Electronic health information quality challenges and interventions to improve public health surveillance data and practice.

OBJECTIVE: We examined completeness, an attribute of data quality, in the context of electronic laboratory reporting (ELR) of notifiable disease information to public health agencies. METHODS: We extracted more than seven million ELR messages from multiple clinical information systems in two states. We calculated and compared the completeness of various data fields within the messages that were identified to be important to public health reporting processes. We compared unaltered, original messages from source systems with similar messages from another state as well as messages enriched by a health information exchange (HIE). Our analysis focused on calculating completeness (i.e., the number of nonmissing values) for fields deemed important for inclusion in notifiable disease case reports. RESULTS: The completeness of data fields for laboratory transactions varied across clinical information systems and jurisdictions. Fields identifying the patient and test results were usually complete (97%-100%). Fields containing patient demographics, patient contact information, and provider contact information were suboptimal (6%-89%). Transactions enhanced by the HIE were found to be more complete (increases ranged from 2% to 25%) than the original messages. CONCLUSION: ELR data from clinical information systems can be of suboptimal quality. Public health monitoring of data sources and augmentation of ELR message content using HIE services can improve data quality.

Tuberculosis genotyping in six low-incidence States, 2000-2003.

BACKGROUND: As tuberculosis incidence declines in the United States, a new tool for TB control efforts is Mycobacterium tuberculosis genotyping. Colorado, Iowa, Montana, New Hampshire, West Virginia, and Wisconsin began routine genotyping of all culture-confirmed TB cases in October 2000. METHODS: M. tuberculosis isolates from cases reported October 2000 through December 2003 were genotyped by spoligotyping, mycobacterial interspersed repetitive units, and IS6110-based restriction fragment length polymorphism methods. Genotyping results were linked to demographic variables from national surveillance records. Patients who were in genotype clusters were interviewed and their records reviewed to determine possible transmission links among clustered patients. Final analysis was completed during April 2004 through June 2005. RESULTS: Of 971 reported TB cases, 774 (80%) were culture-confirmed, of which 728 (94%) were genotyped. Most genotyped isolates (634 [87%]) were unique. Within 36 clusters linking 94 individuals, four clusters involved both U.S.- and foreign-born individuals. For eight clusters, genotyping results led to the discovery of previously unsuspected transmission. Transmission links between individuals were established in 21 (58%) of the 36 clusters. CONCLUSIONS: In these six low-incidence states, most isolates had unique genotypes, suggesting that most cases arose from activation of latent infection. Few TB clusters involved the foreign-born. For 58% of genotype clusters, epidemiologic investigation ascertained that clustering represented recent M. tuberculosis transmission.

Tuberculosis cases in Wisconsin: documentation of treatment improvement and completion of treatment, 2000-2002.

OBJECTIVE: In 2000, the Wisconsin Strategic Plan for the Elimination of Tuberculosis (TB) sets goals of 90 percent treatment completion and 95 percent documentation of treatment improvement for all reported cases of TB. This study measures the success in achieving these goals. METHODS: Data were abstracted from charts of all 249 reported TB cases during 2000-2002. Treatment completion was considered for patients indicated for completion in 12 months or less. Documentation of treatment improvement included therapy adherence, sputum culture conversion, and chest radiograph improvement for pulmonary cases, and therapy adherence and clinical improvement for extrapulmonary cases. RESULTS: Treatment completion was measured in 204 of 249 TB cases; 87.1 percent completed treatment in 12 months or less. There was a significant difference in completion by site of disease, 89.9 percent for pulmonary cases and 66.1 percent for extrapulmonary cases (P < .01). Documentation of treatment improvement was 61.2 percent among pulmonary cases and 83.6 percent among extrapulmonary cases (P < .01). During the study period, there was a significant decrease in documentation rates for patients with pulmonary TB (P < .01). CONCLUSIONS: The goal of 90 percent treatment completion was nearly accomplished but the goal of 95 percent documentation of treatment improvement was not achieved. Barriers to TB treatment in Wisconsin need to be identified. Case management of TB is necessary for control and prevention of TB.

Evaluation of a two-step approach for large-scale, prospective genotyping of Mycobacterium tuberculosis isolates in the United States.

Genotyping of Mycobacterium tuberculosis isolates is useful in tuberculosis control for confirming suspected transmission links, identifying unsuspected transmission, and detecting or confirming possible false-positive cultures. The value is greatly increased by reducing the turnaround time from positive culture to genotyping result and by increasing the proportion of cases for which results are available. Although IS6110 fingerprinting provides the highest discrimination, amplification-based methods allow rapid, high-throughput processing and yield digital results that can be readily analyzed and thus are better suited for large-scale genotyping. M. tuberculosis isolates (n = 259) representing 99% of culture-positive cases of tuberculosis diagnosed in Wisconsin in the years 2000 to 2003 were genotyped by using spoligotyping, mycobacterial interspersed repetitive unit (MIRU) typing, and IS6110 fingerprinting. Spoligotyping clustered 64.1% of the isolates, MIRU typing clustered 46.7% of the isolates, and IS6110 fingerprinting clustered 29.7% of the isolates. The combination of spoligotyping and MIRU typing yielded 184 unique isolates and 26 clusters containing 75 isolates (29.0%). The addition of IS6110 fingerprinting reduced the number of clustered isolates to 30 (11.6%) if an exact pattern match was required or to 44 (17.0%) if the definition of a matching IS6110 fingerprint was expanded to include patterns that differed by the addition of a single band. Regardless of the genotyping method chosen, the addition of a second or third method decreased clustering. Our results indicate that using spoligotyping and MIRU typing together provides adequate discrimination in most cases. IS6110 fingerprinting can then be used as a secondary typing method to type the clustered isolates when additional discrimination is needed.

An outbreak of bronchoscopy-related Mycobacterium tuberculosis infections due to lack of bronchoscope leak testing.

BACKGROUND: Bronchoscopy-related transmission of Mycobacterium tuberculosis is rarely reported. In August 1999, five M tuberculosis-positive bronchial washing culture findings were noted in patients who underwent bronchoscopy in July in a hospital that reported only eight M tuberculosis-positive culture findings from 1995 to 1998, prompting further investigation. METHODS: A case was defined as a M tuberculosis-positive culture finding from specimens obtained from patients who underwent bronchoscopy during January to August of 1999. Bronchoscopy and laboratory records, procedures, and practices were reviewed. M tuberculosis isolates were compared using restriction fragment length polymorphism (RFLP) analysis. RESULTS: During July 1999, 19 bronchoscopic procedures were performed in 19 patients. Bronchial washing specimens for mycobacterial culture were obtained from 18 patients. Ten cases were identified. Two case patients, including the index patient, had signs and symptoms of active tuberculosis prior to bronchoscopy. M tuberculosis infections developed in two more case patients despite starting a standard four-drug antituberculous regimen within 3 weeks after bronchoscopy. Six case patients had positive culture findings but no evidence of infection. All M tuberculosis isolates were antituberculosis-drug susceptible, and all but one were indistinguishable by RFLP analysis. Three bronchoscopes were used during the outbreak period; one bronchoscope was used in 9 of the 10 case patients (relative risk, 8.1; 95% confidence interval, 1.3 to 52). A hole was discovered in the sheath of this bronchoscope. Leak testing, a critical step in bronchoscope reprocessing, was not routinely performed at this institution. CONCLUSIONS: M tuberculosis contamination of the bronchoscope occurred during the index patient's procedure. The hole in the sheath provided access to a space that was difficult to mechanically clean and chemically disinfect. The reprocessing recommendations of bronchoscope manufacturers, including leak testing after each use, should be closely followed.