Missouri CDC EHDI Grant (2001)

GRANT ABSTRACT

GRANT NARRATIVE

Missouri Integrated Information System for Early Hearing Detection and Intervention

In 1999, the Missouri Legislature passed HB 401 (appendix A) that mandates hospitals screen the hearing of all newborns by January 1, 2002. Other components of the legislation include reporting the results of the hearing screen in a manner prescribed by the department, establishing and maintaining a newborn hearing screening surveillance and monitoring system for the purpose of confirming the presence or absence of hearing loss, and referring those with hearing loss for early intervention services; establishing standards and follow-up procedures for all newborns reported with possible hearing loss; referring newborns with confirmed hearing loss to both Part C of the Individuals with Disabilities Education Act (IDEA) system of early intervention services and to the Missouri Commission for the Deaf for census purposes; monitoring the delivery of early intervention services through IDEA Part C data system and reporting early intervention services provided and status of outcomes as identified on the individualized family service plan; and covering newborn screening, necessary rescreening, audiological assessment and follow-up, and initial amplification through individual and group health insurance plans and Medicaid.

During FFY 98, the Bureau of Disabilities Prevention and Injury Control contracted with Southwest Missouri State University (SMSU), to conduct a pilot project designed to identify newborns that have a hearing problem and refer those newborns with hearing problems to appropriate services for follow-up. The information obtained and analyzed from this pilot project was used to assess the feasibility of implementing a statewide universal newborn hearing screening (UNHS) program. Six hospitals from both urban and rural areas of the state were involved in the pilot project.

During calendar year 1999, there were 77,371 infants born in Missouri. The number of infants who had their hearing screened through the pilot project was 6,128. The number screened is based upon nine months, January through September, of UNHS screening data through those hospitals that participated in the pilot program. Of the 6,128 infants who had their hearing screened, 503 infants were referred for a second screen. The number of infants with a confirmed hearing loss is not known since the hospitals in the pilot project did not report this information. Based upon the pilot, we estimate approximately 6,300 newborns will be referred for a second hearing test when we implement the statewide system. There are 80 birthing hospitals in the state and currently ten are known to perform newborn hearing screening. All hospitals will conduct newborn hearing screenings by 2001.

The following challenges and barriers were found as a result of the pilot project and the introduction of legislation.

• During implementation of the pilot project, it was found that even though hospital administration was in support of UNHS, some hospital staff responsible to conduct the hearing screening were not supportive of the program. Their non-support was most likely a result of the newborn hearing screening being added as an additional responsibility to their current job responsibilities. Among the problems the pilot project found were that some staff did not screen all newborns, reported problems with their equipment, required frequent training on use of the equipment, and were slow to send in monthly hearing screening reports.
• Even though the legislation states that insurance will pay the cost of the newborn hearing screen, hospitals do not believe they will be reimbursed additional money for the screen through the "newborn care package".
• The Missouri Department of Insurance received a complaint from a health maintenance organization about the number of false positive hearing screens that had become a significant expense to that HMO.
• There will be a small percentage of parents whose infants fail the initial newborn hearing screen and who, for a variety of reasons, will not bring their baby back for a repeat hearing screen. Achieving one hundred percent parental compliance will be a big challenge.
• The technical challenge will include creating a system that can accept data through the web or through a paper report, training the hospitals and providing a help desk for questions on problems pertaining to the web system.

MOHSAIC Background

In 1992, the Missouri Department of Health (MDOH) embarked on a project to create a public health information system that includes an integrated client record. The department had just completed the Year 2000 Strategic planning process and realized that although it was data rich in many areas, it was information poor. Missouri analyzed its information systems and found that it had 67 separate information systems that lacked compatibility, connectivity, and standardization of information. They also lacked coordination across program and division boundaries. This multiplicity of non-integrated systems hindered MDOH managers' ability to know what data files existed and how to access them. Local public health agency administrators and other public health service providers also lacked information about the clients they served.

A group of high level MDOH managers and representatives from the local public health agencies created a strategic plan for information systems. This plan, the Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC), identified all the functions performed by the MDOH and local public health agencies and the data needed to perform these functions. It also provided the architecture for a statewide information network that could link public and private health care providers electronically.

Much has been accomplished since the creation of the plan including implementation of standards for the purchase of hardware, software and network equipment; development of a wide area network (WAN) which links the central office, seven district offices and 114 local public health agencies; and the connection of over 1300 MDOH employees to one electronic mail system which supports communications with the local public health agencies and others via Internet and the implementation of several major components of MOHSAIC.

Over the next two years, MOHSAIC will replace all stand-alone information systems in the MDOH. This will allow for the integration of data for assessment and assurance purposes. In addition, MOHSAIC will be used to bridge the gap between public and private health information systems.

MOHSAIC has three major components: surveillance (communicable diseases, STDs, HIV, Lead, etc.), regulation (childcare, lead handlers, narcotics registration, hospitals, etc.), and health management (immunization, service coordination, newborn hearing etc.). It also has four generic components (registration, scheduling, inventory and inquiry) that are accessible to the three major components. Following is a description of the generic components and the health management component of MOHSAIC, which will have application to newborn hearing.

MOHSAIC contains a generic registration component. This area captures the demographic information required to register a client, no matter the services provided. There is a core of required information such as the client's name, date of birth, race, sex, ethnicity, and DCN's for a person client.

MOHSAIC uses the Department of Social Services' numbering system to create a unique client number. The number is called a Department Client Number (DCN). This is the same numbering system used by the Medicaid, AFDC, and Food Stamps programs. The common number links all client specific programmatic data. This will facilitate our capability to analyze data in new ways to strengthen policy decisions.

Each child born in Missouri is given a DCN, which is appended, to the birth file. The birth file populates MOHSAIC to establish a population-based system for immunizations and other public health encounters.

MOHSAIC includes an electronic interface with the Department of Social Services (DSS) Medicaid eligibility and Managed Care enrollment files. This interface supports the electronic recording and/or updating of the Medicaid status of each client, the name of any Medicaid managed care plan in which they participate, and dates of participation for each plan.

In MOHSAIC each client is associated with a household. This establishes one address and telephone number related to all members residing together as a "household". Household members not registered in MOHSAIC can also be included as part of the list of household members associated with the address. In the household portion is the inclusion of the calculation of poverty level percentage based on household income and number of members.

Scheduling

Users are currently using this component to make and record appointments for clients to receive services at specific locations. The component allows users to identify sites where services will be provided, identify any clinic or service provider, set the frequency or spacing of client appointments, determine the number of clients to be seen in a given time frame, and document the service requested. MOHSAIC users have access to all scheduled clinics statewide. This allows the flexibility to determine when services are available and make appointments to receive those services.

Inquiry

The inquiry component of MOHSAIC supports the three main components. An inquiry could be a complaint regarding a program, a complaint regarding a public health problem or from someone needing information on available services. The system records who inquired, whether the inquiry was for information or a complaint, the nature of the inquiry and how the inquiry was resolved. This feature allows MDOH to better provide referral information, track complaints, and provide a means to keep current on public health issues.

This part of the system will be useful to record any inquiries from parents or professionals regarding needs or concerns on newborn hearing loss services. The functionality of the system may need some minor modification to capture the level of detailed information needed on newborn hearing inquiries.

Of the three major components of MOHSAIC, health management will serve the widest range of programs. Health management is designed as a person centered database for all public health services delivered to individuals. This includes immunizations, family planning, children with special health care needs, WIC etc. Through this proposal, health management will be expanded to include newborn hearing and metabolic screening. The following is a description of some of the major subcomponents of Health Management that are in operation or in development and pertain to children.

Immunization Subcomponent of Health Management

Some of the functionalities of the immunization component are provided below.

• The central registry is interfaced with the vital records system to capture all new births occurring in Missouri. The Social Security Administration provides social security numbers (SSNs) for newborns on a weekly basis which are merged into the central registry. The file is also interfaced with the adoption and death certificate files to assure proper handling of records for clients included in these files.
• The system supports the documentation in the client's record of vaccines given either by the agency entering the information or by other providers.
• The system assesses each client's immunization status and identifies needed vaccines based on the ACIP recommendations.
• An electronic file of clients that are due or past due for vaccines to assist in reminder/recall activities is created for each provider. This file can be used to create letters to the clients.
• Each month Medicaid billing/encounter immunization data are loaded into MOHSAIC
• The system accepts electronic data from managed care and private provider systems.
• The MDOH is making a concerted effort to bring private providers onto the system. Currently 56% of Missouri two-year-old children have two or more immunizations recorded in MOHSAIC.

Service Coordination Subcomponent of Health Management

Programs that will be supported by Service Coordination are: Children with Special Health Care Needs, First Steps (Part C of the Individuals with Disabilities Education Act), Healthy Children and Youth, HIV/AIDS Service Coordination, High Risk Prenatal Appraisal, TB and Lead service coordination, metabolic and newborn hearing service coordination.

Several key pieces of functionality are being developed in the Service Coordination subcomponent. Schedules for screenings and follow-up visits will ensure the client receives services and care when needed. The use of alerts will aid the service coordinators by notifying them of events that are overdue or potential health risks that may be emerging for a client.

The system will allow for complete service plans to be created and monitored for clients. This includes identifying strategies and interventions that will reduce, eliminate, or control situations and/or diagnosis for the client. Monitoring the service plans will provide the service coordinator the ability to help the client achieve measurable outcomes as a result of the strategies and interventions recommended. The online availability of all care plans will allow the service coordinator to see what strategies other care providers may also be providing.

The analysis phase for the development of the Service Coordination subcomponent has been completed. Implementation of the system will occur by the fall of 2000.

This system will be available for tracking children with newborn hearing loss or late onset or progressive hearing loss. Presently there are 783 children with hearing problems enrolled in the special heath care needs program. These children along with other new children detected at birth with a hearing problem will be enrolled in MOHSAIC and will be a part of this subcomponent.

Data Warehouse

The purpose of the data warehouse is to provide MDOH staff with quick and easy access to department-wide data and pertinent external data to improve policymaking and program management. The data warehouse is built on the philosophy that all data in the MDOH are a resource that should be available to all MDOH programs within agreed upon confidentiality constraints. Each surveillance system and transaction system has a program custodian but the custodian is not the owner. The MDOH is the owner. By making data easily available across bureaucratic lines, the programs will be able to integrate services easier.

The data warehouse focuses on providing better access to each of the MDOH surveillance and transaction files. The MDOH purchased MyEureka software to provide users with an easy-to-use tool for extracting information. With minimal training, users have the capability to customize reports to suit their needs and to "drill down" to more detailed levels of data. In the past only computer programmers and research analysts did this.

Executive Information System (EIS) capabilities of the software generate reports on a periodic basis with conditions set by the program manager. Reports can be distributed on a conditional basis to notify program staff of a new or unusual circumstance that may need their attention. For example, a service coordinator manager can be notified automatically if a child with hearing problems has not received the services according to the time and manner planned.

MOHSAIC and Newborn Hearing

Presently MOHSAIC does not include a component for metabolic screening or newborn hearing. Currently metabolic screening data are sent by the birthing hospital on a laboratory form with the blood sample. The state laboratory enters the demographic data on the mother and child into a computer system provided by Neometrics. The test results are also entered into the same system. Notifications to the health care providers and families are made by fax, letter and telephone call. Staff in the Bureau of Disabilities Prevention and Injury Control do the case follow-up. This stovepipe system has several flaws.

The present approach creates redundant data entry for hospital personnel who fill out the metabolic laboratory form and then enter most of the same data onto the birth certificate. The state laboratory keys the information on the laboratory form. Therefore, much of metabolic information is entered onto three different forms or systems. The present metabolic system does not link with birth records so there is no way to determine population-based rates and metabolic screening compliance. The metabolic system is not integrated with other health data systems so there is no way to track the services provided to children with metabolic disorders.

These flaws could be replicated with another stand-alone newborn hearing surveillance system unless we develop a single integrated system for metabolic screening, newborn hearing, the preparation of birth records and service coordination. During the first year of this grant, we plan to contract the development of a web-based system that will integrate the collection of newborn metabolic screening and hearing data at the hospital level. At a later stage, we will expand the system to include web-based data entry for birth records that will integrate with the newborn metabolic screening and hearing. The newborn hearing and metabolic screening data will become part of MOHSAIC and the data warehouse so that all public health encounters with children will be captured in a person centered database. The following is the goal and the objectives of this project.

Goal: To capture newborn hearing screening information on all children born in Missouri. The information will be integrated in a person centered data system with all other public health encounters to support tracking, interventions, and coordination with public health programs.

Objectives:

• To establish data elements needed for newborn hearing surveillance (Year 1)
• To create a web-based system that integrates the collection of newborn hearing and metabolic screening data. (Year 1)
• To expand the newborn hearing web-based system to include the collection of information for the birth record. (Year 2)
• To integrate the newborn hearing information with the Health Management component of MOHSAIC. (Year 2)
• To include in the Inquiry component of MOHSAIC the capture of information on children with late onset or progressive hearing loss. (Year 1)
• To include in the Health Management component of MOHSAIC the capture of information on inquiries from parents or professionals regarding needs or concerns on newborn hearing loss services. (Year 1)
• To coordinate with appropriate advisory committees and interested parties on the design of the information system. (Years 1 and 2)
• To create a data mart from the data warehouse that supports the production of routine reports, ad hoc reports and analyses on children with hearing loss. (Year 2)
• To create standard reports that track incidence rates by geographic and demographic variables, hospital screening performance, false positive rates, loss to follow-up rates, program participation rates etc. (Year 1,2,3)
• To prepare and publish manuscript(s) that describes the capture of newborn hearing loss information in MOHSAIC. (Year 3)

In 1999 there were 77,371 babies born in Missouri. One hundred eight (108) of the infants died within the first hour of birth and another 286 died within the first 24 hours. Presumably many of these infants would not receive a hearing test. The MDOH has statutory authority to require that all babies born in a Missouri hospital receive a newborn hearing test and the results be sent to the MDOH starting in 2002. The MDOH proposes to implement this mandate by contracting for the development of a web-based system that integrates the collection of newborn hearing and metabolic screening into the same system. The MDOH has used the metabolic screening information system provided by Neometrics as a part of the contract to supply metabolic reagents to the state laboratory. The Neometrics system is a PC-based system that is only accessible to the state laboratory. It is not linked to hospitals or the rest of MOHSAIC.

Through this proposal, we will contract with Neometrics to redesign their system to include a web interface that the hospitals can use to enter both newborn hearing and metabolic screening data. Neometrics uses the Delphi programming language and the Oracle database that is same language and database used for MOHSAIC. This will allow the web-based newborn hearing information to be integrated easily into MOHSAIC.

The following is a description of the Neometrics system and their proposal to develop a web interface to support newborn hearing surveillance.

Neometrics - MSDS III

The Neometrics' Metabolic Screening Database System (MSDS-III) is a multi-user, menu drive system with functions available to perform data entry, organize laboratory work flow, provide on-line search capability, automate results processing, and produce periodic reports including listings of specimens tests and mailers to specimen submitters. This DOS-based software is currently in use in the MDOH's Newborn Screening Laboratory.

Neometrics - CMS-III

The Neometrics' Case Management System (CMS III) functionally continues where our MSDS-III package leaves off and provides for on-going follow-up management of processed specimens. CMS has been designed to handle the various tasks and responsibilities associated with the tracking and management of newborn screening data. Acting as an interface between the laboratory MSDS system, CMS provides a convenient automated method to assign and track follow-up tasks associated with newborn specimen results.

Our case management system allows the Newborn Screening technicians to follow up on all post-natal abnormal (ABN), presumptive positive and unsatisfactory (UNSAT) results. The CMS system has been designed to perform the following critical follow-up tasks:

• Generate initial letters to health care providers (hospitals, physicians), parents or local health departments based on the laboratory test results.
• Generate second notices automatically when repeats are not received in a timely manner.
• Extended Results and Disorder Tracking
• Prepare patient reports based on large quantities of data
• Provide effective search capabilities to locate a patient history.

These functions allow the user to attach additional data to the patient record. The source of this data is normally obtained in the course of patient follow-up from various health care professionals or agencies. The data captured here pertains to external results and disorders that the patient may suffer, such as hypothyroidism and phenylketonuria. It includes specific tests performed and their results.

Additional Follow Up Features

The Case Management System allows the users to perform:

• On-line patient information searches
• Generation of reports for Closed and/or Open and diagnosed and/or undiagnosed cases
• Generation of patient information reports and letters to physicians and parents
• Viewing of specimens on a per patient basis (On-Line Search) or by specific type of data (Case Demographics, Extended Results, Disorders).

MSDS-III will have added capabilities to capture and store the hearing screening method (i.e. ABR, OAE, both ABR and OAE, or Testing not available), Left ear and Right ear results (Not performed, Pass, Refer for further testing), and information on a referral made at the hospital. This information will be available to print on the mailer result report that is sent for each newborn that has had a metabolic screening performed. A limited mailed report suitable for sending to an audiologist will also be made available that would print the hearing results without the other newborn screening test results. Referred test results and "not performed" results will be sent to CMS for follow-up. As data is transferred to CMS, a file is prepared for transmission to MOHSAIC.

The CMS program will be modified to accept the new data being entered in MSDS, post actions based on the hearing results and allow long-term follow-up of hearing disorders. On-line search test result screens will be modified to include the display of hearing results. Security features will be enhanced to allow the separation or combination of hearing screening information and newborn screening laboratory information.

A long-term follow-up questionnaire or patient history form will be developed and a customized entry form and report will be implemented within the CMS software.

Hearing confirmation tests, referral results or other extended test results will be incorporated into the CMS referral data table. This will allow the CMS user the ability to record all testing and referrals beyond the initial screening test as part of the patient history. Presumptive and final diagnosis for hearing disorders as well as case disposition reasons specific to hearing screening will be added to the existing Newborn Screening codes.

Letters for providers, referral physician, parent and service coordinator will be created. Additional reports will be added to the standard CMS software package. These additional reports are described below in the section titled "Sample Reports".

Development of a Web-based System

Web-based functionality will be developed to integrate the collection of newborn hearing and metabolic screening data at the hospital. CMS will also be web-enabled to hearing screening providers and follow-up personnel. The CMS portion of the web system would include a sophisticated search engine that allows the remote users access to the demographic and hearing screening results of patients requiring additional testing or treatments. Audiologists would have security clearance to record confirmatory testing results and additional referral recommendations through a web-based entry form for submission to the centralized CMS software database. The entries made by the audiologists may be "mapped" to trigger follow-up actions just as initial hearing screening results are when merged from MSDS.

Neometrics will utilize advanced encryption and digital certification techniques. This service uses digital keys at each local site to validate access to the web site and for all data transmissions to and from the site.

Critical milestones for project evaluation

The Neometrics implementation plan has four major components: specification, development (includes customization and documentation), acceptance and installation. Once contractual specifications and system requirements are defined, timeframes for deliverables and phases can be determined. Those phases can be completed in approximately six months.

Phase I - Specification

Prior to the contract development and negotiations, functional requirements and specification outlines will be developed to assure that the needs of the MDOH are met. Upon award of the contract, specifications will be obtained initially through a survey that is sent to the MDOH by Neometrics. Following the receipt of this information, Neometrics will send training Product Managers and Systems Analysts to gather additional specifications on-site. The Neometrics personnel will interview key MDOH staff and advisory committee members and perform a comprehensive needs analysis. Once specifications for the system have been obtained onsite, Neometrics technical writing staff will produce a specification document for review by MDOH staff. This document will initiate an interactive change/approval process for the development of the final specifications. Neometrics will host one or more key MDOH personnel at the Neometrics' facilities to review the specification and finalize all necessary details. Neometrics and MDOH staff will provide input into what is required of the system and what can be accomplished by the system. Once a signed and approved final specification has been produced, the custom software portions of the system can be developed.

Phase II - Development and Customization

A trained and experienced staff of software engineers and computer programmers experienced with MDOH requirements from prior installations will conduct software customization in-house at Neometrics. Once the software has been developed, Neometrics' product management staff will conduct quality assurance testing. After the Software Customization portion of Phase II has been completed, the technical writing staff will develop both the on-line help and the manuals that will be delivered.

Phase III - Acceptance

Once the system has been thoroughly tested, our product management and systems integration staff will install it on the acceptance test server at Neometrics. At this point, a system audit will be performed. The next step will be the user acceptance test period. Once again, Neometrics' will host one or more key MDOH personnel to perform the acceptance test. Also included in the acceptance phase is the first phase of system training given by Neometrics training staff. Once full software acceptance has been gained and signatures acquired, the software is ready for on-site installation.

Phase IV - Installation

The on-site phased installation will be coordinated with and performed by Neometrics' product management and technical support staff. At each phase, a system audit and acceptance will be performed to ensure system installation is complete. The phases will be: operation within MDOH, alpha test with WebEBP, and Beta test with WebEBP. The system is delivered with a complete set of training documents and user manuals.

Sample Reports

All reports would be available in formats suitable for on-screen viewing, printing, or web publishing. Eight standard reports are included with the basic CMS software (Patient History, Numeric Sample Listing, Alphabetic Sample Listing, Case Listing, Outstanding Actions, Daily Abnormal Listing, Diagnosed Listing, and Action Worklists). In addition, the following reports would be added to accommodate hearing screening requirements: number of infants served, number of infants referred and number of infants with repeat tests. For each of these reports, a user can select to sort/group by hospital, by type of test, by hospital plus county, region or state. Columns will count infants screened by race/ethnicity, by age of infant at screening.

There will be a State Early Intervention Services Report which is a detailed report with columns for laboratory number, baby's name, baby's date of birth, mother's name, mother's address, mother's phone, provider information (name, address, phone), hospital performing test, date performed, type of test, results from right and left ear.

Training and End-user Support

Training will be provided by Neometrics product management personnel and will be conducted on site as an aspect of the product installation. Our training staff will conduct systems training after the completion of the installation. The project manager will work with MDOH staff to develop a comprehensive training plan that is appropriate. It will include both systems administrators and user training. It includes individualized training for the clerical staff and for professional or laboratory personnel. Both classroom and hands-on training is provided. Neometrics will provide training to MDOH personnel who will then be able to provide the training at remote sites.

The integrated web-based newborn hearing system will be implemented according to the following steps and time frames:

EVALUATION PLAN

The project will be evaluated by determining if the objectives and tasks outlined in this project are met; whether they are met according to projected time frame; whether there is user satisfaction with the information system that is developed and whether children with newborn hearing problems are identified, followed and services provided. Appendix B shows the steps that must be completed to implement an integrated newborn hearing information system and make it successful. We will document the level of success achieved for each step in the progress reports.

Through legislation, a Newborn Hearing Screening Advisory Committee was established. The purpose of this advisory committee is to advise and assist the department in developing rules, regulations and standards for screening, rescreening and diagnostic audiological assessment; developing forms for reporting screening, rescreening and diagnostic audiology assessment results to the surveillance and monitoring system; designing a technical assistance program to support facilities implementing the screening program and those conducting rescreening and diagnostic audiological assessment; developing educational materials to be provided to families; and evaluating program outcomes to increase effectiveness and efficiency.

The advisory committee was appointed by the Director of the Department of Health and is composed of the following sixteen members: three consumers (including one deaf individual who experienced hearing loss in early childhood, one hard-of-hearing individual who experienced hearing loss in early childhood and one parent of a child with a hearing loss); two audiologists who have experience in evaluation and intervention of infants and young children; two physicians who have experience in the care of infants and young children (one of which is a pediatrician); one representative of an organization with experience in providing early intervention services for children with hearing loss; one representative of the Missouri School for the Deaf; one representative of a hospital with experience in the care of newborns; one representative of the Missouri Commission for the Deaf; and one representative from each of the departments of Health, Elementary and Secondary Education, Mental Health, Social Services and Insurance.

The advisory committee has appointed a data subcommittee which will work closely on this project to advise on required data elements, screen flow, system functionality and reports.

As shown in this application this project is built upon collaborative efforts to integrate newborn hearing data, metabolic screening data and service coordination data. Appendix C shows the letters of support of key units within the MDOH, the advisory committee chairman and the hospital association.

This project will combine the expertise of the MDOH and Neometrics. The following is a description of the background, skills and experience of Neometrics.

Neometrics Inc., headquartered on Long Island in New York, is the largest US supplier of diagnostic reagents and computer systems for use by state health departments performing newborn screening. Its business focus is entirely on public health and it maintains a strong capability in automating laboratory operations for public health organizations. Established in 1978, the company claims eighteen of the largest state health departments as users of its computer systems, and a similar number as users of its diagnostic reagents. Neometrics is a bi-coastal company having its diagnostic manufacturing and R&D facilities in Portland, Oregon and its software and system development operations on Long Island in New York. Staffing levels are ten in Portland and twenty-six in New York. Neometrics is a specialist in both hardware and software, as well as diagnostics and has developed a wide range of public health laboratory applications which can be directly used to eliminate operating constraints while providing significant benefits in performance and cost savings. Extensive customer support, on-line context sensitive help screens and user documentation uniquely assist users in providing system friendly operations.

This project is part of the overall MOHSAIC project. MOHSAIC started in 1993 with no funding or staff. The Office of Information Systems at that time had a staff of 27 persons, 12 contractors and an annual budget of $1,800,000. Because of the success of the project, the Missouri Legislature and federal agencies have supported the project to the extent that the current resources include 91 staff, 17 contractors and a budget of $8,000,000. All of this growth is related to the local and wide area networks and development staff required for MOHSAIC.

The success of any large project such as MOHSAIC is dependent upon several factors including securing the necessary funding, securing and maintaining top level managerial support, involving program staff at all levels of the organization, developing and maintaining the cooperation of programs across division lines and providing effective project management for a large development team.

In each of these critical areas, we have been successful in developing MOHSAIC. Missouri is one of a very few states, if not only state, that is nearing completion of a total integrated information system for all public health encounters. The CDC requested and received the MOHSAIC data model for use in developing the National Electronic Disease Surveillance System (NEDSS) Public Health Conceptual Data Model.

MOHSAIC has been developed under the leadership of Garland Land, Director of the Center for Health Information Management and Evaluation. He has a MPH in biostatistics and has 29 years of experience in managing surveillance systems and epidemiological studies. He will serve as the principal director of the newborn hearing screening project. He has a MPH in biostatistics from the University of Michigan. He has directed the Missouri health statistics activities since 1971. He has served on several national committees including the Panel for "Injury in America," Panel of Experts for MCH Information Resource Center, IOM Committee on Using Performance Monitoring to Improve Community Health, Task Force on Community Preventive Services. Mr. Land will provide administrative direction for the project to insure all steps of the project are carried out on time.

The main duties of the MDOH analyst, Christy Butler, assigned to this project are to coordinate activities with the vendor and ensure there is complete understanding on areas of responsibility and deliverables. Since there is data dictionary synchronization issues involved, it is critical that the vendor understands the format and values of the data elements that must be moved into MOHSAIC. The interfaces between the lab database and the MOHSAIC central database will require close collaboration with the vendor and the MDOH Lab staff. Good analytical skills and an understanding of the MOHSAIC data structures are required.

Jim Jeffries, acting director of the Bureau of Disabilities Prevention and Injury Control, will determine the programmatic needs of the system and coordinate activities with the advisory committee.

Appendix D contains the CVs of appropriate MDOH and Neometrics personnel.

The importance of information systems and data to the MDOH is reflected in the organizational structure of the department (appendix E). The department is organized so that the information activities are consolidated in one unit--the Center for Health Information Management and Evaluation (CHIME). CHIME includes the Office of Information Systems, State Center for Health Statistics and the Bureau of Vital Records. CHIME has 165 employees and a budget of $11,940,000. The State Center for Health Statistics has twenty-five professional research analysts and seven support staff that manage surveillance systems, link files, analyze data, answer special requests, conduct surveys, provide statistical consultation and evaluate programs. The Office of Information Systems has a staff of ninety including twenty-five persons developing MOHSAIC.

Technical Architecture

To support MOHSAIC and the data warehouse, MDOH has established a statewide network. All MDOH sites and all local public health agencies in the state are connected through a routed network using high-speed frame relay lines. MOHSAIC is multi-tier system developed in Delphi. The MOHSAIC database is Oracle 8, which resides on an IBM SP running AIX. The MOHSAIC middle tiers, which function as application servers, runs on multiple Windows NT computers in a load-balanced configuration. The thin-client portion of the system runs on Window 95/98/2000/NT clients. The data warehouse also uses Oracle running on a separate node of the IBM SP. The data warehouse is a normalized database, but subject-specific data are downloaded to various data marts that are denormalized. Authorized non-technical users can develop reports from the data marts using MyEureka, Epi Info, Microsoft Access, Crystal Reports, or almost any other standard report generator. Standard periodic reports are developed by MDOH technicians and are placed on the department's Intranet web server so that users can run them when needed.

MDOH uses IBM RS/6000 computers and IBM firewall protection software to protect their Internet server that runs on a separate IBM RS/6000 computer. MDOH is currently researching digital certificates and other means of encrypting confidential data that will be sent to MDOH on the Internet.

This is not a research project. The proposed surveillance system is based upon statutory authority. Therefore, we do not expect that this project is subject to human subjects requirements.