Category Archives: Public Health Reporting

Interoperable: Shares a well-defined interface

 Joe Gibson
Director of Epidemiology
Marion County Public Health Department

Modular systems vs. the Killer App
I am a great believer in having modular, interoperable systems. I have seen too many “Killer Apps;” too many systems that try to do it all, and end up doing their core function well, but most other things badly, like case investigation systems that try to include analysis and reporting, or analysis systems that try to include data capture modules. As much as possible, I want my health department to have a set of distinct systems, where each system does its function very well, and can work with the other systems to support our entire operation. The staff should only have to learn one interface for inputting encounter data, and only one interface for generating reports, just like we have only one application for working with e-mail. Of course, the separate systems have to communicate with each other, so that our encounter data can get into our reports. In other words, the systems have to be interoperable.

True and false interoperability
InteroperabilityWhen people talk about interoperable systems, they often focus on whether the systems share some coding system like SnoMed, ICD10, or LOINC. Under this very limited view of interoperability, two systems would be considered interoperable if they store their information using the same codes, like ICD-9-CM for diagnosis, “M” for male and “F” for female in the Gender field, etc.. If systems were people, this view might consider two people “interoperable” if they had the same native language.

Sometimes discussions of interoperability also include message standards. Message standards define how information is arranged in the messages sent from one system to another. Message standards define what fields should be sent, in what order, with what separators or labels, in what format (HL7, XML, etc.), and with what coding system. Message standards are analogous to grammar; if interoperability were defined as having a shared message standard, two people might be considered “interoperable” if they used valid sentences in the same language.

But interoperability requires much more than this. It is not just having information that is coded in the same way in two systems. It is not just having standard formats for communicating certain kinds of information. It also requires some kind of connection between the systems, just like communication between people requires a telephone, and e-mail system, or being close enough to hear each other. It also requires the message be properly interpreted, so the information can be used for action. And it requires some appropriate, sensible response, often in the form of a confirmation that the message was received and understood, and perhaps an answer, if the original message was a query. We have all had the experience of talking without understanding, despite using valid sentences in a shared language. A productive exchange requires that each side understands the other, and responds in some relevant way.

Interoperable = shared interface
Until recently, when I tried to assess whether two systems are interoperable, I had a hard time organizing all this in my head. I would think about language, message standards, connections, and vague and diverse functions for interpreting information and responding to it. Fortunately, I learned a much more useful way to think about the crux of interoperability from a developer during a recent meeting about collaborative development of immunization registries. He said that to create one software module that will work with the our many, varied immunization systems, we need to define the interface.

An interface is the point of interaction between systems, like the counter at a fast food restaurant. The interface allows systems to connect and exchange something. Think of a fast-food counter: you state your order, the server tells you the cost, you give some form of payment, and the server gives you your food. Each part of the exchange has certain criteria: you may have to order in English or by pointing, and the payment may have to be with cash or credit card. A system interfaces might define how to send an address and get back a geocoded point location from Google Maps, or how to send a laboratory sample ID from an EHR and get back a laboratory result from a LIMS system. A systems interface defines what can cross between the systems, when, in what form, and the allowed responses. The interface does not define the internal operations of system operates, but it does define the inputs and outputs needed for an exchange between the systems. A well-defined interface defines everything that needs to be done for that exchange to occur; to more, and no less. It precisely defines, for a specific function, what is necessary for systems to interoperate.

So now, when I consider whether systems are interoperable, my central question is, “is there a well-defined interface between these systems?” When I think about making two systems interoperable, I see the task being to develop an interface between them.

Why does this matter?
miscommunication_jpegThis concept of interface should be at the core of our conversations about interoperability. I get worried when interoperability discussions are just about language or message format; I worry that public health decision-makers will be misled into investing in systems that are called “interoperable,” when the systems only use the same language or message format, but do not have automatic, built-in functions for communicating and using information from each other. Do not be fooled. Two systems are not interoperable unless they conform to a shared interface. If someone says that a system is interoperable, have them demonstrate how their system sends and receives information from your other systems through a well-defined interface.

Acknowledgements:
Thanks to Nathan Bunker of Dandelion Software and Research for getting me thinking about interfaces this way, the Public Health Informatics Institute for organizing the Immunization Information Systems Joint Development meeting, and the CDC for funding it.

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Public Health Informatics Virtual Event on July 16-18, 2013 – Call for Abstracts!

Connect with colleagues at your own convenience!

ph informatics virtual event

This virtual event provides the opportunity to learn and discuss the latest initiatives in public health informatics with attendees from all over the country and internationally. Call for abstracts is now open and will continue until May 31, 2013. This year’s theme is “Strengthening Public Health – Health Care Collaboration.” Abstract submissions are encouraged in the following areas:

1)  Informatics policy and practice: virtual sessions will focus on national and international policy issues and their implications for public health informatics programs; applied informatics projects for programmatic support; and new initiatives

Examples might include:

  • ICD-10 CM/PCS –deadline for implementations 10/1/2014
  • Meaningful Use & Electronic Health Records
  • Interstate data exchange
  • Data exchange to support ACOs

2)  Research & Innovation: virtual sessions will focus on informatics research and technological innovation to public health and clinical settings.

Examples might include:

  • Applying analytics to new and existing data sources
  • Leveraging Big Data for population and public health
  • Learning health systems to support integration of primary care and public health
  • Novel technologies for population and public health education and communication (mobile, web, social media)

3)  Supporting Public Health Evidence Based through Informatics Practice: virtual sessions will focus on strengthening public health through knowledge sharing, evaluation, visualization and reporting.

Examples might include:

  • Evaluation methodologies and findings
  • Decision support for population health Health status and performance management dashboards
  • Community Health Assessments as part of the community health improvement process
  • Return on Investment (ROI) and Value of Information (VOI) analyses for informatics programs and systems

If any of the items above relate to your area of work, do not miss the opportunity to submit an abstract!

Help us get the word out and share this blog post with your colleagues and friends! And if you’re ready to submit an abstract go straight ahead here.

Meeting sponsors include CDC, NACCHO, and ASTHO.

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.

Public Health – Seattle & King County Implements Certified EHR

CDC/ Debora Cartagena

According to the 2009 Status of Local Health Departments Informatics, over half (55%) of LHDs providing primary care and 39 percent of LHDs providing dentistry services use an electronic, or part electronic, health record. Given the increase in EHR use by LHDs and funding to help EHR users, LHDs are becoming more aware of the importance of electronic health records.

Let’s take a look at Public Health – Seattle & King County and their recent efforts of implementing a certified EHR:

Public Health – Seattle & King County is implementing a new federally certified electronic health record (EHR) integrated with a patient management system through OCHIN/Epic. The new EHR will serve 14 sites, including public health centers, STD/HIV and Tuberculosis clinics, field nursing services, and jail health services.

“Our EHR project is a huge step forward for Public Health’s efforts to advance improvements in individual and public health outcomes while increasing efficiencies,” said Ben Leifer, Chief Administrative Officer for Public Health – Seattle & King County.

Public Health will launch the new EHR system in its primary care clinics beginning in June 2013. The project is expected to be completed by 2015.

“We have been actively planning for the new system since 2009, and our thorough work to date has laid the groundwork for a successful implementation,” said Kristi Korolak, Project Manager.

“OCHIN/Epic will provide us with better tools, in real time, to assess our patients’ needs and improve how we deliver care,” said Dr. Charissa Fotinos, Chief Medical Officer for Public Health. “Further, it will enable better patient coordination with local and regional partners, while supporting broader population-based health promotion and disease control.”

For LHDs who want to learn more information about EHRs, check out these useful resources:

  • HIMSS highlight several tools that can be used to assist in the adoption and implementation of EHR: http://www.himss.org/ASP/topics_ehr.asp
  • The Agency for Healthcare Research and Quality (AHRQ) Knowledge Library includes an implementation checklist to help address potential barriers and challenges to EHR implementation: http://1.usa.gov/cSyYlB
  • The Public Health Data Standards Consortium (PHDSC) Electronic Health Record Public Health Task Force provides information on standards and EHRs: http://www.phdsc.org/health_info/ehr-task-force.asp
  • The Office of the National Coordinator (ONC) for Health Information Technology provides information on the certification programs for EHRs: http://1.usa.gov/bhanF3

For more information on the Public Health – Seattle & King County EHR project, please contact Kristi Koralak.

Many thanks to Kathryn Ross from Public Health – Seattle & King County for contributing to the blog post.

Getting ready for Stage 2 MU PH Reporting Requirements by the Meaningful Use Public Health Task Force

The Stage 2 Meaningful Use (MU) “Final Rules” published in the Federal Register on September 4, 2012, required local and state Public Health Agencies (PHAs) to ramp-up their MU capabilities and establish new processes to receive the relevant MU-compliant public health data from eligible providers, prior to the start of Stage 2 MU (10/01/2013 for EHs and 01/01/2014 for EPs). In Stage 2 MU, the capability to submit electronic data for immunizations is in the core or mandatory set for Eligible Professionals (EPs) and the capability to submit electronic data for immunizations, reportable laboratory results, and syndromic surveillance is in the core set for Eligible Hospitals (EHs). In addition, two new public health objectives for EPs have been added to the menu or options set – the capability to report cancer cases to a cancer registry and specific cases to a specialized registry (e.g., birth defects registries, chronic disease registries, traumatic injury registries). PHAs preparing for Stage 2 MU will require guidance to implement the new objectives and processes, such as:

  • Contributing their PHA’s MU capacity information to the proposed Centers for Medicare & Medicaid (CMS) centralized PHA capacity repository (declaration process),
  • Supporting providers (EPs and EHs) for registration of their intent to submit data for a MU objective,
  • On-boarding and accepting ongoing data submission from providers; and,
  • Providing an acknowledgement or a written communication (which may be in electronic format) from the PHA confirming a provider’s registration and achievement of ongoing submission.

The Centers for Disease Control & Prevention (CDC) has facilitated the establishment of the Stage 2 MU Public Health Reporting Requirements Task Force with representatives from the public health community; including: NACCHO, ASTHO, JPHIT, ISDS, CSTE, PHII, NAACCR, State PHAs, AIRA, ONC, CDC, and others. This task force is currently working to frame deliverables that will identify key concepts, task flows and guidance for PHAs to implement the Public Health objectives and associated new business processes required for Stage 2 MU. The task force has already provided recommendations and requirements to CMS for the establishment of the centralized PHA capacity repository which will provide EPs and EHs information on jurisdictional capacity to accept electronic data for Stage 2 MU public health objectives. The task force is developing guidance for PHAs to facilitate the registration of intent by providers, on-boarding and ongoing submission, and the ability to provide acknowledgements to providers. The task force is also developing guidance related to transport protocols for the electronic submission of meaningful use data to PHAs. The task force has created a specialized registry work group to provide guidance on how public health agencies can leverage the specialized registry meaningful use objective to obtain case information on mandated public health reporting information such as birth defects, traumatic injuries, hearing and vision and other public health surveillance information.

The consensus guidance and recommendations developed by this collaborative Public Health task force, currently scheduled to be available by April 2013, will be shared widely with state and local PHAs. PHAs across the nation will be able to adopt this guidance according to their jurisdictional needs to implement the new objectives and processes required for Stage 2 MU. For more information on this task force please visit http://www.phconnect.org/group/ph-reporting-task-force, and if interested in providing meaningful contributions to this work, please email meaningfuluse@cdc.gov