Texas Syndromic Surveillance (TxS2)

Texas Syndromic Surveillance (TxS2) is the statewide syndromic surveillance system hosted by the Texas Department of State Health Services (DSHS) for use by Local Health Departments (LHDs), DSHS Public Health Regions (PHRs, see map of DSHS PHRs at http://www.dshs.texas.gov/regions/state.shtm), DSHS central office, and data providers (hospitals, free standing emergency centers, and urgent care centers, for example) for enhanced surveillance of emerging public health conditions or threats. Syndromic surveillance utilizes trend analysis to establish a baseline and then uses algorithms to compare the current data to that baseline and issue alerts when aberrations are detected. DSHS has authority to operate TxS2 under Chapter 81 of the Texas Health and Safety Code.

Syndromic Surveillance
History of Syndromic Surveillance in Texas
Goals and Objectives
Governance Structure
TxS2 Configuration and Connection
Status and Timeline
Training
Use Cases and Success Stories
Annual Updates
Policies and Procedures
Meaningful Use
National Syndromic Surveillance Program
Partners

Syndromic Surveillance

The purpose of syndromic surveillance is to protect the health of the community through public health interventions based on enhanced surveillance of emerging public health conditions and consolidation of health-related data statewide. Syndromic surveillance allows for early detection of abnormal disease patterns that could result in high morbidity and mortality. The basic functions of syndromic surveillance include early event detection, situational awareness, and retrospective analysis. 

The basic steps of how syndromic surveillance works are as follows:

  1. A patient goes to an emergency department.
  2. The patient’s information is captured in the facility’s electronic health record (EHR).
  3. Selected elements of the EHR are sent to the syndromic surveillance system.
  4. The information is analyzed by the system for trends and abnormalities and the system creates alerts for aberrations in the data.
  5. The information is available for public health authorities to conduct additional analysis.

To learn more about syndromic surveillance and its uses see: 
MMWR: Overview of Syndromic Surveillance: What is Syndromic Surveillance?


History of Syndromic Surveillance in Texas

In April 2011, DSHS conducted a survey of existing syndromic surveillance systems in Texas. At that time, there were at least six different analysis systems being used in various parts of the state with no data sharing between them. As of March 2018, there are four syndromic surveillance systems in Texas: the North Texas Syndromic Surveillance System (NTXSS) hosted by Tarrant County Public Health covering PHR 2/3, a system hosted by Houston Health Department covering PHR 6/5S, the former Texas Association of Local Health Officials (TALHO) system being maintained by DSHS, and the TxS2 system. While these systems currently are not sharing data, the TxS2 system will incorporate data feeds from both the NTXSS and the Houston Health Department system, as well as replace the former TALHO system and connect other data providers statewide to integrate syndromic data from across the state into one system.

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Goals and Objectives

  1. Implement, configure, and test the information technology (IT) infrastructure for TxS2.
  2. Develop and execute Memorandums of Understanding (MOUs) for data providers to submit data into TxS2 and for LHDs and data providers to access the data in TxS2.
  3. Conduct user training on TxS2 for data providers, LHDs, DSHS PHRs, and DSHS central office.
  4. Onboard data providers that have emergency departments and EHRs and achieve ongoing data submission into TxS2.
  5. Monitor data submission into TxS2 by data providers to ensure stable connectivity and receipt of the TxS2 data set.
  6. Monitor usage of TxS2 by data providers, LHDs, DSHS PHRs, and DSHS central office to determine if additional training and data feeds are necessary.


Governance Structure

A two-tiered governance structure has been established for TxS2. The first tier is the Syndromic Surveillance Governance Council (SSGC) which makes policy recommendations to DSHS regarding TxS2 system functionality and data use. More information, including council members and minutes from previous meetings, can be found at http://www.dshs.texas.gov/ssgovcouncil/default.aspx. Within the second tier are the eight Syndromic Surveillance Regional Advisory Committees (SSRACs, one corresponding to each PHR) which gather input from LHDs and data providers and make recommendations to the SSGC regarding TxS2 system functionality. Contacts for each SSRAC can be found at http://www.dshs.texas.gov/txs2/contact.aspx.

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TxS2 Configuration and Connection

The TxS2 configuration consists of data providers using secure protocols to submit individual level data to DSHS through the Health Services Gateway. Data are stored in a secure database and accessed by users (LHDs, DSHS PHRs, DSHS central office, and data providers) through the analysis software known as ESSENCE (Electronic Surveillance System for the Early Notification of Community-based Epidemics), developed by the Johns Hopkins University Applied Physics Laboratory. 

Data providers located in PHR 2/3 that are connected to NTXSS will continue to submit data to this system and the data will be sent to TxS2. If your facility is located within PHR 2/3 and you would like to connect to this system, please contact Bill Stephens at wfstephens@tarrantcounty.com or (817) 321-5365. In addition, if your facility would like access to view aggregate statewide syndromic surveillance data, please contact TxS2 at syndromic.surveillance@dshs.texas.gov.  

Similarly, data providers located in PHR 6/5S that are connected to the Houston Health Department system will submit data to this system and the data will be sent to TxS2. If your facility is located within PHR 6/5S and you would like to connect to this system, please contact Biru Yang at biru.yang@houstontx.gov or (832) 393-4541. In addition, if your facility would like access to view aggregate statewide syndromic surveillance data, please contact TxS2 at syndromic.surveillance@dshs.texas.gov. 

Data providers outside PHR 2/3 and PHR 6/5S, including those currently submitting data through the former Texas Association of Local Health Officials (TALHO) system, will be connected directly to the TxS2 system. Please contact DSHS at syndromic.surveillance@dshs.texas.gov to obtain more information about registering an intent to submit syndromic surveillance data. Information about obtaining access to view aggregate statewide data will be included in the registration information.

Data providers outside PHR 2/3 and PHR 6/5S, including those currently submitting data through the former Texas Association of Local Health Officials (TALHO) system, will be connected directly to the TxS2 system. Please contact DSHS at syndromic.surveillance@dshs.texas.gov to obtain more information about registering an intent to submit syndromic surveillance data. Information about obtaining access to view aggregate statewide data is included in the registration information. 

Data providers currently submitting data to the former TALHO system should continue to do so until their connections are transferred. Please note – these connections will not be automatically transferred off the former TALHO system. Facilities in PHR 2/3 should work with Tarrant County Public Health to transfer their connections to NTXSS. Facilities in PHR 6/5S should work with Houston Health Department to transfer their connections to the Houston Health Department system. Facilities located throughout the rest of Texas will need to work with DSHS to transfer their connections to TxS2. 

ESSENCE users have access to the data and the ability to view alerts and run data queries. Hospitals and hospital systems can view data within the hospital/hospital system and aggregate PHR and statewide data. LHDs can view data within the PHR and aggregate PHR and statewide data. DSHS (central office and PHR offices) can view data throughout the state and aggregate PHR and statewide data.

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Status and Timeline

The Syndromic Surveillance Governance Council (SSGC) is established and has been meeting quarterly since October 2014. Additionally, the eight Syndromic Surveillance Regional Advisory Committees (SSRACs) have formed and are holding quarterly meetings.

On May 5, 2016, registration opened for hospitals with emergency departments, free-standing emergency centers, and urgent care centers to register their intent to submit data to TxS2. DSHS is currently only accepting registrations from these Data Providers and will not be connecting other Data Providers to TxS2 in 2018.

On May 15, 2017, the TxS2 system became operational and DSHS is onboarding data providers statewide to submit production data into the TxS2 system. As of March 2018, DSHS is working with Tarrant County Public Health to integrate the NTXSS data feed into TxS2. In Summer 2018, DSHS will work with Houston Health Department to integrate their data feed into TxS2. By Summer 2018, all data providers with the former TALHO system should be integrated into the TxS2 system to complete the statewide view.

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Training

DSHS has developed a user’s guide to help users access and navigate the system’s main features through the ESSENCE platform. There is also a protocol for monitoring data and responding to alerts. While it is the responsibility of the local jurisdiction (LHD or PHR acting as the LHD) to determine the appropriate response to an alert in their jurisdiction, this guide provides some general tips for analyzing syndromic surveillance data.

In addition, below are some online training resources for both syndromic surveillance and ESSENCE.

Syndromic Surveillance 101 (4 modules)

ESSENCE Training (3 parts)

Additional Resources

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Use Cases and Success Stories

DSHS is reviewing syndromic surveillance use cases for both day-to-day, routine surveillance and for unexpected events such as hurricanes or transmission of Zika virus in an effort to provide standard and suggested data queries. Additional information will be posted here when it is available. If you have questions or recommendations regarding use cases, please contact DSHS at syndromic.surveillance@dshs.texas.gov

For the system to be valuable, the data within the system must be viewed and analyzed by experienced public health officials throughout the state. As such, DSHS employees, LHD officials, and hospital infection preventionists have been given access to the system. It is important to share the accomplishments of partners throughout the state and to demonstrate to stakeholders the benefits and usefulness of syndromic surveillance. Syndromic surveillance activities and success stories from partners across the state are posted here. Please share your syndromic surveillance activities and success stories with DSHS by sending them to syndromic.surveillance@dshs.texas.gov.

Annual Updates
DSHS produces an annual update to summarize the current status of the TxS2 system and to document syndromic surveillance activities and success stories from across the state.

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Policies and Procedures

Data in the TxS2 system are shared, accessed, used, and stored in a secure, confidential manner in compliance with all applicable federal and state laws governing the protection of health-related information. Policies and procedures for accessing and using TxS2 data are posted here as they are available.

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Meaningful Use

TxS2 supports federal programs regarding the meaningful use of Certified Electronic Health Record Technology (CEHRT) to improve patient care including the Medicaid Electronic Health Record (EHR) Incentive Program and the Merit-based Incentive Payment System (MIPS). 

The objectives of meaningful use include encouraging health care providers to improve clinical outcomes and population health, increasing the transparency and efficiency of patient encounters, and developing more robust research data on health systems.

Consistent with federal guidelines regarding Stage 3 Meaningful Use, on June 30, 2016, DSHS declared readiness to receive data meeting the messaging requirements in the PHIN Messaging Guide for Syndromic Surveillance: Emergency Department, Urgent Care, Inpatient and Ambulatory Care Settings, Release 2.0 (April 2015) and the Erratum, available on the PHIN Messaging Guide web page, as referenced in the 2015 Edition Health IT Certification Criteria, on and after January 1, 2017.

With respect to federal meaningful use programs, DSHS is only accepting registrations from hospitals/hospital systems with emergency departments, and professionals in urgent care centers or free-standing emergency centers at this time. 

For entities/individuals not participating in federal meaningful use programs, DSHS is accepting registrations from hospitals/hospital systems with emergency departments, free-standing emergency centers, and urgent care centers.
 
DSHS will not be connecting other data providers to TxS2 in 2018. DSHS did not operate a statewide syndromic surveillance system in 2013, 2014, or 2015.

More information about TxS2 and the Meaningful Use Program can be found at: http://www.dshs.texas.gov/mu/syndromic.aspx.


National Syndromic Surveillance Program

In November 2017, DSHS completed onboarding with the National Syndromic Surveillance Program (NSSP) to share data collected in the TxS2 system with NSSP. NSSP collaborates with public health agencies and other partners for the timely exchange of syndromic data to improve the nation’s situational awareness and responsiveness to hazardous events and disease outbreaks. 

More information on NSSP can be found at: http://www.cdc.gov/nssp/.

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Partners

TxS2 is a collaborative effort and we depend on our public health partners for success of the project. Therefore, we coordinate with LHDs through the DSHS PHRs and coordinate with data providers through the LHDs and DSHS PHRs.

Tarrant County Public Health and Houston Health Department - Tarrant County Public Health and Houston Health Department host regional syndromic surveillance systems covering PHR 2/3 and PHR 6/5S, respectively, which will then feed into the statewide syndromic surveillance system, TxS2. DSHS staff in both the regional offices and at headquarters maintain a collaboration with these partners for syndromic surveillance activities, including collecting and sharing data and information, to ensure the success of the statewide system as a whole.

Public Health (includes LHDs, DSHS PHRs, and DSHS central office) – Public health partners participate in the system by reviewing data for enhanced surveillance, possible earlier detection, and situational awareness of emerging public health conditions or threats. TxS2 data could also help public health partners identify a significant event’s effects on the population post-event, such as large wildfires, chemical facility exposure incidents, or climate extremes (extended heat or cold), and assist in conducting epidemiological investigations. Public health partners respond to alerts generated by the system and conduct epidemiological investigations as needed based on their protocols for response. Additional roles for these individual partners are included below

DSHS Central Office – Management of the TxS2 system is housed within the Division for Regional and Local Health Operations (RLHO), in cooperation with Information Technology support programs. The Community Health Improvement Division and the Laboratory and Infectious Disease Services Division may review data, assist with efforts to standardize data queries, provide support for LHDs and PHRs during investigations of outbreaks or potential outbreaks, and assist RLHO with data and trend analysis, including statewide trends.

DSHS Regional Offices – DSHS PHRs assist in executing MOUs between data providers in their jurisdiction and DSHS. Regional Medical Directors chair the SSRAC for their PHR and regional staff may participate in SSRACs. Regional staff may also attend SSGC meetings as non-voting members.  Public Health Regions may review data, assist with efforts to standardize data queries, provide support for LHDs during investigations of outbreaks or potential outbreaks, and assist with data and trend analysis, including statewide trends.

Local Health Departments and Health Districts – LHDs assist, as desired, in executing MOUs between data providers in their jurisdiction and DSHS. LHDs also serve on both the SSGC and the SSRAC. LHDs may review data, assist with efforts to standardize data queries, provide support during investigations of outbreaks or potential outbreaks, and assist with data and trend analysis.

Data providers – Data providers participate in the system by submitting admission, discharge, and transfer (ADT) data. Data provider representatives also serve in both the SSGC and SSRACs. Data providers may review data, assist with efforts to standardize data queries, provide support during investigations of outbreaks or potential outbreaks, and assist with data and trend analysis.

Health Associations – RLHO coordinates with health associations [such as Texas Hospital Association (THA) and Texas Organization of Rural and Community Hospitals (TORCH)] to provide education to and obtain feedback from their memberships regarding TxS2, and promote TxS2 use.

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Last updated March 28, 2018