at enabling
Figure 2. Ten Essential Services for Effective Public Health Maintenance (CDC.gov, 2016).
interoperability such as that needed between hospital systems and a universal health information exchange. Priority programs such as surveillance for bioterrorism, epidemic outbreaks, alert systems, and obtaining measurements for evaluating the effectiveness of healthcare measures is also supported.
It is important to note that Emergint has established relationships across various healthcare organizations as a contractor with the CDC, including the Office of Infectious Diseases, the Office of Surveillance Epidemiology and Laboratory Services, and the Division of Health and Quality Promotion’s National Health Safety Network (Kippsdesanto.com). With a solid knowledge of the systems, requirements, and operations of the CDC, Emergint has the ability to offer solutions to problems with system functioning and anticipate future issues. The capabilities of the company will also allow it to expand into other health care systems such as those used by the Food and Drug Administration, National Institutes of Health, the Environmental Protection Agency, and additional areas of Health and Human Services. For these reasons, it was decided for Kentucky health services to align with Emergint, Inc. and its HealthSIS system. The company has served St. Elizabeth’s Hospital and the Northern Kentucky Health Department since 2013.
Monthly Log
The use of a monthly log includes a description of the system to be evaluated in order to meet the following goals: List the objectives of the system, describe the health event(s) under surveillance, draw a flow chart of the system, and describe the components and operation of the system (Appendix A).
In order to address possible deficiencies in the systems, it was necessary to formulate a list of questions to assist in gathering essential information.
What is the population under surveillance?
What is the period of time of the data collection?
What information is collected?
Who provides the surveillance information?
How is the information transferred?
How is the information stored?
Who analyzes the data?
How is the data analyzed and how often?
How often are reports disseminated?
How are the reports distributed?
Emergent: Health Department and St. Elizabeth Interface
The interface created by Emergint Inc. between the Northern Kentucky Health Department and St. Elizabeth’s Hospital allows for efficient exchange of health information (Figure 3).
Figure 3. Interface pathways between the Northern Kentucky Health Department and St. Elizabeth’s Hospital
Performance Issues at St. Elizabeth’s Hospital
The following issues regarding performance at St. Elizabeth’s Hospital were considered in the evaluation of the Emergint/HealthSIS system:
Slow data download. The system requires 15 seconds to 1.5 minutes to download the
data or move around the system.
Unnecessary data exists in the system and needs to be deleted or stored in a different
Necessary case specific investigation forms for disease not embedded in the system. A process must be installed to add those resources in order to be available online for the staff to access for the investigation. The forms should have the option to be filled out online and submitted and reported electronically rather than in print.
Lack of easy and timely communication between health facilities and health
departments.
5. Lack of extra measures to control outbreaks,
6. System lack of built-in previously reported cases; noting dates of all prior reports and
diseases reported; lack of system ability to do statistical reports for up to 3 years prior
residence. These features should be added to the system in order to create more
accurate reports.
7. Determination needed on how to add more log-in and accessibility to the system by
staff.
8. More space was needed on the Epid 200 form to record full lab results.
Questions Regarding Performance Issues at St. Elizabeth’s Hospital
It was necessary for formulate a list of questions regarding performance issues with Emergint/HealthSIS at St. Elizabeth’s Hospital in order to effectively evaluate the system. The answers to the questions allowed for accurate decisions regarding recommendations.
1. Has it always been that slow?
2. If not, when did they notice it get slow? (Approximate dates are fine)
3. Is the slowness associated with any particular time of the day?
4. Does the system have the capacity to refresh? Or does it have to be shut down and restarted to download faster?
5. Is the slowness the same whether downloading a document or uploading one?
6. How often is information archived? Having too much data for the system to sift
through could affect speeds.
7. What security measures are in place? Is the slowness as a result of virus or a security
issue?
8. Is Emergint installed on systems specifically or is it a web-based system?\
9. What happens when the system crashes? Is there a back up in place? Can the data be
retrieved in case of system crash?
Performance Issues at the Kentucky Department of Health
An on-site evaluation of the Emergint/HealthSIS system and interviews with the information technology staff revealed the following information:
1. Server has crashed in the past due to running out of storage space.
2. Howard Miles (Head of IT at Northern Kentucky Health Department) deletes log files on occasion to free space, but system has limited extremely limited maintenance.
3. Server has not been updated or patches installed since it was first installed approximately 5 years ago.
4. System is not regularly rebooted due to an Emergint sequencing startup issue. This can be adversely affecting system performance.
5. The system is currently running Microsoft server software which is adversely affecting system performance and speed.
6. The system at St. Elizabeth is based on Linux, which handles forks and multiple processes far better without memory leaks.
7. System is limited to using Windows because of the EARS Excel spreadsheet
8. Emergint is written in Java and performance will suffer when running a Java Virtual Machine on a Windows based server.
9. It would be possible to switch the server to a Linux based operating system, but that would necessitate all of the macros in that spreadsheet be re-written and it would not be proprietary to Excel. This would allow the EARS spreadsheet to still function properly.
Possible Solutions for Performance Issues
Concerning the slowness of operation, it is necessary to understand which user actions are viewed as slow before addressing any performance issues. For instance, logging into the NKPHD site (1310 EDT) showed the system responds adequately for the login screen, but the Public Health -> Alerts link required approximately 30 seconds to render with 33 entries. Watching Task Manager did show a single CPU core spike to 100% for the duration of that interval. However, data volume (how many unresolved Alerts are present) directly affects the performance. The single server hosting the NYPHD site is located at the Health Department. Archive requirements related to data associated with resolved reports that are older than 1 year are archived on the first of each month. The June 2016 archive was successful. Unnecessary data examples will be supplied at a later date. It is possible the extraneous data is overloading the system and retarding operations.
With regard to system speed, at least 50% of the slowness is due to the system running on a Windows-based platform which is extremely poor when managing memory. The longer the system is running without reboot, the slower the system performance. In addition, it is not Known if the system has had any OS updates every applied. There is the question that the server may still be running Windows 2003 R2 or possibly 2008 R2. The slowness is at least partially a Windows issue. The system at St. Elizabeth’s is based on Linux which handles forms and multiple processes far better without leaking memory. Unfortunately the system is dependent on Windows to use the EARS Excel spreadsheet. There is the possibility of rewriting all the macros in that spreadsheet in order to avoid Excel proprietary rights. The Emergint system is web-based and written in Java, running under Apache Tomcat as a Servlet. Again, because this is on Windows, the JVM is not as efficient as it would be under a Linux system.
Disease-specific investigation forms are needed and the solution includes a TB form. The support of other forms was not in scope during last development cycle (2013 Q1). In addition, security measures required specific questions and concerns such as unauthorized access to the site, accessing data after a server breach, etc. These two problems hinder the staff in operating the system and need addressing. Adding users will be enabled by Administrator access (https://<server_hostname>/MyAdmin); this will allow the creation of users and roles, and assigning data access rights.
The timeliness of communication for source data that is captured by system and resides in St Elizabeth Medical Center is directly tied to lab result transmission by SEMC’s patient care systems and SEMC Infection Control personnel responding to reporting alerts within their server. Examples are needed of the measures used to control outbreaks. Historical data is obtained by executing the desired reports under Archive Reports (Public Health -> Reports – > Archive Reports). Increasing EPID 200 Lab Result space by the submitter of EPID 200 from SEMC can add any lab report information necessary. The form allows the action directly by adding details at NKPHD to submitted EPID 200, but was never previously in scope. `There is a question about the security measures in place. The slowness may be a result of a virus or a security issue. There is a possibility the system has a malware or virus on it. However, that would be more a factor of Windows and maintaining proper OS updates accompanied by efficient AV software and procedures. That is not part of the scope of HealthSIS function. The security of the data 3DES wireline transfer encryption with BLOB storage of all data lies within SQL tables. Again, once data is in the SQL tables, data security is a function of the Data Administrator to secure the tables. The data within those tables is not readable by normal SQL extraction or SELECT statements.
Using DCTS Computer Software
Data Collection and Transformation System (DCTS ) functions in the field of epidemiology to gather and alter data into formats for use by health care providers (Emergint Technologies, Inc). The software facilitates the responsibilities of public health surveillance and notification agencies, researchers, and health departments dedicated to early detection and alert services. In order to promote interdepartmental communication, there is a form available for electronic submission of reportable diseases in the state of Kentucky. The form has prompts of an open list of reportable diseases for the state and many sections electronically fill in. Facility employees have the ability to review and edit the form if needed prior to submission to local health departments.
After data is received, DCTS performs validation of the information prior to modifying it to compatible formats. This allows for rapid analysis to detect early indications of disease outbreak. In addition, the program has the ability to display and Excel version of analysis reports from the CDC, to audit all transmitted data, to send text or email alerts of incoming reports the health departments, and provide an overview of geographical locations in relation to disease outbreaks. The web portal for DCTS is accessible through Internet Explorer 6.x or newer, Firefox 1.5, Mozilla 1.6 or newer, or Safari 4.0 or newer (Emergint Technologies, Inc). Google Earth is required for geospatial observation
DCTS provides a manual for information on logging into and navigating the system. There is a need for some internal processes in the facility to be in place to prevent errors in submitting data. For instance, it is possible for more than one user to select a reportable disease simultaneously and submit a report; in this case, data may be duplicated or inconsistent. If more than one person edits a report, the initial report will be given precedent. Fields that are automatically populated or may be filled in on editing include demographic information, chief complaint, attending physician, date of onset, and sexually transmitted diseases. The more data included in the report, the better the chance coordinating software and public health agencies have in successfully investigating the cause and other pertinent characteristics of a potential public health hazard.
Conclusion and Recommendations
The recommendations for the information technology department and administration at St. Elizabeth’s Hospital are:
1. Reboot the system and dispose of extraneous data in the database.
2. Introduce the new, updated open source software under development by Tim Ellis
and Jeff Grammer to St. Elizabeth’s Hospital and the Kentucky health
3. Both health care facilities need to provide funding to pay software developers and
train more information technology consultants to maintain the system on a regular
basis.
Provide an electronic bridge connection between the EPIC information and
Emergint (HealthSIS) in St. Elizabeth to transfer the patient information and the
lab reports embedded in Emergint.
Add more accessible features to the system to include information such as new
diseases in the community.
Build the system to flag previously reported cases, noting dates of all prior reports
and the diseases reported.
Add the ability to do statistical reports for up to 3 years prior with case counts by disease
and aggregate summaries of age, gender, zipcode, and county of residence.
Works Cited
CDC.gov. (2016). CDC - Public Health System and the 10 Essential Public Health Services –
NPHPSP. Cdc.gov. Retrieved 2 August 2016, from
http://www.cdc.gov/mphpsh/essentialservies.html
Division of Epidemiology and Health Planning Department for Public Health Commonwealth of
Kentucky. Reportable Disease Desk Reference. Division of Epidemiology and Health
Planning Department for Public Health Commonwealth of Kentucky, 2006. Print.
Emergint Technologies, Inc. "Community Surveillance: DCTS User Guide". Emergint
Technologies, Inc. N.p., 2009. Web. 2 Aug. 2016.
INC.com. "Emergint Technologies: Number 3625 on the 2012 Inc. 5000". Inc.com. N.p., 2016.
Web. 1 Aug. 2016.
Kippsdesanto.com. "Welcome To Kippsdesanto – Kippsdesanto & Co. Advises Emergint
Technologies, Inc. On Its Sale to CACI International Inc.". Kippsdesanto.com. N.p.,
2016. Web. 1 Aug. 2016.
Appendix A.
Example of daily log
June 9 Log
Arrived at work 10am
Carolyn explained the steps of the workflow below:
Login to Emergint/Alerts
Look for ID received (new cases)/view/print/mark complete. (ID request is new case, ID Request is ready to print.)
There are many cases on Emergint pages that are extra build up and cannot get rid of them (that could be one of the reasons Emergint being slow).
HOW TO GET RID OF THE OLD REPORTS AND DATA ON EMERGINT?
There is a time frame to report each communicable disease depending on the type of disease (24 hrs to 5 days)
Next step is to investigate the cases.
The case specific forms are downloaded and printed from different sources.
Call the doctor’s office and ask about specifics of the patient symptoms and more.
Gather Epid 200 and the lab report. Check all the details, check with infectious disease control.
“Non-acute” means no need to report
Call the patients and educate them about what they need to carry.
Fill out the case specific form after talking to the patient.
Check the NED and Kentucky gateway for more info and resources.
Submit information to the communicable disease person online: Kentucky online gateway. Will go to state, patient will receive a #.
Notice Reviewed: means it has been looked at and is extra on the system
Not Yet Reviewed: means not looked at yet
Demographics Available: means it has been looked at
ID Received: means to print, investigate, and mark as complete. Will be deleted out of the system.
The cases on the Emergine with a long # need converting to names for review. If there are only #’s, they are extra and need to be removed, but stay in Emergint.
All lab reports received from St. Elizabeth’s should be faxed to the state.
Left work at 2pm.
