Public health labs took advantage of a lull in new flu cases this summer by making themselves better equipped to exchange data if a widespread outbreak occurs later this year.
As of July, 11 states had successfully logged onto a communications network created by the Public Health Laboratory Interoperability project (PHLIP), a four-year-old project sponsored by the Centers for Disease Control (CDC) and the Association of Public Health Labs (APHL).
By year's end a total of 30 states could be using the resource to send test data to the CDC and to each other. PHLIP organizers hope to eventually sign up all 50 states and the District of Columbia.
For early adopters, PHLIP offers a way to automate the tedious task of reporting flu cases to federal authorities, as required by law. For some states with antiquated reporting systems, PHLIP helps liberate skilled lab personnel from the tedium of manually collecting and sending the data via fax machines or e-mails.
But automation comes with a steep price tag, especially as state and local budgets are facing deep cutbacks. Before labs can start using the PHLIP network they must have the technology underpinnings, including the ability to load and manage test results in a laboratory information management system (LIMS).
Also required is middleware known as an information broker to translate the reports into industry standard data formats, medical terminology, and disease-coding standards, such as HL7, SNOMED, and LOINC. Finally, each state agency must run the Public Health Information Network Messaging System (PHINMS), an open-source application available from the CDC.
What's the price tag? About a quarter million dollars to begin exchanging data for just one disease category, such as influenza, according to Patina Zarcone, director for informatics and institutional research at APHL.
Fortunately, the call to action spurred by H1N1 fears unleashed federal grants that have helped cover some of these costs. "Pandemic flu planning has been the driving force for where we are today when it comes to funding this infrastructure," she said.
Next steps
While 11 states can now send flu data to the CDC, PHLIP proponents have more ambitious plans. In time, the network could be used to exchange data on 15 diseases that public labs are required to report to the federal government.
And while public labs will remain the prime users, organizers hope to create a nationwide lab reporting network that also includes private labs and hospitals. APHL recently received a $2 million grant from the CDC to broaden PHLIP. "We are looking at extending the scope of PHLIP from just our world in the public health labs to include health departments and hospitals at the state level," Zarcone said.
Organizers envision a day when data will flow more easily among state health departments. One stumbling block states face is trying to manage the individual network connections and security validations of each state and government agency they want to communicate with. PHLIP officials hope a new system of network hubs will solve this headache.
The Florida Department of Health and the Nebraska Public Health Laboratory each successfully launched and tested two hubs last year. Dubbed "Route not Read" hubs, the staging areas pass lab data along the PHLIP network by reading destination information in packet headers, which means the hubs never view the actual data to determine the proper recipient. RnR hubs hold messages in queues until a state system contacts the hub and downloads any authorized packets.
"If you are on the hub, you can exchange information securely with any other partners on that hub," said Eduardo Gonzalez Loumiet, managing director of Uber Operations, which provides information integration services for several state agencies and worked with Florida on the RnR pilot.
So rather than maintaining numerous connections with multiple recipients, labs and the CDC only need to manage the protocols for exchanging information with their designated hub. Longterm plans call for creating a series of regional hubs, but for now Zarcone says the two existing hubs are able to handle current traffic loads.
Fostering collaboration
Public labs could see some additional benefits by building on this network and hub foundation. For example, the Florida Health Department is working with counterparts in Texas to create a backup system for when either agency becomes overloaded with a sudden surge in test samples from a disease outbreak or if a natural disaster like a hurricane closes down facilities.
The states are coordinating their testing policies and standardizing their LOINC coding procedures so they can easily use each other's facilities. The states have the advantage of already running the same LIMS application from LabWare.
The partnership enables Texas, for example, to enter an order and patient information into its LIMS and send the information across the PHLIP network to Florida. "Because both states would exchange patient demographics electronically no one in Florida has to input that information into their LIMS," said Grace Kubin, emergency preparedness branch manager for the Texas Department of State Health Services. "Florida just has to go through a simple check-in process to see that the actual specimen we sent them matches what they have in their database."
Once the physical specimen arrives at the Florida facility, lab technicians could run the test, enter the results into the local LIMS, and send the data securely back to the point of origin in Texas. The two states also designed the system to create a HIPAA-compliant audit trail.
"We have a chain of custody of the data and know who touched it, who modified it, and when and where it happened," said Janet Firestone, integration program manager and PHIN coordinator at the Florida Department of Health.
The Texas health department is considering its own RnR hub to facilitate communications with local hospitals. "It would allow us to talk to a hospital that's only able to develop a message in HL7 2.1 while our system is 2.3," said Kubin. "Right now they are not totally compatible, but we could use the hub as a kind of decoder box."
By avoiding testing downtime during a pandemic, the ultimate benefit of PHLIP goes beyond modernizing lab processes and achieving administrative efficiency. "If you can get to people who have a communicable disease and tell them they're contagious, you can help stop the disease from spreading," Firestone said. "That saves money all around and it improves public health." "Alan Joch
