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What is public health informatics and what can it do for my local health department?

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  1. 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, adavidson@dhha.org Dr. Anna Orlova, PHDSC & Johns Hopkins University, aorlova@jhsph.edu Moderator: Alastair Matheson, NACCHO, amatheson@naccho.org

  2. 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?

  3. 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 useshould be in your community.

  4. 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.

  5. 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?

  6. 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?

  7. 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.

  8. Informatics • “Informatics is the science that studies the use and processing of data, information, and knowledge” Van Bemmel JH & Musen MA. 1997. Handbook of Medical Informatics. Bohn: Springer-Verlag

  9. 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. Informaticianis a user who designs the solution.

  10. Model Development is the Main Informatics Method Informatics and Modeling • Informatics uses modelsof the problem (application domain) to: • capture domain knowledge; • precisely specifyrequirements, 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 (functionalspecification) as well as how the function is accomplished (implementation) Rumbaugh et al. 1999. Unified Modeling Language. Manual.

  11. 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. 1995 2: 65-67

  12. 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? Modeling User Workflow….

  13. Modeling User Workflow Event Detection EHRS NeighboringJurisdictions Hospital State Public HealthSurveillance 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 LocalPublic HealthSurveillance System 5 – Report test results P U B L I C 5 – Report test results Media Laboratory Response Team Pharmacy

  14. Modeling User Workflow Event Monitoring NeighboringJurisdictions Hospital EHRS State PHSurveillance 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 LocalPublic HealthSurveillance 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

  15. Modeling User Workflow Event Management NeighboringJurisdictions EHRS Hospital State Public HealthSurveillance 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 LocalPublic HealthSurveillance 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

  16. 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

  17. 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

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

  19. 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. 1995. Public health informatics: how information-age technology can strengthen public health. Ann Rev Public Health 16:239-52

  20. 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) Yasnoff WA, Overhage JM, Humphrey BL, LaVenture M. A national agenda for public health informatics. JAMIA 2001; 8 (6): 535-45.

  21. 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?

  22. Modeling User Workflow CVD Surveillance Laboratory Payor Hospital EHRS State Public HealthSurveillance 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 CVDSurveillance System 10 – Conduct Health Education DHHS P U B L I C 6 – Fill Prescription 8– Coordinate Care Media School Pharmacy

  23. Electronic Health Record (EHR) • Electronic Health Record (EHR) isinformation, 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. International Organization for Standardization (ISO) . URL: http://www.iso.ch/

  24. 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: http://www.iom.edu/report.asp?id=14391

  25. 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.

  26. Public Health Informatics • Why Now?

  27. How to find what information we need? • 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 useshould 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?

  28. Health IT Strategic FrameworkPresident 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

  29. 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, 2004. URL: URL: http://www.hhs.gov/healthit/strategicfrmwk.html

  30. ONC HIT Strategic Plan, 2008-2012 URL: http://www.hhs.gov/healthit/resources/HITStrategicPlanSummary.pdf

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

  32. AHIC Use Cases

  33. Scenario 1: Vaccine and Drug Administration and Reporting Health Information Exchange OR Point-to-point exchange OR Specialty Network Capabilities as needed in context: 9.1 Data delivery 9.2 Data retrieval 9.3 Subject-data matching 9.4 Data provisioning 9.5 Support for personally controlled health records Legend 9.6 Emergency access Focus Contextual Emergency Priorities 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 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 Public Health Agencies 5 7.2.1 Identify individuals needing prioritized intervention 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 Supply Chain 8

  34. HITECH Act - 2009 • 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

  35. 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

  36. ARRA FundingMany 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, 2011-2016 Appropriations for HIE Community Health Centers $1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems • 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 Broadband and Telehealth $4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants

  37. 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 (2009-2011) • 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

  38. 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

  39. Alert: patient with symptoms in outbreak region

  40. 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?

  41. Public Health in a NHIN

  42. 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

  43. How to find what information we need? • 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 useshould 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?

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

  45. Public Health in HIE: Issues to Consider 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

  46. Public Health in HIE: Issues to Consider 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.

  47. Responsibilities of State PH Agencies: 2001 Source: Beitsch LM et al. Structure and functions of state public health agencies. APHA. 2006:96(1):167-72

  48. Responsibilities of Local PH Agencies: 2003 Source: Scutchfield, F.D., & Keck, C.W. Principles of public health practice, 2nd ed. 2003, Thomson/Delmar Learning: Clifton Park, NY.

  49. State Health Department: Organizational Chart

  50. Public Health in HIE: Issues to Consider All public health activities are supported by customized information systems (databases, registries) developed to address the programmatic needs.