Hospital Alerting for Syndromic Surveillance: COVID-19/SAR-CoV-2

Added 7/29/21

Yes, MDH continues to monitor trends, changes, and potential outbreaks of COVID-19 through the ADT data, along with using these data in reports and response efforts that provide situational awareness.

Added 7/29/21

Hospitals and health systems can opt-in to participate in the CDC NSSP via one of two vendors – Audacious Inquiry or Koble. These vendors send all ADT visit data to the CDC NSSP following the syndromic surveillance messaging requirements. The NSSP feed may replace the current ADT feed for COVID-19 surveillance, resulting in an enhanced ADT feed to MDH for syndromic surveillance. This would result in one syndromic surveillance feed from a health system going to two locations: CDC NSSP and MDH. This is currently being piloted by health systems in MN. The CDC NSSP feed includes data on all visits (i.e., the COVID and COVID-like diagnosis code filter is removed), and it also continues to use only de-identified data. The CDC NSSP participation is promoted by the CDC for implementation in every state and is one of four public health reporting requirements for hospitals and health systems in the May 10, 2021, Centers for Medicare & Medicaid Services (CMS) proposed rules effective January 1, 2022. Refer to Federal Register: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Proposed Changes to Medicaid Provider Enrollment; and Proposed Changes to the Medicare Shared Savings Program.

Updated 5/4/20

As part of Minnesota's overall surveillance efforts, MDH urgently needs data that tells us more about who is seeking care in a hospital setting for symptoms that may be related to COVID-19. This syndromic surveillance effort requires MDH to be able to compute "ratios" of the volume of inpatient and emergency department patients presenting with COVID or COVID-like symptoms as a function of total daily emergency department and hospital patient volume. This will enable monitoring of hot-spots as social distancing policies are adjusted and assist in the state's response effort.

MDH is utilizing an existing service to support this activity. Prior to the COVID-19 pandemic, beginning a few years ago, the Department of Human Services (DHS) funded the Encounter Alert Service (EAS) infrastructure to support statewide care coordination. MDH has been working with DHS to leverage this existing EAS infrastructure to fulfill the syndromic surveillance use case since more than half of the hospital capacity in MN (as measured by licensed beds) already participates in EAS. Therefore, MDH has asked that all MN hospitals participate in the EAS, by sending ADT data to EAS for all patients. Then, EAS can filter the ADT stream for COVID and COVID-like diagnoses, and send MDH ADT messages data that does not include names, addresses, or date of birth. EAS is also providing MDH information about the total number of visits in order to compute the "ratios" described above.

Added on 4/24/20

Yes, this information is encrypted at MDH. Therefore, the exception to consent requirement is met.

Situational Awareness results from the process of active information gathering to assess health threats, as well as health system and human services resources, health-related response assets, and other information that could impact the public's health to inform decision making, resource allocation, and other actions.

Syndromic Surveillance is public health surveillance that emphasizes the use of near real-time pre-diagnostic data and statistical tools to detect and characterize unusual activity for further public health investigation. Syndromic surveillance systems may be utilized for outbreak-specific situational awareness to further characterize an outbreak beyond initial detection and notification processes, to monitor the spread of an outbreak, and/or to monitor the effectiveness of outbreak response and intervention strategies. These data help public health officials detect, monitor, and respond quickly to local public health threats and events of public health importance.

This data is currently being used by MDH to identify trends in COVID-19-related symptoms and chief complaints through emergency department and inpatient hospital visits (through admission, discharge, and transfer data).

As the COVID-19 pandemic progresses, it is possible that MDH will update its inclusion criteria for syndromic surveillance. At this time, the current syndromic surveillance inclusion criteria include:

• Influenza Like Illness
• Pneumonia
• COVID (includes COVID, virus identified, virus not identified)
• Coronavirus
• COVID exposure
• Cough
• SOB
• Fever
• Sore throat
• Muscle ache
• Headache
• Diarrhea
• Loss of smell and taste
• Fatigue/malaise

These criteria may be updated as more information is learned about COVID-19.

At this time, MDH is focusing on Minnesota-based hospitals only. A future phase could include hospitals in other states or other settings, but our priority now is to connect Minnesota hospitals.

These facilities are excluded from this data submission.

Updated 5/4/20

MDH will use the following data elements in the ADT messages:

• Presented symptoms, diagnosis, sending facility, patient age, gender, race, ethnicity, city, zip code, county, event and admit date and time, and possibly census tract.
• Patient name, address and birth dates will not be included in the data submitted to MDH.
• Reports will be aggregated to a level where patient identity will be protected.
• Reports will be aggregated to a level where individual facility names will be protected.

Audacious Inquiry will receive the admit diagnosis and update the ADT if that diagnosis changes.

The Minnesota Department of Health has the authority to collect the data under Minnesota Statute, section 144.05, subdivision 1. Specifically, it says:

“The state commissioner of health shall have general authority as the state's official health agency and shall be responsible for the development and maintenance of an organized system of programs and services for protecting, maintaining, and improving the health of the citizens. This authority shall include but not be limited to the following:

(1) conduct studies and investigations, collect and analyze health and vital data, and identify and describe health problems;”

Because of the provisions in HIPAA that allow for personal health information to be shared for public health purposes and because the Minnesota Health Records Act allows exceptions for consent when there is specific authorization in law, hospitals do not need to obtain consent for the sharing of this information with the Minnesota Department of Health.

Minnesota Statutes, section 144.293, subdivision 2 states:

Subd. 2. Patient consent to release of records. A provider, or a person who receives health records from a provider, may not release a patient's health records to a person without:
(1) a signed and dated consent from the patient or the patient's legally authorized representative authorizing the release;
(2) specific authorization in law; or
(3) a representation from a provider that holds a signed and dated consent from the patient authorizing the release.

That information is related to mandated case reporting and case follow-up for those patients; this information would not be part of the ADT feed – the information is different and for two different purposes.

MDH will be working with the Minnesota Hospital Association to understand the number of requests and to look for ways to align and streamline those requests when possible.

Updated 5/4/20

Audacious Inquiry will do the filtering on all ADTs. It's important for MDH to get the denominator, so Audacious Inquiry needs the entire feed. Audacious Inquiry will delete the others but keep the denominator for reporting data to MDH to ensure that MDH is able to have information on the rate of COVID-like illness among those going to the hospital.

Updated 5/4/20

Audacious Inquiry and Koble-MN will do the filtering for several reasons:

• It is important to have the denominator for surveillance purposes.
• Having the source sites do the filtering will also create additional custom work for Audacious Inquiry and Koble-MN.
• While COVID-19 is the current focus for this surveillance effort, public health has many ongoing and rapidly changing surveillance needs.
• Both Audacious Inquiry EAS and Koble-MN also support other HIE use cases and initiatives for which a basic, unfiltered ADT feed is essential (for example, the CMS e-Notification Condition of Participation or DHS's alerts for IHP beneficiaries to improve care coordination).

Covered entities are not required to make a minimum necessary determination for public health disclosures that are required by other law. See 45 CFR 164.512 (b)(1)(i). More information about disclosures for public health activities can be found at HHS: Disclosures of Public Health Activities.

Submissions begin as soon as possible and will likely continue for the next year for this first phase. Any future phases will be determined at a later date.

MDH recognizes the unique burden on hospitals on this time. While it is the goal of MDH to get to 100% adoption to support our syndromic surveillance efforts, we understand that implementation will take some time. We are hopeful that all hospitals can make this a priority as soon as practical, and we hope to build on existing connectivity in the next month.

No. This is generally a concern with exchanging from Provider-to-Payor, but not Provider-to-Provider or Provider-to-Public Health.

For example, regional and area reporting for a given region or city would be useful for planning across systems for surge in COVID patients. We may just need separate operational planning tool for us to coordinate tracking and surge across systems in given areas but could benefit from this data feeding back to an operational model for that planning.

MDH is also working on developing data systems for health care capacity. MDH will look at what can be done to support those efforts as well as determining what syndromic data can be provided back at the community level.

Hospitals will continue to report lab results for public health as they have been. Syndromic surveillance is a separate tool for a separate purpose.

There should not be any additional work or manual abstracting beyond the standard ADT feed.

Non-COVID data would be purged a couple of days after the initial message to ensure the most up to date information is used for analysis.

This syndromic surveillance activity is a separate use case from event alerting services. However, sharing the hospital and emergency room ADTs will set up an organization to add the event alerting service for care coordination use case at a near future date. Recent federal regulations will require all hospitals to begin sending event notifications (ADTs) within the next year for care coordination purposes. This public health opportunity will help your organization also meet that federal requirement.

Because this work is specific to COVID-19, MDH will make this a top priority to get executed as quickly as possible. We are working to get new grants executed in two weeks or less time. Moving the grant agreement quickly is dependent on hospital staff availability for review of the grant agreement and the signature process.

No, this will not replace those mandated reporting for suspect and confirmed COVID-19 cases.

MDH is still working on the analysis plan for the data; however, facility or patient identities will not be disclosed.

The data being collected for this syndromic surveillance activity will include inpatient and emergency department ADT information. The other settings are also useful information, but at this time, MDH is prioritizing the hospital ADT data.

Hospitals should reach out to Audacious Inquiry or Koble-MN to either 1) update their current participation agreement to include all ADTs for this syndromic surveillance use case, or 2) start a participation agreement and establish a plan to get connected to either Health Information Exchange Service Provider. As stated in the letter, grant funds are available for organizations wanting funding to make this connection. After the participation agreement is signed and the interface is put in place, hospitals will work with their vendor to confirm data quality and to align as needed to COVID-required coding inclusion criteria.

Updated 5/4/20

At this time, MDH is focusing only on COVID-19 syndromic surveillance. It may be possible to use this approach in the future for other related activities, but that will require additional planning after MDH's COVID-19 response has slowed down. The COVID-19 information collected for this syndromic surveillance activity will not be used for any other syndromic surveillance. The reason for expanding to other diagnoses would be to streamline data collection for data that MDH is already collecting for other emerging public health threats and would be used to help minimize the burden of reporting by hospitals.

Audacious Inquiry will work with the current participants to update the policies which are incorporated into the agreement and Business Associate Agreement.

Please contact Audacious Inquiry for more information.

Added 5/4/20

Hospitals do not need to obtain patient consent to share this information with the Minnesota Department of Health because HIPAA allows for personal health information (PHI) to be shared for public health purposes and the Minnesota Health Records Act allows exceptions for consent when there is specific authorization in law.

Specifically, 45 CFR § 164.512 (b)(1)(i) allows hospitals to use or disclosed PHI for public health activities and purposes to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease. HIPAA doesn't apply to us getting it. Minn. Stat. 144.293, subd. 2 (Minnesota's Health Records Act) also allows the release of patient records if there is a specific "authorization" in law, and 144.05 and 45 CFR 164.512(b)(1)(i) provide that authorization.