Monthly Archives: April 2013

Community Data, Data Stewardship & Public Health

By Max Gakh, JD, MPH,  Partnership for Public Health Law, maxim.gakh@apha.org

Communities are seeking data as part of their public health work

community _ health dataChild Watch, in Pittsburgh, Pennsylvania, is launching a website with extensive data about the children of Allegheny County.  Website data will provide users with information about health, education, and demographics of the county’s youth.  The website is intended to function as a data clearinghouse, providing policymakers and partners with access to streamlined data.

Community partners like Child Watch are using local health information to address public health needs.  Protecting de-identified information is a core element of a new, national stewardship framework for the use of community health data.

Data stewardship principles to guide community work

Data access and use comes with responsibility.  Communities are rapidly learning how to be responsible stewards of data.  Data stewardship requires balancing the same considerations generally at issue in public health: the rights of individuals on one hand and the needs of the community on the other.

Data stewardship ensures responsible use, collection, analysis, and storage of data and information.  It also focuses on data accuracy and integrity.

On December 5, 2012, the National Committee on Vital and Health Statistics (NCVHS), which advises the U.S. Department of Health and Human Services (HHS) on health data and information policy, recommended to HHS a framework for data stewardship by communities using data to advance health.  As health data are disseminated for public use, the framework emphasizes cultivating trust and accountability.

Using public health department data for community health

Communities typically use local health data that do not identify individuals.  NCVHS’s data stewardship framework stresses the importance of protecting this type of “de-identified” data.  De-identified data is exempt from the HIPAA Privacy Rule and other privacy protections.

NCVHS expresses several concerns about communities that use de-identified data. One concern is that de-identified data may be used to re-identify specific persons by merging it with other sources of information.  Re-identification may be difficult or expensive and it may be hard to achieve in some parts of the country.  But if re-identified information is misused, it could threaten privacy and lead to economic or social difficulties for the identified individuals.

State laws governing disclosure of information by public health agencies

When providing data to communities, public health departments should recognize that determining whether data identify individuals may be difficult.  Yet this determination may control whether certain state legal provisions apply.

Research indicates that 25 states and Washington, D.C. explicitly prohibit disclosure of any personally identifiable information held by public health agencies except when clearly permitted by law.  Many of the other 25 states protect the disclosure of personally identifiable information related to specific diseases and through practice rather than legal provisions.

Public health departments that provide data to community partners should understand laws governing disclosure of personally identifiable information.  Ohio, for instance, prohibits state and local health departments and boards of health that receive “protected health information” from disclosing it.  “Protected health information” either directly reveals the identity of an individual or could be used to determine that identity.  It may be disclosed only for treatment, to ensure the information is accurate, under a search warrant or a subpoena related to a criminal investigation, or to address a threat to an individual or the public’s health.  Public health agencies in Ohio may also disclose de-identified information in aggregate or statistical forms.

Public health departments that encourage robust data stewardship systems and practices among community partners can ensure community trust by reducing the likelihood that properly disclosed aggregate information will be used to identify individuals.

Max Gakh is a Visiting Attorney with the Partnership for Public Health Law.  The Partnership is a collaboration of NACCHO, the American Public Health Association (APHA), the Association of State and Territorial Health Officials (ASTHO), and the National Association of Local Boards of Health (NALBOH).

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Guidance for Public Health Agencies Preparing for Stage 2 Meaningful Use

If you hadn’t considered taking a look at what Stage 2 of Meaningful Use has to offer to public health, there is no better time than now. Earlier this week, the Stage 2 Meaningful Use Public Health Reporting Requirements Task Force published a guidance for public health agencies (PHAs) preparing for Stage 2 Meaningful Use (MU).

InteroperabilityAt Stage 2 it’s all about achieving interoperability through common standards among diverse systems and organizations exchanging information.

On September 4, 2012, the Stage 2 Meaningful Use “Final Rules” was published in the Federal Register, requiring local and state Public Health Agencies (PHAs) to ramp-up their MU capabilities and establish new processes to receive the relevant public health data from Eligible Professionals (EPs) and Eligible Hospitals (EHs).

Two important things to highlight for Stage 2 of Meaningful Use:

1) Ongoing submission of electronic data for immunizations is in the core (i.e., mandatory) set for Eligible Professionals and on-going submission of electronic data for immunizations, reportable laboratory results, and syndromic surveillance are in the core set for Eligible Hospitals.

2) EPs have menu (i.e., optional) objectives for reporting syndromic surveillance data, for reporting to cancer registries, and other specialized registries (e.g., birth defects registries, chronic disease registries, traumatic injury registries).

While supporting Stage 2 MU objectives is neither a requirement nor an obligation for PHAs, it is however encouraged. These objectives represent tremendous opportunities for PHAs to improve their surveillance capabilities. Under the Stage 2 MU regulations for the public health objectives, it is suggested that PHAs perform four (4) new administrative tasks to fully support Stage 2.

The Figure listed below (from the Readiness Guidance document), shows these four administrative tasks and the timeline to develop them (prior to the state of Stage 2, 10/01/2013 for EHs and 01/01/2014 for EPs):

Four New Administrative Tasks for PHAs to support MU2

Top Reasons to Read this Document:

  1. Understand the requirements and terminology from the LHD perspective
  2. As a reminder that you need to get up to speed with your state’s MU Stage 2 plans
  3. You will likely be getting questions from your providers very soon

The Task Force developing the Stage 2 MU Public Health Reporting Requirements consists of representatives from the public health community including: NACCHO, ASTHO, ISDS, CSTE, PHII, NAACCR, State PHAs, AIRA, ONC, CDC, and others.

This is the first of many documents that will be developed by this Task Force. Please consider following the efforts of this group.

For more guidance on meaningful use, visit our website and review the resources: http://www.naccho.org/topics/infrastructure/informatics/resources/meaningful-use.cfm.

Celebrating National Public Health Week: Local Health Departments utilizing EHRs for ROI

This week is National Public Health Week (NPHW), celebrating the contributions of public health workers in communities all across the nation as they strive to improve the health of all of their residents. In commemorating National Public Health Week, the ePublic Health blog is highlighting some of the great successes achieved by three local health departments that are moving into 21st century healthcare through the use of EHRs.

This year’s theme, “Public Health is Return on Investment (ROI): Save Lives, Save Money” highlights the value of prevention and the importance of well-supported local public health systems that work to  prevent disease and save lives. But achieving those goals are getting harder in the context of a fundamental fact that American healthcare costs continue to grow.

Local health departments play a vital role in the health and care of patients where they live. They provide unique services and have data reporting requirements to state and federal agencies. Clinical care and population-specific interventions are funded in a variety of ways and settings and many continue to face systematic funding challenges that complicate the delivery of their services.

Whether it’s at the municipal, county, state or federal level, these organizations provide coordinated care to some of the country’s most vulnerable citizens. And one tool used by these departments to improve population health is Electronic Health Records (EHRs). EHRs already play a vital role in helping prevent disease and save lives while working to coordinate care and help control healthcare costs for underserved populations across the country.

Otter Tail County, Minnesota

In Fergus Falls, MN, the Otter Tail County Public Health Department predominately serves adults who are enrolled in the county’s medical assistance program.

“Most of our clients have chronic health and comorbid conditions,” explains Diane Thorson, the Director/CHS Administrator at the department.

“The best value or ROI due to the recent implementation of the EHRs is the ability to query information regarding whether clients have had the appropriate immunizations such as flu, pneumonia, TDAP, and Zostavx,” Thorson says.

Thorson said she believes the ability to quickly obtain aggregate data through the EHR is important. The EHR, she says, describes outcomes of care rather than the numbers of units of service and helps the department avoid duplicate immunizations. It gives the health workers the ability to “guide evidence-based practice.” Otter Tail’s team uses tools available from the Public Health Informatics Institute (PHII) and talks with colleagues at other departments to guide decision making and exchange lessons learned.

Through the use of the EHR, the Otter Tail health department has been able to better manage and coordinate care for patients who rely on the care provided by doctors and nurses in the county health department.

District Health Department 10, Michigan

The District Health Department #10 (DHD10), which is responsible for 10 counties in Michigan, serves a similar underserved population as the Fergus Falls health department. More than half of the people DHD10 serves (54 percent) live in rural areas and are at, or slightly above, the national poverty level. With an unemployment rate of about 15 percent, about 55 percent of births in the counties DHD10 serves are reimbursed by Medicaid.

According to Sheryl Slocum, the EHR Liaison/Family Planning Supervisor for District 10, many of their patients have co-morbidities and unhealthy lifestyle habits. The population struggles with obesity, smoking and abusive behaviors.

Because of the diversity and difficulties in treating its residents, District 10’s Family Planning and Breast and Cervical program has 10 local sites which patients can use, each with connection to the LHD-wide EHR system.

The benefits of this portability are telling, according to Ms. Slocum. Quality assurance activities are now more efficient. While quality improvement activities are underway, it is expected that the EHRs will make processes more efficient and streamlined.

Cabarrus County, North Carolina

Since the fall of 2011, the Cabarrus Health Alliance (CHA) of North Carolina has been systematically implementing an electronic health record, Insight, throughout the clinical and support areas, according to William Pilkington, CEO and public health director.

The patients Cabarrus serves often can’t afford health insurance or treatment and many of these low-income patients live with multiple social stressors that often compound their existing medical conditions.

A particular area of specialty for CHA is high-risk maternity patients. Although maternity patients are seen in the clinic daily, given the clinic’s staffing issues (only one obstetrician), deliveries are often handed off to experienced OB/GYNs who work at the local hospital.

Before the alliance adopted the use of EHRs, it was common for patients to receive additional tests and more extensive pre-natal exams when they arrived at the hospital, because their medical records didn’t travel with them. While it is critical to have this information if a mother delivers early, this is precisely when the paper system was most likely to break down, Pilkington explains.

Now, a mother’s medical record is available to labor and delivery staff at any hour on any day of the week, even when the delivery is unexpectedly early, thanks to the EHR.

The EHR has also made it possible for clinicians to automate best practices throughout the Alliance’s facilities, such as in CHA’s Pediatric Clinic in Kannapolis, NC.  The American Academy of Pediatrics instituted its Bright Futures curriculum in 2011.  Bright Futures is a national health promotion and disease prevention initiative which includes extensive, evidence-based preventive services recommendations for pediatric practices.  Recommended screenings and services are now automated by the EHR which presents age-appropriate material based on the curriculum.

Mothers and their newborns who are treated by the Cabarrus Health Alliance can be assured that their records will provide their doctors with the right information they need where they need it, thanks to the adoption of EHRs across the county facilities, helping to make the care they receive that much more efficient.

The Return on Investment for Public Health

While ROI is typically thought of in a purely business sense and revolves around financial gain, many local health departments are actively demonstrating that EHRs can provide a return on investment in different ways. These tools have been proven to help connect patients with needed health and social services in Cabarrus County and ten counties in Michigan. They are streamlining processes and saving valuable time in Otter County.

But one thing is clear, those departments that are using EHRs won’t be going back to paper records because they are seeing the benefits of health IT.  They are demonstrating that Public Health ROI does save lives and money – goals that are worth celebrating during National Public Health Week.

A special thanks to Kathy Cook, Diane Thorson, Sheryl Slocum, and William Pilkington for their
contributions to this post.