Local health departments (LHDs) are presented with an unprecedented opportunity to use real-time, standardized data to inform public health practice in a post–Affordable Care Act era marked by interorganizational collaborations and availability of large amounts of electronic health care data through health information exchanges.1–4 In a dynamic public health environment filled with emerging demands for evidence-based public health practice, it is ever more imperative for LHDs to harness these data and integrate them into their decision support systems in order to efficiently meet public health practice needs.5 Some of these public health needs dictating integration and exchange of data include information needs for emergency management,6 disease reporting, early detection of outbreaks,7,8 surveillance,9,10 assessment of community health status, needs and resources for evidence-based decision making,11 and enabling assessment of health disparities,12 to name a few.
Research shows that some LHD staff members already perceive an increased responsibility for collecting, analyzing, and reporting data to community partners and, in turn, growing greater epidemiologic and surveillance capacity.13 However, efficient data management and use may be hindered by the reality that LHDs' data needs vary considerably, as does their infrastructure. The complexity of data needs and availability present difficulty in using and managing data, particularly because much of these data are stored in noncomparable formats and cannot be easily combined with other data systems without additional work.14 Smaller LHDs are less likely to be informatics savvy due to lack of financial and human capital, so managing information systems and using information technology (IT) tools are bigger challenges for them.15–18
LHDs cannot take advantage of the opportunities to utilize large amounts of data from all sectors of society if their information systems are unable to interact with external, often more sophisticated, data systems. This issue is often referred to as lack of interoperability. Interoperability is the capacity of IT systems for bidirectional communication and exchange of information allowing the multiple agencies to use the exchanged information and communicate or work together.19,20 Interoperability between systems may improve communication, efficiency, and accuracy of information transmission, eventually leading to improvements in health outcomes and cost-effectiveness for patients and providers.20
Interoperability of health IT is generally classified into 3 levels—foundational, structural, and semantic.21 Foundational interoperability refers to the lowest and most basic level of interoperability, in which an IT system is required to allow the data transmitted by other health IT systems to be received, with no requirement of data interpretation for the system on the receiving end of the transmission.21 Structural interoperability encompasses use of defined formats and syntax of data exchange [eg, Health Level 7 (HL7)], thus the focus being on the packaging of the data via message format standards to ensure that clinical meanings of data are preserved. Semantic interoperability is the highest level of interoperability that involves exchange, codification, and interpretation of data, which further produces useful results as defined by the end users of information exchange systems.21
Incentivized by the HITECH Act, “Meaningful Use,” and related developments, health care industry and other community partners now generate massive amounts of data across various settings.4,22,23 The ability to electronically exchange health information has been a central goal of the ongoing digitization of the health care sector, resulting in many benefits.24,25 Use of big data and information science and technology can allow care coordination for LHDs providing clinical services.26,27 Data-driven assessments can help with detection of health inequities28 and reinforce efforts to promote Health in All Policies.23 Interoperable data available from community partners can be useful to many public health programs, for example, environmental health monitoring and protection,29,30 reportable disease surveillance and control,31–33 communicable disease prevention interventions,31 food and waterborne outbreaks detection,7,34,35 emergency response and program evaluation,30 and community health promotion.36 In addition, adequate informatics capacity and its efficient use can support quality improvement, research, reporting, culture of health, and efficient provision of public health services.37–39
Despite progress toward nationwide health information exchange, health departments are not fully engaged.39 It is vital to assess the level of interoperability of LHD information systems and factors associated with them in order to support advocacy and capacity-building efforts targeting public health agencies. There is a dearth of research assessing the interoperability levels of information systems managed and used by LHDs. This study aims to fill the evidence gap by investigating the extent to which LHDs' information systems are interoperable and factors associated with interoperability. Findings from this study show many modifiable aspects of LHD infrastructure that significantly condition LHDs' ability to improve their information systems, providing clear policy recommendations.
Data and Methods
This research is based on an exploratory mixed-methods design. The study first employed a qualitative key informant interview phase, followed by a national survey where the instrument was informed by the first phase. Results are analyzed and presented in an integrated fashion.
Key informant interviews were conducted with 50 LHD staff members in 2014 across the United States. Potential interviewees were selected on the basis of their LHD's geography, size of the population it served, and how sophisticated their LHD's information systems were, based on responses to the 2013 NACCHO Profile.40 These interviews were recorded by telephone, transcribed, verified, and independently coded by 2 researchers. One interview had a technical error, resulting in 49 interviews used in coding and analysis. A codebook was developed on the basis of the interview instrument, which had 3 major domains: data systems, informatics capacity, and perceptions around the future of informatics. Intercoder reliability was examined; in coded portions of transcripts that did not match, a consensus definition was established, and interviews were recoded. Interviewees were asked a number of questions about the types of information systems their LHD managed, had access to, and how interoperable these various systems were. Interview data were analyzed thematically in NVivo 10 (QSR International, Burlington, Massachusetts).41
The quantitative data were drawn from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by the Jiann-Ping Hsu College of Public Health at Georgia Southern University in collaboration with National Association of County & City Health Officials (NACCHO). This Web-based survey had a target population of all LHDs in the United States. A representative sample of 650 LHDs was drawn using a stratified random sampling design, based on 7 population strata: less than 25 000; 25 000-49 999; 50 000-99 999; 100 000-249 999; 250 000-499 999; 500 000-999 999; and 1 000 000 and more. LHDs with larger population were systematically oversampled to ensure inclusion of a sufficient number of large LHDs in the completed surveys. The targeted respondents were informatics staff designated by the LHDs through a mini-survey conducted prior to the main survey. A structured questionnaire was constructed and pretested with 20 informatics staff members. The questionnaire included various measures to examine the current informatics capacity and needs of LHDs. The survey questionnaire was sent via the Qualtrics survey software to the sample of 650 LHDs. The survey remained open for 8 weeks in 2015. A total of 324 completed responses were received, with a 50% response rate. Given that only a sample of all LHDs participated in the study and the larger LHDs were oversampled and overrepresented, statistical weights were developed to account for 3 factors: (a) disproportionate response rate by population size (7 population strata, typically used in NACCHO surveys); (b) oversampling of LHDs with larger population sizes; and (c) sampling rather than the census approach. A multivariable logistic regression was conducted, using interoperability status of the information systems as a binary outcome (Yes/No). If an LHD answered “Some of the systems are interoperable,” “Most the systems are interoperable,” or “All of the systems are interoperable” to the question “How interoperable are the information systems used for your LHD?” then it was coded as “Yes” (1); otherwise, it was coded as “No” (0) if an LHD answered “None of the systems are interoperable.”
On the basis of previous studies on factors associated with IT capacities and information systems implementation,42–44 independent variables were selected, including jurisdiction characteristics (population size) and governance characteristics as independent variables. LHD governance structure was coded as state/shared versus local governance, and LHD jurisdiction population size was transformed into logarithmic values in logistic regression analysis because the absolute values resulted in skewed distribution. LHDs' informatics capacity building is shaped by whether it is formally included in LHDs' strategic plans and whether formal assessments are conducted to understand the gaps in capacities relative to the needs.45 Variables representing strategic priorities and formal assessment processes included completion of review of IT system in the past 2 years (Yes/No), creation of IT strategic plan throughout LHD (Yes/No), completion of business process analysis and redesign (Yes/No), and provision of project management (Yes/No). Other variables showing LHD's control over various aspects of informatics covered through variables such as control of data management (Yes/No), control of data quality (Yes/No), control of IT budget allocation (Yes/No), support from leadership (Yes/No), access to technical support (Yes/No), and LHD self-rating of IT infrastructure (poor/fair, average, and good/excellent). SPSS 23 (IBM Corporation, Armonk, New York) was used for conducting the multivariable logistic regression analysis of factors associated with interoperability.46
Qualitative perspectives on barriers to interoperability and negative impacts
Barriers to interoperability
As displayed in Table 1, there are 5 main barriers reported by respondents, such as resource-intensive nature of initiatives of interoperable systems, lack of master-patient index, LHDs not being in control of the IT system, different codes/standards, different levels of sophistication, and lack of appropriate staff. Overall, the 3 main issues are lack of financial resources and IT expertise at LHDs, and different IT systems that are incompatible.
Negative impacts due to lack of interoperability
There are 8 main themes depicting negative impacts. They included difficulty in coordination of care with other providers and within LHD clinics, data from state or federal level becoming less useful at local level, duplication of efforts in collecting data, delay in detecting outbreak of disease at local level, cumbersome log-on process, LHDs' inability to get data from hospitals in a timely manner, and IT systems not talking to each other. Thus, the incompatible IT systems at the local level resulted in difficulties in coordination of care/service both internally and externally, issues concerning timely data sharing, and duplication of efforts in collecting data.
Sample characteristics are presented in Table 2. About 41% of LHDs reported their IT systems are interoperable (some, most, or all systems). About 81.5% of LHDs in the sample had decentralized/local governance with respect to state authority. Roughly 40% of LHDs' survey participants rated their IT infrastructure excellent or good, but more than a quarter of them rated it as poor or fair. Twenty-four percent of LHDs created a strategic plan for their information systems, and 24% conducted business process analysis.
Status of interoperability of LHDs' information systems
The Figure displays the status of IT system interoperability by jurisdiction population size. LHDs with jurisdictions with larger jurisdiction population seemed to have better interoperability, as 69.5% of LHDs with a jurisdiction population size of 500 000+ reported most of their IT systems were interoperable. In contrast, 32.5% of LHDs with a population size of less than 50 000 and 43.4% of LHDs with a population size of 50 000-499 999 reported having most systems interoperable (P < .01). The proportion of LHDs reporting “none of their IT was interoperable” was 31.1% in LHDs with a population size of less than 50 000 but 19.8% in LHDs with 500 000+ population.
Multiple logistic regression results
The multiple logistic regression model results showed that LHDs with larger jurisdiction population size were more likely to have an interoperable IT system than smaller LHDs (adjusted odds ratio [AOR] = 1.20; 95% CI, 1.11-1.29). LHDs with a state/shared governance structure (AOR = 1.75; 95% CI, 1.32-2.32) were more likely to have an interoperable IT system than LHDs with a local governance structure (Table 3).
LHDs that had completed IT system review (AOR = 1.66; 95% CI, 1.31-2.10) or created an IT strategic plan (AOR = 1.92; 95% CI, 1.51-2.43) in the past 2 years were more likely to have an interoperable IT system. In addition, LHDs that provided project management (AOR = 2.14; 95% CI, 1.71-2.66) or conducted business process analysis and redesign (AOR = 1.49; 95% CI, 1.17-1.90) were more likely to have data management capacity (AOR = 2.31; 95% CI, 1.57-3.40) were more likely to have an interoperable system. LHDs that controlled their own data management (AOR = 2.31; 95% CI, 1.57-3.40), data quality (AOR = 1.69; 95% CI, 1.32-2.16), and IT budget allocation (AOR = 2.48; 95% CI, 1.68-3.67) were more likely to have an interoperable IT system. Finally, LHDs that had leadership support (AOR = 3.54; 95% CI, 2.72-4.60) or had adequate access to IT technical support (AOR = 1.39; 95% CI, 1.11-1.73) were more likely to have an interoperable IT system.
The study results revealed several barriers and facilitators of interoperability of systems used or maintained by LHDs. Both qualitative and quantitative data highlighted the importance of leadership, both within the agency and potentially at the state. State health agencies can create information systems that link many LHDs to state data, as well as each other. This is especially the case in centralized, or shared governance model states and also potentially very useful in home-rule/decentralized states.47 Our findings about leadership support as the strongest facilitator of interoperability are consistent with the findings from a qualitative assessment in another study that revealed that leadership support was critical for LHD informatics.48 Interview participants reported significant financial, human, and technical difficulties preventing greater interoperability. A long history of project and LHD-specific databases and proprietary data formats have impacted interoperability of information systems. Because of such a lack of interoperability, many LHD information systems are incapable of interacting with outside organizations, as well as within their own agency.
Interoperability of information systems used by local public health agencies is in general poor, with roughly 4 in 10 LHDs reporting some, most, or all of their information systems being interoperable. Having informatics-savvy health departments is desirable across the spectrum of LHDs, as their capacities to exchange and manage information are critical in an era of health care reform.2,17,18 Although many LHDs do not provide clinical care directly, the absence of direct provision of clinical services does not diminish LHDs' need for health care information to guide their surveillance and assessment efforts. Regardless of clinical care needs, LHDs may want to engage in interorganizational information sharing with a large number of community partners in order to take advantage of data-driven decision making. Information sharing may also be essential for assessment and surveillance. Lack of interoperability may hamper LHDs' efforts to perform many essential public health functions. For instance, LHDs' inability to efficiently receive and use data will make it difficult to deal with the changing environment that requires evidence-based administrative and service delivery practices.
Factors related to the control of various aspects of LHD informatics were also significant factors for IT interoperability, including IT budget allocation, data management, and data quality control. This may imply that when LHDs may not control their own budget allocation, the system interoperability may not get priority. When LHD staff do not have control of budget allocation, those engaged in budgetary decisions may not be as aware of the benefits associated with having interoperable systems as the LHD staff.
Our findings also support the proposition that if LHD information systems or other informatics issues are not included in the list of high priority strategic issues and, in turn, do not become part of the strategic plan, LHD informatics cannot be strengthened.
The study results also indicated that LHDs that had reviewed their information systems to determine whether they need to be improved or replaced or those with strategic plans for information systems had better levels of interoperability of their information systems. This is consistent with the idea that assessment and strategic prioritization of informatics needs lead to better outcomes.45 Adequate availability of technical support was also a positive influence on interoperability of information systems.
Our study shows that LHD population size is a significant influence on interoperability levels of LHDs, suggesting that larger LHDs may have an edge due to economies of scope and scale. LHDs under state governance or in shared governance arrangements are also better off than those in decentralized governance structures. The favorable impact of state/shared governance indicates that unlike many other aspects of LHD informatics where locally governed LHDs have stronger informatics capacities,41 being centrally governed or having shared governance is beneficial for interoperability of the information systems.
Our study findings should be interpreted within the limitation that a definition of interoperability was not provided to the survey participants, leaving the meaning of the term to their interpretation. Although we examined level of interoperability, the type of interpretability (foundational, structural, semantic, etc)21 was not explored in this study.
Public health informatics is about both the infrastructure of health departments' information systems and the capacity to use data to further the public health enterprise. Data use capacity and IT infrastructure go hand in hand, and their inadequacy serves as the primary limiting factor in the field of public health. Leadership, financial support, assessment of existing IT systems, strategic prioritization, better LHD control over IT-related decision making, and technical know-how are key promoters of interoperability within LHDs nationwide. Local and state health department leadership have key roles to play in motivating informatics uptake, which itself holds the promise to transform the practice of public health. Interoperability may allow, not only, greater interaction and access to big data, but it can also facilitate greater cross-jurisdictional sharing of services and promote public transparency through improved data availability to all stakeholders. Interoperable systems may improve connectivity of LHDs with other community partners to support health improvement efforts with real-time visualization of health data. Despite all the potential benefits associated with informatics uptake, the majority of LHDs in this nation—especially those serving smaller jurisdictions—do not have systems that can talk to each other. Greater investment in LHDs' IT and human resource capacity will be necessary to move the field forward within public health.
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business process analysis; informatics; information systems; information technology; interoperability; IT infrastructure; local health departments; local public health agencies