Layout 1


ISDS Annual Conference Proceedings 2012. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

ISDS 2012 Conference Abstracts

Objective
To document the current evidence base for the use of electronic

health record (EHR) data for syndromic surveillance using emer-
gency department, urgent care clinic, hospital inpatient, and ambula-
tory clinical care data.

Introduction
Historically, syndromic surveillance has primarily involved the use

of near real-time data sent from hospital emergency department (EDs)
and urgent care (UC) clinics to public health agencies. The use of
data from inpatient and ambulatory settings is now gaining interest
and support throughout the United States, largely as a result of the
Stage 2 and 3 Meaningful Use regulations [1]. Questions regarding
the feasibility and utility of applying a syndromic approach to these
data sources are hampering the development of systems to collect,
analyze, and share this potentially valuable information. Solidifying
the evidence base and communicating the results to the public health
surveillance community may help to initiate and build support for
using these data to advance surveillance functions.

Methods
We conducted a literature search in the published and grey litera-

ture that scanned for relevant articles in the Google Scholar, Pub Med,
and EBSCO Information Services databases. Search terms included:
“inpatient/ambulatory electronic health record”; “ambulatory/inpa-
tient/hospital/outpatient/chronic disease syndromic surveillance”; and
“EHR syndromic surveillance”. Information gleaned from each arti-
cle included data use, data elements extracted, and data quality indi-
cators. In addition, several stakeholders who provided input on the
September 2012 ISDS Recommendations [2] also provided articles
that were incorporated into the literature review.

ISDS also invited speakers from existing inpatient and ambulatory
syndromic surveillance systems to give webinar presentations on how
they are using data from these novel sources.

Results
The number of public health agencies (PHAs) routinely receiving

ambulatory and inpatient syndromic surveillance data is substantially
smaller than the number receiving ED and UC data. Some health de-
partments, private medical organizations (including HMOs), and re-
searchers are conducting syndromic surveillance and related research
with health data captured in these clinical settings [2]. 

In inpatient settings, many of the necessary infrastructure and ana-
lytic tools are already in place. Syndromic surveillance with inpatient
data has been used for a range of innovative uses, from monitoring
trends in myocardial infarction in association with risk factors for car-
diovascular disease [3] to tracking changes in incident-related hospi-
talizations following the 2011 Joplin, Missouri tornado [3]. 

In contrast, ambulatory systems face a need for new infrastructure,
as well as pose a data volume challenge. The existing systems vary
in how they address data volume and what types of encounters they
capture. Ambulatory data has been used for a variety of uses, from
monitoring gastrointestinal infectious disease [3], to monitoring be-
havioral health trends in a population, while protecting personal iden-
tities [4].

Conclusions
The existing syndromic surveillance systems and substantial re-

search in the area indicate an interest in the public health community
in using hospital inpatient and ambulatory clinical care data in new
and innovative ways. However, before inpatient and ambulatory syn-
dromic surveillance systems can be effectively utilized on a large
scale, the gaps in knowledge and the barriers to system development
must be addressed. Though the potential use cases are well docu-
mented, the generalizability to other settings requires additional re-
search, workforce development, and investment.

Keywords
Syndromic surveillance; EHR; Meaningful Use

Acknowledgments

We thank the ISDS Meaningful Use Workgroup for their assistance with
the literature review, and all the presenters in the ISDS Meaningful Use
Webinar series (http://www.syndromic.org/webinars/meaningfuluse).
Work supported by CDC through ISDS contract with Task Force for
Global Health.

References

1. Health Information Technology for Economic and Clinical Health
(HITECH) Act. Title XIII of Division A and Title IV of Division B of
the American Recovery and Reinvestment Act of 2009 2009; Pub. L.
No. 111-5.

2. ISDS. Electronic Syndromic Surveillance Using Hospital Inpatient and
Ambulatory Clinical Care Electronic Health Record Data: Recom-
mendations from the ISDS Meaningful Use Workgroup. 2012.
www.syndromic.org

3. Various presenters. ISDS Meaningful Use Webinar Series: 3/1-
3/21/2012. http://www.syndromic.org/webinars/meaningfuluse

4. Pavlin JA, Murdock P, Elbert E, Milliken C, Hakre S. Conducting pop-
ulation behavioral health surveillance by using automated diagnostic
and pharmacy data systems. MMWR 2004;53 (Supp.):166-172.

*Rebecca Zwickl
E-mail: bzwickl@syndromic.org

Utility of Syndromic Surveillance Using Novel Clinical
Data Sources
Rebecca Zwickl*, Charles Ishikawa and Laura C. Streichert

ISDS, Brighton, MA, USA

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 5(1):e33, 2013