Curbside Consult with Dr. Jayne 5/4/20

Many organizations are knee deep in the process of expanding coronavirus testing. Although it has become easier to get test kits, some of us are still eagerly awaiting the rapid kits from Abbott.

One of the challenges though with adding COVID-19 testing to your scope of services is dealing with the reporting aspect. COVID-19 is a reportable disease in all public health jurisdictions. Depending on how large your organization is (and how many counties or states it serves), the reporting aspect can be daunting.

I was excited to attend a webinar last week that was presented by the American Medical Informatics Association (AMIA). They reviewed the “eCR Now” effort to broaden the use of electronic case reporting for COVID-19. From a clinical informaticist’s point of view, it was the most exciting thing I’ve seen in weeks. For those of you who were like me and hadn’t heard of it, I’ll give you the highlight reel.

Electronic Case Reporting (eCR) is the ability to automate generation and transmission of case reports from EHRs to public health agencies so that those agencies can review and act on them. Depending on the jurisdiction, that might include sending a formal quarantine order to an affected patient, performing contact tracing, or enrolling them in a daily disease tracking and/or surveillance program. Public health agencies rely on case reports for numerous diseases and conditions beyond COVID-19, from sexually transmitted infections to dog bites.

The problem for providers is that each public health jurisdiction has its own reporting process, which may range from email to fax to phone calls. Automating this process from data already in the EHR is key, both in reducing the delay in getting information to the agencies as well as receiving information back from the public health agency.

Apparently a pilot for eCR was already in the works well before COVID-19 hit our shoes. Coordinated by a collaborative of healthcare, public health, and health IT industry partners, Digital Bridge came together to solve the problem of data exchange. After some small implementations, the effort began to expand in late 2019, with sites implemented in Texas, Utah, New York, and California, plus 19 other state and local public health agencies.

Once COVID-19 became a thing, they started reporting those codes through the existing infrastructure. By the end of January, 142,000 case reports had been sent from seven implementations. The process uses HL7 standard documents to move information from providers through HIEs or other exchange frameworks to a platform that is supported by the Association of Public Health Laboratories (APHL). For public health agencies that aren’t completely integrated, the platform can render the files in HTML, which functions a lot like the faxes they previously received.

Most of the current implementers are Epic and Cerner sites, but given the importance of public health reporting for COVID-19, there is a push to move eCR capabilities into more EHRs. They’ve created a program called “eCR Now” that has three main parts:

1. Rapid implementations for cohorts of organizations that have eCR-enabled EHRs.
2. A FHIR app that non-eCR-enabled EHRs can rapidly implement.
3. Extension of the existing eHealth Exchange policy framework through a developing Carequality eCR implementation guide

As far as the accelerated implementation cohorts, what used to take 2-3 months is now taking 3-4 days. In fact, Sutter Health has issued a challenge, promising a bottle of wine for any cohort participant that can beat Sutter’s implementation record.

Organizations whose EHRs don’t support the standard can use the FHIR app, which was due (along with its source code) to be released May 1. There’s a nationwide HL7 FHIR Virtual Connect-a-thon scheduled for May 13-15. EHR vendors that don’t support the standard are being encouraged to develop the ability to trigger report generation and send data based on the standard, and state and local public health agencies are being encouraged to accept eCR instead of requiring manual case reporting. Who doesn’t love getting rid of a clunky manual process?

Needless to say, I immediately took this information to a couple of the organizations I work with, because it’s the kind of project that’s a win-win in a lot of ways. Manual reporting sucks up time that could be spent doing other things, and being able to rapidly process information about COVID-19 diagnoses and lab tests is going to be key to our management of the disease especially without a vaccine or broadly-applicable treatments. Plus, I selfishly want one of my clients to bite on the idea because I love this kind of a project – it takes me back to my first “build from scratch” project more than a decade ago, when we decided to add CCOW functionality between several applications at my health system.

I still remember the calls with Sentillion, when they agreed to give us the software development kit and I had to quickly learn about Vergence and the fact that “the vault” didn’t live in a bank. It was probably my first deep dive into the world of development, and led me to meet all kinds of wild and crazy developers and even build a friendship with my own personal “Citrix Guy.” Sure, there were many late-night testing sessions (since we didn’t have a complete test environment and had to quietly test things in production after the physicians were off the system, but before the backups and billing runs started) and probably too much alcohol, but it was a really fun time that I will always remember.

Technology moves on. Microsoft bought Sentillion, all those developers are now working at other places, and CCOW has mostly gone the way of the dodo as healthcare organizations either move onto monolithic platforms that handle everything or instead move the data around through interfaces.

I’m hoping I get to work on an eCR project and that it continues to grow well beyond COVID-19 and into the realm of all the other reportable diseases that require complicated manual reporting. Many of us believe healthcare is entering into a time of massive transition, and we’re going to need lots of tech to get us through.

Anyone looking for an ex-CCOW expert that likes to play with FHIR? Leave a comment or email me.

Email Dr. Jayne.