Decision Support for Public Health Practice: Research Findings in the Development of Knowledge Management and Disease Surveillance Tools University of Ljubljana July 10, 2007 Sherrilynne Fuller, PhD Co-Director, Center for Public Health Informatics Professor Biomedical and Health Informatics, School of Medicine University of Washington, Seattle, USA Center for Public Health Informatics University of Washington

USA Center for Public Health Informatics University of Washington NOTE: Map NOT to Scale for Alaska Seattle, Washington Alaska Vancouver, British Columbia, Canada

Center for Public Health Informatics University of Washington University of Washington Center of Excellence in Public Health Informatics UW Center of Excellence in Public Health Informatics Administrative Core A Epidemiology & Biostatistics Core Informatics Technology Core C Informatics Technology Core C Knowledge Management myPublicHealth Knowledge Management myPublicHealth Surveillance Integration Project WA State Dept of Health Regional Health Information Organizations WA State local health agencies Technology & Design Core “Improving the public’s health through information integration”

Center for Public Health Informatics University of Washington

Role of Medical Care in 20 th Century Public Health Achievements PH AchievementDue to Medical Care? VaccinationIndirect Motor-vehicle safetyNo Safer workplacesNo Control of infectious diseases+/-  Coronary heart disease/stroke deaths +/- Safer and healthier foodsNo Healthier mothers and babies+/- Family planningNo Fluoridation of drinking waterNo Recognition of tobacco as health hazardNo RA Patrick O’Carroll, MD Region X Health Administrator

RA Patrick O’Carroll, MD Region 10 Health Administrator

Clinical PH Information Interchange – Research Questions Clinical (patient) information to support chronic disease interventions in communities: what is the minimum data set? Situational awareness data exchange – how to do in a focused, timely, comprehensive way? PH clinical data (e.g. immunization, disease status, relevant community information) to electronic health record? Timely approaches to people and directory type information interchange? Research findings – how to extract from the literature and present to practitioners? Utilization of community health information for decision support for individual patients? Center for Public Health Informatics University of Washington

8 CPHI Key Research Areas Knowledge in Practice 1.Managing information resources and data for PH practice 2.Business process analysis and workflow characterization Surveillance Data for PH practice 1.Collection and Analysis 2.Geospatial Presentation

Center for Public Health Informatics University of Washington Knowledge in Practice: The Challenge Neither the creation nor the distribution of information resources* upon which public health practitioners depend is managed or presented in any systematic or comprehensive way at the present time *data of all types, guidelines, research findings, maps, policies, laws, evaluation metrics, teaching materials, etc.

10 Center for Public Health Informatics University of Washington Approach Research workflow and information needs of public health practitioners to support evidence-based practice Develop and optimize a knowledge management system to support iterative refinement of a set of retrieval and information management tools for public health practitioners

Center for Public Health Informatics University of Washington Information Needs of Public Health Practitioners: Observations nFew formal studies of information needs, information- seeking behavior or workflow of PH professionals nRapidly expanding volume of data and information nMajor barriers: time, resource reliability; discerning credibility of information nPeople are a critical source of information in public health nSilos of surveillance information – lack currency and context nLack of linkages between individual patient information and public health information systems Revere D, Turner A, Madhavan A, Rambo N, Bugni PF, Kimball AM, Fuller SS. Understanding the information needs of public health practitioners: A literature review to inform design of an interactive digital knowledge management system. J Biomed. Informatics Special Issue on Public Health Informatics.

Center for Public Health Informatics University of Washington Information Needs of Public Health Practitioners  Resources used influenced by job function, disciplines & training  Want resources that are easy to access & use, up- to-date, free, pre-digested & stable, focused  One size/approach does not fit all; personal customization is highly desired  Revere D, Turner A, Madhavan A, Rambo N, Bugni PF, Kimball AM, Fuller SS. Understanding the information needs of public health practitioners: A literature review to inform design of an interactive digital knowledge management system. J Biomed. Informatics Special Issue on Public Health Informatics.

Center for Public Health Informatics University of Washington 1.Information from areas beyond biomedical domains: e.g. social, legal, policy 2.Systematic reviews & summary information 3.Government reports (grey literature) & conference proceedings 4.Evidence-based resources – e.g. full-text research articles; synthesized reviews of clinical topics 5.Data from community-based and clinical systems with geographic mapping and analysis capability Information Needs of Public Health Practitioners: Resource Types

Center for Public Health Informatics University of Washington Why a Content Management System? CMSs streamline the process of creating, managing & delivering content, & put processes in place to manage & control information as it is moved & changed Archive / RetireCreate / Capture ManageDeliver Content Management Solution Review / Approve Content intelligence Collaboration services Transformation Renditions Process automation Library services Repository services Authoring Importing Aggregation Imaging Publishing Web delivery Portal delivery Content distribution & syndication Streaming Real-time content Records management Final form storage

Center for Public Health Informatics University of Washington Rapid Prototyping: Iterative Refinement Process

Center for Public Health Informatics University of Washington Prototyping the Interface Beta Version Toolkits Locally customizable, role-based resources views Advanced retrieval tools

Center for Public Health Informatics University of Washington

Usage of myPH Prototype: Data summary, 03/05/2007 Promotion began ramp-up - Feb 2007

19 Core Workflow Problem The information processes and workflow of public health practice are not well characterized, making it difficult to build public health information systems that efficiently support practice.

20 Workflow Analysis Research Faculty from the UW-CPHI are participating in requirements definition projects: –Kitsap County Health District - chronic disease prevention and control (J. Baseman, A. Turner) –Spokane County Health District - public health preparedness (B. Karras) Significance to PH Practice: improved efficiency, cost savings, improved disease surveillance, and improvements to the health of communities

21 Biosurveillance Research Value of data –Decision support for biosurveillance: Utility functions for identifying and evaluating a minimum data set (J. Doctor, J. Baseman, B. Lober) Notifiable condition reporting –Electronic forms to support notifiable condition reporting in a health information exchange infrastructure (B. Lober, J. Baseman, B. Karras) Future: Bayesian networks for case identification –Algorithms for probabilistic reporting criteria Geospatial mapping of disease incidence

22 Uncertainties about Biosurveillance Data Timeliness –Organizational processes –Data entry, system architectures –Network traffic delays Integrity –Accuracy, Completeness –Depends on quality control Relevance –Depend on purpose of data analysis Outbreak detection, situational awareness, program monitoring & evaluation, community assessment Multi-attribute Utility Theory - Utilizing to determine trade-offs

23 Relevance Time tradeoff –Children exposed to a child w/. suspected measles. Low prior probability  confirmation needed. Time tradeoff w/ efficacy of vaccination. Utility of a lab result in N hours? Subjects/Sampling/Instrument –PH professionals practicing at County PH offices – request sent to County PH Officers in WA –Interactive Web Survey - Tradeoff questions, rating scales and demographic questions

Notifiable Conditions Survey

25 Utility as a function of lab delay on time to act - measles outbreak Data elements have tractable utility representations, and utility tradeoffs. PH professionals place nonlinear value on time-to-act, preferences

Center for Public Health Informatics University of Washington 26 Electronic Notifiable Condition Reporting Electronic forms using Xforms technology (XML) Form instance and data instance Demonstration showcased: –Provider engagement –Efficiency through form pre-population –Efficiency through electronic transmission –Inherent auditing, recording workflow

Lung Cancer in Washington State Age Adjusted rates Incidence: ICD-0: C34.0-C34.9, excluding histology codes 9140, Mortality: ICD-9 ( ): , ICD-10 (1999- ): C34 Tables Center for Public Health Informatics University of Washington

Conclusion Integrated PH decision support systems are in their infancy in the U.S. We can learn from lessons of clinical decision support system design and deployment It is critical that we figure out how to optimize timely data exchange of critical information between clinical and public health information systems Much more work is needed to understand information needs and practice in order to optimize the decision support environment for public health practitioners Centerfor Publ ic Health Informatics University of Washington

Bibliography – Cont. Revere D, Madhavan A, Turner AM, Rambo N, Kimball AM, Bugni P, Fuller S. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomedical Informatics 2007 (Special Issue on Public Health Informatics). Revere D, Bugni P, Fuller S. A Public Health Knowledge Management Repository that Includes Grey Literature. Publishing Research Quarterly 2007 (Special Issue on Grey Literature 2007). Revere D, Bugni PF, Fuller S. An interactive digital knowledge management system to improve public health practitioners' access to public health resources. In Proceedings of the American Medical Informatics Association (AMIA) Annual Fall Symposium, Nov Washington DC. Revere D, Madhavan A, Kimball AM, Turner A, Bugni P, Fuller S. myPublicHealth: Research in Public Health Knowledge Management to Support Evidence-Based Practice. In Proceedings of the CDC's Public Health Information Network (PHIN) Conference, Sept Atlanta GA. Center for Public Health Informatics University of Washington

Bibliography – Cont. Revere D, Madhavan A, Kimball AM, Turner A, Bugni P, Fuller S. myPublicHealth: Research in Public Health Knowledge Management to Support Evidence-Based Practice. In Proceedings of the CDC's Public Health Information Network (PHIN) Conference, Sept Atlanta, GA Doctor, J. Baseman, JG, Lober, BD, Davies, J., Kobayashi, J., Karras. B., Fuller, S. Time tradeoff utilities for identifying and evaluating a minimum data set for event detection in time-critical biosurveillance. Submitted: Medical Decision Making. Hoskins RE, O’Connor C, Johnson C, O’Carroll P, Fuller S. EpiQMS: An Internet Application for Access to Public Health Data for Citizens, Providers, and Public Health Investigators. Journal of Public Health Management and Practice, 8(3):30-36, Center for Public Health Informatics University of Washington