eCR Overview

What is Electronic Case Reporting?

Electronic Case Reporting (eCR) is the automated generation and transmission of case reports from electronic health records (EHRs) to Public Health Agencies (PHAs) for review and action. eCR reduces the burden on healthcare providers to accomplish their reporting requirements to public health and improves the timeliness and completeness of case reports at the local, state, and national levels.

Reporting diseases and conditions of interest to public health by healthcare providers in required by law in all US States and Territories.  Requirements of this reporting vary by /disease/condition as well as by public health jurisdiction. Historically, healthcare providers must identify that their patient has a disease/condition of interest to public health, create a reportable condition case report using time-intensive manual processes (e.g., written reports, fax or mail) and submit the report to the appropriate PHA. This has lead to significant underreporting and therefore, delayed identification of events that require public health intervention, such as dangerous disease outbreaks. 

History of eCR

From 2013 to 2015 both the Centers for Disease Control and Prevention (CDC) and The Office of the National Coordinator for Health Information Technology (ONC) lead the Public Health Tiger Team (PHTT) Initiative as part of the ONC’s Standards and Interoperability Framework. The PHTT strived to streamline resources and consolidate meetings in an effort to increase efficiency and communications among our partners to include PHAs, public health organizations, federal partners, and vendors as an effort to promote and strengthen public health promotion by leveraging technologies and standards.

From 2013 to 2016 the Association of State and Territorial Health Officials (ASTHO) convened public health partners as part of the Public Health Community Platform (PHCP).  The PHCP was a community-led initiative to provide shared infrastructure, services, and applications to the public health community as solutions for complex public health informatics problems. The initiative established a governance structure led by an executive committee representative of the public health practice community, which included eCR as one of the use cases and defined an approach for implementation. More about PHCP efforts can be found in this ASTHO Press Release March 2015, ISDS 2014 Conference Abstract, and ISDS 2015 Conference Abstract.

With challenges faced and lessons learned, significant progress was made and the PHCP grew into the Digital Bridge, a national governance model for systems change, bringing together software vendors, public health, and health care. More about this transition can be found in this Journal of Public Health Management and Practice March 2018 article and this Public Health Reports 2016 article

In June of 2016 Digital Bridge governance body also prioritized the eCR use case and facilitated and managed select pilot sites to implement infrastructure to support bi-directional communications between public health and health care.  More about these implementation sites is included below.

Below please find some artifacts created by the Digital Bridge initiative

During these different initiatives, the importance of needing public health standards to support eCR became apparent.  During the summer of 2015, CSTE convened a taskforce to develop the minimum data elements required for public health surveillance, becoming the starting point to develop a standard message for eCR. Following this work, in September of 2015 Health Level Seven International (HL7) agreed to take on eCR as a project and first balloted the electronic Initial Case Report (eICR) standard in January 2016, increasing the level of participation and diversity of comments from all across different public health domain areas.

Where We Are Now

In August of 2019, eCR continues to move forward as it transitions out of the Digital Bridge initiative into operations supported by APHL, CDC, and CSTE to open implementation for other interested partners. For more about this team please visit the About Us page on this website.

eCR Initial Implementation Sites

To effectively test the technical approach, Digital Bridge coordinated eCR implementations at selected pilot sites through August 2019. Each site included a PHA, a healthcare provider and a data provider/EHR vendor. California, Houston, Kansas, Massachusetts, Michigan, New York, and Utah were pilot sites and details of the participants are below.

California Department of Public Health (CDPH)

CDPH is the public health partner for the California implementation site. Dedicated to protecting the health and well-being of residents in California, CDPH employs practices and initiatives that support infectious disease control and prevention, chronic disease prevention, environmental health safety, and public health laboratory services. On a mission to advance public health surveillance and reporting in California, CDPH has prioritized and actively engaged in electronic case reporting to serve as a model for future states and territories implementing eCR.

UC Davis Health System

The only academic health center in the Sacramento region, the UC Davis Health System includes four primary entities: UC Davis School of Medicine, Betty Irene Moore School of Nursing, UC Davis Medical Center and UC Davis Medical Group. Its core operations span four main functional areas, including education, health care, research, and management, facilities and operational support. These focused activities support UC Davis’ mission to educate health care practitioners, conduct research on various health issues, and provide patient care and public service. UC Davis Health is the health care partner for the California implementation site.

Epic Systems

Epic is a national leader in health care software development and electronic health record (EHR) systems, supporting some of the largest integrated health systems in the world. Its suite of services centers on all aspects of patient care, including registration, scheduling, billing, and clinical systems for care providers. Epic serves as the health IT vendor for the California implementation site.

Houston Health Department

The Houston Health Department (HHD) is dedicated to working in partnership with the community to promote and protect the health and social well-being of all Houstonians. HHD is a nationally accredited local public health department with an expanding informatics capacity. As a pilot site for the reportable conditions knowledge management system (RCKMS) supported by the Council of State and Territorial Epidemiologist (CSTE), HHD has been engaged in electronic case reporting activities since 2014. HHD participated on the content development team to build standardized machine-processable reporting specifications, assisted in the development of federal and local disease reportability logic sets, and tested the initial version of the RCKMS authoring tool. In addition, HHD collaborated with the Public Health Informatics Institute (PHII) to pilot tools that were part of the EHR toolkit to advance hepatitis C surveillance. HHD is the public health partner for the Digital Bridge Houston pilot site.

Houston Methodist

Houston Methodist is one of the nation’s leading health systems and academic medical centers. The health system consists of seven hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, six community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area. Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care, emergency care and imaging centers; and outpatient facilities. Houston Methodist employs more than 20,000 people and had more than 810,000 outpatient visits and more than 100,000 admissions in 2017.

Epic Systems

Epic is a national leader in health care software development and electronic health record (EHR) systems, supporting some of the largest integrated health systems in the world. Its suite of services centers on all aspects of patient care, including registration, scheduling, billing and clinical systems for care providers. Epic serves as the health IT vendor for the New York implementation site.

Kansas Department of Health and Environment (KDHE)

KDHE’s primary public health services include disease control and prevention, epidemiology, public health informatics and community health systems. The public health partner for the Kansas implementation site, KDHE previously worked with a state health information exchange (HIE) to automate the transmission of patient health records using diagnosis codes to match reportable infectious diseases. Although this process still included manual data entry, KDHE recognized the value of automation and will work to improve this approach as an eCR implementation site. KDHE staff have also been actively involved in eCR standards development work.

Lawrence Memorial Hospital (LMH)

Lawrence Memorial Hospital is the health care partner for the Kansas implementation site. Established in 1921, LMH is a nonprofit hospital whose purpose is to be a partner in lifelong health. LMH has approximately 1,800 associates and 250 physicians serving northeast Kansas.

Cerner Corporation

Cerner’s health technologies connect people and information systems at more than 27,000 contracted provider facilities worldwide dedicated to creating smarter and better care for individuals and communities. Recognized globally for innovation, Cerner assists clinicians in making care decisions and assists organizations in managing the health of their populations. From 2014-2016, Cerner participated in ASTHO’s Public Health Community Platform and electronic case reporting initiatives by providing guidance on the requirements, architecture and overall strategy on approaching eCR. They demonstrated these efforts at the 2016 Public Health Informatics Conference (PHIC), leveraging the APHL Informatics Messaging Service platform (AIMS). Cerner is the health IT vendor for the Kansas implementation site.

Massachusetts Department of Public Health/Bureau of Infectious Disease and Laboratory Sciences

The public health partner for the Massachusetts implementation site, the Massachusetts Department of Public Health (MDPH), Bureau of Infectious Disease and Laboratory Services (BIDLS) was an early adopter of eCR efforts. MDPH, in collaboration with Harvard Medical School’s Department of Population Medicine, was awarded a Center for Excellence in Informatics to support development of ESP (EHR Support for Public Health), an open source application that can extract and analyze data from EHRs for public health surveillance. Through this project, Massachusetts has accumulated significant experience managing and using data sent from EHRs. BIDLS staff have also participated in CSTE workgroups that focused on eCR standards development.

BIDLS has a robust technical infrastructure supporting integrated infectious disease surveillance activities. These components include the MAVEN surveillance and case management system and the Health Information Reporting Portal, the conduit for all electronic laboratory reports, reports from ESP and the city of Boston’s surveillance system. Massachusetts has 100 percent of its eligible hospitals and the majority of reference laboratories submitting electronic laboratory reports, constituting 98 percent of ELR data, and is now focused on efforts to support eCR expansion.

Michigan Department of Health and Human Services (MDHHS)

MDHHS is the public health partner for the Michigan implementation site. In 2016, MDHHS participated in ASTHO’s Public Health Community Platform eCR pilot project where they tested sending eICR test messages for chlamydia, pertussis, salmonellosis, and gonorrhea to MiHIN using direct secure messaging. Previously, MDHHS staff have been involved in CSTE-sponsored workgroups to define eCR content for public health referrals and to develop the eCR Toolkit.

Michigan Health Information Network Shared Services (MiHIN)

MiHIN is the state-designated entity and runs the statewide network for routing electronic health information to the state of Michigan. Today, MiHIN processes more than 15 million messages per week, including more than a million public health messages weekly. The Digital Bridge approach to eCR aligns closely with Michigan’s existing approach for public health reporting, which can be leveraged to enhance two-way data exchange and increase the accuracy of case reports for infectious diseases.

New York City Department of Health and Mental Hygiene (NYC DOHMH) / New York State Department of Health (NYSDOH)

NYSDOH and NYC DOHMH are collaborating as the public health partners for the New York implementation site. Both agencies have participated in previous projects that aimed to automate infectious disease reporting using electronic health record (EHR) data. In partnership with CSTE, APHL, CDC and the Public Health Data Standards Consortium (PHDSC), NYSDOH participated in the design and implementation of a pilot project to demonstrate electronic data exchanges between clinical EHR systems and public health information systems in 2012. In 2013, NYC DOHMH partnered with the NYSDOH pilot project to expand its reporting to include pertussis data from its EHR into the NYC DOHMH surveillance system.

Both agencies have been involved in work related to RCKMS. NYC DOHMH surveillance staff provided input into the initial concepts that laid the foundation for RCKMS and engaged in focus groups; NYSDOH participated in an RCKMS workgroup to determine the criteria of reportable diseases, gather requirements regarding development of the authoring interface, and contribute test cases. In partnership, NYC DOHMH and NYSDOH are developing a web service and database to collect and store electronic initial case reports; these will be freely available to other jurisdictions at the conclusion of the implementation project.

Institute for Family Health

The Institute for Family Health serves a critical role as a primary care provider for NYC residents, providing medical, dental and behavioral health care at 26 locations in the city. As NYC DOHMH’s health care partner for the New York implementation site, the Institute has a strong interest in case reporting and has produced various publications that demonstrate the value of their work on related disease reporting projects. Its past electronic reporting work to public health includes syndromic influenza-like illness data, chronic disease indicators, improved detection of reportable diseases in the EHR, and provider alerts in outpatient EHRs.

SUNY Health Science Center at Syracuse (Upstate)

Upstate is NYSDOH’s health care partner for the New York implementation site, and it is the only academic medical center in central New York. Its mission is to improve the health of the community through education, biomedical research and health care. Upstate focuses on the most prevalent human diseases, including cancer, diabetes, and infectious diseases, and serves over 1.8 million people.

Epic Systems

Epic is a national leader in health care software development and electronic health record (EHR) systems, supporting some of the largest integrated health systems in the world. Its suite of services centers on all aspects of patient care, including registration, scheduling, billing and clinical systems for care providers. Epic serves as the health IT vendor for the New York implementation site.

Utah Department of Health (UDOH)

UDOH is the public health partner for the Utah implementation site. Prior to participating in the Digital Bridge collaborative, the agency implemented a fully automated eCR process for four pilot conditions: gonorrhea, chlamydia, HIV and syphilis. UDOH has also been involved in past eCR-related activities that include serving as a pilot site for the Public Health Community Platform (PHCP) initiative in 2016 and participating in CSTE’s RCKMS focus group, testing the jurisdiction-specific reporting criteria tool. Additionally, UDOH collaborated with the Public Health Informatics Institute (PHII) on its STI eCR Expert Panel in 2015 and on evaluating the implementation guide and trigger criteria for gonorrhea and chlamydia in 2016.

Intermountain Healthcare

Intermountain Healthcare is a nonprofit health system based in Salt Lake City, Utah with 22 hospitals, a broad range of clinics and services, and 1,400 employed primary care and secondary care physicians at more than 185 clinics in the Intermountain Medical Group. Previously, Intermountain collaborated with public health authorities, a clinical decision support (CDS) vendor, and the CSTE RCKMS team to demonstrate the feasibility of using a central decision support service to determine the reportability of a clinical case. Intermountain is the health care provider for the Utah implementation site.

Cerner Corporation

Cerner’s health technologies connect people and information systems at more than 27,000 contracted provider facilities worldwide dedicated to creating smarter and better care for individuals and communities. Recognized globally for innovation, Cerner assists clinicians in making care decisions and assists organizations in managing the health of their populations. From 2014-2016, Cerner participated in ASTHO’s Public Health Community Platform and electronic case reporting initiatives by providing guidance on the requirements, architecture and overall strategy on approaching eCR. They demonstrated these efforts at the 2016 Public Health Informatics Conference (PHIC), leveraging the APHL Informatics Messaging Service platform (AIMS). Cerner is the health IT vendor for the Utah implementation site.