2014.ISDS.Abstracts.Final.pdf


ISDS Annual Conference Proceedings 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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ISDS 2014 Conference Abstracts

So Long and Thanks for All the EARS: Lessons Learned 
from Tennessee’s Ongoing Syndromic Surveillance 
Transition

Caleb Wiedeman*, Tonya McKennley, Glenn Yates and Erin Holt

Tennessee Department of Health, Nashville, TN, USA

Objective
To share lessons learned in Tennessee during its transition from 

a jurisdictional syndromic surveillance system to a state-wide, 
centralized system.

Introduction
Syndromic surveillance generally refers to the monitoring of 

disease related events, sets of clinical features (i.e. syndromes), or 
other indicators in a population. Originally conceived as a tool for 
the early detection of potential bioterrorism outbreaks, syndromic 
surveillance is also used by health departments as a tool for monitoring 
seasonal illness, evaluating health interventions, and other health 
surveillance activities.

Over the past decade, the Tennessee Department of Health (TDH) 
has utilized syndromic surveillance at the jurisdictional level. These 
standalone, jurisdictional systems utilized chief complaint data 
from local emergency departments (EDs) and the Early Aberration 
Reporting System (EARS) developed by CDC. Some jurisdictions 
integrated other local data for analysis in EARS including 911 call 
center data, over the counter drug sales, and other non-traditional data 
sources. The analyses conducted on the data varied from jurisdiction 
to jurisdiction.

CDC dismantled the EARS program in 2011, prompting the need 
for a complete syndromic surveillance overhaul. TDH decided to 
implement a centralized, statewide system that would maintain all 
the capabilities that jurisdictions currently had while allowing for 
statewide data analysis and aggregation. During this implementation 
process, TDH has been balancing the short term goal of supporting 
and maintaining the existing jurisdictional systems while moving 
forward with acquiring a statewide syndromic surveillance solution 
and establishing the infrastructure to support it.

Methods
TDH supports existing EARS systems when possible. Failing 

EARS systems have been replaced with hybrid systems using Epi 
Info 7 and SAS. When possible, data transport from hospitals to 
jurisdictions and TDH is enhanced through automation with scripts 
written for Microsoft Outlook and WinSCP (a free SFTP client).

TDH is acquiring ESSENCE to serve as a long term syndromic 
surveillance solution. The ED component of the system will be 
supported with standardized, HL7 messages received through TDH’s 
electronic data interchange. Large hospital networks are being 
targeted to pilot the sending of syndromic surveillance messages until 
TDH declares readiness to receive syndromic surveillance messages 
for Meaningful Use in October of 2015.

Results
Maintenance and enhancement of the existing jurisdictional 

systems has progressed well. Although some of the solutions are 
not ideal, they have allowed for continued surveillance activities in 
jurisdictions. Raw, non-standard data from the hybrid systems will be 
aggregated using SAS and integrated into ESSENCE once available.

TDH’s acquisition of ESSENCE has been an arduous process. 
Administrative delays in the contract and information technology 
approval process resulted in nearly a year and a half internal review. 
The HL7 onboarding of hospitals has been a slow process and 
hospitals and their vendors often require long periods of time to 
respond to requests for necessary changes.

Many jurisdictions in Tennessee revisited their data use agreements 
(DUAs) and memorandums of understanding (MOUs) with local 
hospitals to ensure appropriate permissions and data elements were 
being provided. Not all of the existing DUAs and MOUs were 
appropriate for a statewide system and many agreements had to be 
rewritten. Communications with hospitals have become confused in 
some instances due to disconnect between the technology departments, 
traditional public health contacts, and members of hospital staff.

Conclusions
Moving from a jurisdictional syndromic system to a statewide, 

centralized syndromic surveillance system is a slow moving and time 
consuming process. Administrative delays have hindered our ability 
to get a solution in place rapidly and have resulted in additional work 
to reproduce failed systems.

Although aggregation and transport of existing non-standard data is 
possible, we would only recommend it for hospitals that do not have 
infrastructure for HL7 messaging. Centrally received HL7 messaging 
makes the data transport process much more efficient and removes the 
technical burden of receiving and constantly validating data files from 
our jurisdictional health departments and local hospital staff.

Clear and unified communication among regional and state health 
departments with hospitals and their corporate leadership is crucial 
in avoiding confusion and efficiently moving any agreement process 
forward.

Keywords
Surveillance system; Tennessee; Syndromic surveillance; Lessons 
learned

*Caleb Wiedeman

E-mail: caleb.wiedeman@tn.gov    

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * (1):e173, 201