Labs Quickly Move Toward Electronic Reporting of Public Health Information

When Patricia Quinlisk, M.D., joined the Iowa Department of Public Health (IDPH) two decades ago, laboratories reported their results in a time-honored fashion: paper forms filled out by hand or typewriter. Those forms could then be folded down to the size of an envelope and mailed in—only to require more manual inputting on the agency’s side. Quinlisk, who is the IDPH’s medical director, admits that much has changed in the subsequent years. Virtually every laboratory of size now submits their data electronically—a change that has had a substantial impact on how the agency identifies and addresses potential health crises. “If you go back to the late 1980s, everything was done by hand, and entered into logbooks,” Quinlisk said. The process gradually morphed into manual entries into a computerized database, and then all-electronic submissions. That has cut substantial time from identifying and responding to potential epidemics and other public health crises, and the state of Indiana has benefited as a result. But even in the private sector, labs have been changing how data is aggregated and reported. Quest Diagnostics recently used its billions of test results and the data it has generated over the years to publish an eyebrow-raising study about the nationwide state of diabetes diagnosis under the auspices of the Affordable Care Act (ACA). Indeed, the ACA was highlighted in a recent study by the U.S. Centers for Disease Control and Prevention (CDC), which noted that funding made available from the health care reform law has also transformed the way labs transmit public data. According to the CDC, 67 percent of the 20 million or so reportable conditions submitted by laboratories were sent electronically last year. That compares to 62 percent in 2013, an increase of about 8 percent in a single year. Although the proportion of hospital-based labs submitting electronically last year was only 20 percent, that’s up from 14 percent in 2013—a nearly 50 percent increase in a single year. Large commercial laboratories still account for a large proportion of electronic transmissions—39 percent. Some states saw even more dramatic uptakes. In North Carolina in 2013, 76 percent of all laboratory reports were received electronically by the state’s Division of Public Health. That’s up from 56 percent in 2012. In Kansas, 29 laboratories were reporting electronically as of last fall, with nearly three-quarters of reports being submitted in that fashion. Those reports arrive nearly three days sooner than they did when labs fax them in—an average of 3.3 days versus six days. Not every lab is adopting so rapidly. Smaller laboratories, particularly those in rural areas, are far less likely to submit reports electronically, according to Quinlisk. Whether they will obtain the resources to do so in the near future remains to be seen. States also have to remain on top of electronic submissions to make sure the data they contain is correct. The California Department of Public Health’s CalREDIE submission system has to be monitored “to ensure that messages continue to flow correctly,” said Gil Chavez, M.D., the department’s deputy director and state epidemiologist.
Quest study Quest was able to use its own testing for diabetes to come to a stark conclusion as to how the ACA is unfolding in the United States. The New Jersey-based company analyzed the de-identified results of 434,288 of its patients who tested positive for diabetes throughout the country. Quest’s conclusion: The rate of new diabetes diagnoses rose 23 percent in states that chose to expand their Medicaid eligibility under the ACA. By contrast, the rate of diagnoses in the non-expansion states— many of them with already below-average health trends—barely changed. The conclusion was sobering: Not only is the disease in a nearly pandemic state in the U.S., but in the 20 states that have so far declined to expand their Medicaid programs, they will likely be facing a demographic time bomb in the coming years. “Our study demonstrates the value of objective insights gleaned from aggregate diagnostic data for informing population health strategies that can promote better health outcomes,” said Jay Wohlgemuth, M.D., a Quest senior vice president and chief scientific officer for research and development, in a press release. “If the lab (sector) wants to validate value of individual lab tests, we have to migrate to more health outcomes studies, and be involved with more health economics,” said Harvey Kaufman, M.D., a Quest senior medical director. Kaufman said Quest has expanded funding and staff for future research.
Iowa’s Response According to the CDC, Iowa was caught flat-footed in 2006, when there was a national outbreak of mumps. There were nearly 2,000 cases in Iowa, and handling the response required temporary reassignments of staff members and the hiring of temporary employees for data entry. We’ve always encouraged labs if they see something unusual, and that they pick up the telephone and call us,” Quinlisk said, referring to the pre-digital era. “The bigger problem is if one lab sees three (cases of) salmonella, and another saw two, they might not have realized they were seeing a piece of an outbreak.” That has changed in recent years. In 2012, the agency was able to handle sizable outbreaks of pertussis and the gastrointestinal condition cryptosporidiosis—more than 3,200 cases in total—without the need to divert any personnel or other resources. In the latter instance, the IDPH also used social media to urge the public to undergo stool testing after a sharp-eyed epidemiologist spotted a pattern in some slides that were submitted to the agency from area labs for inspection.
A Conflict Between Technology and physical Collection But as lab testing progresses, it does not necessarily mesh with more consistent physical collection of public health data. For example, the long-used stool test used to identify cryptosporidiosis allows for preservation of specimens on slides. A 2012 article in the CDC publication Morbidity and Mortality Weekly Report noted that “cryptosporidiosis collection and molecular characterization of Cryptosporidium isolates would further the understanding of U.S. cryptosporidiosis epidemiology by revealing transmission patterns and potential risk factors.” But that would also mean phasing out “the practice of preserving stool specimens with formalin,” suggesting that public health labs would not have physical slides for inspection. Quinlisk noted that the lack of physical slides also impacts salmonella reporting. The recent molecular testing method for the bacteria—pulsed-field gel electrophoresis—excludes slides that can be sent to public health agencies for study. “If the clinical lab does one of these platforms, they get a ‘yes’ or ‘no’ for salmonella, and we may never even find out,” she said. Takeaway: The Affordable Care Act and the expansion of digital technology has played a significant role in the way laboratories, collect sort and report test data.