In 1850, Ignaz Semmelweis saved lives with three words: wash your hands.
In December 2019, a new outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was reported in Wuhan, Hubei Province, China. Within weeks, the outbreak spread to other countries. On January 30, 2020, the World Health Organization (WHO) declared that the SARS-CoV-2 outbreak constituted a Public Health Emergency of International Concern. On March 11, 2020, the WHO declared the novel coronavirus outbreak (COVID-19) a global pandemic. On March 13, 2020, the President of the United States announced the coronavirus pandemic a national disaster.1 By April 17, 2020, worldwide confirmed cases of COVID-19 had reached 2 240 191 and rising. Globally, more than 153 822 deaths were linked to COVID-19. In the United States, by this same date, confirmed COVID-19 cases had climbed to 699 706, with more than 36 773 deaths.2
Inadequacies of the US Health System
The COVID-19 pandemic has exposed inadequacies of the US health system.3 Despite its highest spending, the US health care system lacks the capacity to sustain a continued increase in demand for its services.4 This in no way minimizes the heroic commitment of the health professionals fighting the COVID-19 pandemic. However, it does highlight the deficiencies of the US system that must be addressed to avoid future failures.
So far, social distancing, washing hands, quarantine of infected individuals, and contact tracing have been effective in curbing the spread of this contagion. For years, public health professionals in the United States had lamented about decreasing budgets and lack of resources for prevention.5 This lopsided focus on spending more on treating conditions that are preventable while decreasing investments in public health systems has brought us to a situation where the health care delivery system and dedicated health professionals are all threatened to be overwhelmed within days and weeks without large-scale public health measures across the board.
Reliable Data and Information Are Needed to Fight COVID-19
The COVID-19 pandemic has clearly shown that global health crises are also information crises.6 National, state, and local public health agencies and hospitals have relied heavily on disease surveillance and pandemic modeling to make difficult decisions. The White House has relied heavily on the University of Washington Institute for Health Metrics and Evaluation's disease model, whereas health departments around the country have used a variety of other sources of projections models, data, and information systems. Health care is an information-intensive business. Both individual care and population health management require information availability and management.7 In the age of personalized e-marketing and advertising, the inadequate health informatics translates into less effective, more expensive, and unsystematic response to a pandemic.8 Without good data, opinions quickly create disagreements and trigger ideological debates about best strategies to fight the pandemic.
Reliable data help fuel innovative approaches to guide our response to outbreaks. For instance, Geographic Information System (GIS) has supported global efforts to fight COVID-19 and associated illnesses. The 2014 Ebola outbreak in West Africa highlighted the utility of GIS in combating the disease.9 GIS can help in pandemic responses: (1) disease tracking for epidemiologists and responders; (2) public awareness of local outbreaks to reinforce self-isolation behaviors; and (3) locating vulnerable populations based on demographic and other data.10 During the COVID-19 pandemic, GIS has already played a critical role. Preeminent in this role has been Johns Hopkins University's Center for Systems Science and Engineering (CSSE).11 Since the CSSE coronavirus GIS map went live on January 22, it has become the leading global source of data for the public, media, and researchers.2,11 The Florida Department of Health has extended this work by providing specific case numbers by zip code.12 GIS has thus become one of the primary ways to spatially analyze and publicize data for responders, researchers, and the lay public.
Health Informatics Capacity in Local Health Departments
Interoperable information systems are essential to get reliable data for a coordinated containment and screening plan to work. Without proper information systems, it will be hard to coordinate virologic testing offered by hospitals, laboratories, federal agencies, as well as states and local agencies. Health informatics, when implemented in collaboration with strategic partners, can support a systematic response to COVID-19 and in curbing misinformation. It is essential for public health agencies to create collaborative synergies and act as true “chief health strategists” to address COVID-19.13
There is an urgent need to strengthen the informatics infrastructure and capacity of local health departments (LHDs) in the United States. Many LHDs (30%) have no interoperable systems, whereas for 38% only some of the systems are interoperable. Leadership support, authority over information technology (IT) budget allocation, and control of data systems are significant drivers of having interoperable systems in LHDs. It might surprise many that a small proportion of LHDs in the United States still do not have access to high-speed Internet,14 and although 9 in 10 LHDs provide clinical services, LHDs most commonly use paper records for storage of clinical data (29%) and nonclinical data (59%).15 LHDs have a general lack of control over decisions concerning the selection of hardware, software, and other components of informatics. Data from national surveys show unrealized informatics training needs and gaps in capacity.16
Research cited earlier highlights 3 key facts: first, the COVID-19 epidemic cannot be won without a close partnership between public and health care organizations; second, availability of data and information in a timely fashion is essential to implement effective strategies; and, third, LHD capacity in collecting, managing, analyzing, and sharing health information is quite limited and will play a decisive role in the long-term fight against COVID-19 and such other epidemics in the future.
There is a dire need to pay attention to these shortcomings and invest in the building of the health informatics capabilities in LHDs. While a better planned and long-term strategy is needed to build the informatics capacity of LHDs, there are some steps that can be implemented in the short run and prioritized to fight COVID-19 response.
Urgent Steps to Strengthen LHDs' Informatics Capabilities
Thanks to the investment of billions of dollars in informatics infrastructure, almost all the hospitals and physician practices in the United States are using electronic health records (EHRs).17 However, that system is still fragmented and still incapable of responding to epidemics. Many regions have established regional health information exchanges (HIEs) that provide a common hub for integrating data from multiple EHRs. LHDs can share data with health care systems with one connection to an HIE, without having to develop multiple interfaces and negotiate legal agreements.18 Local HIEs have done most of that work and hence should be promoted and supported by policy makers to help strengthen local public health reporting. Currently, many local HIEs have to initiate COVID-19 data collection activities rather than being approached by LHDs to use their existing infrastructures for this national crisis.
LHDs have limited capabilities to manage and analyze data to inform public action and policy. This is due to reductions in public health budgets and outdated informatics systems that are incapable of deriving value from the data collected by LHDs. Sixty-two percent of LHDs had no informatics training provided in the past 12 months. Retraining existing staff in IT and informatics so they can be smarter users of data and work more effectively in this information-focused world is needed.19 LHDs should be provided with resources to engage with academic institutions to fill those gaps. Academic institutions and universities have qualified faculty and competent students who are keen to work on data sets if made available through LHDs. In return, LHDs can get analysis and insights to inform local actions. These collaborations can also be initiated in a relatively short period of time and contribute tremendously in developing local projections and strategies for COVID-19.
We have mentioned a few practical steps that may help in the fight against COVID-19. Local public health systems have to rise above their usual cautious approach to take leadership in this fight against COVID-19. They have a powerful tool for enjoying the public's trust. That trust is shown by the legislatures giving public health immense powers to collect and demand data about individuals. This is the time to cash that trust and legal protection to use the tool that will be most effective in this current crisis—information. LHDs need to immediately embark on a strategic plan to build their capacity for information management and analysis on a war footing, while also keeping an eye on the long-run capabilities to face the next such crisis, which we all know is lurking somewhere around the corner.
Surely, the time to execute a concerted national and local strategy for building and strengthening local public health capabilities is now. If we do not act immediately, we will be losing many lives, and our systems will collapse, much like the prognosis of a COVID-19 patient with a weak immune system. We need to put our LHDs in policy intensive care units and provide them with the care that is needed to help in their recovery to be healthy and fight off this virus.
1. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19)—situation summary. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html
. Updated April 7, 2020. Accessed April 7, 2020.
2. Johns Hopkins University & Medicine, Coronavirus Resource Center. https://coronavirus.jhu.edu/map.html
. Accessed April 17, 2020.
3. Blumenthal D, Seervai S. Coronavirus is exposing deficiencies in U.S. health care. Harv Bus Rev. https://hbr.org/2020/03/coronavirus-is-exposing-deficiencies-in-u-s-health-care
. Published March 10, 2020. Accessed April 11, 2020.
4. Johns Hopkins Bloomberg School of Public Health. U.S. health care spending highest among developed countries. https://www.jhsph.edu/news/news-releases/2019/us-health-care-spending-highest-among-developed-countries.html
. Accessed April 6, 2020.
5. Shah GH, Ye J, Leep CJ, Leider JP. Local health departments' approaches to deal with recession: what strategies are used to minimize the negative impact on public health services to community? J Public Health Manag Pract. 2016;22(6):537–541.
6. Xie B, He D, Mercer T, et al. Global health crises are also information crises: a call to action. J Assoc Inf Sci Technol. 2020:1–5. doi:10.1002/asi.24357.
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9. Nic Lochlainn LM, Gayton I, Theocharopoulos G, et al. Improving mapping for Ebola response through mobilizing a local community with self-owned smartphones: Tonkolili District, SierraLeone. PLoS One. 2018;13(1):e0189959. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752033/pdf/pone.0189959.pdf
. Accessed April 11, 2020.
10. esri.com. Mapping epidemics: from SARS, Zika, and Ebola to the pandemic of COVID-19. https://www.esri.com/about/newsroom/blog/maps-that-mitigate-epidemics
. Accessed April 11, 2020.
11. Dong E, Du H, Gardner L. An interactive Web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020. doi:10.1016/S1473-3099(20)30120-1.
12. arcgis.com. Florida COVID19 data and surveillance by zip code. https://fdoh.maps.arcgis.com/home/webmap/viewer.html?webmap=7810ed79d26a445288b5a93feeefcc2f
. Accessed April 11, 2020.
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15. Shah GH, Vest J, Lovelace K, McCullough JM. Local health departments' partners and challenges to participation in health information exchanges. J Public Health Manag Pract. 2016;22(6)(suppl):S44–S50.
16. Drezner K, McKewon L, Shah GH. Assessing skills and capacity for informatics: activities most commonly performed by or for local health departments. J Public Health Manag Pract. 2016;22(6)(suppl):S51–S57.
17. The Office of the National Coordinator for Health Information Technology. Quick IT stats. https://dashboard.healthit.gov/quickstats/quickstats.php
. Accessed April 16, 2020.
19. Williams KS, Shah GH. Electronic health records and meaningful use in local health departments: updates from the 2015 NACCHO Informatics Assessment Survey. J Public Health Manag Pract. 2016;22(6)(suppl):S27–S33.