State Electronic Disease Surveillance Systems --- United States, 2007 and 2010

State Electronic Disease Surveillance Systems --- United States, 2007 and 2010Weekly
October 21, 2011 / 60(41);1421-1423

The National Electronic Disease Surveillance System (NEDSS) is a web-based infrastructure for public health surveillance data exchange between CDC and the 50 states (1). In 2007, the Council of State and Territorial Epidemiologists (CSTE) conducted an assessment to evaluate states' electronic disease surveillance capacity (2). In 2010, CSTE conducted a follow-up assessment to evaluate the operational status and progress of integration, interoperability, and capacity of state electronic disease surveillance systems. This report summarizes the results of that assessment, which indicated a 17.5% increase from 40 states in 2007 to 47 states in 2010 with fully operational general communicable disease (GCD) electronic surveillance systems, a 211.5% increase from 13 to 39 states in the number of systems that were interoperable, a 22.4% increase from 23 to 34 states in the number with integrated systems, and a 20.0% increase to 42 states with the capacity to receive electronic laboratory reports (ELRs). New Centers for Medicare and Medicaid Services rules for meaningful use of health information technology encourage data exchange between electronic health record systems and public health agencies, including submission of ELRs (3). To meet national goals for health information exchange to improve population health, variation in disease surveillance systems should decrease, and functionality should increase.

In 2009, an ad hoc CSTE working group developed a questionnaire to assess progress in electronic disease surveillance system development, functionality, and capacity. Within the assessment, "integrated" was defined as interconnected systems or applications (which can include modules) that shared a common database and user interface and "interoperable" was defined as the ability of two or more electronic systems to exchange and use information. In February 2010, the questionnaire was distributed via an online survey to NEDSS coordinators and state epidemiologists in all 50 states and the District of Columbia; representatives of all 50 states responded (47 NEDSS coordinators and three state epidemiologists). Respondents also were asked to identify the development source for their electronic disease surveillance systems, indicating whether they were 1) state developed, 2) commercial off-the-shelf (COTS), 3) CDC developed, or 4) hybrid (state developed combined with COTS or CDC developed).

In 2010, a total of 47 (94%) states reported fully operational and implemented electronic GCD surveillance systems, a 17.5% increase in the number of states compared with 2007 (Table 1). A total of 39 GCD surveillance systems were interoperable, a 211.5% increase from 13 states in 2007.* In addition, 34 GCD surveillance systems were integrated, a 22.4% increase from 2007,† and 42 GCD surveillance systems had the capacity to receive electronic laboratory reports (ELRs), a 20.0% increase (Table 1).

COTS accounted for 24% of GCD surveillance system sources, states and CDC for 30% each, and hybrids for 16% (Table 2). Regardless of development stage, all hybrid systems were integrated and interoperable, whereas seven (44%) COTS systems were integrated, and 10 (71%) CDC-developed systems were interoperable. Weighted averages of interoperability and integration among all surveillance systems demonstrated that non--CDC-developed systems had higher levels of integration (22%) and interoperability (42%) than did CDC-developed systems (3% and 5%, respectively).

Of states responding to system-specific questions, 32 of 45 (71%) reported using CDC-developed systems for human immunodeficiency virus surveillance (Table 2). Twenty (43%) of 47 states reported their sexually transmitted disease surveillance systems were CDC developed, and 18 other states reported their systems were either state developed or hybrids. Most states with noninfectious health data surveillance systems used state-developed systems, including 12 (55%) of 22 for environmental disease and 12 (57%) of 21 for poisoning. Thirty-one (68%) of 45 responding states reported using more than one surveillance system to manage arboviral diseases, averaging 1.8 systems per state (range: 0--3). Eighteen (40%) of 45 used more than one to manage foodborne diseases, averaging 1.5 systems per state (range: 0--3).
In 2010, among GCD surveillance systems, 84% of states reported the capacity to receive ELRs, 15% to receive electronic health record data, and 47% to receive structured public health case reports. Among states with ELR capacity, 90% reported receiving at least some infectious disease laboratory reports through
ELRs, and 22 (45%) reported receiving at least half of their infectious disease laboratory reports electronically. States tended to have less capacity for noninfectious disease ELRs than for infectious disease ELRs; however, 26 (59%) reported receiving at least some noninfectious disease laboratory reports (e.g., blood lead levels) electronically. Most (72%) reported at least one system had case-management functionality, 79% reported contact-tracing functionality, and 47% reported outbreak-management capability (Table 1).

On average, states reported using 7.6 (range: 0--28) full-time equivalents for information technology, programmatic, and administrative support of electronic disease surveillance systems, with most in information technology. On average, 35% of electronic surveillance systems funding was through the federal Epidemiology and Laboratory Capacity Cooperative Agreement and 50% through the Public Health Emergency Preparedness Cooperative Agreement. More than half (58%) of states responding reported receiving no funding from state sources to maintain or develop their electronic surveillance systems.

Reported by
Kathryn Turner, PhD, Idaho Dept of Health and Welfare. Lisa Ferland, MPH, Council of State and Territorial Epidemiologists, Atlanta, Georgia. Corresponding contributor: Kathryn Turner, turnerk@dhw.idaho.gov, 208-334-5939.

Editorial Note
The ability of public health agencies to receive and manage surveillance data has improved considerably since 2007, but progress has resulted in substantial variation among states in the electronic systems used for disease surveillance. Statutes, regulations, health department priorities, resources, and information technology requirements influence all aspects of these systems (e.g., design, implementation stage, diseases and conditions tracked, functionality, and use of standards). Over time, independent decisions have produced electronic surveillance systems that range from narrowly focused disease-specific systems to systems used for monitoring a broad spectrum of conditions of public health interest.

Since the 2007 assessment, states have improved interoperability, integration, and data exchange functionality as resources have allowed; however, the need to exchange information with external partners is escalating. For continued progress in supporting national and state-level electronic data exchange priorities, continued collaboration among states combined with financial support by funding agencies must be public health priorities.

Assessment findings could not be used to evaluate fully the use of multiple surveillance systems for single reportable conditions, and system redundancy is a subject for further investigation. Higher levels of integration and interoperability in non--CDC-developed systems than CDC-developed systems most likely results from states using CDC-developed human immunodeficiency virus and sexually transmitted disease systems designed before integration and interoperability were considered priorities or as a result of constraints on programmatic funding.

The findings of this assessment are subject to at least three limitations. First, state-specific systems have been implemented independently, and quantitative measurement of functionality and capacity concepts is difficult because of a lack of universal definitions. Second, different interpretations of questions based on perspectives of the person answering the assessment questions could result in higher or lower proportions in certain response categories. Finally, although the questionnaire allowed for open-ended comments to qualify quantitative responses, these comments did not result in changes being made to the quantitative data.

By looking to states with strong ELR capacity, best practices and strategies for achieving success might be learned that could lead to similar success in states with less-developed capacity. Two important challenges to electronic surveillance system implementation identified by states were funding shortages and lack of infrastructure support (e.g., number of staff members with appropriate skill sets, training opportunities for existing staff, policies and regulations, and information technology architecture). Funding to maintain surveillance systems and employing staff members with appropriate education and skills remain ongoing challenges and areas for focus in the future.

Requirements for Stage 1 of Meaningful Use include data exchange from electronic health records to public health agencies, specifically for immunizations, reportable laboratory results, and syndromic surveillance (4). Decreased variability and increased functionality and capacity in disease surveillance systems, and increased support resources, will be required to meet the goals of national health information technology initiatives. These initiatives have amplified the need for improved surveillance system interoperability as pressure to comply with national standards for data exchange has increased. CSTE will continue to assist states in developing and using electronic disease surveillance systems and evaluating the results of those efforts.

Acknowledgments
Council of State and Territorial Epidemiologists Working Group members Hwa-Gan Chang, Sherri Davidson, Mark Conde, Jim Collins, Lesliann Helmus, Tom Safranek, Rita Altamore, Lynn Giljahn, JA Magnuson, Scott Danos, Sara Huston, Lindsay Oweida, Monica Huang.

References
CDC. National Electronic Disease Surveillance System. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/phin/tools/nedss/index.html. Accessed October 17, 2011.
CDC. Status of state electronic disease surveillance systems---United States, 2007. MMWR 2009;58:804--7.
Office of the National Coordinator for Health Information Technology. Health IT strategic framework: strategic themes, principles, objectives, and strategies. Version 31; 2010. Available at http://healthit.hhs.gov/portal/server.pt/document/911373/hit_strategic_framework_2010-04-01_pdf. Accessed October 17, 2011.
Centers for Medicare & Medicaid Services, US Department of Health and Human Services. Electronic health record incentive programs. Baltimore, MD: US Department of Health and Human Services, Centers for Medicare & Medicaid Services; 2011. Available at https://www.cms.gov/ehrincentiveprograms. Accessed October 17, 2011.

* In 2007, "interoperable" was defined as the extent to which the configuration of a surveillance system allowed exchange of information by electronically connecting various stand-alone, disease-specific modules within the state or allowed exchange of information among dissimilar systems in different states.
† In 2007, "integration" was defined as the extent to which a system included all of the separate disease modules in the same system.


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State Electronic Disease Surveillance Systems --- United States, 2007 and 2010