Public Health Information Systems Essay Example

Public Health Information Systems Essay Example Public Health Information Systems Paper Public Health Information Systems Paper Executive Summary The development of this White Paper has been facilitated by the Public Health Data Standards Consortium (PHDSC) 1 and the Integrating the Healthcare Enterprise (IHE). 2 The White Paper was developed by the participants of the PHDSC-IHE Task Force. The information in this document represents the views of the individual Task Force participants and may not represent the views of their organizations. The overall goal of this effort is to facilitate standardization of health information exchanges between clinical care and public health. The objective is to engage the public health community in a dialogue with health information technology (HIT) vendors to assure that the work processes and data needs of public health stakeholders in health information exchanges are 1) well understood and agreed upon by stakeholders themselves, and then (2) communicated clearly to the developers of the interoperable clinical Electronic Health Record (EHR) systems and Public Health information systems (EHR-PH Systems). The White Paper consists of three sections. The first section describes public health and population health practices of public health agencies that require health information exchanges with clinical care. The second and third sections describe Immunization and Cancer Surveillance domains in the IHE Technical Tasks for Information Exchanges outline. The Appendix section contains the description of examples of other public health domains (research, chronic care, personal health record, surveys, obesity, cancer, etc. ). The PHDSC-IHE Task Force participants believe that this effort will result in the formation of a Public Health Domain at IHE to begin collaboration between public health and HIT vendor communities to guide the development of the IHE Integration Profiles for the Electronic Health Record Systems to enable electronic information exchanges between clinical and public health settings. So, this White Paper serves as a framing document for the creation of the Public Health Domain at IHE. PHDSC and IHE invite public health experts to review the White Paper. During the review period, we would like to invite representatives of public health domains/programs to submit a description of their domains/programs using the IHE Technical Tasks for Information Exchange outline, so the final White Paper can include other examples of public health domains in addition to the immunization and cancer surveillance domains. This will help to identify potential public health domains/programs for the development of the IHE Integration Profiles in the upcoming year(s). We also would like to invite the reviewers to join our Task Force to participate in the formation of a Public Health Domain at IHE to begin collaboration between public health and HIT vendor communities to guide the development of the IHE Integration Profiles for the Electronic Health Record Systems, to enable electronic information exchange between clinical and public health settings. 1 2 Public Health Data Standards Consortium (PHDSC). URL: phdsc. org Integrating the Healthcare Enterprise (IHE). URL: himss. org/ASP/topics_ihe.asp 6. What is Public Health Mission The mission of public health is to protect the public from health threatening diseases, assure disease prevention by providing access to care for individual patients, promote and restore wellness, and â€Å"to assure the conditions in which people may be healthy. † 3 The patient-centric mission of public health is carried out using publicly-funded healthcare services. Vulnerable or at-risk patients may receive patient care services directly in their homes or at a health clinic funded by a public health agency. There are community health centers funded in the US by the Health Resources and Services Administration (HRSA) that provide a safety net for low income families. Public health funds may also be used to pay for and provide laboratory, pharmacy and other services for eligible populations. In this role, public health care is similar to private health care. The population-based mission of public health is carried out on various levels of government. The public health infrastructure includes agencies that operate on a local, state and/or federal level. In the US, there are 3000 local health departments, 50 state health departments and several federal health agencies, including the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Indian Health Service (IHS), and many others. In some states, the state health agency plays the key role in delivering services to communities; in other states, local health departments take the leading role. In some jurisdictions, public/private partnerships or other organizational entities may be involved in delivering public health services (e.g. , immunization coalitions – community-based groups that include parents). Stakeholders To fulfill its population-based and patient-centric mission, public health is represented by at least the following stakeholders: 3 Population at large Public health practitioners (including epidemiologists, environmental health specialists, health educators, public health nurses, administrators) Health care providers (including, but not limited to, publicly-delivered healthcare providers, e. g. , safety net clinic) Laboratories Payers Healthcare purchasers Pharmacies Other governmental agencies (e. g. , environmental, law enforcement) Professional Associations Research institutions Individual consumers, particularly vulnerable populations. Institute of Medicine. Future of Public Health. Report. 2002. 2nd edition. URL: iom. edu/? id=15251 7 Public Health Organization During the past 40 years, the population-based services of public health have been delivered using a categorical disease-specialized and services-specific domain approach. For example, public health agencies usually include the following programmatic areas and services: communicable disease control, lead poisoning prevention, vital registration, injury control, mental health services, substance abuse prevention and treatment, chronic disease prevention, newborn screening, immunizations, etc. (Tables 1 and 2). 4 This domain-specific organization of public health is supported by funding allocations that in turn shape the disease/domain-specific organizational structure of public health agencies, public health research activities, and workforce training. 5 Table 1. Personal Health, Population Level Assurance and Environmental Health Services Provided by Local Health Departments (LHD) 6 , 7 Personal Health Services Adult immunization Childhood immunization Tuberculosis treatment Sexually transmitted disease (STD) treatment Women, Infant Children (WIC) Family Planning Services Outreach and enrollment for medical insurance EPSDT LHDs Population Level LHDs Providing. Assurance Services Providing Service, Service, % % 91% Communicable 89% Disease surveillance 90% Tuberculosis 85% screening 85% Environmental Health 75% surveillance 61% High blood pressure 72% screening 67% 69% 58% Tobacco use  prevention HIV/AIDS screening 42% Blood lead screening 46%. Prenatal care Oral health care 4 40% Sexually transmitted disease screening Obesity prevention 31% Vector control Environmental Health Services Food service regulation Public swimming pool regulation Septic tank installation Schools/daycare centers LHDs Providing Service, % 76% 67% 66% 65% Private drinking water protection Lead inspections 57% 66% Hotels/motels regulation 49% 64% 39% 54% Campgrounds/ RVs regulation Smoke-free ordinances Groundwater / surface water protection 67% 56% 53% 38% 40% / 33% Lasker RD, editor. Medicine and public heath: the power of collaboration. 1997. New York, NY. Burke TA, Shalauta NM, Tran NL, Stern BS. The environmental Web: a national profile of the state infrastructure for environmental health and protection. J Public Health Manag Pract; 3(2):1-12. 6 Scutchfield, F. D. , Keck, C. W. Principles of public health practice, 2nd ed. 2003. Thomson/Delmar Learning: Clifton Park, NY. 7 2005 National Profile of Local Health Departments, National Association of County City Health Officials, July 2006. www. naccho. org 5 8 Personal Health Services Obstetrical care LHDs Population Level Providing Assurance Services Service, % 32% Diabetes screening Laboratory services 32%. Home health care School-based clinics 28% 25% HIV/AIDS treatment 26% Correctional health 20% Comprehensive primary care Behavioral/mental health services Substance abuse services Emergency medical services 14% 13% 11% 7% Unintended pregnancy prevention Cancer screening School health activities Chronic disease surveillance Injury control Cardiovascular disease screening Behavioral risk factors surveillance Syndromic surveillance Substance abuse prevention Violence prevention Injury surveillance Mental illness prevention LHDs Environmental Providing Health Services Service, % 51% Public drinking water protection 51% Health-related facilities regulation 46% Food processing 41% Mobile homes / housing inspections 41% Indoor air quality activities 40% Solid waste disposal regulation 36% Tobacco retailers LHDs Providing Service, % 30% 30% 30% 29% 29% 28% 21% 36% Animal Control 21% 33% Hazardous material response Hazardous waste disposal Land use planning Noise pollution Occupational safety health activities Radiation control 19% 26% 25% 24% 14% 18% 16% 14% 12% 10% 9 Table 2. Examples of Healthcare and Public health Responsibilities of State Health Departments (SHD) 8 Responsibilities SHDs Responsibilities SHDs Providing Providing Service,% Service,%. Healthcare Responsibilities Public health laboratory 79 Medical examiner 21 Rural health 79 State mental health authority 19 Children with special healthcare 77 State public health licensing agency 17 needs Minority health 72 State mental institution or hospital 17 Institutional licensing agency 60 Partial/split responsibility for 17 Medicaid State health planning 53 Medicaid state agency 15 development agency Partial/split leadership of 51 Lead environmental agency 15 environmental agency Public health pharmacy 34 State tuberculosis hospital 15 State nursing home 28 Health insurance regulation 15 Public Health Responsibilities. State public health authority 97 Disaster Preparedness 77 Newborn Screening 100 Perinatal Epidemiology 77 Immunizations 87 Violence Prevention 68 Bioterrorism 89 Emergency Medical Services 64 Regulation and Service Provision Injury Control Epidemiology 87 Quality Improvement or 62 Performance Measurement Injury Control Prevention 87 Toxicology 57 Breast and Cervical Cancer 87 Breast and Cervical Cancer 45 Screening Treatment Chronic Disease Epidemiology 85 Radon Control 55 Tobacco Control and Prevention 83 Institutional Review Board 45 State Title XXI Children’s health 28 Cancer Epidemiology 83 Insurance Initiative Environmental Epidemiology 79 8 Beitsch LM et al. Structure and functions of state public health agencies. APHA. 2006:96(1):167-72 10 Public Health Functions As a health care provider, public health clinics carry out all functions of a health care delivery system. As a governmental agency, public health is mandated to protect and improve the health of all people within a legal jurisdiction. It regulates healthcare services and coordinates healthcare delivery and resources allocation. The activities of public health agencies are focused on the following three core functions and ten essential services 9 , 10 : Assessment Monitor health status to identify community health problems; Diagnose and investigate health problems and health hazards in the community; Evaluate effectiveness, accessibility, and quality of personal and population-based health services; Research for new insights and innovative solutions to health problems Policy development and implementation Develop policies and plans that support individual and community health efforts Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Assurance Enforce laws and regulations that protect health and ensure safety Assure a competent public health and personal health care workforce. Link people to needed personal health services and assure the provision of health care when otherwise unavailable Public Health Data Sources Individual-patient clinical data comprises a large portion of data used to conduct communicable disease surveillance, case investigation, case management, and care coordination. Aggregated clinical data are used to perform surveillance to detect public health threat events and monitor the population’s health status. To fulfill the goal of protecting the public’s health, health care providers and public health agencies need the capability to exchange pertinent health information about individuals and communities. In addition to clinical data, other data sources are needed for public health decision making. For example, public health practitioners use environmental data, housing data, socio-economic data, geographic data, as well as information generated from surveys and research activities to meet the goals of public health programs. 11 9 Institute of Medicine. Committee for the Study of the Future of Public Health, 1988. Public Health Foundation. URL: www. health. gov/phfunctions/public. htm 11 Yasnof W, Overhage J, Humphrey B, LaVenture M. A national agenda for public health informatics. J Am Med Inf Ass 2001;8(6):535s of Domains, Stakeholders, Functions, Services Interventions, Data Sources Public Health Domains Stakeholders Infectious diseases Injury/Trauma Sexually transmitted diseases Consumer product safety Environmental health Occupational health Substance abuse. Mental health Chronic diseases Bioterrorism Disability Elected official Policy maker Health Department Researcher Private sector Clinician Educator Citizen Community Population Communitybased organizations Core Public Health Functions Assessment Policy development and implementation Assurance Essential Services Interventions Data Sources Data Types Monitoring Surveillance Screening Survey Risk assessment Policy research Policy development and implementation Regulation Outreach Case management Advocacy Social Marketing Education Evaluation Physician’s office patient medical record Registries Patient hospital records Emergency. Medical Services records Governmental regulations and guidelines Research databases Peers of Public Health Domains/Programs. 1 Research 6 Trauma Registries 2 Personal Health Record (PHR) 7 Chronic Diseases 3 Cancer Surveillance 8 Birth and Death Registries 4 Patient Safety and Population Health Perspectives 9 Obesity 5 Surveys 12 Orlova AO and Lehmann HR. A UML-based meta-framework for system design in public health informatics. AMIA 2002 Symposium Proceedings, November 9-13, San-Antonio, TX: 582-586. 12 Health Information Technology in Public Health For many decades, public health agencies and research institutions have been utilizing information technology (IT) to facilitate data management activities (data gathering, analysis, reporting, etc.). Public health information systems are created to support specific needs of disease-specific program areas within health departments, i. e. , newborn screening, birth defects, vital registration, immunization, communicable disease surveillance, chronic disease surveillance, school health, injury prevention, preparedness, etc. (Tables 1 2). These systems deploy various software products that are often custom-made and are not interoperable. Many of these systems contain redundant data; however, the varying data formats and standards preclude data integration across systems for public health decision support and research. These sytems lack the ability to provide real-time data back to providers for care coordination and disease prevention. The sections below describe the public health data gathering activities of clinical data that represent the major portion of public health data of interest. Current Practices on Data Reporting from Clinical Settings to Health Department Programs Most public health information systems are populated with data reported by health care providers. There is mandatory data reporting to CDC on 62 notifiable infectious diseases across all 50 states in the US 13 . This data is reported by clinicians to their local health departments. The latter reports this data to the state health department that in turn reports this data to CDC. In addition, various jurisdictions require clinicians to also report data on the conditions that are of interest for a specific jurisdiction (reportable conditions). Besides infectious disease reporting, various other public health programs receive data from clinician, e. g. , immunization registries, chronic disease registries, etc. In some jurisdictions, clinicians are expected to report data to both their local health department programs and their state health department programs. In many jurisdictions, data is currently reported using paper forms sent by fax or mail. For example in one state, providers (primary and emergency physicians) need to report data on 62 notifiable (mandatory) conditions and 32 reportable (state-specific) conditions using (a) over 50 various disease-specific Adobe Acrobat-generated paper forms required by the state communicable diseases surveillance system. This is in addition to providing data to other numerous programs maintained by the state health department. Lack of integration and interoperability across public health systems leads to the duplication of efforts and frustration among providers and consumers asked to provide the same information on multiple forms of varying formats to various programs. None of these activities are reimbursed by health insurance. According to the national data, public health data systems currently suffer from limitations such as underreporting (only 49% of cases are getting reported to public health agencies), 14 , 15 lack of 13 Centers for Disease Control and Prevention (CDC). Nationally Notifiable Infectious Diseases. URL: cdc. gov/EPO/DPHSI/phs/infdis. htm 14 Campos-Outcalt D, England R, Porter B. Reporting of communicable diseases by university physicians. Public Health Rep 1991;106:579-583. 15 Marier R. The reporting of communicable diseases. Am J Epidemiol 1977;105:587-590. 13 representativeness, lack of timeliness, inconsistency of case definitions across systems, inability to integrate data across the systems, etc. 16 , 17 Figures. 1a-d present schematic views of paper-based data reporting by healthcare providers to various public health data systems at the State and local levels. These views may also be applicable to any web-based data reporting to individual public health data systems maintained by the programs. EHR-based Health Information Exchanges between Clinical Care and Public Health Because of the automation of clinical data – inpatient and increasingly outpatient – via the Electronic Health Record Systems (EHRS), public health programs stand at the threshold of change in the way in which they gather programmatic data. Many of the information systems used by local health departments are not capable of exchanging data through RHIOs or with health care service delivery agencies. Many of them are not capable of sending/receiving HL7 messages and cannot or do not comply with other nationally accepted vocabularies and standards. In addition, many of the systems are not configured to serve as an electronic medical record to receive information from physicians; this restricts their ability to contribute to a longitudinal health care record for those clients for whom they serve as a primary care provider Nationally, electronic health record systems are beginning to be certified taking into account these considerations. The issue of compatibility/interoperability of these systems with public health systems to be able to send, receive and exchange relevant data for both public health and clinical practice needs to be addressed. 18 16 Centers for Disease Control and Prevention (CDC). Lesson Five: Public Health Surveillance. Principles of Epidemiology in Public Health Practice. Third Edition (Print-based). 336-409. Available at: cdc. gov/training/products/ss1000/ss1000-ol. pdf. Last accessed November 29, 2006. 17 Konowitz PM, Petrossian GA, Rose DN. The underreporting of disease and physicians’ knowledge of reporting requirements. Public Health Rep 1984;99:31-35. 18 Laverne Snow. Personal Communications. June 9, 2007. 14 Health Education/Risk Reduction Genetic Disorder Communicable Diseases Communicable Diseases Vital Statistics Provider 1 Provider 1 Immunization Provider 2 Immunization EPSDT Provider 3 Lead and Environmental Epidemiology Provider 2 Injury Control Injury Control Provider 3 School Health Provider 4 School Health Chronic Care Chronic Care Provider 4 Biosurveilance, BT, Preparedness Biosurveilance, BT, Preparedness WIC Provider X WIC Occupational Safety and Health Public Health Laboratory Provider X HEDIS Cancer a b Genetic Disorder Genetic Disorders Vital Statistics Health Education/Risk Reduction Provider 1 Communicable Diseases Provider 2 Immunization HRSA Communicable Diseases Provider 1 AHRQ Lead Registry Immunization Provider 2 Provider 3 Vital Records Injury Control Injury Control School Health School Health Chronic Care Chronic Care Biosurveilance, BT, Preparedness Biosurveilance, BT, Preparedness WIC WIC Public Health Laboratory Occupational Safety and Health HEDIS Provider 4. Provider X CDC Injury Control Immunization EPSDT Provider 3 Communicable Diseases Provider 4 School Health Chronic Care Biosurveilance, BT, Preparedness Provider X HEDIS Cancer c d Fig 1. Paper-Based Data Reporting by Health Care Provider to Various Public Health Data Systems: a Provider’s Data Reporting to Local Health Department Data Systems; b Provider’s Data Reporting to State Health Department Data Systems: c Provider’s Data Reporting to Local and State Health Department Data Systems; d Multiple Providers Data Reporting to State Health Department Data Systems. 15 â€Å"Many public health agencies are examining their existing information systems and seeking to improve their ability to support programmatic needs to detect, assess, and respond to a range of threats to the public, including infectious diseases, pandemics, such as avian flu, bioterrorism, and chronic diseases such as obesity, diabetes and asthma. The challenges of transitioning from a paper environment to an electronic environment involve rethinking the workflow, staff skills, resources, habits, and culture of an organization†. 19 Electronic transmission of data from the clinical care settings to public health agencies via EHRS is essential to (1) support key public health functions and services and (2) supply public health data repositories, e. g. , registries, research databases, etc. , for aggregated analysis of the health status of populations. 20 Provision of real-time aggregated community-level information back to providers bi-directional EHRS-based data exchanges between public health practitioners and clinicians will inform clinical decision support, improve care coordination and response capabilities to a public’s health threat event. The integrated Electronic Health Record-Public Health (EHR-PH) systems will become the backbone of a NHIN and regional HIEs. Fig. 2 represents a schematic view of the difference between the current public health data reporting mechanism (Fig. 2a) and the future standardized EHR-PH health information exchange (Fig. 2b). When the EHR-PH connectivity is completed, various public health data systems will be able to electronically receive data from clinical EHRS, so when an authorized provider enters patient data into his/her EHRS, various public health programs as authorized users can receive/retrieve/view/access their data of interest. 21 To facilitate the development of interoperable EHR-PH systems there is a need for standardization of health information exchanges across the clinical and public health enterprise. The US Health Information Technology Standards Panel (HITSP) 22 identified the following categories of standards for system interoperability: 1. Data content standards, i. e. , vocabularies and terminology standards (CDA2, SNOMED, ICD, X12, NCPDP, Omaha, etc. ) 2. Information content standards (Reference Information Models (RIMs) standards) 3. Information exchange standards, e. g. , messaging standards (HL7) 4. Identifier standards, e. g. , National Provider Identifier (NPI) standard 5. Privacy and security standards the US Health Insurance Portability and Accountability Act (HIPAA) privacy regulations provide a framework to protect privacy 19 Common Grounds: Transforming Public Health Information Systems. Robert Wood Johnson Foundation. 2006 Call for Proposals. URL: rwjf. org 20 Public Health Data Standards Consortium. Electronic health record-public health perspectives. White Paper. PHDSC Ad Hoc Task Force on the Electronic Health Record-Public Health. March 9, 2004. : 27p. plus 9 Attachments. URL: phdsc. org/knowresources/papers/docsandpdfs/PHDSC_EHRPH_WhitePaper2004. pdf 21 Orlova AO, Dunnagan M, Finitzo T, Higgins M, Watkins T, Tien A, Beales S. An electroninc health recordpublic health (EHR-PH) system prototype for interoperability in 21st century health care systems. Am Med Inform Assoc. (AMIA), Annual Symposium, Proc. , 2005. 22 Health Information Technology Standards Panel (HITSP). American National Standards Institute (ANSI). URL: amsi/org/hitsp 16 confidentiality of personal information; however, they do not cover all potential actors in health data exchanges. 23 6. Functional standards, i. e. , workflow/dataflow standards 24 7. Other, i. e. , information technology infrastructure standards, interoperability standards (IHE). HIE Genetic Disorders Communicable Diseases Provider 1 Immunization Provider 3 Communicable Diseases CDA2 Provider 2 Vital Records Provider 1 Genetic Disorders HL7 Provider 2 Immunization Vital Records Provider 3 Injury Control Provider 4 X12 Injury Control Provider 4 School Health School Health NCPDP Chronic Diseases Chronic Diseases Provider X Biosurveilance, BT, Preparedness Provider X Biosurveilance, BT, Preparedness, Syndromic Surveillance LAB IHE HEDIS HEDIS a b Fig. 2. Health information exchanges between clinical care and public health agency: a – current paper form – based information exchange; b – standardized EHR-PH –based information exchange. Fig. 2b presents examples of standards (CDA2, HL7, X12, NCPDP, IHE) that the EHR-PH HIEs will have to support. To help facilitate the development of the standardized EHR-PH health information exchanges, it is critical to start a dialogue between the public health community and EHRS developers to assure that the work processes and data needs of public health stakeholders are well understood and agreed upon by stakeholders themselves and then communicated clearly to the developers of the interoperable EHR-PH systems. The section that follows presents two examples of the beginning of this dialogue by describing one of the public health domains in the IHE suggested framework for the technical tasks for information exchanges. 23 See ncvhs. hhs. gov/060622lt. htm Developing a Vision for Functional Requirements Specification for Electronic Data Exchange between Clinical and Public Health Settings: Examples of School Health and Syndromic Surveillance in New York City. Public health Data Standards Consortium. 2006, 40p plus attachments. 24 17 Technical Tasks for Information Exchanges: Examples of Public Health Domains IHE provided a list of Technical Tasks for the description of the information exchanges related to a domain as follows: 1. What is ? 2. Who are Stakeholders? Technical Tasks for Information Exchanges 3. Expressing the criteria 4. Selecting a site 5. Identifying a patient meeting certain criteria 6. Retrieving additional data elements (queries) 7. Reporting data elements (notifications) 8. Data review/feedback (filters) 9. Analysis/evaluation 10. Mapping 11. Aggregation/Reporting 12. Communication We used Immunization and Cancer Surveillance as examples of public health domains (Tables 1 2) and have attempted to describe them in terms of the IHE proposed technical tasks for information exchanges between clinical and public health EHR-PH systems. The section below includes the descriptions of the existing use cases and standards identified by the immunization domain and cancer surveillance experts to date as well as the existing IHE profiles applicable to these domains. It also includes the list of existing and emerging standards and possible future IHE profiles needed to meet the EHR of Immunization Domain 1) What is the Immunization Domain? Immunization is critical to control many infectious diseases including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles),