Date: Thursday, April 30, 2009 Time: 12:00 – 1:30pm EDT

What is public health informatics and what can it do for my local health department?
Date: Thursday, April 30, 2009 Time: 12:00 – 1:30pm EDT Speakers: Dr. Arthur Davidson, Denver Public Health, Dr. Anna Orlova, PHDSC & Johns Hopkins University, Moderator: Alastair Matheson, NACCHO,

Welcome and overview Why should I care about informatics?
Scenarios that are relevant to your work Questions raised by these scenarios Compelling reasons to get involved What will the benefits be for you? What are some of the issues in informatics? Why is it important for local public health to be involved? What are the next steps? What the stimulus can and cannot do for you What should you do now? What is NACCHO doing? There may be a spectrum of listeners and skills in our listeners regarding public health informatics. We hope that this introductory webinar provides a stimulus for the listeners to become more engaged. This short discussion will not solve your jurisdiction’s information problems, but it may begin to point to real opportunities in our field right now. The time is right for you to be an advocate for public health informatics within your jurisdiction and beyond. NACCHO believes that informatics plays an important role in advancing public health and the health care reform agenda.

Scenarios Scenario 1: Communicable Disease
CDC has activated its Emergency Operations Centers to coordinate the agency’s response to the swine influenza outbreak. Scenario 2: Chronic Disease The mayor/county commissioner/city council person for your jurisdiction made an inquiry about public health efforts to improve cardiovascular disease care and outcomes in your community. Scenario 3: Health Information Exchange The local medical society is organizing an effort to respond to the recent incentive packages for physicians and hospitals to adopt electronic health records. The president of the society calls you to see if you would help them determine was meaningful use should be in your community.

Scenarios (continued)
Scenario 4: - Workforce New federal preparedness funding guidance focuses on building connectivity between the personal and public healthcare environments for situational awareness. The state health department (SHD) is encouraging local health departments (LHD) to develop tools for interoperability with the state and the larger health care community regarding biosurveillance systems.

How to find needed information?
Scenario 1: - Communicable Disease CDC has activated its Emergency Operations Centers to coordinate the agency’s response to the swine influenza outbreak. How do you go about answering questions in your jurisdiction regarding: potential sources of infection? comparing current and prior year rates of seasonal flu? How do you acutely improve your surveillance methods? How do you share data and analyses with neighboring jurisdictions and CDC? How are you communicating information to the public?

How to find needed information?
Scenario 1 – Swine Influenza What information systems, if any, do you use to support CDC response? What has been your experience to date in getting data and how you are using these information systems?

Informatics a field that helps users (public health professionals, clinicians, etc.) to communicate to developers user needs for information technology (IT) products, so these IT products will be useful in finding information to support public health decisions. Typical paper-based systems are inadequate to match the tasks most LHD and SHD are faced with over the past few days. Answering these questions requires new tools. The public is expecting a measured and balanced response by public health agencies. Getting the info right is the only way to avoid the pressure by the media to promote fear and panic. Learning how to use the data we have to create information and knowledge is the first step. Informatics is the process to help build that knowledge. Informatics is a focused approach on communicating between the end-user and the developer of information systems as described in this definition.

Informatics “Informatics is the science that studies the use and processing of data, information, and knowledge” Along the continuum, our public health activities collect data, but the systems need to transform that into information and ultimately actionable knowledge. To answer many of the preceding questions, we are looking for the information to Speak with certainty about potential sources of infection? Compare current and prior year rates of seasonal flu? Or we are looking for systems that are flexible and can: Ramp up to acutely improve your surveillance methods? share data and analyses with neighboring jurisdictions and CDC? Or we may be looking for tools that help with: communicating information to the public? Van Bemmel JH & Musen MA Handbook of Medical Informatics. Bohn: Springer-Verlag

Informatics vs. Information Technology
Informatics is NOT Information Technology (IT). Informatics is the field that describes the problem (application domain), e.g., Flu Surveillance, for which an IT solution (application, tool) is needed, e.g., Flu Surveillance Information System to (1) track cases of sick individuals, (2) generate public health alerts, (3) monitor vaccine distribution, etc.. Informatics through modeling helps to select best IT solution to address a Problem. So, an IT professional (developer) is an engineer who builds the tool for the solution. Informatician is a user who designs the solution.

Informatics and Modeling
Model Development is the Main Informatics Method Informatics and Modeling Informatics uses models of the problem (application domain) to: capture domain knowledge; precisely specify requirements, i.e. specifications for a solution so that all stakeholders may understand and agree on them; guide the thought process; generate potential system configuration describing a generic structure and meaning; abstract specifications of the essential structure of the system; tell what something does (functional specification) as well as how the function is accomplished (implementation) Rumbaugh et al Unified Modeling Language. Manual.

Problem (domain) modeling is FOUNDATIONAL for a successful IT application
Information Technology Informatics CP Friedman. Where's the science in medical informatics? J. Am. Med. Inform. Assoc : 65-67

Using Informatics Tool of Modeling
Scenario 1: - Communicable Disease CDC has activated its Emergency Operations Centers to coordinate the agency’s response to the swine influenza outbreak. How do you go about answering questions in your jurisdiction regarding: potential sources of infection? comparing current and prior year rates of seasonal flu? How do you acutely improve your surveillance methods? How do you share data and analyses with neighboring jurisdictions and CDC? How are you communicating information to the public? Now returning to our scenario, how would you go about modeling the user workflow. Who would do this work? What skills are required? Some of these questions will be addressed as we get to other scenarios, but it is important to begin thinking that modeling is a public health skill set or competency. These are natural tools for a system as complex as public health where we are a very outward facing organization with an incredible network of partners on whom we depend for much of our preparedness and response capacity. Some of these modeling activities are addressed in the series of slides that follow: Modeling User Workflow….

Modeling User Workflow Event Detection
EHRS Neighboring Jurisdictions Hospital State Public Health Surveillance System 1- Report/retrieve symptoms, diagnosis & medication prescription data from EMRs 7 – Report on the positive case electronically & by phone 2 – Data mining of EMR notes Ambulatory Care 3 – Notify on increased number of cases & recommend to order pathogen test 4 – Order pathogen test CDC Local Public Health Surveillance System 5 – Report test results P U B L I C 5 – Report test results Media Laboratory Response Team Pharmacy

Modeling User Workflow Event Monitoring
Neighboring Jurisdictions Hospital EHRS State PH Surveillance System 3 - Monitor ER visits & hospitalizations data from EMRs 1 – Send health alert 2 - Monitor newly diagnosed cases & vaccination data from EMRs 9 – Send updates on the event Ambulatory Care 4 – Order pathogen test 6 – Send order to activate emergency vaccination Local Public Health Surveillance System 5 – Report test results 10 – Send health alert to the public CDC P U B L I C 5 – Report test results 7 – Order/ Supply vaccine Media 8 – Monitor vaccine supplies Lab Response Team Pharmacy

Modeling User Workflow Event Management
Neighboring Jurisdictions EHRS Hospital State Public Health Surveillance System 3 - Monitor ER visits, hospitalizations data from EMRs & utilization data 1 – Send Outbreak updates 2 - Monitor newly diagnosed cases & vaccination data from EMRs 9 – Send outbreak updates Ambulatory Care 4 – Order pathogen test 6 – Send Rapid Flu Test Kits 10 – Send outbreak updates to the public Local Public Health Surveillance System 5 – Report test results CDC P U B L I C 5 – Report test results 9 – Activate coordinated response 7 – Order/ Supply vaccine Media 8 – Monitor vaccine supplies Lab Response Team Pharmacy

Output of Informatics Modeling Tools
Modeling helps identify and define: Participants Actors involved in the information exchanges regarding the swine influenza outbreak: Hospitals, Ambulatory Clinics, Laboratories, Vaccine Supplies and Distributors, Local and State Health Departments, CDC, Schools, Media Interactions Actions between participants in the information exchange answering questions regarding: potential sources of infection, comparing current and prior year rates of seasonal flu, methods to acutely improve your surveillance methods, sharing data and analyses, communicating information to the public

From User Needs to System Development
Informatics Concepts: Public Health Concepts Problem / Domain: Flu surveillance Goal: Help coordinate CDC response on Swine Flu outbreak Stakeholders (Actors) Participants in information exchange Functions (Actions) Interactions among participants in the exchange Data: Cases by jurisdiction, lab data, vaccine supplies data, etc. Information: Event detection, monitoring, response Knowledge: Situational awareness Tool (Modeling): Workflow and dataflow Flu Surveillance Information System Specifications Design Trial Implementation Deployment Evaluation

Informatics Applications
Adjectives are used to distinguish the field where informatics is applied such as medical environmental dental nursing public health ....

What is Public Health Informatics?
“Public Health Informatics is the application of information science and technology to public health research and practice” Friede A, McDonald M, Blum H Public health informatics: how information-age technology can strengthen public health. Ann Rev Public Health 16:239-52

Lagging National Agenda for PH Informatics
Funding and Governance (11 Items) Architecture and Infrastructure (10 Items) Standards and Vocabulary (11 Items) Research, Evaluation and Best Practices (14 Items) Privacy, Confidentiality, and Security (12 Items) Training and Workforce (16 Items) Nearly a decade ago, these important observations were made by public health practitioners. To date, have we really made much progress in these areas. Do you have an understanding of what these items really mean? How would your department begin to address contributing knowledge to these items or benefiting from those who have been working in these areas? Yasnoff WA, Overhage JM, Humphrey BL, LaVenture M. A national agenda for public health informatics. JAMIA 2001; 8 (6):

How to find what information we need?
Scenario 2 – Chronic Disease The mayor/county commissioner/city council person for your jurisdiction made an inquiry about public health efforts to improve cardiovascular disease (CVD) care and outcomes in your community. What are your sources of data for responding to the following questions: How bad is the problem in our community? Do we know of any ongoing interventions? Where are they being conducted? What have been the results of those efforts? Can we compare current to prior year rates? Do you have any ideas on how to improve surveillance and methods for intervention? A foundation is interested in supporting public health efforts: how would you propose next steps? Again a modeling approach can help define the actors and actions for each of these questions. There may not yet be a good system within your community to address these difficult questions. Some communities may be ahead in these metrics or interventions but most still have not thought globally or in a systems way about this enormous epidemic. Would your approach to the foundation’s interest resort to a specific intervention or should you review what systems would be required to effectively answer the preceding questions

CVD Surveillance Modeling User Workflow EHRS P U B L I C Hospital
Payor Hospital EHRS State Public Health Surveillance System 9 - Monitor ER visits, hospitalizations data from EMRs & utilization data 1 – Conduct Routine Check-ups 4 – Prescribe Medication and Treatment Plan 11 – Send reports Ambulatory Care 12– Conduct Surveys (BRFSS) 5 – Monitor Treatment 2 – Order cholesterol test 7 – Report Data to Public Health 3 – Report test results Local CVD Surveillance System 10 – Conduct Health Education DHHS Describe the flow here. Then allude to how this may apply to any chronic disease: asthma, obesity, diabetes. The goal of the modeling process is to define the actors and actions for a specific problem or domain but also to see the similarities. The investment in models should seek clearly reusable components. The investment in technology should consider flexible solutions that apply to multiple program areas. P U B L I C 6 – Fill Prescription 8– Coordinate Care Media Laboratory School Pharmacy

Electronic Health Record (EHR)
Electronic Health Record (EHR) is information, assembled and maintained in an electronic format which pertains to the health status of an individual and the health services delivered to an individual. EHR is also defined as: standardization in the field of health information and communications technology to achieve compatibility and interoperability between independent systems to ensure compatibility of data for comparative statistical purposes (e.g., classifications), and to reduce duplication of effort and redundancies. Introduce concepts and meaning of EHR International Organization for Standardization (ISO) . URL:

Electronic Health Record System (EHR-S)
Electronic Health Record System (EHR-S) includes longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual; authorized users; provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and support of efficient processes for health care delivery. Critical building blocks of an EHR system are: the electronic health records (EHR) maintained by providers (e.g., hospitals, nursing homes, ambulatory settings) and the personal health records (PHR) maintained by individuals Key capabilities of an EHR System. Institute of Medicine. Report. July 31, 2003. URL:

Electronic Health Record (EHR) Infrastructure
EHR Infrastructure is comprised of: databases, programs, software, hardware, servers, firewalls, access rules, Virtual Private Network (VPN) linkages, and web browser capabilities of the electronic health record system. Can you reap the benefit of community implemented EHR without more fully understanding the various components? How do they all work and how they might communicate with your health department? If they don’t communicate with your health department will you get any of the benefits described in the modeling process?

Public Health Informatics
Why Now?

Scenario 3: Health Information Exchange The local medical society is organizing an effort to respond to the recent incentive packages for physicians and hospitals to adopt electronic health records. The president of the society calls you to see if you would help them determine was meaningful use should be in your community. What are issues that you should consider as a member of the planning team? Who on your staff would best serve as a liaison to the group? What would you want to be an outcome from your LHD involvement?

Health IT Strategic Framework President Bush 2004 Launch
Goal 1: Inform Clinical Practice Incentivize EMR adoption Reduce risk of EMR investment Promote EMR distribution to rural and underserved areas Goal 3: Personalize Care Use of personal health record Enhancement of informed consumer choice Promote telehealth systems Strategic Framework Goal 2: Interconnect Clinicians Foster regional collaboration Develop Nationwide Health Information Network (NHIN) Coordinate federal health information systems Goal 4: Improve Population Health Unify PH surveillance architectures, Streamline quality and health status monitoring Accelerate research and dissemination of evidence into practice The steps to developing a health information exchange have been evolving over the past decade. Significant investments by the federal government started about 5 years ago but more substantial investments are being realized through the recent ARRA. A strategic framework was introduced during the last administration. It may be valuable to visit some of the processes, components and progress in that area of health information exchange. Notice the emphasis in Goal 4: improve population health. The federal government considered the need to unify PH surveillance architectures, streamline quality and health status monitoring and accelerate reseratch and dissemination of evidence into practice. All of these are important pieces and directly relate to our operational definition of a LHD.

Federal Vision Build a Nationwide Health Information Network (NHIN)
regional health information organizations (RHIOs) and exchanges (RHIEs) RHIOs and RHIEs would in turn be formed by: health care providers (HCPs) integrated electronic health record systems (EHRS) to improve patient safety and deliver quality care personal health records payers ancillary services (labs, pharmacies, radiology) Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, URL: URL:

ONC HIT Strategic Plan, 2008-2012
URL:

American Health Information Community
National Health IT Landscape Executive Branch HIT Initiatives American Health Information Community Business needs and priorities Use Cases NHIN Network service providers Architecture specifications Certification Criteria development Testing Cycles Standards Interoperability Specifications Business Deployment Sustainable business models State / regional partnerships Software and Evaluation HIE HIO RHIO Policies State laws and regulations Federal leadership Source: ONC, Second Nationwide Health Information Network Forum, Oct 2006

AHIC Use Cases

Scenario 1: Vaccine and Drug Administration and Reporting
Perspectives/Roles Information Sources & Recipients May be one or more of those listed below: Section 7.1 Clinician Section 7.2 Public Health Section 7.3 Consumer Section 9.0 Information Exchange Section 7.4 Registries Immunization Knowledge Providers 7.1.1 Incorporate immunization schedules into clinician systems 1 Health Information Exchange OR Point-to-point exchange Specialty Network Capabilities as needed in context: 9.3 Subject-data matching 9.2 Data retrieval 9.1 Data delivery 9.4 Data provisioning 9.5 Support for personally controlled health records 9.6 Emergency access 1 7.4.1 Incorporate immunization schedules into registries 7.3.1 Provide available immunization information 1 3 4 Health Registries 2 7.3.2 Request immunization information 2 Individuals Requiring Intervention - Public Health Case Reporting Use Case 5 7.4.2 Provide vaccine or drug administration information 2 Health Care Organizations 7.1.2 Identify individuals to receive vaccine or drug 2 4 7 Other Immunization Information Systems 7.4.3 Retrieve vaccine or drug administration information 3 7.1.3 Administer vaccine or drug 7.3.3 Receive Vaccine Recall Information 8 3 Payors 7.1.4 Report administration information to registries 7.4.4 Receive vaccine or drug administration information 5 5 Public Health Agencies 7.2.1 Identify individuals needing prioritized intervention This is the flow diagram for one aspect of the immunization and response management use case. It is a very high level view of what we do every day in our local health departments. We may at times play the role of the clinician or the public health department. Our perspectives may be multiple. The key point is that again the modeling approach and detailed analysis of information flow, with actors and actions is imperative if we are to build systems either internally or in a large community that effectively exchange data to benefit population health. This modeling approach looks at the actors as perspectives or roles along the top and potential information sources or recipients of information along the column on the right. Each of the data flows are represented by an arrow that points to an action. All of these are highly detailed in the implementation specifications provided by HITSP (the Standards Panel) and then passed along to the Certification Commission for evaluation of functional capacity in the products that vendors sell to clinicians in our communities. If we don’t clearly state our particular perspective well during these use case efforts, our public health or populations health needs may not be possible with the major investments by providers. 6 7.1.5 Monitor for adverse events 7.4.5 Provide vaccine recall information 7 Emergency Response Entities 8 VAERS / Public Health Case Reporting Use Case 6 Schools 7.1.6 Receive vaccine recall information Emergency Priorities Contextual Focus Legend Supply Chain 8

HITECH Act Policies, new technologies, and approaches for protecting privacy and security of health information Strategies to enhance use of HIT to: improve quality of care reduce medical errors, reduce health disparities, improve public health, increase prevention and coordination with community resources improve continuity of care among health care settings Specific plans to ensure that technology is designed to be appropriate for populations with unique needs

HITECH – 2009: Implementation Framework
Federal Health IT Strategic Plan 2 Goals: Patient-focused health care Population health 4 “themes” Collaborative governance Adoption of electronic health records Interoperability Privacy and security  2004 Goals Inform clinical practice Interconnect clinicians Personalize care Improve population health

ARRA Funding Many Sources, Many Purposes
Appropriations for Health IT New Incentives for Adoption $2 billion for loans, grants & technical assistance for: National Resource Center and Regional Extension Centers EHR State Loan Fund Workforce Training Research and Demonstrations New Medicare and Medicaid payment incentives for HIT adoption $20 billion in expected payments through Medicare to hospitals & physicians $14 billion in expected payments through Medicaid ~$34 billion expected outlays, Appropriations for HIE Community Health Centers At least $300 million of the total at HHS Secretary’s discretion for HIE development Funneled largely through States or qualified State-designated entities For planning and/or implementation A key point in this chart is that to date there has been no clear direct funding for PH activities. Yes there are funds for community health centers and these are typically under and uninsured and part of our safety net mission but for most of the other 10 essential services, we have no clear guidance or funding stream identified. Thus, LHD need to be ready to join with those who are the beneficiaries of this HITECH funding $1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems Broadband and Telehealth $4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants

HITECH Components: Implications
State planning/implementation grant(s) (2009) Matching funds may be required 09-10, will be required 2011 State EHR adoption loan fund (2010) Competitive grant to states Matching required Providers must agree to submit quality reporting, use EHR for exchange, submit plan for sustainability Extension Program ( ) All providers in region Prioritize public/nonprofit, Federally Qualified Health Centers, rural, primary care Research and consulting, assist with implementation, adoption/ maintenance, facilitate HIE, develop curricula for HIT education 50% of annual capital and operating budget for 2 years, optional after The implications for action by your health department are significant. Each state is to be awarded some funding for HIE – some may be working on planning others on implementation. If you are unclear who will be receiving these funds, it might be a good time to check with your governor or state health department. Funds are to be received by states or a state-desginated agency. All of these activities are to be highly accountable and tranparent. In its 2005 National Profile of Local Health Departments, NACCHO found that only 29% of LHDs had implemented electronic medical records. LHDs need to be able to harness the potential of integrated systems with clinical and public health providers. While the EHR adoption loan fund may not apply to you, it may if you provide primary care services. These funds may be a crucial resource to promote adoption by LHD. In particular the extension program may be of interest of a method for you to get involved in assuring that curricula for HIT education focuses not only on those capacities for EHR implementation but the informatics skills to assure that the environment being built is suitable to address the population health needs after the EHR systems are deployed. Here may be opportunities to work with FQHC in your communities who will be receiving large amounts of funding as described in the previous slide.

HITECH: “Meaningful Use” (as we speak)
To receive incentives, providers must meaningfully use a certified EHR: Use electronic prescribing Be connected in “a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination” Submit information on clinical quality measures Others: public health reporting (biosurveillance, disease surveillance), outbreak management, immunizations, electronic lab reporting, bidirectional communication While NACCHO and ASTHO and many others actively try to influence the decision at a national level about meaningful use, the final decision may be a smorgasbord to pick from. Unless your health department advocates locally or in a coalition statewide for those meaningful use activities more tightly aligned with public health, the outcomes in your community may not be all that beneificial to our mission. Meaningful use must intentionally provide public health with the full range of data and reports needed to assess and act on threats to the public’s health. If the definition of meaningful use is inclusive of public health, the potential exists to improve the response to emergencies and outbreaks. A broader interpretation or implementation of meaningful use may also support exchange with patients and their lay care givers to improve primary and secondary prevention programs. The current swine flu outbreak offers a stark example of the need for timely information exchange among these parties that can be analyzed and acted upon by public health officials.

Alert: patient with symptoms in outbreak region
After entering his chief complaints of cough and fever, along with vital signs, a new BPA appears. This BPA has been set to trigger with chief complaint of cough for patients presenting at our Parkchester center only.

How will public health be integrated into NHIN?
Public Health in a NHIN What should be the relationship between NHIN and US public health agencies? and How will public health be integrated into NHIN?

Public Health in a NHIN Currently, CDC researchers and colleagues around the country are making significant progress and working on the exciting concept of a public health grid. The grid is a network of network that is organized to provide seamless integration of data and services all in a very secure environment. Public health is not alone in this concept. Many of the other circles represented on this conceptual diagram are also pursuing the grid connectivity that provides vocabulary services to assure a common meaning to terms across all domains. These eventually will all be hooked up (see the upper left hand corner) with the RHIOs and providers (lower right) around the country. We may look at the grid as something serving to public health, but another perspective may look at it serving their role or need. The key point is that ultimately to benefit from this interoperability and connectivity, public health (from the federal agencies on the lower left) to the state and local agencies (in the upper right) all need to begin to see themselves as players in this environment.

Vision: PH Surveillance under NHIN
Percent of Children Tested for Lead with BLL>10 µg/dL in the USA Source: Eileen Koski. Quest Diagnostics. PHIN-2004, May, Atlanta GA

Scenario 3: Health Information Exchange The local medical society is organizing an effort to respond to the recent incentive packages for physicians and hospitals to adopt electronic health records. The president of the society calls you to see if you would help them determine was meaningful use should be in your community. What are issues that you should consider as a member of the planning team? Who on your staff would best serve as a liaison to the group? What would you want to be an outcome from your LHD involvement?

Public Health in HIE: Issues to Consider
Public health nowadays is: Agency Healthcare provider Laboratory Purchaser Payer Pharmacy Research

Public health nowadays is: Agency Healthcare provider Laboratory Purchaser Payer Pharmacy Research Publicly-delivered direct care, so EHR adoption issues are the same as for clinical care

Public Health Agency: Core Functions Assessment, Policy Development and Assurance There are local, state, and federal public health agencies. Their activities are organized by disease-specific programs.

Responsibilities of State PH Agencies: 2001
% State public health authority 97 Medical examiner 21 Public health laboratory 79 State mental health authority 19 Rural health State public health licensing agency 17 Children with special healthcare needs 77 State mental institution or hospital Minority health 72 Partial/split responsibility for Medicaid Institutional licensing agency 60 Medicaid state agency 15 State health planning & development agency 53 Lead environmental agency Partial/split leadership of environmental agency 51 State tuberculosis hospital Public health pharmacy 34 Health insurance regulation State nursing home 28 Source: Beitsch LM et al. Structure and functions of state public health agencies. APHA. 2006:96(1):167-72

Personal Health Services Population Level Services
Responsibilities of Local PH Agencies: 2003 Personal Health Services (%) Population Level Services Adult Immunizations 91 Communicable Disease Control 94 Childhood Immunizations 89 Health Education 87 Tuberculosis Testing 88 Epidemiology and Surveillance 84 STD Testing and Counseling 65 High Blood Pressure Screening 81 HIV Testing and Counseling 64 Tobacco Use Reduction 68 EPSDT 59 Cancer Screening 58 Family Planning Diabetes Screening 53 WIC 55 Cardiovascular Disease Screening 50 Prenatal Care 41 Injury Control 37 Dental Care 30 Violence Prevention 22 HIV Treatment 25 Occupational Safety and Health 13 Primary Care 18 Source: Scutchfield, F.D., & Keck, C.W. Principles of public health practice, 2nd ed , Thomson/Delmar Learning: Clifton Park, NY.

State Health Department: Organizational Chart

All public health activities are supported by customized information systems (databases, registries) developed to address the programmatic needs.

Number of Public Health Information Systems
Public Health in HIE: Issues to Consider Number of Public Health Information Systems Total number of programs: 23 programs in the Local Health Departments (HDs) 19 programs in the State Health Departments There are 3000 local HDs and 50 State HDs in the US 23 x 3000 (Local HD) = local programs/systems 19 x 50 (State HD) = 950 state programs/systems There may be as many as 70 thousand public health information systems -- all of them are customized, siloed systems.

Electronic Health Record – Public Health Systems Interoperability
Public Health in HIE: Issues to Consider Electronic Health Record – Public Health Systems Interoperability

Public Health Reporting

Public Health Reporting
Currently most data are sent as paper reports (forms) from a provider office to a public health program via mail, fax, or phone. This requires data entry at every clinical setting as well as every public health setting. Duplicative data entry activities cause errors and inefficient use of resources. Customized legacy systems that utilize their own data formats, vocabularies, and often software products cannot be interoperable to transmit data across these systems.

Public Health Reporting: Local Health Agencies
Health Education/Risk Reduction Provider 1 Communicable Diseases Provider 2 Immunization EPSDT Provider 3 Injury Control School Health Provider 4 Chronic Care Biosurveilance, BT, Preparedness WIC Provider X Occupational Safety and Health

Public Health Reporting: State Health Agencies
Genetic Disorder Vital Statistics Communicable Diseases Provider 1 Immunization Lead and Environmental Epidemiology Provider 2 Injury Control Provider 3 School Health Provider 4 Chronic Care Biosurveilance, BT, Preparedness WIC Public Health Laboratory Provider X HEDIS Cancer Source: Beitsch et.al Structure and Function of State Public Health Care Agencies” / AJPH, January, 2006.

PH Reporting: Local/State/Federal Agencies
Genetic Disorder Vital Statistics Health Education/Risk Reduction CDC Communicable Diseases Provider 1 HRSA Communicable Diseases Immunization AHRQ Lead and Environmental Epidemiology DHS Provider 2 Immunization EPSDT Injury Control Provider 3 Injury Control School Health School Health Chronic Care Provider 4 Biosurveilance, BT, Preparedness Chronic Care Biosurveilance, BT, Preparedness WIC Public Health Laboratory WIC Provider X Occupational Safety and Health HEDIS Cancer Source: Beitsch et.al AJPH, January, 2006.

Public Health Data Reporting
Genetic Disorders Communicable Diseases Provider 1 On average 49% of cases got reported (CDC, 2006). Immunization Provider 2 Vital Records Provider 3 Injury Control Provider 4 School Health Chronic Care Biosurveilance, BT, Preparedness Provider X HEDIS

EHR-based Public Health Data Reporting
Health Information Exchanges (HIEs) HIE Genetic Disorders HL7 Vital Statistics Provider 1 Communicable Diseases CDA2 Provider 2 Immunization Environmental Health X12 Provider 3 Injury Control School Health Provider 4 Chronic Care NCPDP Biosurveilance, Preparedness Women & Children Provider X Public Health Laboratory IHE Quality Improvement

EHR-based Public Health Reporting
EHR-PH systems will enable electronic data transmission from a provider office to a public health programs via a Web-based interface. Data entry will be done once at the point of data generation, i.e., clinical setting, where EHR system will be installed. Public health programmatic resources will be used not on data management activities but programmatic activities, e.g., case management, care coordination, health education for prevention. System will be interoperable because they will utilize standardized data formats and vocabularies, messaging standards and software products that will support interoperability of EHR systems.

Public Health Informatics – National Context
Scenario 4: - Workforce New federal preparedness funding guidance focuses on building connectivity between the personal and public healthcare environments for situational awareness. The state health department (SHD) is encouraging local health departments (LHD) to develop tools for interoperability with the state and the larger health care community regarding biosurveillance systems. What internal resources have your LHD to begin to address some of these interoperability questions? Does anyone on your staff have the skills to participate in the planning process with the SHD? How can you be sure these individuals are sufficiently trained and qualified to address the planning needs?

Role of PH Professionals as Informaticians
Building interoperable information systems for public health will require working with: Public Health Community Clinicians Vendors

Working with Public Health Community to Understand interactions between public health data systems within a health department and across health departments Understand commonalities of data and data system architectures across public health data systems Define common public health needs in EHR-based health information exchanges

Working with Clinicians to Define public health needs in EHR-based health information exchanges Understand interactions between clinical care and public health data systems Understand commonalities of data and data system architectures across clinical and public health data system

Working with Vendors to Know computer-based tools available to public health professionals Communicate public health needs for interoperable EHR-based health IT applications and non-EHR IT applications Be able to participate in the design of information systems in public health under a NHIN

Vendors involved in Health IT
Points to highlight: IHE has not only healthcare industry professionals, but also software and hardware professions from the computing industry involved, including organizations such as IBM, Oracle and Microsoft.

Public health professionals as informaticians have to be able to develop / critique IT technical documents including: Business Process Documents Functional Requirements Specifications Interoperability Specifications Integration Profiles Content Profiles Implementations Guides, etc.

Providers, PUBLIC HEALTH and Software Developers
Integrating the Healthcare Enterprise (IHE) Providers, PUBLIC HEALTH and Software Developers Work Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings

Local PH Strategic Planning Business processes System requirements
Drives Influences Portfolio Performance Management Information Information IT Investment Management IT Governance & Management Processes Technology Technology Investment Investment Management Management Supported by Improved by Enterprise Architecture Enterprise Architecture Enterprise Architecture Public Health Informatics Institute

What is NACCHO doing? Running webinars such as these.
Developing tools and templates Funding demonstration sites to show that it can be done. Advocating for local public health informatics at a national level.

QUESTIONS?

Questions for our listeners
What do you believe might/should be your next step? Do you feel you have adequate information to take any step regarding public health informatics at your local level? Is this format of information sharing helpful to you or your LHD? What might the NACCHO Informatics Workgroup do to support further information sharing or helping your department get more involved in the near future?

Date: Thursday, April 30, 2009 Time: 12:00 – 1:30pm EDT

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