# Presentation: 669546

## BioSense Application Trainingfor Hospital Users

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

## Overview

- Purposes of BioSense
- Background
- BioSense real-time data initiative
- Health situational awareness
- Data
- Analysis
- Definitions
- Application modules
- User Support

## 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

## Background: Initial Data

- Department of Defense (DOD) outpatient Medical Treatment Facilities (n=355)
- ICD-9 CM diagnosis codes
- CPT procedure codes
- Veterans Affairs (VA) outpatient medical centers and clinics (n=849)
- ICD-9 CM diagnosis codes
- CPT procedure codes
- LabCorp
- Reason for test orders (ICD-9 CM)
- Diagnostic test orders

## Initial Data Visualizations(demonstration data)

- Currently, the BioSense application provides analytical results, time series, geographical, and detailed line list displays of data to assist in early event detection
- CDC staff review data on a daily basis (BioIntelligence Center)

## 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

## 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

## 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

**Notes:**
With BioSense RT we are taking a slightly different approach. 
Less emphasis on early detection of an event – thought that remains and important component -  and more on how the health care system will deal with the event.
In the midst of an ongoing event, Where are our available resources, where are the most needed?

## Target Patient Populations

- Emergency Department
- Hospital Inpatient
- Ambulatory Care

## Target 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 I**

## Preprocessing: 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

## Preprocessing: 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

## Syndromes

- Data mapped to 11 syndrome categories
- Botulism-like
- Fever
- Gastrointestinal
- Hemorrhagic illness
- Localized cutaneous lesion
- Lymphadenitis
- Neurological
- Rash
- Respiratory
- Severe illness/death
- Specific infection

## Sub-syndromes (n=79)

- 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

## Sub-syndromes (n=79)

- 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

## Sub-syndromes (n=79)

- 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

## 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**

## 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

## 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

## CuSum

- Adapted from Lori Hutwagner (CDC EARS)
- Indicates recent data value changes by comparing to a 7-day moving average
- C1<C2<C3 sensitivity

- 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

## 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

## Definitions

- Geo Area
- State or metropolitan reporting area (MRA)
- Facility
- Site of patient encounter or data source
- Facility type
- Examples: Hospital, Poison Control Center, Laboratory
-  Data type
- Examples: All visits, Chief complaint, Physician working diagnosis, Discharge ICD-9 diagnosis
- Patient class
- Examples: Emergency Department, Ambulatory Care, Inpatient
- Event type
- Examples: Syndrome, Sub-syndrome
- Event
- Examples (syndrome): Respiratory, Gastrointestinal
- Examples (sub-syndrome): Abdominal pain, Allergy

## Definitions

- 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 patient’s medical record
_**No personally identifiable information**_

## Application Modules and Purpose

- 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

## 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

## User Support

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