Background: Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. Objective: The aim of this study is to investigate whether excess visits where the word “cough” was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. Methods: A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. Results: The percentage of patients presenting with an EHR reason for visit containing the word “cough” to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. Conclusions: A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges.

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中文翻译：

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COVID-19 大流行前几个月，美国大型卫生系统因咳嗽和肺部疾病就诊的患者过多：时间序列分析。

背景：准确评估 COVID-19 等疾病的区域活动对于指导公共卫生干预措施非常重要。利用电子健康记录（EHR）来监测门诊患者的临床情况可能会发现新出现的疫情。目的：本研究的目的是调查 2019 年 12 月至 2020 年 2 月与前 5 年相比，EHR 就诊原因中出现“咳嗽”一词的超额就诊以及因急性呼吸衰竭住院的情况是否更为频繁。方法：从美国一个大型卫生系统中确定了一个回顾性观察队列，该系统拥有 3 家医院、180 多家诊所，每年接待 250 万名患者。包括2014年7月1日至2020年2月29日的患者就诊数据。使用季节性自回归综合移动平均 (SARIMA) 时间序列模型来评估观察到的 2019/2020 年冬季比率是否高于预测的 95% 预测区间。与前几个季节相比，计算了 2019/2020 年冬季预计超额就诊和住院人数。结果：2019 年 12 月 22 日当周，因 EHR 就诊原因包含“咳嗽”一词的患者百分比超过了 95% 预测区间，并且在整个 10 周内一直高于 95% 预测区间。 2020 年 2 月的情况也出现了类似的趋势。从 2019 年 12 月 22 日开始，急诊科就诊和住院治疗也出现了类似的趋势，观察到的数据分别在 10 周中的第 6 周和第 7 周超过了 95% 的预测区间。通过从当前季节减去前五个季节的最大值或平均值得出，2019/2020 年冬季 3 个月的估计超量为每 1000 名门诊患者因咳嗽超额 1.6 或 2.0 人次，即 11.0 或 19.2 人次。每 1000 次急诊就诊中因咳嗽而就诊的次数分别为 21.4 次或每 1000 次因急性呼吸衰竭住院而额外就诊的次数分别为 21.4 次或 39.1 次。超过预测区间95%的超额病例总数为门诊168例、急诊56例、因急性呼吸衰竭住院18例。结论：从 2019 年 12 月下旬开始，一直持续到 2020 年 2 月，患有呼吸道疾病的患者数量显着增加，这表明 SARS-CoV-2 在建立临床意识和检测能力之前就已在社区传播。这提供了一个案例，说明卫生系统分析如何与 EHR 数据相结合，提供强大而灵活的工具来识别患者群体的未来趋势何时超出预期范围。

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