Kirkwood, James MPH; Jarris, Paul E. MD, MBA
Association of State and Territorial Health Officials, Arlington, Virginia.
Correspondence: James Kirkwood, MPH, Association of State and Territorial Health Officials, 2231 Crystal Dr, Ste 450, Arlington, VA 22202 (email@example.com).
The authors declare no conflicts of interest.
Clinical care providers, particularly those in primary care, have increasingly embraced public health concepts in the care they provide their patients. Federal, state, and local governments have developed public health policies and initiatives that increase the efficiency of health care delivery while reducing health care costs. Advances in health information technology (IT) have been an important part of these trends, but much more can be done. For the local, state, and federal public health enterprise to continue to take advantage of health information system interoperability, agencies will need to better coordinate across programs, look to new solutions to implement systems, and place a greater focus on their informatics workforce.
The meaningful use incentive program provides monetary incentives to health care providers and hospitals that purchase, implement, and use electronic health records (EHRs) if they adhere to “meaningful use” requirements established by the Centers for Medicare & Medicaid Services and standards and certification requirements promulgated by the Office of the National Coordinator for Health Information Technology. In clinical care settings, stage 1 of meaningful use requires incentive recipients to satisfy at least 1 public health objective—sending immunization or syndromic surveillance information in the case of providers, sending those 2 information types plus electronic laboratory reporting in the case of hospitals. Electronic health records must also report on clinical quality measures related to hypertension, screenings related to tobacco assessment and cessation, and weight screening.
To support interoperability among those who purchased EHRs, each state received funding to establish a health information exchange (HIE). The federal government awarded $547 million to states and territories in the form of HIE grants so they could plan and implement HIEs. A number of states include public health activities such as immunization, syndromic surveillance, and electronic laboratory reporting in their strategic and operational plans, and a 2009 survey found that more than 30% of state health agencies had significant involvement in HIE planning.1
The focus on promoting interoperability and EHR adoption has resulted in a dramatic increase in the number of physicians adopting EHRs. The number of office-based physicians who have implemented a basic EHR has increased from 10.5% in 2001 to an estimated 33.9% in 2011, and 51.8% plan to apply for meaningful use incentives.2 The result is a great number of physicians interested in sending data to public health information systems.
In addition, the Affordable Care Act has implemented programs that will result in the need for state public health agencies to collect data from hospitals and health care providers, analyze that data, and report results back to hospitals and providers. Nonprofit hospitals will be required to assess and serve the specific health needs of the communities they serve. The act also expands programs designed to reduce health care–acquired infections and establishes accountable care organizations.3 In this environment, state public health agencies will need to accept more data electronically and be better integrated with health care providers.
Public health agencies are taking on these challenges at a time when their resources are shrinking. Since 2008, state public health agencies have cut nearly 17 000 jobs4 and local health departments have shed more than 34 000 jobs.5 All signs point to continued cuts to public health funding at federal and state levels, and public health agencies already cite a lack of funding as their greatest concern in getting their systems ready for meaningful use standards.6
Respondents to the 2010 meaningful use readiness survey cited the lack of technical expertise among current informatics staff as a barrier to implementing their public health information systems.6 Anecdotally, many public health agencies express concerns about retaining the current workforce in a job market where well-trained health IT informatics staff are at a premium. In addition, because of the increase in the electronic exchange of data and public health's reliance on information systems, public health program staff, such as epidemiologists and public health nurses, will need to work effectively in an informatics environment.
There are also significant administrative barriers that hamper public health informatics. Because public health agencies receive most of their federal funding for disease-specific programs, the development of information systems these programs support are not well coordinated or integrated. For example, an HL7 interface for an immunization information system does not necessarily support an electronic laboratory reporting system or a cancer registry. This can result in one organization building the same functionality multiple times for multiple systems.
Organizations outside of public health often complain that public health agencies ask for data in somewhat different ways. While some differences may be minor, in aggregate across public health agencies, these differences can add up to significant variability, which makes it that much harder to integrate with other systems.
While some of these challenges will require significant amounts of funding, some solutions can be achieved through better coordination within agencies and across state and local public health jurisdictions. Funded by the Robert Wood Johnson Foundation's Common Ground Project, the Public Health Informatics Institute and the Minnesota Department of Health created a toolkit to develop public health informatics profiles that describe the following: the current state of public health information systems and future capabilities of public health information systems, the current and future needs for public health information, desired information-trading partners, and the resources to meet these needs.7 Using the toolkit enables public health agencies to look across their programs, determine which informatics services are reusable for different programs, and identify a strategy for how the department will work with its data-trading partners, such as HIEs and the health care community, to collect data in a way that will lead to actionable public health strategies.
Another innovation is the redesign of BioSense, the formally Centers for Disease Control and Prevention–based syndromic surveillance system. For a number of years, the system had little success because of a lack of state and local buy-in. Through an extensive redesign process, the system now focuses on state and local needs and sharing data among participating jurisdictions. Other changes include a shared governance model where local, state, and federal governments share responsibility for the program and a move to secure cloud services to dramatically lower the cost of data storage.8 By sharing services, state and local health departments can use the system to spread the cost of one system build across multiple organizations and focus on using the information for public health action.
And there are many other successes, too. The New York State Department of Health and the Michigan Department of Community Health developed innovative ways to collect and use HIE data. Nebraska has been exemplary in updating existing data collection laws to match the needs of health IT innovation. And the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists developed a reportable condition mapping table for standard laboratory vocabulary codes which will make mapping laboratory results to reportable conditions easier for health agencies.
There is much work still to be done, however. First and foremost, federal funding and grants that include information systems as part of the objective must include language that solidifies a holistic approach to health IT systems. Development of technology that is designed to collect and monitor a single issue needs to become a relic of the past. Public health is an enterprise, and the IT systems built to support it must take that into account. Seeing the complete data picture will enable public health agencies to make policy and programmatic decisions that will dramatically improve the health and wellness of the people they serve.
Another critical action is the training of the public health workforce. Public health informatics warrants a call to action similar to that invoked in health emergency preparedness. There are many lessons to be learned by applying an all-hazards preparedness approach to health informatics solutions. In all-hazards preparedness and response, state and local public health, the health care providers, and many others have modeled effective, shared solutions to system, information, and service delivery needs. Similar to incident command training, all public health agency staff should have a base level of training in informatics.
It is time for the entire federal, state, and local public health enterprise to create unified, coordinated, and responsibly funded action to ensure that public health informatics rises to its full potential to transform health information into actionable interventions that improve health for all.
1. Association of State and Territorial Health Officials. Public Health Involvement in the Health Information Exchange Planning Process. Arlington, VA: Association of State and Territorial Health Officials; 2011.
2. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic Health Records and Intent to Apply for Meaningful Use Incentive Among Office-Based Physician Practices: United States 2001–2011. Hyattsville, MD: National Center for Health Statistics; 2011. NCHS Data Brief No. 79.
3. Patient Protection and Affordable Care Act. Pub L No 148-111, 2010.
4. Association of State and Territorial Health Officials. Budget Cuts Continue to Affect The Health of Americans: December 2011 update. Arlington, VA: Association of State and Territorial Health Officials; 2011.
5. National Association of City & County Health Officials. Local Health Department Job Losses and Program Cuts: Findings From the July 2011 Survey. Washington, DC: National Association of City & County Health Officials; 2011.
6. Association of State and Territorial Health Officials. Meaningful Use Readiness Survey. Arlington, VA: Association of State and Territorial Health Officials; 2010.
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