Tag Archives: Public Health

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.

The Search for Business Models for Public Health Participation in an HIE

Marcus Cheatham
Health Officer
Mid-Michigan District Health Department

Have you read the recently released report by the Trust for America’s Health “Healthier America 2013”? It is an excellent attempt to summarize the opportunities for public health to transform itself during the roll-out of the Affordable Care Act. Over and over again the urgent need for public health to work hand-in-hand with health care systems is highlighted in the report.

Public health departments must adapt to work with new entities and financing mechanisms in the reformed health system, such as by working with Accountable Care Organizations (ACOs) or within newly capitalized care structures and global health budgets, to help improve health beyond the doctor’s office.

A key component of this, obviously, will be the ability to exchange health information with other parts of the health care systems electronically. Let’s consider my health department’s Children’s Special Health Care Services (CSHCS) program as an example. This program coordinates care for children with qualifying medical conditions. Our health department has an electronic health record (EHR) system. We manage our CSHCS cases using the EHR which works quite well. We are completely paperless—well, almost. In managing these cases we collaborate with Medicaid Health Plans. Information going back and forth between us and the health plans still goes by old-fashioned, messy faxes.  Just this morning, I found two “lost” CSHCS faxes floating around in our copy room.  We would love to join a Health Information Exchange (HIE) so we would be able to exchange this information directly out of our EHR and ditch the faxes.

In fact, last week we met with one of the two big HIEs in our state to talk about doing just that. This HIE offers a sweet product for managing referrals which is exactly what the CSHCS program is looking for. Physicians’ offices in our area are starting to jump aboard the HIE, and even some of the Medicaid health plans are on their system.  We would love to go forward, but there is a snag: the cost.

Participating in the HIE would only cost a few thousand dollars. The problem is that our health department is looking at budget cuts next year of many tens of thousands of dollars. Our state pays for part of public health out of a health fund that is going to take a big hit this year; there is sequestration; and some of the counties in our district are warning that their general funds are still underwater. If joining the HIE allowed us to expand CSHCS, maybe we could use that additional revenue to join the HIE. But the CSHCS caseload is fixed. The way CSHCS is managed in our state, the Medicaid health plans gets first crack at the most lucrative billable services in CSHCS and we get what is left. We actually expect CSHCS revenue to fall, with or without the HIE.

Another complicating factor is that our health department is between two large medical trading areas, each with its own HIE. In order to provide CSHCS services electronically across our district, we would need to join two HIEs, at twice the cost. Most frustrating of all, the two HIEs only exchange information between themselves using a protocol called Direct, which is very limited.  It’s kind of like secure email. It would not permit the kind of exchange we really need to make CSHCS referrals efficiently.

Yet not joining the HIE at this point poses a risk, too. As more and more physicians join the HIE more of them will be making referrals electronically using the HIE’s product. If the health department does not appear in their system because we haven’t joined, referrals for things like women’s health, family planning and the various testing and screening services we offer will start going elsewhere. Now, I don’t think government should be competing with the private sector to deliver these services. My concern is that medically complicated or vulnerable people who should be seen at a health department may miss that opportunity. Our services need to be sustainable so that we can be here for those who need us.

That’s the challenge we are wrestling with now. We need to come up with a business model through which we partner with the health care system and generate the revenue we need to be part of our local HIEs. Fortunately we are in a community where our hospitals are interested in helping us make that happen. We have a meeting scheduled this month to begin exploring potential solutions

*Note blog submission reflects dates in 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).

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.

Integrating Technology into the WIC Experience – ‘Anna’ the Avatar by Dr. Phred Pilkington

Anna the AvatarBy Dr. Phred Pilkington Chief Executive Officer & Director of Public Health Cabarrus Health Alliance

With funding through the Beacon Community Program, Cabarrus Health Alliance and the North Carolina Institute for Public Health (NCIPH) collaborated to adapt a Virtual Character or avatar to the Women, Infants and Children (WIC) environment. The avatar, ‘Anna,’ leverages Embodied Conversational Agent (ECA) technology from Engineered Care. ‘Anna’ was designed to introduce WIC to new participants.

The first module of the avatar is an overview of the WIC Program which teaches participants how to effectively use their benefits. ‘Anna’ is a pregnant WIC participant excited to share with her peers. She uses teach-back questions and answers to ensure user comprehension.

An additional component of the first phase of the project was to assess satisfaction with and effectiveness of the avatar technology in the WIC programs. The Southern Piedmont Beacon Community includes the counties of Cabarrus, Stanly, and Rowan and each of their local WIC Departments. This cross-section of counties allows us to study the effectiveness in rural, rural-urban, and urban health departments. The study assessed the resources and time required to implement a digital health education solution. Touch-screen tablets were provided to two WIC Programs and small computer systems were provided to the third. Paper surveys were provided to WIC clients following the interaction to assess client satisfaction, knowledge and confidence.

At this time, the evaluation is still in process; however, preliminary findings suggest that WIC participants find the ‘Anna’ experience to be an engaging one. Anecdotally, participants offered that “This was better than face-to-face cause I have a tendency to zone out when someone talks to me” and “I liked her.” In addition, ‘Anna’ appears to be an effective learning option with participants noting that “Anna is …better than a DVD” and “this was better than someone talking to you.”

Effectively this project is a pilot intended to collect some preliminary findings about the efficacy of a computer avatar as a health educator. Assuming positive results with WIC clients, we plan to expand the role of ‘Anna’ to include health education in other public health clinical services and for community-based interventions.

For a five minute demo of ‘Anna,’ please click here [wmv file].

Social Media Supporting a Public Health Emergency by the Boston Public Health Commission

Written by:

  • Anita Barry, MD, MPH, Director, Infectious Disease Bureau at Boston Public Health Commission
  • Craig Regis, MPH, Project Manager, Infectious Disease Bureau at Boston Public Health Commission

FLU_TwitterEffective and timely communication with the public has always been a critical function of local public health departments.  Whether it be alerting citizens to recent health events or distributing informative materials on disease prevention, risk communication requires public health practitioners to be on the forefront of the communication revolution.

Since the advent of the Internet, social media has revolutionized the way the public obtains information.  Though certain populations still rely heavily on traditional media such as television, radio, and print, the technological advances have caused new information services to emerge.  Social networking services such as Twitter and Facebook are widely used throughout the world, and more and more people are relying on them as their primary source for information.  Smartphones are providing immediate, on-demand access to social networking services.  As smartphone usage is higher among Black and Hispanic mobile phone users, social media also presents an opportunity to reach some vulnerable populations.1  In this new era of instant, crowd-sourced, mass communication, public health departments are using these new tools to quickly and effectively disseminate important information, especially in urgent situations where time is of the essence.

The Boston Public Health Commission (BPHC) was faced with such a situation in early 2013.  By early January, Boston had seen over ten times as many reported influenza cases than in all of the 2011-12 season.  The number of people going to emergency rooms and other healthcare sites for influenza like illness also markedly exceeded the prior season, creating a large burden on the healthcare system in the city, particularly the hospitals.  The Mayor of Boston declared a public health emergency on Wednesday, January 9, 2013, in order to raise awareness and to mobilize the city’s resources, including encouraging health centers to hold free influenza vaccination clinics that following weekend (January 12-13, 2013).

BPHC was faced with the task of not only keeping an anxious public informed about best practices for influenza care and prevention, but also constantly assembling and circulating a rapidly changing schedule of free influenza vaccination clinics at neighborhood health centers in response to the emergency.  No sooner was the interactive “flu calendar” updated than newly scheduled clinics required additional postings to BPHC’s public website.  The dynamic, real-time nature of social media platforms made them the best method to keep the public adequately informed about a constantly evolving situation.

BPHC’s communication infrastructure includes Twitter with tweets in both English and Spanish, Facebook, YouTube, and a blog.  BPHC’s twitter handle, @HealthyBoston, constantly tweeted updates, linked to factsheets, directed the public to the online calendar for vaccination clinics, and encouraged residents to be vaccinated.  The campaign extended to BPHC’s Facebook page, which also provided a direct link to the clinic calendar.  These platforms allowed for the swift response required during a public health crisis, and facilitated a surge in visitors to the BPHC website.  The influenza section received over 20,000 hits in less than two weeks during the emergency.  Over 80% of these hits were from new visitors, and over 16,000 were to check the clinic calendar.  The response also resulted in an increase in Twitter followers.  In weeks leading up to the flu emergency, @HealthyBoston averaged about 60 new followers per week, but gained over 600 new followers over the next month.

Social media played a pivotal role in keeping the public up to date about an ever-evolving situation with timely and accurate information.  Currently, @HealthyBoston has nearly 11,000 Twitter followers, and over 3,000 Facebook “likes.”  Recognizing the potential of social media to reach a younger audience, the BPHC Communications team launched a youth-oriented twitter handle last month called @WhatheHealth.  Though it takes a dedicated staff and time to build momentum, utilizing social media in public health communications is worth the investment.  It has the potential to increase the presence of an organization, broaden its audience, and revolutionize public health campaigns.

1Kellogg, Don. “Among Mobile Phone Users, Hispanics, Asians Are Most-Likely Smartphone Owners in the U.S.” Nielsenwire.com. N.p., 1 Feb. 2011. Web. 25 Feb. 2013.

http://blog.nielsen.com/nielsenwire/consumer/among-mobile-phone-users-hispanics-asians-are-most-likely-smartphone-owners-in-the-u-s/

Follow BPHC on Twitter @HealthyBoston and Facebook

Insights from Kansas Information Management and Exchange Workshop

Recently Vanessa Holley and I were asked to facilitate a workshop with local health departments (LHDs) in Kansas.  We were slated to discuss how to help LHDs make two decisions:

  • Do they need an electronic health record (EHR) system?
  • If/how should they connect to the health information exchange (HIE)?

Through the course of the discussions, it quickly became apparent that the decisions to have an EHR or connect to the HIE were only part of the story and in some ways were over emphasized because they are easier to conceptualize.  But the discussions began to broaden and clarify some of the issues.  As it turns out, I think we actually stumbled upon a pretty good road map for ePublic Health.

Let’s look closer at what I mean.

Before you can effectively take advantage of any technology or HIE option:

  • Step 1: develop the future vision for your LHD and clarify both what value and what services you plan to offer your community.  You first need to determine what services your LHD will be focused on in the new world of healthcare.  This is critical because if, for example, your health department is not going to continue to heavily invest in clinical services, then considering a practice management or EHR system may not be a good investment – despite current needs.  On the other hand if you plan to increase your case management and care coordination role in the community, you’ll want to be sure whatever system you purchase or build takes into account those requirements in order to best support your work.
  • Step 2: is to create or update your statewide collaborative Health Information Management Plan and planning body with a wide representation from LHD, state, and program personnel.  Even if this already exists, ensure that representatives are both well informed and doing a complete job of communicating out decisions that are made.  To begin this step you have to begin to coordinate at a heightened level with your state and neighboring LHDs.  In Kansas, they have had a great relationship with their state and a very active LHD association.  However, they still realized that they could benefit by making a more formal body that is charged with coordinating and collaboratively developing the Health Information Management Plan for public health.  This is different from the statewide HIT plan because it is much more than information technology and is solely focused on creating one public health voice for health departments throughout the state.  This is so critical because your partners need to hear a coordinated and unified voice for public health.  Also, most of the Meaningful Use solutions are designed and managed at the state level.  Therefore it is imperative that LHDs are collaborating with the state to understand how their information needs will be met and how these solutions will interact with their local systems.  There has been so much to keep up with in the fast pace of Meaningful Use that many states have not yet formalized this body and its charge.  However states that have recently created such a coordinating body, like Ohio, report huge successes in making decisions and dealing with unforeseen issues related to the changing world of ePublic Health (See CDC Charter Lite Template).
  • Step 3:  gain a clearer appreciation for your LHDs capabilities, needs, and desires. This can often involve an assessment of the systems you have, the needs that are met and the gaps that exist.  It might even be good for the aforementioned Health Information Planning group to survey LHDs and display results.  This will help LHDs identify peers they can work with and peers who can offer peer assistance or advice about vendors.  It is important that this not be done from a standpoint of competition or condemnation, but rather of bettering each health department.
  • Step 4: delineate the benefits of practice management and EHR systems. Though clinical operations and responsibilities for LHDs can vary wildly, most LHDs have some sort of specialty clinics that they run (examples include STD/HIV, TB, Maternal and Child Health, etc).  And though the state is often preparing systems to meet Meaningful Use requirements, LHDs must come up with their own solutions for meeting the demands of these clinics.  Complicating matters, LHDs often have cross over between local clinic information needs and programmatic reporting to state or federal partners.  In our discussions in KS, we discovered that even with smaller programmatic clinics there are good reasons to deploy one or both of these types of systems.  Especially since costs have decreased dramatically in the past 5 years.  Benefits include more efficient programmatic reporting, increasing overall clinic efficiency resulting in a higher volume of visits, increased recovery of costs and billing, decreased need for record space, etc.  Once you have determined that the benefits offered by these systems fit within your LHD vision, conduct a review of specific systems based on your unique requirements, and understand the costs and benefits you can expect, then you can make an informed decision as to which system you should deploy (see NACCHO’s All-Systems-Go tool).
  • Step 5:  know your requirements for exchange and assess/pursue your local HIE options to support those requirements. For this final step, our discussions in KS turned to the HIE options that exist in their state.  Since they have been a leader in Health Information Exchange and LHDs have been heavily involved, they have a couple of really nice options.  In their state, LHDs can get basic HIE services for free, which include direct secure messaging and access to a provider web portal.  And KS LHDs are finding really interesting ways to use these services – like using the web portal for case investigations and sending follow-up testing requests and outbreak summary reports to physicians using direct secure messaging.  The state health department is working to connect their reporting systems to LHDs through the HIE, but work remains to make local and state systems interoperate in this fashion.  It also came to light that there were other exchange requirements that the LHD had that aren’t a part of their “free” set of services, but have enough value that they will want to understand the costs/benefits and pursue those options.  For example, local clinic managers would like to perform clinical assessments on their clients and provide test results and other clinical notes to the referred provider or receive visit summary documents when the referred visit is complete.  Though there is still much work to do, what was clear was that in the not so distant future one could imagine LHDs in KS having an efficient and interoperable connection to the state and other community based systems through their HIE.  In order to have this sort of success, it is critical that your LHD get involved, stay involved, or increase involvement locally with your HIE options.  Be aware of what services your HIEs provide, how these services can benefit your LHDs vision for the future, and see if you can negotiate special rates for LHDs.

If LHDs earnestly and systematically pursue these five steps, I believe they will have a thriving and successful transition into becoming an efficient LHD of the ePublic Health future.  At NACCHO, we’re working with our ePublic Health workgroup to develop more detailed tools that will support LHDs who go through each of these steps – so stay tuned.  I want to give a special thanks to the Kansas Health Foundation, Kansas Association of Local Health Departments, and Kansas Department of Health and Environment for allowing me into their rapidly developing world of ePublic Health.