The Surveillance, Informatics and Epidemiology Triangle

By Linda R. Greene, RN, MPS, CIC

The last decade has brought unprecedented changes in healthcare delivery. Although there has been continued development of new devices, drugs and techniques, the major change for those in infection prevention and epidemiology is to identify, manage and use clinical data to provide important information leading to early recognition of disease including prevalence and risk factors for infections, in and across multiple healthcare settings. The potential for more rapid identification and dissemination of important information extends from public health to the individual organization level.(1)

Advances in health information technology (HIT) will continue to affect all areas of healthcare from administration to clinicians and front line staff. These advances have been spurred by the enactment of The American Recovery and Reinvestment Act of 2009. This act identified three main components of what is referred to as “meaningful use.” These include the use of a certified electronic health record in a meaningful manner, the electronic exchange of healthcare information, and the use of technology to submit quality and other important information. Recommendations for stage 3 of this process include a focus on tools to measure and improve outcomes.(2)

From an infection prevention perspective, requirements for public reporting of healthcare-associated infections (HAIs), increased focus of infection prevention efforts across the continuum of care, and rapid advances in information technology have provided new opportunities for strengthening epidemiology and surveillance activities. As changes in surveillance definitions have evolved, so have the methods of surveillance, spurred by rapid advances in information technology. For example, the widespread adoption and improvements in the electronic health record (EHR) offers unparalleled opportunities to improve surveillance and epidemiology.

By definition, health informatics is a multidisciplinary field that uses HIT to improve health care by combining higher quality, higher efficiency and new opportunities. It deals with the resources, devices and methods required to  optimize the acquisition, storage, retrieval and use of information in healthcare. Health informatics tools include computers, clinical guidelines, formal medical terminologies and information and communication systems.(3)

Surveillance is a core function of public health agencies that requires timely, accurate and complete data. Electronic records offer an opportunity to improve links between healthcare providers and public health departments, making surveillance more effective and timely. Advances in health information technologies, including the EHR systems, electronic laboratory reporting (ELR) and health information exchange (HIE), have provided public health departments with information systems and networks to automate disease reporting and surveillance. Historically, public health agencies have relied on physicians and infection preventionists (IPs) to manually report notifiable diseases following diagnosis, usually from a confirmatory laboratory test result. HIE is the electronic transfer of clinical and administrative information across diverse and often competing healthcare organizations  Several studies in public health informatics have successfully demonstrated that less manual, more automated approaches like ELR, which utilize EHR systems and HIE networks, can improve the completeness and timeliness of notifiable disease surveillance efforts.(4)

The evolving field of surveillance informatics presents both challenges and opportunities. The challenges include finding efficient and effective ways of combining multiple sources of complex data and information into meaningful and actionable knowledge (e.g., for situational awareness). As these challenges are met, opportunities will arise for faster, better and lower cost surveillance and interpretation of health events and trends.

HAIs and antimicrobial resistance are major problems in U.S. healthcare institutions. Surveillance is a critical component of prevention efforts. At the organizational level, HAI surveillance will involve the capture and use of data in existing electronic databases. These data can be used to enhance case findings, populate fields in data entry screens, detect and calculate rates of certain events and detect clusters and outbreaks. EHRs and clinical decision support systems (CDSSs) have the potential to enhance antimicrobial stewardship. These systems enable clinicians and antimicrobial stewardship programs (ASPs) to more efficiently review pharmacy, microbiology and clinical data. With the increased emphasis on antimicrobial stewardship, the ability to link antimicrobial use patterns, microbiology reports and pharmacy records cannot be understated. In addition, CDSS tools can be utilized to perform prospective audit and feedback.(5)

As such electronic systems become more advanced and robust; there are limitless opportunities for infection prevention. Currently EHRs can provide important information regarding care processes and implementation of evidence based practices. These process measures enhance the ability to interpret findings from outcome-based surveillance and lead naturally to focused prevention efforts.

One logical next step is to leverage the electronic health record to identify key risk factors for the development of certain infections in individual patients, thereby identifying patients at risk and pre-emptively implementing preventive strategies. Infection surveillance will certainly undergo dramatic changes over the next few years as it transitions from a paper or partially automated system to a fully automated system. With these changes will come both opportunities and challenges. Each organization’s infection control program is unique based upon the demographics of the patient population and scope of services provided, but the expectation is that each is based on sound epidemiologic principles.

Given the pace of change, it is essential that informatics principles be widely understood if IPs are to develop the capacity to manage and utilize information systems to address HAIs and other adverse events. As technology leads to changes in surveillance and data reporting, IPs can focus their efforts towards data analysis, education, collaboration and implementation of evidence based interventions. As the field of healthcare informatics continues to evolve,  the IP should be involved in adoption efforts at local, regional, and national levels to leverage the opportunities created by current health IT initiatives.(6) This will ensure that IPs are engaged in leveraging technology and helping to create the roadmap for tomorrow.

Linda R. Greene, RN, MPS, CIC, is manager of infection prevention at Highland Hospital, an affiliate of the University of Rochester Medical Center.

References:
1. van Mourik MS et.al. Automated surveillance for healthcare-associated infections: opportunities for improvement  Clin Infect Dis July 2013;57;1: 85-93.
2.  http://www.hrsa.gov/healthit/meaningfuluse/stage1clinicalquality/whatis.html/. Retrieved Oct.16, 2015
3.   http://www.cdc.gov/mmwr/preview/mmwrhtml/su6103a5.htm/. Retrieved Oct.14, 2015
4. http://www.cdc.gov/ehrmeaningfuluse/index.html/. Retrieved Oct.19, 2015
5.  Forrest G, et.al.  Use of Electronic Health Records and Clinical Decision Support Systems for   Antimicrobial Stewardship CID 2014:59 (Supp3): S122- S133
6.  Atreja A, et.al. Opportunities and challenges in utilizing electronic health records for infection surveillance, prevention, and control AJIC; 36; 3: S37- S46