Syndromic Surveillance: Insights into Healthcare Policy

Health Monitoring Systems is discovering that syndromic surveillance can also provide a rich source of information for public policy. Recently an American College of Emergency Physicians (ACEP) study found that ER physicians believe they are busier now than they were before implementation of the Affordable Care Act’s individual mandate. The study was covered in USA Today, giving it national exposure. We read the article with great interest, wondering if the data we’d collected supported the physicians’ perceptions.

So we peeked at the data collected inHMS1A-pg1-WEB-OPTIMIZED EpiCenter, comparing the same ERs reporting quarter-by-quarter from California to New Jersey.   That data shows that the ACEP survey was indeed correct; most facilities had more visits after the inception of the individual mandate than before.   But—and this is significant—for most facilities we looked at, there were fewer visits than in 2012.  So, why the belief that more people were coming into the ER? And what does the ACA have to do with the perceived increase?

We reached out to the author of the USA Today article, healthcare reporter Laura Ungar, to learn more about the policy implications of what ACEP’s respondents believe to be going on in ERs across the country.  Ms. Ungar explained that ACEP doesn’t have recent data related to physicians’ perceptions.
And that too is significant.  Public health departments operating syndromic surveillance systems have unique insight into healthcare utilization—insights not available elsewhere.

The peek at our data showed that from 2014 to 2015, out of 324 ERs that reported consistently in that period, 254 (78%) saw an increase in visits. By contrast, from 2012 to 2015 only 42.7% (117 of 274) of ERs had increased visits. Variation like that seems to indicate something is happening beyond the ACA’s individual mandate, which took effect on January 1, 2014.

HMS1A-pg2-WEB-OPTIMIZEDThat said, the effect of the Affordable Care Act on emergency departments is a real concern.  The promise of increased health insurance coverage is that emergency department usage for non-urgent visits will decline.  The theory goes that the uninsured population uses the emergency department as a surrogate for a primary care physician.  But for this promise to be fulfilled, the uninsured  —who live mainly in lower-income urban or rural areas with poor access to healthcare options — need access to more healthcare options.   That won’t happen overnight.

A deeper look at emergency department visits shows that the ACA’s individual mandate and the expansion of Medicaid may not be the only factors affecting ER visits and physician perceptions:

  • Through the 2000s, a long-term trend in ER visits resulted in an increase of over 35% from 2000 to 2010.
  • At the same time, the number of ERs decreased by nearly 10%.
  • Urgent care centers, which can be a substitute for ERs, have multiplied: from none in the 1980s, there are now some 9,000 facilities in the United States, about twice the number of hospitals.
  • The Oregon Study [http://www.nber.org/oregon/] showed that the newly insured Medicaid patients used emergency departments at a rate 40% higher than average.
  • For the four years after the 2008 economic downturn, healthcare spending was at its lowest level in five decades; this was due to changes in the economy, not the ACA.
  • Part of the ARRA, Meaningful Use requirements ushered in the era of EMR. The results are an increase in non-patient-related administrative tasks, making physicians even busier.

There’s no simple answer to the complex problem of ER utilization. But our data does indicate that the individual mandate in the Affordable Care Act can’t be the primary cause of rising visits by 2015.

All of this proves it’s time to rethink the role of syndromic surveillance: It’s not just a monitoring tool, but also a platform upon which the public health community can build healthcare policy.  The ACEP survey demonstrates just such an occasion.  ER physicians are concerned with the impact of the ACA on patient visits, but other factors confound their ability to understand what is affecting ER utilization.

Public health syndromic surveillance infrastructure can help address these policy concerns. No one else is as well equipped to tackle this challenging problem.

Perspective: Foreign Travel Classification

In the event of an outbreak, public health routinely strives to accurately identify all potential cases of disease. This process includes differentiating between the “worried well,” who may reference an infectious disease by name simply because it is receiving widespread media coverage, and patients who cite genuine causes for concern, like contact with an infected person or travel to a region where an outbreak is peaking. To help address these concerns, EpiCenter users in public health have requested the implementation of a foreign travel classification.
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Diagnosis Codes and Syndromic Surveillance

The long-awaited ICD-10 compliance date of October 1, 2015 is fast approaching, and we’ve spoken with many concerned physicians and technical contacts at acute care facilities about how these changes may affect EpiCenter senders. EpiCenter has been capable of accepting ICD-10 codes since the initial ICD-10 compliance date of October 1, 2013, and over the past year we have worked with dozens of hospitals and ambulatory care offices on successfully testing their syndromic surveillance feeds with ICD-10 codes.
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Welcome to EpiCenter 3.1

EpiCenter 3.1 is now live. Along with several bug fixes, there’s some new functionality geared toward making medical and triage notes reports more easily navigable.

When a cell in the report contains lengthy triage or observation notes, it was previously difficult to expand the window enough to be able to read the full text. Now, double clicking on a row will bring up a detailed report window where the full text can be browsed and even copied to be pasted outside the application.
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ISDS 2014: 'Twixt Miami and Denver

Moose ornament labeled 'Park City'Since the ISDS annual meeting is in December, every year I bring home Christmas ornaments for my kids representing the city I visited. The other night we hung 6 years worth of those ornaments on the tree–a moose from Park City, St. Louis Cathedral in New Orleans, the Constitution from Philadelphia–bringing back quite a few memories in the process.
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Philadelphia-Bound: ISDS 2014

Several HMS staff members are headed to Philadelphia next week for the 2014 ISDS Conference.

You can hear from us at the following talks:

Impact of Demographics on Healthcare Utilization
Who: Dr. Andrew Walsh
Where: Columbus Ballroom C
When: 10:30am to 10:50am on Wednesday December 10th*
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Big Changes in EpiCenter 3.0

As we’ve mentioned previously, the Health Monitoring Systems team has been hard at work on incorporating extensible data types into EpiCenter. These extensible data types include Triage Notes and Observations. Now that EpiCenter 3.0 has been released, we’re excited to share these new enhancements with our users.
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The Future is Now

“In a recent article on Venturebeat.com, an online publication covering tech news, Bryan Sivak, CTO of the Department of Health and Human Services, was quoted as saying: ‘Wouldn’t it be great if the CDC could be immediately alerted if a patient showed up at a clinic somewhere with a temperature of 104 degrees, and who recently traveled to West Africa?'”
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The Peculiarity of Ebola Policy

The impulse to implement a travel ban to African countries is understandable. Essentially, it is taking the concept of quarantine to what seems like to be its logical conclusion.

In 2003, the SARS outbreak provided a deadly precedent to the Ebola threat that we now face, and the handling of the SARS outbreak provides an excellent example of how to combat a deadly and more contagious disease than Ebola.
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Visualizing the Cost of Health Care

We’ve written a lot about health care spending in the US, and about the ways we could lower costs and improve outcomes.

This nicely-designed widget from the Institute of Medicine creates  visualizations that further clarify the exorbitant costs of healthcare in the US, and also provides information on lowering costs and improving outcomes. Take a look:
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