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) led the Public Health Tiger Team (PHTT) initiative as part of ONC’s Standards and Interoperability Framework. The PHTT strived to streamline resources and consolidate meetings in an effort to increase efficiency and communications among partners, including 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 (external link), ISDS 2014 Conference Abstract (external link), and ISDS 2015 Conference Abstract (file download).
With challenges faced and lessons learned, significant progress was made, and the PHCP grew into the Digital Bridge (external link), a national governance model for systems change, bringing together software vendors, public health, and healthcare. More about this transition can be found in this Journal of Public Health Management and Practice March 2018 article (external link) and this Public Health Reports 2016 article (external link).
In June 2016, the Digital Bridge governance body also prioritized the eCR use case and facilitated and managed select pilot sites to implement infrastructure to support bidirectional communications between public health and healthcare. More about these implementation sites is included below.
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, the Council of State and Territorial Epidemiologists (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 2019, eCR continues to move forward as it transitions out of the Digital Bridge initiative into operations supported by the Association of Public Health Laboratories (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, healthcare provider, and data provider/EHR company. California, Houston, Kansas, Massachusetts, Michigan, New York, and Utah were pilot sites, and details of the participants are below.
Houston Health Department
The Houston Health Department (HHD) (external link) 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 CSTE, HHD has been engaged in eCR 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 (external link) 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 throughout the Houston metropolitan area; and one long-term acute care hospital. Houston Methodist also includes a research institute; 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 (external link) is a national leader in healthcare software development and 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 company for the New York implementation site.
Kansas Department of Health and Environment (KDHE)
KDHE’s (external link) 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 worked 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 (external link) is the healthcare 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 an estimated 1,800 associates and 250 physicians serving northeast Kansas.
Cerner Corporation
Cerner’s (external link) 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 organizations in managing the health of their populations. From 2014 to 2016, Cerner participated in ASTHO’s PHCP and eCR 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 company 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) (external link) 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 (external link) is the public health partner for the Michigan implementation site. In 2016, MDHHS participated in ASTHO’s PHCP eCR pilot project, where they tested sending eICR test messages for chlamydia, pertussis, salmonellosis, and gonorrhea to the Michigan Health Information Network Shared Services (MiHIN) using Direct Secure Messaging. Previously, MDHHS staff have been involved in CSTE-sponsored workgroups to define eCR content for public health referrals and develop the eCR Toolkit.
Michigan Health Information Network Shared Services (MiHIN)
MiHIN (external link) is the state-designated entity that 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 (external link)and NYC DOHMH (external link) 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 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 set the foundation for RCKMS and engaged in focus groups. NYSDOH staff 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 eICRs. These will be freely available to other jurisdictions at the conclusion of the implementation project.
Institute for Family Health
The Institute for Family Health (external link) serves a critical role as a primary care provider for New York City residents, providing medical, dental, and behavioral healthcare 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 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 (external link) is NYSDOH’s healthcare 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 healthcare. Upstate focuses on the most prevalent human diseases, including cancer, diabetes, and infectious diseases, and serves more than 1.8 million people.
Epic Systems
Epic (external link) is a national leader in healthcare software development and 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 company for the New York implementation site.
Utah Department of Health (UDOH)
UDOH (external link) 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, including gonorrhea, chlamydia, HIV, and syphilis. UDOH has also been involved in past eCR-related activities that include serving as a pilot site for the 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 evaluating the implementation guide and trigger criteria for gonorrhea and chlamydia in 2016.
Intermountain Healthcare
Intermountain Healthcare (external link) 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 healthcare provider for the Utah implementation site.
Cerner Corporation
Cerner’s (external link) 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 organizations in managing the health of their populations. From 2014 to 2016, Cerner participated in ASTHO’s PHCP and eCR 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 company for the Utah implementation site.
