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1. el i i A 7 gt gt l Z A 2 Bs 2 2 2 25 25 P l N en Data Normal Data Warning W Data Alert E R gap 2 T1 44524 37 89495 Gu camen Gore 4 Click anywhere on the graph to swficn to Interactive view Last Updates 03Aug12 01 36 PM Each widget has several buttons at the top right corner which allow the user to minimize the widget refresh the widget adjust the configuration of the widget or to delete the widget Time Series Graph ILI a st X Time Series Graph ILI a 60 B B nd ee ESEESE EE DESEEN NEEE px oan VERNON Rt eee ne NER M e D 2 4 m b o P Click anywhere on fe graph to swich fo Interactive view Last Updated 05 0312 01 31 PM myESSENCE tabs can be exported to a PDF file by clicking on the Export to PDF button at the top left of the page They can also be shared with other ESSENCE users by clicking on the Share Tab button at the top left of the page 48 OEE sen Tab awe Time Series Graph ILI Time Series Graph Therm Combined 60 40 20 0 2 7 A O 2 2 x A 2 ah ak V V UV V Ve e 2 2 2 v z v v o P e Data Normal Data Warning W Data Alert ning B Data Alert ons Downica Time Series Graph OTC2 Fever 0 Q 2 A o 2 2 12 Q 4 gt VOS SS V WW AU TUN E Data Normal Data Warning Data Alert Graph Opora Gowniosd Click anywhere on the graph to switch to Interactive view 49 Appendix 1 Flowchart for Analys
2. 2000 A e d T 1800 Meme S e e 1600 1400 4 1200 1000 BOO 4 00 a 4 a e ml 9 9 e9 e 400 200 0 z D o D gt 2 o gt o 2 t t t t D e o z e v T 4 e O D gt gt Deleting your saved query 1 Go into the query manager 2 Click in the checkbox next to the query you would like to delete 3 Click delete at the top of the page to permanently delete the query Saved Query Manager Expand All Groupings Collapse All Groupings Multiseries Time Series Create myAlert Edit Share Label Link Link Today Date Created Shared By Start Date End Date z Grouping Attack 4 4 Category A Agents Show Show Today 22Nov 10 24Aug 10 22Nov 10 ricin Show Show Today 08Sep11 10Junii 08Sep11 You can share a saved query with other ESSENCE users by checking the query you wish to share and then clicking on the share button at the top of the page K myESSENCE The myESSENCE feature allows the user to create multiple dashboards using the various ESSENCE data sources available in the Maryland system Each dashboard is contained in a tab These tabs work much like the tabs in an internet browser The tabs can be configured in various ways different column numbers and sizes and may contain numerous widgets including time series graphs myAle
3. GI query 2 fever andnot congestion andnot sore andnot cought and diarrhea andnot sor e andnot back andnot cough or fever andnot sore andnot cough and vomit andnot congestion Gl query 3 diarrhea or vomit andnot preg andnot pregnancy Gl query 4 vomit andnot headches andnot headache or diarrhea or abdominal pain andnot polyps andnot headache andnot high blood suger Food poisoning query food poison or food andnot NO FOOD andnot fatty food dinner andnot UNABLE TO EAT SOLID FOOD andnot CANT DIGEST FOOD andnot EATING L ESS andnot PNEUMONITIS andnot stuck andnot choking andnot choke and not hot andnot esophagus andnot allergic andnot allergy andnot tray andnot gagging andnot trapped andnot tolerate andnot throat andnot bolus andnot c onsumption andnot intake andnot tube andnot impaction andnot swallow andn 52 ot in throat andnot down or food poisoning andnot EATING LESS Skin infection query MRSA or staph infection or spider bite or skin lesion or staff infection Fever and Rash query rash and fever or chickenpox or chicken pox or measles Viral query virus andnot BRONCHIOLITIS andnot upper andnot S YNCYTIAL andnot stom ach or viral andnot S YNCYTIAL andnot stomach andnot gastritis andnot gast roenteritis andnot upper respiratory infection andnot uri andnot HUMAN IMMUNOD
4. All Triage Note Syndromes Bot_Like E Select Ten Year Age Group m Write your free text query here Regression EWMA 1 2 All Ten Year Age Groups Unknown 00 09 10 19 sa Additional Filters All CDC ILI Reporting Age Groups Is Unknown 3 00 04 Select Distribute Age Group 05 24 25 49 v All Sexes hems Select Patient Class Male Unknowon All Disposition Categories ADMIT DECEASED DISCHARGED All Distribute Age Groups Unknown 00 01 02 04 05 17 All Patient Classes Emergency Inpatient Outpatient Pre admit As Percent Query Select Start Date able Builde ESSENCE data can also be queried using words or strings of words known as free text queries To query the free text chief complaints 1 Click on query portal in the main toolbar Adv Qr 22 2 Select ED data source 3 Select a geography system a medical grouping system and a time resolution To query the free text you will need to select the chief complaint medical grouping and then click submit 4 Next in the select chief complaints field you can type in your free text chief complaint query using wildcards and Boolean operators examples of which are and andnot or The purpose of the or wildcard symbol is to tell the system that you want to see chief complaints with the word s enclosed in the plus any other w
5. as pue nasus uen e sn pue num ini nn rst tir au o rerea be es e isse ten eeaeee por e fume ee sr a res trees ER by Patient 11 Clicking on time series for an alert displays a time series graph of the number of cases over time for the particular date and syndrome you selected This is often called drilling down into the data and is a good way to see how an alert compares to baseline data and previous alerts Here is a time series graph that was generated by clicking on time series The title of the graph and other details can be changed by clicking on graph options below the time series graph ESSENCE Maryland Time Series Query name Save Query Create myAlert Add to myESSENCE Share URL Configuration Options Data Series Options Graph Daily Data Counts Data Normal Data Warning Data Alert Graph Options Download Popup Options Iime Series Data Details Map View c Data Details There are three places where you can access the data details line list view Directly below the time series graph generated in b time series above you can click on data details to see a line list of the data in your query for the entire range of dates included in your time series If you would like to see only one particular day s data details then you could either click on the data point in the graph or click the data de
6. El 8 Region 5 Red Alerts Overview 1900 Jan 01 8 18 49 AM Select Today 11 OTC Resp Med Sales Graph Time Series 1900 Jan 01 9 23 03 AM Select Today Working with your bookmarks select versus select today Bookmark Manager Expand All Groupings Collapse All Groupings Order Bookmark Name Page Date Created Select Today 3 l Grou ping unassigned 9 1 Region 1 amp 2 Graph Matrix Portal 1900 Jan 01 9 35 26 AM Select Today Fmiiz Region 1 amp 2 Red Alerts Overview 1900 Jan 01 3 29 36 AM Select Today Once your bookmarks have been saved you can click on the name of the bookmark in the bookmarks page to run the query as you created it without a change in dates For example if your selected date range for the query was from January 1 2010 to March 30 2010 this option will produce results for that same date range If you click on select today you will see the results of your query for the most recent three month period up to the most recent day Editing or deleting your saved bookmark 1 Click on the bookmarks tab in the main toolbar 2 Click on the check box next to the bookmark you wish to edit or delete or delete if you would like to permanently delete the bookmark Edit and delete are above the list of bookmarks 4 Bookmark Manager Expand All Groupings Collapse All Groupings Order Bookmark Name Page Date Created Select Today 3 Grouping unassigned 9 1 Region 1 amp 2 Graph Matrix Port
7. Region Syndrome Based Temporal Alerts Last Updated July 25 2012 8 36 AM lt D gion Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of An Reset 3 Level Sorting Region Syndrome Based Temporal Alerts ins ue Danone Resin aun Sex Sime peor res Got russi oet mesas nna ER Pas bs an jo esee ome fs fs pe 10 In the Region Syndrome view and as in most tables like this in ESSENCE you can sort alerts by any of the column headings A maximum of three columns can be sorted at a time Note The region column in the example above and in other sections of this manual has been blocked for confidentiality reasons When you log into ESSENCE you should be able to view this information Other useful features within the Region Syndrome view a Configuration Options ESSENCE Maryland Alert List Region Syndrome Based Temporal Alerts Last Updated July 30 2012 8 36 AM Data Configuration M LIENS IEEE es r Room Data by Hospital Location Emergency Room Data by Patient Location Over the Counter Chain Combined Poison Control Center Allegany MD Anne Arundel MD BALTIMORE CITY Baltimore MD Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Sub
8. myESSENCE Home AlertList myAlerts myESSENCE Event List Y Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More v Home ILT Add New Tab Add New Widget B Export to PDF Share Tab Time Series Graph My Alerts Detection My Alerts Records of Interest Map Rich Text Label 4 Choosing Time Series Graph will bring up a menu which allows the user to choose from all of the saved queries in the Query Manager At the bottom left of this menu there is another drop down list which allows the user to adjust the time frame for the time series graph The user can choose the dates that the query was saved with by choosing Default Saved Query Default Saved Query Show Last 90 Days End Date to Yesterday End Date to Today Start Date One Year From Today Start Date Six Months From Today The following is an example of a myESSENCE dashboard for influenza like illness surveillance Widget Options Legionela 3UJUmz ugani U3ADpFIZ A E foodborne D4Apr12 035ep11 035ep11 F Overdose Final 04Juni O Now11 Of Now 1 E OTC2 Gl HI 30Jun12 31Jul11 115ep11 OTC3 GI HI 30Jun12 31Jul11 115ep11 P Psychologicalz 30Jun12 214ug11 045ep11 F Waterborne 30Jun12 2ohMay 1 264ug11 E Respiratory Issues 01Jul12 24Jun12 30Jun12 E HEAT FINAL 18Jul12 01Jun12 18Jul12 vPDs 2 18Jul12 19Apr12 18JuH2 E T
9. 1 It is important to keep in mind the data source ED and poison control data and the various kinds of disease outbreaks that you might expect to see given the context of these data For instance in EDs you will see some percentage of patients who lack another source of health care and as a result utilize the ED for that purpose and those who truly have a health emergency or are at least very concerned about their health for whatever reason 2 The way patients present to the ED for example has to be in such a way that our attention is drawn to these visits One way is for the number of observed ED visits for a given syndrome to exceed the expected value by some statistically significant margin For follow up to occur we also often like to see some other kind of clustering in the data e g by zip code or age or geographic location in addition to the increased overall count A second way to draw attention to specific visits is related to what is said in the chief complaint text For instance if a specific disease name is mentioned or if a group of seemingly related patients all mention food poisoning or something similar Getting Started The secure ESSENCE website can be accessed by going to https essence dhmh maryland gov Please add this website to your list of trusted websites Logging on 1 Click on the link in the middle of the page to begin accessing ESSENCE ESSENCE Site This Information is for Authorized use on
10. 3 ESSENCE Maryland Map Portal No Comments Available Map Configuration CUTS MERE DT FEN Map Configuration Help The Full Data Map shows a map with all available datasources for the chosen time period This will map the raw data associated with the datasource Each data layer is accompanied by a corresponding detector layer which will Full Data Map Type Description show any alerts for that datasource c per Te Decor At Maps mp vi Tenpora and Spi Desc Aers for nen ine pid Start Date Choose a Start Date to filter the data that will be displayed on the map Choose a End Date to filter the data that will be displayed on the map CUTEM 777 7050 RR G The map portal is where the user can map statistical alerts temporal and spatial 39 across the different data sources When you click on the map portal link a map configuration page loads From this page the user can select what data source they are interested in seeing in the alert list selection list The outcome selections then change as appropriate when the user selects a given data source Examples include 1 Region Syndrome this option shows the user counties where there were temporal alerts for a selected syndrome If the user selects more than one day in the date range the map will map the alert with the lowest p value 2 Hospital Syndrome this option shows the user hospitals where there were temporal alerts for a selected syndrome If the user sel
11. By clicking on a cell within the data matrix you will see a table with hyperlinks for ESSENCE to create a time series graph data details line list map view or an alert list Remote Query ox pue e Cc m Add Add URL to Comment No Comments Available v ESSENCE Maryland Matrix Link Portal ER by Patient Time Series Data Details Map View Alert List 4 By selecting the time series option you can see the time series for the last three months of available data including the time period selected within the matrix portal By selecting data details not shown ESSENCE will produce pie charts bar charts and a line list of the chief complaints data for the specific day you clicked on in the data matrix This view would be similar to any data details page By selecting the map view not shown you will see a map for the specified syndrome and day you 36 clicked on in the data matrix By selecting the Alert List option not shown you can view more details about the syndrome alerts for the day you picked in the data matrix Data Series Options Graph Daily Data Counts o 1 A o FT S w 4o J a oU S 2d S d vs i QU yr WS e E Data Normal Data Warning W Data Alert Graph Options Download G WEEKLY PERCENT Weekly percent allows a user to view graphs of percent ED visits for one of the available medical grouping options by week
12. ESSENCE will generate can contain up to 30 000 cells at a time and will look similar to this 17Nov09 292 19 802 2417 11 694 180 772 Tr 247 2230 206 Clicking on data details would produce pie charts bar graphs and a line list of the data Clicking on overview portal will take you to the following screen Overview Parameter Overview Parameter Region ofthe Hospital Submit Here you could click on the drop down menu to select a variable by which to stratify the data For example if you select region of the hospital ESSENCE would stratify the data by county and produce 24 graphs each representing a county jurisdiction in Maryland 3l Creating a bookmark for your query Once you have run a query you can bookmark that query so that you don t have to go through all of the steps each time You can do this by typing in the name you would like to give the query and clicking on bookmark page in the top left corner of the page below the main toolbar Bookmark Name Bookmark Page You can access your bookmarks later by clicking on the bookmarks tab in the main toolbar Free text chief complaint queries Sourc Emergency Room Data by Patient Location Medical Grouping System ChiefComplaints Time Resolution Dai Current Data Query Selections Next Selections Select Triage Note Syndrome Allegany MD Anne Arundel MD BALTIMORE CITY MD Baltimore MD Y
13. OVERVIEW PORTAL o ESSENCE Maryland R Y 4 b Home Alertlist myAlerts myESSENCE Event List f Overview Portal J Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More Y Alert List Overview portal allows a user to examine multiple time series graphs for the previous three months a default time frame Some of the parameters for which these time series can be created are region of the hospital county syndrome and medical subgrouping The medical subgrouping option enables the user to view graphs by sub syndrome Sub syndromes are clinically defined subgroupings of the 11 main ESSENCE syndromes There are two main ways to get to the overview portal One way is through the query portal and the other is through the overview portal tab in the main toolbar To access the overview portal through the query portal 1 Click on query portal in the main toolbar 2 Select your desired data source option 3 Next choose a geography system a medical grouping system and a time resolution 4 Inthe next screen make all necessary selections and change the date range if need be then click on overview portal at the bottom of the page 5 Once the graphs appear on the screen you may go back and change your previous selections by clicking on the plus sign next to configuration options 25 ESSENCE Maryland Overview D sw Query Options Add Timeseries to m
14. This function also works for OTC medications sales You can choose one or several options in each category year category or medical grouping data source geography and age group For geography region stands for Maryland s health and medical regions Selecting aggregate by any of the fields will combine the different options for that particular category into one producing one trend line instead of several for the same variable For example if you click on aggregate next to age this will collapse the different age categories 00 04 05 19 etc into one group for your analysis As an example let s look at a graph of influenza like illness in Maryland for the past three years To do this 1 Click on the weekly percent tab in the main toolbar ENCA D ESSENCE Maryland Matrix Portal Home Alert List myAlerts myESSENCE EventList Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More v 2 Holding the control key down on your keyboard mouse over 2012 2011 and 2010 in the year field 37 3 Select ILI from the category field 4 Click on the emergency room data by patient location data source option This is the only available data source in weekly percent 5 Select Maryland from the geography field 6 Holding the control key on your keyboard down mouse over all the age groups and then check the aggregate check box
15. and click on show graph below the page ESSENCE Maryland Multi Year Weekly Percentage Graph Select All elect All Deselect All Emergency Room Data by Patient Location E Over the Counter Chain Combined alanis All Deselect All Region Deselect All Region Ill Region IV Region V F elect Al The graph produced will show the proportion of total weekly ED visits that are due to ILI for the state of Maryalnd for the three year period Weeks run from Sunday through Saturday in weekly percent 38 ESSENCE Maryland Multi Year Weekly Percentage Graph Select a Different Graph Weekly Percentage of Visits 3 75 3 50 3 25 3 00 2 75 2 50 2 25 2 00 1 75 1 50 YN 1 25 b 1 00 Pert 9 e e 2 0 75 as a 0 50 0 25 0 00 Percent Wi ou e T e w Mo E Week of Visit er ILI Maryland AGG 2012 er ILI Maryland AGG 2011 Wi er ILI Maryland AGG 2010 Graph Optiond Download ev Graph shows proportion of total weekly cases seen in a particular syndrome subsyndrome over the total number of cases seen Weeks run Sunday through Saturday and the last week shown may be artificially high or low depending on how much data is available for the week To change your previously selected options click on select a different graph above the time series graph and this will allow you to make your changes H MAP PORTAL Add to Comment j AENA Re
16. 24 7 contacts is tested on a quarterly basis using call down drills through the Maryland Health Alert Network MD HAN See Appendix B All members of the DHMH Office of Preparedness amp Response staff are included in the call down drills including the epidemiologists responsible for 24 7 coverage of the ESSENCE system See 4 4 4 6 Health Department Staff Alerts The epidemiologists at DHMH are responsible for the ESSENCE program review alerts daily and if an ESSENCE alert is determined to have public health significance the appropriate individuals within DHMH and or local health departments are contacted for follow up Alerts are conducted through MD HAN Members of senior staff at the Health Department including the Health Officer Deputy Health Officer Emergency Preparedness Director and Director of Communicable Disease receive real time alerts from HAN 4 7 Retrieving ESSENCE Data The Harford County Health Department has one username and password for accessing the web based system https essence dhmh maryland gov This system provides the Health Department with access to the following information Alert lists Data queries Statistical analysis of data sets Reports in the form of maps time series charts and tables HCHD Policy ADMIN 00 08 Page 2 of 2 Appendix A Maryland Department of Health and Mental Hygiene Office of Preparedness amp Response ESSENCE User Guide Version 2 0 October 2012 This should be conside
17. E CITY MD BALTIMORE CITY MD Baltimare MD E Baltimore MD E All Tnage Note Syndromes Bot_Like E Bot Like E Fever E Select Triage Note Syndrome Fever Gl Gl Hem Il Hem III Unknown Select Detector Regression EWMA 1 2 0 4 5 17 18 44 All Sexes Female Male Unknowon Emergency Select Patient Class Inpatient Outpatient Pre admit All Disposition Categories E ALII ADMIT 12 12 30AM E Select Disposition Category DECEASED Select Time Interval qid Se DISCHARGED 1 30 2 AM Additional Filters aS Table Builde To make multiple selections of any of the variables hold the control key down on your keyboard and click on your choices For example to select both the Fever and GI syndrome hold the control key down and click on Fever and Gl Select a minimal number of syndrome categories from the select syndrome field to avoid duplication of data Once you have made all your selections you can click on time series at the bottom of the page to see a time series graph of the data 30 Daily Data Counts A wow ON NN BRA SM NS XX SS o o o o o o o o o o o mDxa Normal Data Warning Data Alert Oraon Ostona Alternatively you could click on table builder to see a tabular view of the data Once you have clicked on table builder you would need to select a column variable and a row variable in the next screen and click on create table The tables that
18. EFICIENCY ILI query fever and sore throat or fever and cough or flu andnot shot andnot leaking andnot reflux a nadnot flush andnot fluid andnot flushed andnot flutter andnot diarrhea andnot nausea andnot vomit Possible Reportable Disease query crypto or cryptosporidiosis or cyclos or cyclosp or mercury or encephalitis o r botulism or smallpox or shigellosis or shigella or salmonellosis or salmonell a or hepatitis andnot alcoholic or anthrax or ciguatera or dengue or malaria or measles or mumps or varicella or chicken pox or lead poisoning or pertussis or meningitis or whooping cough or campylobacteriosis or cholera or creutzfeldt or CJD or diphtheria or ehrlichiosis or ecoli or escherichia coli or glanders or haemophilus or leprosy or hansen or hantavirus or legio nell or leptosp or listeriosis or listeria or lyme or melioidosis or meningococ cal or meningococcemia or mercury or pesticide or plague or polio or psitta cosis or q fever or rabies or rocky mountain or rubella or streptococcal or toxoplasm or trichinosis or tularemia or typhoid or typhus or vibrio or yellow fever or hemorrhagic or expos 53 Emergency Department Section References 1 Centers for Disease Control and Prevention 2001 Updated Guidelines for Evaluating Public Health Surveillance Systems recommendations f
19. HARFORD COUNTY HEALTH DEPARTMENT POLICY Title of Policy Surveillance System Program Area All Programs Approved By Wieza Vec c _ Original Effective Date July 11 2013 Susan Kelly Health Officer i Revised Dates 1 0 POLICY As a unit of the Maryland Department of Health and Mental Hygiene DHMH the Harford County Health Department HCHD participates in the state wide web based surveillance system ESSENCE to identify disease outbreaks suspicious patterns of illness and other potential public health emergencies HCHD follows the DHMH Office of Preparedness and Response s Essence Users Guide Version 2 Appendix A in conducting surveillance activities 2 0 PURPOSE The purpose of the ESSENCE system is to provide an intuitive environment for epidemiologists to conduct routine descriptive epidemiologic analysis to monitor morbidity and mortality trends over time geography and across multiple data sources and thereby provide information that can assist with making decisions on how to improve population health HCHD works with the DHMH epidemiologists in using the information provided by ESSENCE particularly in identifying threats to public health 3 0 DEFINITIONS 3 1 Surveillance The ongoing systematic collection analysis interpretation and dissemination of data regarding health related events for use in public health action to reduce morbidity and mortality and to improve health ESSENCE User Guide Versio
20. Lid 22442 4 Region Li 2222211 SLRRARSS SE SFR HFSeesee LA AA A A DOA A A dh A A a AA A Li fid c 2czs TdeheexaxM L2 2212 2 Ch vi t OTC Pise Bot Like Fever GI Hem lll Loc Les Lymph Neuro Rash Resp SI Deat wt DAA wkk dde vd xn vef Rh fece deme LIRZILIRLERA uw ewe dee vv een wwe dex fr de ewe yr temm e wr Ty eoe ven der nn vc e ye ed Maryland wore TRAAATLALK 0 esRUE RUA WKAR LHX Tee de Ns xS EFRR NATA Fkk CEVCVreVTre WRK Each cell of asterisks represents the past nine days for a given syndrome listed chronologically with the current day being on the far right Asterisks will appear as grey yellow or red A yellow asterisk indicates a warning and a red asterisk indicates an alert that may warrant further investigation When looking at the data across regions please keep in mind that ED coverage can vary considerably The top tier of asterisks provides a sense of syndromic alert activity over time By clicking on individual asterisks you can further investigate the data used to generate the data point The bottom tier of asterisks shows whether any event list entries have been posted in a particular region In Maryland no events of public health importance are recorded in the Event List feature so clicking on these asterisks will provide no information For further details about the event list see the event list section Region Syndrome Click on region syndrome to review alerts by county region county
21. Network PHIN Partner Communications and Alerting PCA requirements The program intends to ensure that each community has rapid and timely access to emergent health information a cadre of highly trained professional personnel and evidence based practices and procedures for effective public health preparedness response and service on a 24 7 basis HCHD Policy ADMIN 00 08
22. Overview In the mid 1990s the Johns Hopkins University Applied Physics Laboratory JHU APL began a collaborative biosurveillance project with the Maryland Emergency Management Agency MEMA and the Maryland Department of Health and Mental Hygiene In 2000 the team realized that the Walter Reed Army Institute for Research WRAIR was conducting a similar effort called ESSENCE These two projects soon merged and JHU APL and Walter Reed entered into a collaborative research and development agreement to continue working on the technology and expand system access to both military and civilian public health authorities across the region In 2001 a worldwide United States military version of ESSENCE was implemented by JHU APL In 2004 the military assumed the responsibility and implementation for the military version of ESSENCE JHU APL has continued to maintain and develop the civilian version of ESSENCE In 2005 the Maryland ESSENCE system was deployed At this time approximately 15 hospitals from the National Capital Region NCR and the Baltimore metro area were contributing data to the ESSENCE system By the summer of 2009 acute care hospitals in the state of Maryland would be participating in the program Currently the system in Maryland includes four different data sources each with its own module 1 de identified emergency department data from all acute care hospitals in Maryland and two urgent care centers n247 2 de identified poison co
23. Sh ESSENCE Maryland Bookmark Name _Bookmark Page n Home Page No Comments Available Add to Comment N AT Home Alertlist myAlerts myESSENCE EventList Y Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More v Version 1 16 03Oct12 i i 030ct12 BALTIMORE reporting 4 4 hospitals for 02 Oct 2012 30c zn i c o p gu 03O0ct12 GARRETT reporting 1 1 hospitals for 02 Oct 2012 m 03Oct12 HARFORD reporting 2 2 hospitals for 02 Oct 2012 03Oct12 HOWARD reporting 1 1 hospitals for 02 Oct 2012 The homepage displays key information about the ESSENCE data including the total number of hospitals per county that are reporting ED data for the previous day as well as the total number of Maryland hospitals reporting their ED chief complaint data for the previous day The most recent ED data in ESSENCE is usually the previous day s data Please note that if only some of the hospitals in your geographic area have reported their data at a particular time this will have a direct influence on how you interpret the ED data Monitoring of data completeness is one of the first activities each morning at OP amp R If a hospital has not sent a file or another problem is discovered we will work with you and the hospitals to resolve it If you observe a problem with ESSENCE please contact ESSENCE Help mdessence maryland gov The next se
24. SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting Pio Cael a s e TET Peso Cale Poison Control Center Regression EWMA 1 2 1 625 Poison Control Center Regression EWMA 1 2 1 625 Poison Control Center Regression EWMA 1 2 0 429 This feature also provides alerts for the PCC data It gives users a snapshot of exposure calls made to the Poison Control Center by chemical substance 17 Hospital Sub Syndrome Time of Arrival ESSENCE Maryland Alert List Hospital SubSyndrome Based Temporal Alerts Last Updated July 30 2012 10 03 AM Description Table Configuration Options Configuration Options Data Configuration Anne Arundel Medical Center 3 AbdominalCramps 3 Atlantic General Hospital SubSyndrome AbdominalPain Baltimore Washington Medical Center AbdominalPainGroup Bon Secours Hospital Y AbdominalTenderness S Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism J Hospital SubSyndrome Time of Arrival All Hospital Al 12 12 30 AM E Time Interval 12 30 1 AM 1 1 30 AM 1 30 2AM Start Date 28Jul12 3 End Date 30Jul12 3 Change Configuration The hospital sub syndrome time of arrival alert list looks for clustering of patients based on the time they arrive at the hospital ED Analysis of
25. al 1900 Jan 01 9 35 26 AM Select Today _ Select Today Region 1 amp 2 Red Alerts Overview 1900 Jan 01 9 29 36 AM P 2 3 Region 3 Graph Matrix Portal 1900 Jan 01 9 44 28 AM Select Today 4 Region 3 Red Alerts Overview 1900 Jan 01 9 43 46 AM Select Today egion 4 Grap x Porta 900 Jan 01 9 54 elect Today 2 Region 4 Graph Matrix Portal 1900 Jan 01 9 54 04 AM Select Tod egion 4 Red Alerts verview 300 Jan 01 10 03 38 ele aday 6 Region 4 Red Alerts Oo 1900 Jan 01 10 03 38 AM Select Today egion 5 Grap Matrix Porta 900 Jan 01 9 58 19 Ab elect Today T Region 5 Graph Matrix Portal 1900 Jan 01 9 58 19 AM Select Tod F egion 5 Red Alerts view 900 Jan 01 8 18 49 elect Today 8 Region 5 Red Alerts Overvie 1900 Jan 01 8 18 49 AM Select Tod C Resp Med Sales Grap ime Series 900 Jan 01 9 23 03 Ab elect Today 11 OTC Resp Med Sales Graph Time Seri 1900 Jan 01 9 23 03 AM Select Tod 3 Follow the prompts to edit or delete your bookmark Editing bookmarks also includes grouping them into custom named groupings sort of like email folders J QUERY MANAGER suh ESSENCE Maryland a b Query Manager NC En IA Home Alert List myAlerts myESSENCE Event List Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Saved Query Manager Expand All Groupings Collapse All Grou
26. ally the chief complaint is what the patient says is wrong with them to the triage clerk at the ED The triage clerk could be a nurse or someone who does not have much medical training This can impact how much medical interpretation goes into the chief complaint text A hospital might also utilize a standardized drop down selection of symptoms rather than typing in a free text description of the patient s statement which often makes the chief complaint less descriptive 51 Appendix 2 Free text query examples Note These examples are shown to illustrate how various queries can be structured within the ESSENCE system These queries are not necessarily used by surveillance epidemiologists who use the ESSENCE system Display the total ER census you can also simply leave the default all text and click submit Carbon monoxide query carbon or carbon monoxide Rabies query people visiting the ER for rabies shots rabies Animal Bite query cat bite or catbite or puppy or kitten or dogbite or dog bite or animal bite or raccoon or racoon or fox or bobcat or bat bite or bitten andnot bugs andnot ants andnot child andnot fireants andnot i nsect andnot person andnot snake andnot rattle snake andnot pygmy rattler andnot red ants andnot red fire ants andnot something andnot spider andnot wasp andnot leg spider GI query 1 blood and stool or blood stool and blood urine
27. anager 1 Click on query manager in the main toolbar 2 Check all check boxes next to the names of the queries you would like to create the multi series time series graph for 3 Click on multi series time series at the top of the page Saved Query Manager Expand All Groupings Collapse All Groupings Multiseries Time Series B Intersecting Time Series i Edit are Delete Label Link Link Today Date Created Shared By Start Date End Date 3 Grouping Attack 4 Category A Agents Show Show Today 22Nov 10 244ug 10 22Nov 10 ricin Show Show Today 08Sep11 10Jun11 085epi1 Tularemia Show Show Today 22Nov 10 24Aug10 22Mov 10 White Powder Show Show Today 06May11 5Feb11 06May11 3 Grouping Daily Disease 5 Exposure Show Show Today 29Aprii 29Jan11 29Apr11 measles Show Show Today 13Junii 15Marii 13Jun11 Meningitis Show Show Today 22Nov10 244ug10 22Nov 10 4 Rabies Bite Show Show Today 30Jun12 23Mar 12 23Mar 12 TB Show Show Today 20Mar 12 01Mar12 19Mar 12 4 This should bring you to the configure multi series time series display For style select single and the system will plot all your selected queries from step 2 on the same chart Multiple large will plot each query on its own large chart and multiple small will plot each query on its own small chart For the date alignment actual dates uses the dates saved with each 43 individual query to run detection on th
28. and Department of Health and Mental Hygiene DHMH Office of Preparedness amp Response OP amp R with questions about ESSENCE It should be noted that access to some features described in this training guide might not be available to all individuals For example hospital personnel can only view data for their hospital Please contact ESSENCE Help mdessence maryland gov for questions regarding access to data Purpose Public health surveillance is often defined as the ongoing systematic collection analysis interpretation and dissemination of data regarding health related event for use in public health action to reduce morbidity and mortality and to improve health 1 A second definition of syndromic surveillance more specifically is an investigational approach where health department staff assisted by automated data acquisition and generation of statistical signals monitor disease indicators continually to detect outbreaks of disease earlier and more completely than might otherwise be possible with traditional methods for reporting disease 2 The purpose of the ESSENCE system within this context is as a system that provides an intuitive environment for epidemiologists to conduct routine descriptive epidemiologic analysis to monitor morbidity and mortality trends over time geography and across multiple data sources and thereby providing information that can assist with making decisions on how to improve population health
29. at query Global dates uses the dates provided in your queries to run detection on all selected queries Start together uses each query s individual dates but aligns them so that they all start at the leftmost side of the graph And end together uses each query s individual dates but aligns them so that they all end at the rightmost side of the graph Further instructions are provided in the text below the configuration options Configure Multiseries Time Series Display x Basic Parameters Denominator Parameters Style Single w Denominator No Denominator a Type Date Alignment Global Dates w Days from Today 90 j Start Date r3 End Date r3 Legend Style single Plots all queries on the same graph Multiple Large Plots each query on its own large graph Multiple Small Plots each query on its own small graph Date jnment Actual Dates Uses the dates saved with each individual query Global Dates Uses the dates provided on the form for all selected queries Start Together Uses the dates saved with each individual query but aligns them so that they all start at the leftmost side of the graph End Together Uses the dates saved with each individual query but aligns them so that they all start at the rightmost side of the graph Denominator Type No Denominator Does not use a denominator Global Denominator Uses the denominator provided on the form to calculate the percents to be plotted on the graph S
30. ave to repeat all of these steps each time At the top of each page is the bookmark page button Bookmark Page Bookmark Name Type in the name you would like to give the query and click on bookmark page Bookmarks can be accessed by clicking on the bookmarks link in the main toolbar Using the overview portal practical example One use of ESSENCE is for situational awareness You may want to monitor the ESSENCE syndromes and sub syndromes to identify potential events of public health importance The simplest way to do this is to use the overview portal to obtain small graphs stratified on your variable of interest In this example we will look at graphs of sub syndromes to see if there are any alerts that may require further investigation 1 Click on the overview portal tab in the main toolbar 2 For this example choose your data source as either emergency room data by patient location or emergency room data by hospital location The first option will provide the ED data for patients based on their zip code or county of residence The second option emergency room data by hospital location will give you information on all ED visits irrespective of the patient s county of residence 3 Select medical subgrouping from the list of overview parameters and click submit This should return graphs of all the sub syndromes in ESSENCE You can click on any portion of any of the graphs and then click on a data po
31. bed in A alert list above provides alerts for 10 of the 11 syndrome categories in ESSENCE myAlerts on the other hand allows users to customize which stratifications of the ESSENCE data they are interested in monitoring for routine daily surveillance It also enables users to set criteria for alerting that include statistical thresholds minimum counts and consecutive days of alerting Alerts can be created for the standard syndrome and sub syndrome categories free text queries of the ED data as well as for any of the other data sources available in ESSENCE Creating myalerts and Records of Interest To create a my alert for a sub syndrome category for example 1 Click on query portal and then select your data source Data sources include emergency room data Poison Control Center data OTC medication sales data and school absenteeism data 2 In the next screen select your geography system and the medical grouping system chief complaint sub syndrome You may also select one of the five time 20 resolution options to examine daily weekly monthly quarterly and yearly time resolutions of the data Statistical alerting algorithms only work on daily and weekly time resolutions For weekly time resolutions consider using CDC C2 When done click submit st Mal Ge Som ChiefComplaintsubSyndromes sk Ting tt st Ti Resin 3 In the next screen choose the sub syndrome for which you wish to create the alert from the se
32. ctions of this manual provide a basic step by step introduction to navigating through the ESSENCE system and shares examples of the data analysis and visualization tools For the purposes of this manual all tools will be explained using the ED data It is expected that by learning to use all tools with the ED data the user will be able to apply these tools to the other data sources contained within the ESSENCE system If further assistance is required to work with these other data sources please contact ESSENCE Help mdessence maryland gov Emergency Department Data A ALERT LIST SSENCPA ew ESSENCE Maryland 4 T i Home Page AL Home Alert List myAlerts myESSENCE EventList Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More v The alert list provides a tabular view of alerts for 10 of the 11 syndromes in ESSENCE it excludes the other category and gives the user the ability to drill down into the data from the alert list page The alerts are the result of statistical analyses performed within the ESSENCE system ESSENCE uses the last 30 days as a baseline minus the 2 most recent days and compares the current data s counts to that baseline to see if there is a statistically significant increase A yellow flag indicates a statistically significant p value between 0 01 and 0 05 while a red flag indicates a p value of 0 01 The statistical alerts presented
33. ding by Hospital Show Show Today 020ct12 01Sepi2 010cti2 Legionella Show Show Today 30Juni2 Anikah Salim 04Jan12 03Apr12 7 NVD By County Show Show Today 020ct12 04Jul12 020ct12 42 The query manager allows users to save and manage queries from sessions in the query portal Described in Query Portal This saves the user from having to re write chief complaint free text queries should it become necessary to re run the same query or a similar one Query manager is similar to bookmarks but it also has other useful features that are not available in the bookmarks For example you can create your my alerts in the query manager described in B Alert List You can group your saved queries into custom named groupings just like bookmarks You can also share queries with other ESSENCE users Also you can create multi series time series graphs which are described below Multi Series time series graphs Multi series time series graphs allow a user to overlay trend lines from different time series graphs including from different data sources For example to compare trends in influenza like illness ILI activity for two counties two separate time series graphs can be generated in ESSENCE one for each county From the two graphs a single multi series time series graph can be produced in ESSENCE to compare trends in ILI activity for the two counties To create a multi series time series graph of saved queries in the query m
34. ects more than one day in the date range the map will map the alert with the lowest p value 3 Spatial this option shows the user the zip codes that were included in a spatial alert for a selected syndrome 4 Region Caller Site this option shows the user the county where temporal alerts occurred for poison control center calls associated with the origin of the call If the user selects more than one day in the date range the map will map the alert with the lowest p value 5 Region Generic Substance this option shows the user the county where temporal alerts occurred for poison control center calls associated a particular substance If the user selects more than one day in the date range the map will map the alert with the lowest p value 6 Hospital Sub syndrome time of arrival this option shows the user the hospitals that were included in a sub syndrome time of arrival alert 7 Region OTC Category this option shows the user the county where temporal alerts occurred for specific categories of OTC medication sales If the user selects more than one day in the date range the map will map the alert with the lowest p value 8 School Absenteeism this option shows the user the county where temporal alerts occurred for school absenteeism If the user selects more than one day in the date range the map will map the alert with the lowest p value I BOOKMARKS ENCED to F ESSENCE Maryland 4d s l Map Portal emm Home Alertlist m
35. eed Temporal Alerts bree Sertiee Lint Ova Lit Owe Halt Hour Stet tad Hout ieri Dats Source Howptm f0ur Dan Otada 215ap 16 amp 33 7 AN 50 AME ER trr Heaptai Good Samaritan Mie F ever r tils Follow the time series or data details link for additional information on these data 18 School Absenteeism Alerts school absenteeism alerts are alerts for the school absenteeism data An algorithm developed specifically for school absenteeism data is utilized to generate these alerts This algorithm uses the day of the week to determine whether or not the observed absenteeism proportion for any given day is higher than expected That is to say if you are looking at absenteeism data for a Monday the algorithm uses all historical Monday s to determine if the absenteeism proportion for the Monday in question is higher than expected Using the data configuration button will allow you to choose individual school s as well as the date range ESSENCE Maryland Alert List School Absenteeism Alerts Last Updated July 30 2012 10 00 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting School Absenteeism Alerts WEDNESDAY 54491 30 877 us e There is also an alerting mechanism for sch
36. eful for monitoring rare events with small counts To create a record of interest follow the same steps as you would to create an alert steps 1 through 5 above In the create myalert pop up shown in step 5 above check the box next to records of interest and click save myalert 24 C EVENT LIST ENC ED ESSENCE Maryland P J Alert List a y Nc i Home AlertList myAlerts myESSENCE Event List J Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More Y The purpose of the event list feature in ESSENCE is to allow users who find alerts or other information in the system that may warrant further attention to complete an entry describing their findings or recommendations The event list is not currently promoted for use in Maryland because most ESSENCE activities are conducted by OP amp R epidemiologists who work in close concert with one another However if users would like they are welcome to use the event list if they feel it would benefit them locally Contact ESSENCE Help mdessence maryland gov if you would like more information In states where this feature is utilized users can view events within the summary alerts feature in alert list These events would show up in the second tier of asterisks please see section A on alert list above In Maryland ESSENCE clicking on any of these asterisks would not return any meaningful results D
37. f complaints from your area to find the best combination of terms that will provide the best results for a query F MATRIX PORTAL The matrix portal allows you to create a custom report for ER data by patient location along with a bar chart or line graph for your county of choice You can also create custom reports for OTC medication sales data To look at aggregate data for all the counties please select all the counties in the region field Also select all the age groups if you are not interested in looking at the data for any one age group Below is one example of a line graph but many different line graphs and bar charts can be created in the matrix portal ENCA la SSE M ESSENCE Maryland ge J Matrix Portal x Home AlertList myAlerts myESSENCE EventList Y Overview Portal Query Portal f Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More Y Description Configuration Options Data Configuration Datasource Syndrome Emergency Room Data by Patient Location Bot Like Over the Counter Chain Combined Region Allegany MD Unknown Anne Arundel MD E 0 4 BALTIMORE CITY MD 5 17 Baltimore MD 18 44 Calvert MD 45 64 Caroline MD 654 Columns Rows Datasource oo Syndrome x Graph Type Bar Graph x Start Date 26 Sep 12 EmdDate 03 Oct 12 hange Confiquration 1 To create a line graph that shows all ED visits
38. for Maryland by syndrome for a particular time period in matrix portal first click on matrix portal in the main toolbar and then select emergency room data by patient location Holding the control key down on your keyboard click on your syndromes and age groups of choice To create a graph for the entire state please select all regions In the columns category select syndrome and in the rows category select date range Select line graph from the graph type field In the start date and end date section enter the time period of interest and click on change configuration below the date fields 35 2 At the top of the matrix portal page you will see a description of everything included in the data table Scroll down to see the data matrix and line graph The matrix shows all of the cells in which a red or yellow alert has occurred The graph is a line graph that shows the trend in each syndrome during the specified period for the state of Maryland Here only a small section of the data table is shown 3 7 Data Matrix Data Matrix a Fever 24Jun12 172 25Jun12 103 26Jun12 106 106 118 27Jun12 28Jun12 29Jun12 108 30Jun12 I5 866 Total Graph Matrix Portal Graph 180 160 140 120 80 40 2 A gt ka b k e gt DateRange Fever GI ll Rash Resp Download 3
39. h Daily Data Counts IET i m Li m Til i Aj in i 35 a 9o P P ew ud 2 Q K Kc o Data Normal Data Warning W Data Alert Graph Options Download As you can see from the time series graph there were significantly higher numbers of ED visits associated with carbon monoxide poisoning than expected in the month of January You can click on the data details hyperlink directly below the time series graph to see a line list of ED visits for your query for the entire range of dates included in your time series If you would like to see only one particular day s data details then you could either click on the data point in the graph or click the data details hyperlink in the data table below the time series graph This information can be used along with supporting information from other sources to determine whether interventions should be aimed at a particular geographic area and or demographic group A map view might also be helpful in this case not shown This example is only one of many ways the query portal can be used As you explore this feature you will identify other utilities that will benefit your geographic area 34 Again please remember that the nature of chief complaint text may vary by hospital and the free text chief complaint queries may change based on language used in the chief complaints from your particular jurisdiction It is therefore important to be familiar with the chie
40. ic data sources are described below Emergency Department Data The syndromic classification of emergency department ED data in ESSENCE is based on the patient s chief complaint which is generally some variation on what the patient said was the reason for visiting the ED Some things to consider include 1 Chief complaints may be a comprehensive free text statement that mirrors the patient s actual statement very closely 2 Chief complaints may be an abbreviated free text statement that includes only the primary reason for the ED visit or 3 Chief complaints may be a selection from a standardized pick list of possible chief complaints from within a hospitals data system that best fits the patient s actual statement 4 Chief complaints may include misspelled words and or medical short hand 5 Another limitation is that chief complaint data vary in their diagnostic precision which is also affected by the type of chief complaint text provided by the hospital Systems like ESSENCE tend to prefer options 1 and 2 above because they often include additional information that can be helpful for free text querying as well as with the syndrome categorization These kinds of chief complaints lend themselves well to impromptu free text query development and systems with free text chief complaints may be flexible enough to add particular phrases to a patient s chief complaint in certain circumstances e g adding the word Haiti in a patient s ch
41. ief complaint Whenever available we ask that hospitals send us the free text chief complaints but this isn t always possible Regarding misspellings and medical short hand the language parsing algorithms in ESSENCE include a large number of common misspellings and medical shorthand terms and will show what it thinks is the correct version of the chief complaint Statistical Analyses Automated statistical analyses in alert lists my alerts and of time series data assists the user by generating alerts when observed counts exceed a particular threshold While this information can be very helpful with focusing our attention on specific data users should not interpret statistical significance to necessarily mean public health significance Epidemiologists should conduct additional review of the data details line list and distribution of the data to determine whether additional investigation is warranted for a given circumstance Appendix 1 provides an example of how to review emergency department data Additional information is available on the statistical algorithms in the ESSENCE Help section and the Detector Algorithms section both at the top of the webpage once you have logged in Outbreak detection has always been one of the major goals of syndromic surveillance In Maryland we have had success in detecting otherwise unreported outbreaks using both the ED data and poison control data In this context there are a few things to understand
42. int on the graph to examine the data for a particular day more closely You can also change your date range and other parameters by going to the configuration options In the screen shot below only 4 of the 100 sub syndrome graphs generated by ESSENCE are shown 27 Description E Overview Parameter Overview Parameter Overview Parameter wecscarsubGroupe Submit 3 Configuration Options Graph AbdominalPain AcuteBloodAbnormalities m m ANH ANY ME aun Mn 564 d ect Cur um aes e UU EM we m en wh Sn WO uy A Data Nome Das Warnng Dota Ale Dets Severe 49 Deta Normal Deta docui I aca Nan th s Severe Click amy where ca the graph to aytar ts interactive view Click anywhere on ihe graph te a AcuteBronchitis Agitation MAL o 41 IB IT PD e Ve 2 E e MAN hn wi aii o a e o o b i ib ib b b t 6 5 65 Dats Norma Dea Warning amp Data Alant Dats Severe Dus hema Data Vuwmhg Data et e Data Severe Cicek anywhere om the graph te switch to interactive vew C ck emywhere an the gragh te swich tn interactive vew E QUERY PORTAL Home Alert List myAlerts myESSENCE Event List Overview Portal Matrix Portal Weekly Percent Map Portal Remote Data Stat Table Bookmarks Query Manager More v The query portal allows users to perform various searches of Maryland data in ESSENCE Based on your level of access you may view and analyze eme
43. ions Graph Daily Data Counts 13 000 12 000 4 11 000 10 000 1 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 ow a 1 ore sore a v v N V 4N v V Data Normal Data Warning Data Alert Graph Options Download After you click save query a box will appear that will allow you share your query with other registered ESSENCE users Select the users you would like to share your query with and then hit save If your query was successfully saved you will see a dialog box similar to this Operation Complete X The query was successfully saved OK Click OK To create your sub syndrome alert click on the create myalert button on the same page The create myalert dialog box will pop up Here you can check the box next to detection choose a variable by which to stratify the detection algorithm select threshold p values or leave as default and or input the minimum count of ED visits for which the alert should be created then click save my alert to save the alert You could also check the box next to records of interest discussed below if you are interested in monitoring rare events with small counts Your myalerts may be accessed and monitored routinely through the my alerts feature in the main toolbar You also have the option of sharing your myalert with other registered ESSENCE users 22 Create myAlert x Name
44. is and Response to Syndromic Surveillance Data Evaluation Complete Chief Complaint of Concern Collect Additional Information Characterize the Alert Magnitude Continuity aK Collect Historical Perspective 4 N Yes y Yes id I 5 VERRE RISUS Significant gt Notify DHMH Characteristics Age P Physician Sex Chief Complaint On Call Discharge Diagnosis and Disposition Evaluation Evaluation Complete Complete Evaluation Complete 50 One way to approach the review of syndromic surveillance data is to begin with those categories that produced statistical alerts However in depth analyses of syndrome categories and or more specific free text chief complaint queries regardless of alerting status have been used successfully to discover previously unknown outbreaks For example say you use the query vomit or diarrhea and the normal number of cases in your county is 30 per day Then on X day you find that there are 25 patients in this query there is no alert produced but when you review the line list by time of ER visit and zip code you find that 8 patients visited the ED very close in time and lived in the same zip code This clustering of cases is worth following up on even though no statistical alert was generated It is important to become somewhat familiar with what a patient s chief complaint looks like in your county and to understand the limitations Gener
45. iteria the number of requested variables may increase over time and the data will become more real time Poison Control Center Data Module The Poison Control Center PCC data in ESSENCE is transmitted daily from the two poison control centers that serve Maryland This data feed provides coverage for all 24 jurisdictions in Maryland A large number of variables are included in the ESSENCE PCC interface including demographic data to orient the data by time person and place as well as information on substances substance categories clinical effects information on the exposure and how it was managed clinically These data have been used to detect outbreaks associated with exposures to various chemical substances detecting individual cases of some reportable diseases e g carbon monoxide poisoning pesticide poisoning and providing situational awareness as it relates to chemical substance exposures in Maryland Over the counter OTC Medication Sales Data Module The OTC data in ESSENCE is transmitted daily from two large pharmacy chains that provide coverage for all 24 jurisdictions in Maryland Data from these two large 44 pharmacy chains can be viewed separately or combined Thermometer sales are included along with other OTC medication sales Variables included in the ESSENCE OTC interface include information on the product purchased such as a product description product type product category and a product UPC code Other infor
46. lect chief complaint sub syndromes field make all other desired selections and click on time series at the bottom of the page Select Triage Note Syndrome Select Age Group Allegany MD Anne Arundel MD BALTIMORE CITY MD Baltimore MD All Triage Note Syndromes All Age Groups Unknown 04 5 17 18 44 v Select CDC ILI Reporting Age Group All CDC ILI Reporting Age Groups ES Unknown 00 04 05 24 25 49 bs Select ChiefComplaintSubSyndromes Select Detector Select Ten Year Age Group All ChiefComplaintSubSyndromeses EB AbdominalCramps AbdominalPain AbdominalPainGroup AbdominalTenderness Regression EWMA 1 2 x Unknown z 00 09 I 10 19 20 29 v Select Distribute Age Group All Distribute Age Groups Ez Unknown 00 01 02 04 05 17 Select Disposition Category oo Additional Filters EET Female Male Unknowon a ADMIT DECEASED DISCHARGED Select Patient Class All Patient Classes Emergency Inpatient Outpatient Pre admit Data Data Details Table Builder Builde Time Series Series Graph Builder Overview Portal 4 In the next screen you will notice at the top of the time series graph a query name field Type in the name of your query and click save query 21 Save Query Create myAlert Add to myESSENCE Share URL T ontiguration Upton Data Series Opt
47. ly Your ability to access this information is granted with the expectation and understanding that you will comply with and not violate privacy information policies This is a private system and is only to be used by authorized users By continuing the user is stating that they are the indicated user 2 When prompted by the dialogue box enter your username and password To obtain ESSENCE access please contact ESSENCE Help mdessence maryland gov User ID Password Log In 3 The ESSENCE homepage will appear All of the major functions of the software are accessible using the main toolbar We will describe most of the application tabs e g query portal alert list in the next pages The remote data and user admin tabs will not be discussed since these functions are not often utilized by ESSENCE users in Maryland Prior to examining specific data outputs you may want to look at the items on the very top of the tool bar which describe 1 history and background of ESSENCE and its relationship to syndromic surveillance 2 syndrome and sub syndrome definitions 3 detector algorighms a description of statistical techniques for outbreak detection 4 the data dictionary a glossary of common ESSENCE terms and 5 the help section which contains FAQs additional background information and useful links Please be aware 7 that many of these items have not been updated to reflect recent changes in the ESSENCE system EN E
48. mation provided includes the date of purchase a unique store identifier the zip code of the store as well as a promotion indicator These data have been used in concert with other data sources to maintain situational awareness during large scale events They are also an indicator of disease activity including gastrointestinal illness and influenza School Absenteeism Data Module The school absenteeism data in ESSENCE is transmitted on a daily basis from all 24 local public school systems in Maryland Raw absenteeism numbers are provided for all public schools For each school data is provided on the number of students enrolled and the number of students absent and these numbers are used to generate a percent of students absent Other variables included in the data are the date zip code of the school jurisdiction system the school is located in the type of school i e elementary middle or high school and the type of day e g normal exam snow etc The 2012 2013 school year will be the first full school year this data will be received and utilized for surveillance purposes Limitations and Other Context An understanding of the limitations of a particular data source enables users to make correct interpretations of the data This is especially the case with syndromic surveillance data where the focus of the surveillance is on reporting timeliness and not necessarily the specificity and completeness of the data Limitations for specif
49. medical region but in the region syndrome hospital syndrome and hospital sub syndrome time of arrival alert lists region means county jurisdiction ER toe Bot Like Fever GI Hem Ill Loc Les Lymph Neuro Rash Resp SI Deat tttTvTAXYXT HE kastet SRSA SERRATE SES SFRSERAAFE TTvYYeYR jrrxXTERTYS EArt EST RSF Re RFS Yee xn n G S de Yn de een n ir sie de dn d n 0 AX LE IR A2 deve eder dede twtr veka eeeeerke kk vkek ewkeed se yr dede desk nn IIIIIZIIX utt eee vede wt x f ww GOANA CAAD AA AAS AERA vB vg n n wdev f wurOevw AA kAd DAE Tr eereee eS L RAiii1 RA A ve ern ew Region I egion HF RR ck wwet FA RR t FELTON RT kett T Lekerewres I22222b2 1 wtvWW E TRYRA watt wr v e mtYT jede vede v uve deve jedem ebr dw i kes es eux dw de M LARRY KA ER i Ake eS Region Il egion wood s wu ede eodem omo We wd 9 9 9 B9 4996 0 B gt w 0 nM 990g dedu we de de oo ot omo oo A Region SREEERRES ewe ABER TH HB RHE SERA FREE own SEARA 4n yE BH BH Xxx SEAHRESEA BHEREKREAE BH BEES IH tei TAESATLT BERARERESHE wRRRETPRbTTT BFESRSSAREX PRF Tttt vbATTRYTREMA XxXETAETSS SRKVESLER rIfZXPERETTE vfT rTEE Region de ve fn gen den wkeewtewre wn tte LIJZARIIIT A RRidikA g se Yee ie de dar nn Prrrkse ee vw Ye veut yn rn m de Yer LA R2 Z 2 E IV RASA MERI LPL2IISIMEM LDILIAILPLIAMERSPLPLLi 3e RO Seve egere dedere Ro Ceeveee S det w tw RSXC w t kkt WTReKAKY veux RRR Se 2 es ee ee wuewhwwxx RRR o iili
50. n 2 0 October 2012 pg 3 4 0 PROCEDURES 4 Data Sources ESSENCE incorporates traditional and non traditional health indicators from multiple data sources Data are submitted on a daily basis as close to real time as possible Data sources are statewide and include e Acute care hospital emergency departments and freestanding emergency rooms e Maryland Poison Control Call Center e Over the counter OTC medication sales data from two large pharmacy chains e School absenteeism from Maryland public schools HCHD Policy ADMIN 00 08 Page 1 of 2 4 2 Data Collection ESSENCE data are automatically extracted via a Secure File Transfer Protocol from participating surveillance site databases For example in an emergency room demographics chief complaints and diagnosis data are all automatically sent from a hospital s information system to the ESSENCE server Data are grouped into syndromes and then analyzed with warnings and alerts produced based on statistical algorithms 4 3 Confidentiality Data collected in ESSENCE do not have identifiers and access to the data is limited to ensure security and confidentiality 4 4 24 7 Coverage Data are collected 24 hours a day all days of the week DHMH Office of Preparedness and Response epidemiologists are available to receive alerts by phone whenever they occur The epidemiologists contract phone numbers are 410 767 6745 and 410 767 2074 4 5 Testing 24 7 System The availability of
51. nne nnn nna 27 E QUERY POP DAL BM 28 dies idi chief Omno T Qe uuu ecd dean qu Ou E 32 sing the query portal practical examqyle cese nnn n unu n uuu u uuu uuuuuuuuuuuuuuuuuuuuuuuuuuuunuu uu uuRnRRRRRRRRRRsA 33 F MATRIX PORTAL asus i A i E MY 35 G zz aciie mc 37 i MAP PORTAGE c nena aou o autos LL eeu eeu a Cate 39 L BOOKMARKS ree arene nis ais antes aa omnes ree neat caries este ee E E 40 J QUERY MANAGER asa acces te ae eet eee eae eres AE AEAEE EE 42 Multi Series time series GraplS s scccsescccsnncssnncsssnnnsnsnsnsnsnscsnensnensnansnenensnsnensnenensnenensnenensnenensnenensnenensnenes 43 K myESSENGE ui oueisues odd eta a dier veinte anc i Oo tered end edu TU uL 45 APPENDIX 1 Flowchart for Analysis and Response to Syndromic Surveillance Data 50 APPENDIX 2 FREE TEXT QUERY EXAMPLES arcas crece dca ccu ncmpe miim cna nccu sucpD cran dn Cunuuse 52 EMERGENCY DEPARTMENT SECTION REFERENCES Maryland Electronic Surveillance System for the Early Notification of Community based Epidemics MD ESSENCE Introduction This user manual is intended as a self study guide to help the Electronic Surveillance System for the Early Notification of Community based Epidemics ESSENCE user navigate through some basic functions in ESSENCE As changes are made to ESSENCE we will try to update this document as quickly as possible Please contact ESSENCE Help mdessence maryland gov at the Maryl
52. ntrol center data 3 de identified over the counter OTC medication sales data from two large chain pharmacies and 4 de identified school absenteeism data All data sources are updated daily Including multiple streams of data in ESSENCE permits the visualization and descriptive epidemiologic analysis of several data sources in one location Each of these data sources is briefly described below Emergency Department Data Module The data elements included from the EDs are patient age sex chief complaint date of visit time of visit zip code of residence discharge disposition e g admitted discharged etc discharge diagnosis patient resident zip code a unique identifier for the patient and visit and hospital name Unfortunately not all hospitals provide a discharge diagnoses and discharge dispositions at this time Automated parsing of the free text chief complaints place these data into 11 syndrome categories gt 100 sub syndrome categories and allow for free text querying of the chief complaint text These data are with very few exceptions always one day behind When users log in today the ED visits for the previous 24 hour period are available for review The data are loaded automatically on weekends and holidays on the same schedule as noted above ESSENCE analyzes and displays the findings for use at the state county zip code and hospital level Note As a result the HITECH Act and the syndromic surveillance Meaningful Use cr
53. odes it may be noted as a red or yellow alert The alert list will present information on the p value the observed count the number of zip codes in the cluster and the center zip code in the cluster The interface has the option to click a map view and time series view so that you can drill down into these data Note For a more detailed explanation please see the paper by Howard Burkom in the Johns Hopkins APL Technical Digest Volume 24 No 4 2003 Development Adaptation and Assessment of Alerting Algorithms of Biosurveillance A google search of the title will return a few locations where the paper can be downloaded ESSENCE Maryland Alert List Zipcode Syndrome Based Spatial Alerts Last Updated July 30 2012 11 25 AM egion Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting Zipcode Syndrome Based Spatial Alerts Links Links Date Syndrome Pvalue Number of ZipCodes Cluster Size Center ZipCode Region Data Source Time Series 30712 Resp IR by Patient usas presas ama Ras TI Ss 28Jull2 Resp IR by Patient Map View Time Series IR by Patient Map View Time Series iR by Patient MapView Time Serie
54. of myAlert cougn Query cough Enablec Ei This myAlert is being created for Records of Interest iv Detection Detector Regression EVVMA 1 2 E Stratif cations Use Origina ai Geography Age Group Sex Le DispositionCategorny Red P value Ir Yellow P value m Min mum Count alerts in the past days consecutive alerts Cancel Save myAlert Alternatively once you have clicked on the save query button and your query has been successfully saved you can click on the query manager tab in the main toolbar where you can create the alert If you have some previously saved queries your new query will appear at the bottom of the list Check the check box next to your query name and click on create myalert at the top of the page Labe Ln Link Tods Date Created tart Date End Date pr E p lt Creu i A m A RRA 5 otal ED census Shc S oda z0Jan1c 220 20Jan1 L D H SDA Pot ano Today zZzijanit 1AuUgUE 34 23 Creating alerts for your free text queries To create a my alert for your free text query select chief complaints as the medical grouping system in step 3 above click submit and in the next screen enter your free text query in the select chief complaints field ESSENCE Maryland Data Query Current Data Query Selections Data Source Emergency Room Data by Patient Location Geography System Medical Grouping System ChiefComplaints Triage Note System Time Re
55. on the Alert List page should be interpreted simply as there being a larger than expected number of ED visits for a particular syndrome category on a given day This is an attempt to create an efficient way to scan through all the data automatically and tell the user where to focus additional review However statistical significance does not necessarily equal public health significance and inevitably there are many alerts generated that do not warrant additional follow up with the hospital It is up to the user to analyze the data and try to determine when additional follow up and investigation is warranted Appendix 1 provides an example of how to review alerts for the emergency department data in ESSENCE To begin navigating through the alert lists click on the alert list icon Note For a more detailed explanation please see the paper by Howard Burkom in the Johns Hopkins APL Technical Digest Volume 24 No 4 2003 Development Adaptation and Assessment of Alerting Algorithms of Biosurveillance A google search of the title will return a few locations where the paper can be downloaded Summary Alerts The Temporal Alerts Summary page is the first page displayed after clicking on the Alerts List button It shows a graphical summary of syndromic alerts for the state of Maryland and individual regions Please note ESSENCE uses the term region in different ways throughout the system In the summary alerts region means health and
56. ool absenteeism data based on thresholds Since the 2009 H1N1 pandemic each Maryland public school system has had in place a school absenteeism threshold When this threshold is exceeded the public school system contacts their respective local health department These thresholds have been programmed into ESSENCE and ESSENCE will generate an alert when the threshold is exceeded These alerts can be seen by clicking on the Schools Threshold link on the Alert List page 19 School Based Threshold Alerts Last Updated October 3 2012 6 45 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial Schools Threshold f School Absenteeism Hospital SubSyndrome Time of Arrival Configuration Options Reset 3 Level Sorting ST mus fois sro Bem e pamece scm use o foame scr us o mene Bevons om fo femmes Bevons hus e faamoe Reviewing Alerts in ESSENCE Please refer to Appendix 1 to see a flowchart of how to analysis syndromic surveillance alerts in order to identify possible events of public health importance B MY ALERTS ENCA LEENA ESSENCE Maryland WV Home Alert List myAlerts myESSENCE EventList Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More v The alert list feature descri
57. ooth Pain Children 198Jul12 01Jul11 30Jun12 ILI 03Augi2 O5May12 03Aug12 E Show Last 90 Days Cancel Submit 47 Home ai Add New Tab Add New Widget ExporttoPDF Share Tab Rich Text Widget s 9x Rich Text Widget alx My Alerts Detection ED Data OTC Sales Data Alerts Time Series Graph ILI 9x Time Series Graph Therm Combined 4 eg ix Alert D Stratific Date Data So Level Count Expected Times B i Ti Time Series Graph ILI Time Series Graph Therm Combined ae aco MEE ee NN S NaN Imeser gp 2500 2000 60 1500 40 1000 20 500 0 0 r 2 2 Q Q 4 E T z z E gt a a o o S OQ o o 2 o 2 e G e o o A 7 gt gt wf d b ob ob ob ob b ob DB BD och amp amp amp 9 6 6 3 N 3 S X S o gt o o 5 5 o BD S9 Ww Q B BW B 9 W Data Normal Data Warning W Data Alert W Data Normal Data Warning Data Alert Seon Conon own cea Seon Cones Downes Click anywhere on the graph to switch to Interactive view Click anywhere on the graph to swhton to Interactive vies Last Updated 03Aug12 01 31 PM Last Updated 03Aug12 01 34 PM Map ILI a 2 X Time Series Graph OTC2 Fever 9x Time Series Graph OTC2 Fever 80 A t P a 60 f 40 fo i L v 20 E B j 2 Qo e Ux o z x2 2 B g 2 o A 7 2 e E
58. ords If you don t use the then you will only get chief complaints with that specific word s Wildcards and Boolean operators must be separated by commas Examples of a few free text queries include Carbon monoxide poisoning carbon or carbon monoxide Fever and stiff neck fever and stiff neck or mening Pneumonia without mention of aspiration pneumonia pneumonia andnot aspiration To make multiple selections of any of the variables hold the control key down on your keyboard and select your choices which will all be highlighted in blue You can also write more complex queries based on your specific needs Please see appendix 2 tor additional examples of free text queries After you have typed in the free text query and made all the necessary changes to the other fields you can click on time series at the bottom of the page to see a time series graph of the data You can click on the data details hyperlink directly below the time series graph to see a line list of ED visits for your query for the entire range of dates included in your time series If you would like to see only one particular day s data details then you could either click on the data point in the graph or click the data details hyperlink in the data table below the time series graph To change your previously made selections click on the plus sign next to configuration options above the time series graph You can also click on the plus sign ne
59. pear and can be further investigated by clicking on the time series hyperlink ESSENCE Maryland Alert List Hospital Syndrome Based Temporal Alerts Last Updated July 30 2012 8 50 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting FR Hone at in Rowena 2M 00s suse isi mar etr omi MEE 29Jul12 ER by Hospital Regression EWMA 1 2 1542 MDWAHERCC 29Jull2 ER by Hospital A Neuro Regression EWMA 1 2 EXER TERI MDATLGHERCC 29Jul12 ER by Hospital Ap Newo Regression EWMA 1 2 pex 0 143 MDCRHCERCC 29Jul12 ital An Resp Regression EWMA 1 2 2929 MDSHSDorGHERCC Time Series DM ital AE Loc_Les Regression EWMA 1 2 3 893 MDGSHERCC Clicking on the plus sign next to configuration options in the region syndrome view will allow you to view alerts for selected regions syndromes age ranges and start and end dates Leave the data source field as all data sources and the sex field as all sexes After you have made the necessary changes click on change configuration to generate your new output In the region syndrome alert list syndromes are often presented in an aggregated view for age Within the configuration options age can be delineated into subgro
60. pings Multiseries Time Series Intersecting Time Series Create myAlert Edit Share Delete 7 Label Link Link Today Date Created Shared By Start Date End Date 8B E Grouping Attack 4 7 Category A Agents Show Show Today 22Nov10 24Aug10 22Nov10 7 ricin Show Show Today 08Sepii 10Junii O8Sepii 7 Tularemia Show Show Today 22Nov 10 24Aug10 22Nov 10 7 White Powder Show Show Today 06May11 O5Febii O6May 11 8B E Grouping Daily Disease 5 E Exposure Show Show Today 29Aprii 29Janii 29Aprii E measles Show Show Today 13Junii 15Marii 13Jun11 7 Meningitis Show Show Today 22Nov 10 24Aug 10 22Nov 10 7 Rabies Bite Show Show Today 30Jun12 Anikah Salim 23Mar 12 23Mar 12 fm TB Show Show Today 20Mar 12 01Mar 12 19Mar 12 3 7 Grouping Events 6 7 Injuries Show Show Today 26Augii 12Aug11 26Aug11 7 MRSA and Staph Show Show Today 26Augii 12Augii 26Aug11 7 Psychological2 Show Show Today 30Juni2 Anikah Salim 21Augii O4Sepii Resp Arrest Distress Failure Show Show Today O8Sepi1 10Junii O08Sep11 E Respiratory Issues Show Show Today 01Jul12 24Jun12 30Jun12 7 Tetanus Show Show Today 26Augii 12Aug11 26Augii B E Grouping Food and Water 12 7 Food Poisoning Show Show Today 22Nov 10 24Aug10 22Nov 10 foodborne Show Show Today 04Apr12 O3Sepii 03Sep11 F GI Show Show Today O4Apr 11 04Janii O4Aprii 7 GI Bleeding By County Show Show Today 020ct12 015ep12 010cti2 7 GI Blee
61. red an evolving guide due to the periodic changes made to Maryland s ESSENCE system It will be updated as necessary and as resources allow Department of Health and Mental Hygiene TABLE OF CONTENTS INTRODUCTION MIENNE Y 3 PURPOSE eet H9 Mn 3 OVERVIEW E 3 LIMITATIONS AND OTHER CONT EXT 225a cot neuste sosta scusa cen cot sanus er sns a sre con cotes encres areae n cosa p Scenes ennnen 5 AACERT EIS E E EREE EE EER M MM MM EUM UM MUS 9 VOY eee ez dA Td FEET E PH 9 PROOIOIN SV IO LOINC PET 10 FIOSON AUS YIIGIOING a set i is ste wedi A ioe as Sinan cites ds EEEE uua gue ae aia wen ae AE Palouse TUA cease 15 ED SP all FUICIAS Pe E A 16 Region Caller Site Alert List for Poison Control Data ccsssssecsscsenssenscnsnnnsnssnnsnnsenssnnsnssansensenaees 17 Hospital Sub SyYndrome Time of Arrival s ccssecccsneccssnscsssnscsnsnscsnsnacsnsnecsnenansnensnsnsnensnenensnenensnenensnenensnenes 18 School Absenteeism Alerts 66 issu Ice seoudtat uetus gag eddie ation eee ou eel CEU UE VUE 19 Reviewing Alerts in ESSENCE iiss adada iiA 20 Be MY AER US r ot toc c eEem Ec 20 UN m D BS and Records OF Intelest ion eere tore o aprenda Eo DRE Hexe EEN EESE DEEE EEEREN 20 D OVERVI POP p m 25 Using the overview portal practical example llceullllllllllli rne n
62. rgency department data PCC data OTC sales data and or school absenteeism data This section focuses on emergency department ED data Subsequent sections will explain how to analyze PCC data OTC Sales data and school absenteeism data To access the ED data 1 Click on query portal in the main toolbar 2 Select data source 28 Next Selections Select Data Source Cmergency Room Data by Patient Locator The first three options in the data source list provide access to the ED data Emergency room data by patient location categorizes the ED visits by the patient s location zip code and county This option will provide ED data based on the patients zip code or county of residence The second option emergency room data by hospital location will give you information on all ED visits irrespective of patient Zip code or county of residence The next several options will allow you to access the PCC data OTC sales data and school absenteeism data which will be discussed later in this manual In the example below we will select the emergency room data by hospital location option 3 In the next screen select a geography system a medical grouping system and a time resolution option For the geography system you can select hospital region which will allow you to select a county or grouping of counties You can also select hospital if you would prefer to see graphs of the ED data for a pa
63. rom the guidelines working group Morbidity and Mortality Weekly Report 50 RR 13 1 35 Available at http www cdc gov mmwr preview mmwrhtml rr50132a1 htm 2 Centers for Disease Control and Prevention 2004 Framework for Evaluating Public Health Surveillance Systems for the Early Detections of Outbreaks recommendations from the CDC working group Morbidity and Mortality Weekly Report 53 RR 05 1 11 Available at http www cdc gov Mmwr preview mmwrhtml rr5305a1 htm 54 Appendix B Excerpt of the Maryland Department of Health amp Mental Hygiene Health Alert Network User Guide Revised June 9 2010 INTRODUCTION TO THE MARYLAND HEALTH ALERT NETWORK When an event threatens the health of Marylanders fast efficient and reliable communication to those responding to the event can prevent illness and save lives The Maryland Health Alert Network MD HAN provides a uniform alerting and notification system capable of rapid distribution of health alerts and secure collaboration among a defined set of public health professionals working to protect the public during a disease outbreak environmental threat natural disaster or act of terrorism The MD HAN system from the Maryland Department of Health and Mental Hygiene DHMH is provided with federal funds from the US Centers for Disease Control and Prevention CDC and is in compliance with federal alerting and notification requirements as outlined in the CDC Public Health Information
64. rticular hospital or hospital grouping Time resolution allows you to look at daily weekly monthly quarterly or yearly time resolutions of ESSENCE data For the medical grouping you have the option of selecting one of three medical groupings ESSENCE syndromes chief complaint sub syndromes or chief complaints The first two options bring you to pre categorized groupings of chief complaints The ESSENCE syndromes include 11 syndrome categories and the sub syndrome groupings include over 100 sub syndrome categories For more information on the syndrome definitions please click on the syndrome definitions link at the top of the page We will focus on ESSENCE syndromes for now and discuss the other two options later Once you have made all the necessary selections click submit Select Geography System HospitalRegion Select Medical Grouping System ESSENCES yndromes Select Triage Note System TNSyndromes Select Time Resolution Su bmi il 29 4 In the next view you can select your variables of interest Please note that in the query portal region means county Jurisdiction If the age group you want to look at is not one of the pre set age categories click on the select age range drop down menu to customize the age or age range All Region of the Hospitals All Patient Locations Allegany MD Sj Allegany MD Select Region of the Hospital Anne Arundel MD Select Patient Location Anne Arundel MD BALTIMOR
65. rts maps rich text labels etc The myESSENCE feature allows the user to see data for multiple data sources using multiple visual tools in a quick and easy to understand format The graphs and other widgets contained on each tab can be configured within the tab and can be made to automatically refresh so that queries etc do not have to be re run To create a myESSENCE tab 1 Click on the myESSENCE button in the main toolbar 45 f ENCES F ESSENCE Maryland Query Manager pY cy Pal AD Home Alert List myAlerts myESSENCE event List Overview Portal Query Portal Weekly Percent Map Portal Remote Data Stat Table Bookmarks Query Manager More v 2 Click on Add New Tab at the top left of the screen 4 a ESSENCE Maryland m J myESSENCE Home Alert List myAlerts myESSENCE Event List Y Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data StatTable Bookmarks Query Manager More Home LI Add New Widget Export to PDF Share Tab This will bring up a menu which allows you to create a name for the tab as well as select the column configuration for the tab Tab Options Tab Label Layout 2 Columns 3 Columns 3 Once you name the tab and select the column configuration you can begin adding widgets to the tab To do this you click on Add New Widget at the top left of the screen This brings up a drop down menu of widget options 46 ESSENCE Maryland
66. s IR by Patient MapView Time Series 26Jul12 Resp IR by Patient 16 Region Caller Site Alert List for Poison Control Data ESSENCE Maryland Alert List Region Caller Site Based Temporal Alerts Last Updated July 30 2012 10 00 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts J Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting mesas psu Pon Ce Cone mesas psu Pon Coe Coe oe mesas pun Pon Cs Cone mesas pun Pon Coe Coe mesas pun Pon Cone Coe 22 Peon Comet Cae aa in Cot Cee These alerts are for the Poison Control PCC data They provide a snapshot of exposure calls made to the PCC by caller site The alerts show if the number of calls on a particular day exceeds the baseline number of calls for a health care facility workplace school residence restaurant or public area in a particular county You can examine a time series graph of the data by clicking on the time series link County Generic Substance Alert List for Poison Control Data ESSENCE Maryland Alert List Region Call Type Based Temporal Alerts Last Updated July 30 2012 9 01 AM Region Syndrome Hospital Syndrome Region OTC Category f Region Call Type Alerts f Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital
67. sit This field can be used to determine if duplicate records occur in the dataset It can also be used to facilitate communications among public health partners and hospital staff during follow up or investigations d Map View Data Table Data Link Date Data Expected Detection Data Details 28Jun10 o 12679 0s Data Details 27Jun10 19 12357 oos Data Details 269m10 10 12 393 0 644 There are three locations where you will find map view hyperlinks 1 beneath the time series graph 2 in the data table below the time series graph and 3 on the data details aka line list page Depending on your query clicking on the map view will create a map of your data by either county or zip code 13 E ax XVI 5 Shoe d P CARROLL j f f FREDERICK BALTIMORE pA Ds e d ASIAN AT j N j IOWARD eT N P ns Y VP A s MA ir tat Selected Layer Legend a ANNE AY Counties Counties aM agp 2 l Ww ap Ea a CCa L8 L9 L3 CA 3 e 8 L6 A di TE Er lt as Sh S Label Acti Download PRINCE GEORGES Zips Zipcode Hie b fs A DORCHESTER E W abe es x E a A S Ve qt Region Syndrome Warning Wale Ext i WORCESTER t Soeren j 3d W 2 p 5 te Ye gt f A 50 km 20 mi 79 41156 40 52813 Global Parameters Once in the map the user can zoom in by double clicking on the map and zoom out using the slider on the lef
68. solution Write your free text query here Allegany MD Anne Arundel MD BALTIMORE CITY MD Baltimore MD All Triage Note Syndromes Bot_Like E Fever Select Detector Select ChiefComplaints all E Select Triage Note Syndrome Regression EWMA 1 2 x All Ten Year Age Groups Unknown E 00 09 Select Ten Year Age Group 10 19 20 29 Y Unknown E 00 01 S 02 04 05 17 M a Emergency Inpatient Outpatient Unknown J 00 04 Select Distribute Age Group 05 24 25 49 M Select CDC ILI Reporting Age Group Select Sex Female Male Unknowon Select Patient Class Pre admit M Select Disposition Category ios AI DISCHARGED Additional Filters As Percent Query Select Start Date 01May12 3 Select End Date 30Jul12 si Table Builder Time Series Data Details Graph Builder Overview Portal Proceed to steps 4 and 5 as outlined above Records of Interest Records of interest allows ESSENCE to produce a line list of ED visits in ESSENCE that match a specific query It is useful in those instances where the user wants to review each ED visit for a particular query For instance if you want to look at any ED visits with specific reportable disease names you would use the record of interest feature The records of interest feature is us
69. stance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival De MS Data Source Bot Like EF Syndrome GI All Regression EWMA 1 22 Regression 1 2 EWMA 1 2 CDC C1 Detector Fever Hem Ill Unknown All Age Range 18 44 All Female Male Unknowon AllAggregated E 0 4 5 17 Start Date juz 22Jul12 End Date Date End Date 30Jul12 Change Configuration Clicking on the plus sign next to configuration options in the region syndrome view will allow you to view alerts for selected regions syndromes age ranges and start and end dates Leave the data source field as all data sources and the sex field as all sexes After you have made the necessary changes click on change configuration to generate your new output In the region syndrome alert list syndromes are often presented in an aggregated view for age Within the configuration options age can be delineated into subgroups b Time Series ESSENCE Maryland Alert List Region Syndrome Based Temporal Alerts Last Updated July 30 2012 8 36 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Reset 3 Level Sorting Region Syndrome Based Temporal Alerts
70. t side of the map At the top center of the map above are 5 tools the user can select to drill down into the map for more information These include select by square select by polygon select by path select by point and map grabber The first 4 of these allow you to select parts of the map in different ways and the selections you make will appear in a table below the map The table will include some information about what you selected and a time series link so that you can produce a time series view of the selected data for that geography On the right hand side you can see a column with Layers and Global Parameters selections via a or sign These function allow the user to manipulate the map in various ways including adding layers to visualize changing the date range of the data displayed in the map changing the algorithm that creates the color ranges change the number of ranges and lets you download the shapefile of the map you have created click the picture of a disk under results Once the shapefile is downloaded the user can import it directly into ArcMap for further manipulation 14 Hospital Syndrome Clicking on Hospital Syndrome will allow you to view the previous 8 days of alerts by reporting hospital This option offers additional focus vs Region by further individualizing the data If an elevated number of cases in a particular syndrome are reported in a hospital s data a yellow or red alert will ap
71. tails hyperlink in the data table below the time series graph Data Table e Data Link Map Link Date Data Expected Detection Data Details Map View z2B amp Jultz 104 af 25 Data Details Map View aT 2 111 25 964 Data Details Map View 245 ul12 112 Br 214 Data Details Map View Z3Jul12 104 25 429 Data Details Map View 22 JuliZ B0 05 25 The following are examples of figures and a line list that can be generated by clicking on data SEIS Columns are blocked out for confidentiality reasons Disposition Categery Age Group B eras B Male B Other mg DISCHARGED ADMIT 355 g 2034 g 5574 pg 09004 D oie eph Options Save imece _Draph Options Seve mage Enhanced Gragh requires java 1 4 5 plug in Basic Graphs Date Time HospialName Repion of the Hospital Zipcode Orig Zipcode Region Age Group Age Sex ChiefComplaintOrig L2Febi0 04 48 AM 55 74 68 Mak RESPIRATORTY DISTRESS 5 74 71 Mae LEAKAGE FROM PROSTATE BIOPSY 05 19 17 Mak PED VS AUTO BLAKE TRANSFER 20 34 21 Female BIT BY A SPIDER SWOLLEN AND PAINFUL AREA 05 19 6 Femde STREP THROAT COUGH 00 04 0 Female COLD 35 54 19 Femak UPPER BACK PAIN The line list information can also be sorted using the 3 sort function Each case record has fields for date admit time zip code age chief complaint zip code etc All of these data are essential for evaluating alerts The field MedRecNo is a unique identifier for the patient and the patient s vi
72. these data is by hospital patient sub syndrome and the time the patient arrived at the ED A minimum of 4 visits is required to produce an alert i e p value lt 0 0001 This tool will help find clusters of patients who arrive at a hospital with similar symptoms and within a small time interval but whose total volume is not enough to create a statistical alert in the daily total alert lists The development of this tool was based on known outbreaks that were detected using a manual version of this approach Make the selections you would like from the available fields in the data configuration view and then click Change Configuration When the table loads you will see on the left side Region i e county Hospital and Alert Count Along the top are the 30 minute time intervals which is the minimum time interval used in the time of arrival analysis You can change this table view by clicking on the sign next to Table Configuration Options and then selecting sub syndrome in the row field drop down Open the next to Configuration Options and click change configuration to update the table view The red boxes in the table are the time intervals where a statistical alert was produced To drill down click on the red box A table will load at the bottom of the page with the information on the alert you clicked on Descrpoca S Tabi Configuration Options Configuraticn Optikas p E un fit Hospital SelrSyndrmes Sa
73. tratified Denominator Uses the denominator and the stratifications provided on the form to calculate the percents to be plotted on the graph see the legend for Stratifications to learn more about how this works Stratifications Use Original Uses the selected query and denominator with no modifications to plot all the points in the graph Any Other Stratifications Uses modified versions of the selected query and denominator to plot the graphs For instance if the stratifications selected are Age Group and Sex the original Age Group and Sex parameter values in the selected query are removed and replaced with each combination of the Age Group and Sex parameter values i e 0 4 AND Male 0 4 AND Female 5 17 AND Male and so forth Please note that due to the large number of graphs that can be generated using stratifications queries that return na data will not be plotted stratification options are only avaiable if a single query was chosen to be plotted from the Query Manager Go To MultiSeries Timeseries Cancel The chart below is an example of a multi series time series graph comparing rash illness in one county to rash illness for the entire state of Maryland Separate queries were run to generate two time series graphs and the multi series time series graph was created by going into query manager selecting the queries of interest and proceeding as described above to create the graph 44 Multi Series Time Series 2200
74. ups See the graphic below for a better idea of the selections a user can have with this option ESSENCE Maryland Alert List Hospital Syndrome Based Temporal Alerts Last Updated July 30 2012 8 50 AM Region Syndrome Hospital Syndrome Region OTC Category Region Call Type Alerts Region Caller Site Alerts Region Generic Substance Alerts Spatial School Absenteeism Hospital SubSyndrome Time of Arrival Description Configuration Options Data Configuration Emergency Room Data by Hospital Location Anne Arundel Medical Center Data Source Emergency Room Data by Patient Location Hospital Atlantic General Hospital Over the Counter Chain Combined Baltimore Washington Medical Center Poison Control Center id Bon Secours Hospital Y Bot_Like Regression EWMA 1 2 Syndrome Fever Detector Regression 1 2 Gl EWMA 1 2 Hem Ill CDC C1 i Al a Unknown E Female Age Range 0 4 S Sex Male 5 17 Unknowon 18 44 z AllAggregated eau o x Start Date 4 22Juli2 End Date 30Juli2 Change Configuration 15 ED Spatial Alerts The spatial alert list is different from the temporal alert lists in that it only looks for clusters over space in this case by zip code centroids If a particular combination of zip codes has abnormally high counts of ED visits for a given syndrome as compared to many combinations of the surrounding zip c
75. xt to description to see a summary of all variable selections you have made to generate your results Using the query portal practical example Suppose you have heard that unsafe attempts at home heating in Maryland lead to an increase in carbon monoxide poisoning in January and you want to explore this issue 33 1 First click on query portal in the main toolbar 2 Next select emergency room data by hospital location as your data source option and click submit 3 Then select chief complaints as your medical grouping system to allow you to specifically query ESSENCE for ED visits pertaining to carbon monoxide Since you would like to look at trends for the entire state you can leave the geography system s hospital region To examine the data for a particular hospital or hospital grouping you would select hospital as a geography system 4 In the next screen type your free text query in the select chief complaints field For this example we will use carbon or carbon monoxide to find ED visits related to carbon monoxide Also leave the select region of the hospital as the default all regions of the hospitals and leave all the other fields as the default unless you want to look at specific stratifications of the data The time period in this example is September 2009 through June 2010 Save Query Create myAlert Add to myESSENCE Share URL Data Series Options Grap
76. yAlerts myESSENCE EventList Overview Portal Query Portal Matrix Portal Weekly Percent Map Portal Remote Data Stat Table f Bookmarks JQuery Manager More v The bookmarks feature allows the ESSENCE user to save searches and use the same criteria to recover data on a daily weekly or as needed basis without doing the stepwise work To save a search you type in the name you would like to give the query and click on bookmark page in the top left corner of the page below the main toolbar Bookmark Name Bookmark Page You can access your bookmarks at a later date by clicking on the bookmarks tab in the main toolbar ESSENCE will bring you to the following page and you can click on the 40 name of the bookmark or select today to re run your query Bookmark Manager Expand All Groupings Collapse All Groupings Order Bookmark Name Page Date Created Select Today 3 Grouping unassigned 9 1 Region 1 amp 2 Graph Matrix Portal 1900 Jan 01 9 35 26 AM Select Today 2 Region 1 amp 2 Red Alerts Overview 1900 Jan 01 9 29 36 AM Select Today 3 Region 3 Graph Matrix Portal 1900 Jan 01 9 44 28 AM Select Today 3 Region 3 Red Alerts Overview 1900 Jan 01 9 43 46 AM Select Today Pl 5 Region 4 Graph Matrix Portal 1900 Jan 01 9 54 04 AM Select Today TIE Region 4 Red Alerts Overview 1900 Jan 01 10 03 38 AM Select Today Imi 7 Region 5 Graph Matrix Portal 1900 Jan 01 9 58 19 AM Select Today
77. yESSENCE Zl Overview Parameter Overview Parameter Overview Parameter Syndrome Configuration Options apti Bot Like 84 74 6 5 4 44 3 1 21 1 0 s e e a R A E A ck 5 X X 4 5 5 5 4 Data Normal Data Warning W Data Alert Download Click anywhere on the graph to switch to interactive view Fever 150 100 WX x x 5 5 6 6 E 2 23 25 2 o e Bs o 2 Data Normal Data Warning W Data Alert Download Click anywhere on the graph to switch to interactive view The other way to get to the overview portal clicking on the overview portal icon in the main toolbar provides a quick way to visualize time series graphs stratified on a specified parameter hospital region syndrome medical subgrouping age group sex or disposition category 1 Click on overview portal in the main toolbar 2 Select a data source 3 Select an overview parameter in the next screen and click submit You can click on any portion of one of the small graphs or click on switch to interactive view at the bottom right corner of the graph to activate the graph and examine the data more closely Fever 800 600 400 200 Data Normal Data Warning W Click anywhere on the graph Data Alert to switch to interactive view 26 ESSENCE also allows you to bookmark your queries so that you don t h

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