Florida

Each year, the Florida Lead Poisoning Prevention Program (LPPP) receives an estimated 270,000 blood lead results from healthcare providers, hospitals, and laboratories. Blood lead level (BLL) results are received by electronic lab reporting (ELR), Excel files via secure email, and paper-based faxes. Data received via ELR are directly uploaded into Florida’s reportable disease and condition surveillance system, Merlin. Excel files are reformatted and uploaded into Merlin, whereas paper-based results are manually entered. Data in ELR are used to auto generate lead poisoning cases for BLLs ≥3.5 µg/dL. BLLs <3.5 µg/dL are classified as “not a case” and are stored and managed in Merlin. Due to limited funding, delays in reporting occur because results need to be manually entered. As a result, surveillance trends may not indicate the true burden of lead poisoning in Florida.

To streamline data reporting and improve the quality, quantity, and efficiency of BLLs reported, LPPP implemented an ELR web portal in May 2021. The portal standardizes the reporting of blood lead data. This online reporting portal supports both manual data entry and batch data uploads via csv files. The objective of this portal is to transition LPPP away from paper-based data faxing and non-ELR. Reporting blood lead data via the ELR portal improves data quality and allows county health departments to quickly initiate case management services.

Since the launch of the ELR portal, 317 facilities have been onboarded. They have reported 18,531 blood lead results from 2021–2022. Their reports have triggered the detection of 41 cases of lead poisoning in 2021 and 847 cases in 2022. The portal has assisted in standardizing BLL results. State- and county-level personnel are tracking the number of providers transitioning to electronic reporting. LPPP continues to increase the numbers of providers reporting on the ELR portal in 2023.

All blood lead level (BLL) results are reportable in Florida; however, only results associated with lead poisoning levels meeting the state case definition (BLL ≥10 μg/dL) have been historically stored and managed within the state’s reportable disease surveillance application, called Merlin. Non-identifiable screening results that do not meet the surveillance case definition have been housed in a separate electronic laboratory reporting (ELR) database that few people are able to access. Analyzing and characterizing lead screening data has been extremely difficult due to the structure of the databases, the need to combine data from multiple databases (Merlin and ELR), and the inherent difficulties with de-duplicating records. This approach has made it challenging to access data at the county level to identify gaps in screening.

In 2017, Florida implemented system enhancements in Merlin to automate processing and create records of all BLL results. All laboratory results received either create an identifiable record within Merlin or are associated with an existing person-centric record without user intervention. Sophisticated matching algorithms within Merlin that were developed and fine-tuned over years can now be used for person matching of all BLL results. When a person-centric record is created, the system assigns a case classification of “confirmed”, “suspect”, or “not a case” based on the laboratory results associated with the record. Any record determined to be “not a case” is automatically closed in the system without any end-user involvement. BLLs between 5 μg/dL and 10 μg/dL can be counted as a confirmed or suspect case, but the system closes the case without requiring end-user involvement. However, end users can access and view these cases if they choose to do additional follow-up.

Improvements to Merlin enable effective tracking of children over time, as well as increase the ability to estimate the number of children screened, rather than just the number of screening tests performed. These system enhancements have allowed for back-loading of previous years’ data and the creation of 723,692 person-centric records with 1,068,564 laboratory results. Staff members are currently working on entering all previous data. Since any Merlin user can now access these records to better assess lead screening practices in their counties, the time to respond to data requests from the public has decreased from days to hours. Florida was able to use these data to characterize screening rates to identify and address gaps.