An informatics framework for public health information systems: … · 2017-08-29 · Keywords Public health informatics Information systems Public health emergency preparedness and

ORIGINAL ARTICLE

An informatics framework for public healthinformation systems: a case studyon how an informatics structure for integratedinformation systems provides benefit in supportinga statewide response to a public health emergency

Ivan J. Gotham • Linh H. Le • Debra L. Sottolano •

Kathryn J. SchmitReceived: 17 April 2013 / Revised: 8 October 2013 / Accepted: 23 January 2014 /

Published online: 8 February 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract This chapter illustrates how a well-established public health informatics

framework provides an integrated information system infrastructure that assures and

enhances the efficacy of public health emergency preparedness (PHEP) actions

throughout the phases of the health emergency event life cycle. Key PHEP activities

involved in supporting this cycle include planning; surveillance; alerting; resource

assessment and management; data-driven decision support; and intervention for

prevention and control of disease or injury in populations. Information systems

supporting these activities are most effective in assuring optimal response to an

emergent health event when they are integrated within an informatics framework

that supports routine (day to day) information exchange within the health infor-

mation exchange community. In late April 2009, New York State (NYS) initiated a

statewide PHEP response to the emergence of Novel Influenza A (H1N1), culmi-

nating in a statewide vaccination campaign during the last quarter of 2009. The

I. J. Gotham (&)

School of Public Health, Department of Health Policy Management University at Albany,

State University of New York , 1 University Place, Rensselaer, NY 12144, USA

e-mail: [email protected]

L. H. Le � K. J. Schmit

New York State Department of Health, Office of Information Technology Service,

Empire State Plaza, Room 148, Albany, NY 12237, USA


K. J. Schmit


L. H. Le

Department of Nursing, Sage College, Albany, NY 12180, USA

D. L. Sottolano

Center for Health Care Quality & Surveillance, New York State Department of Health,

875 Central Avenue, Albany, NY 12206, USA


123

Inf Syst E-Bus Manage (2015) 13:713–749

DOI 10.1007/s10257-014-0240-9

http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-0240-9&domain=pdf

http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-0240-9&domain=pdf

established informatics framework of integrated information systems within NYS

conveyed significant advantages and flexibility in supporting the range of PHEP

activities required for an effective response to this health event. This chapter

describes, and provides, performance metrics to illustrate how a public health

informatics framework can enhance the efficacy of all phases of a public health

emergency response. It also provides informatics lessons learned from the event.

Keywords Public health informatics � Information systems �Public health emergency preparedness and response

1 Introduction

1.1 Public health informatics and information systems

While there are many definitions of ‘‘Information System’’ in the literature, one

could distill the authors’ thoughts into the following description:

An Information System is the arrangement of data, processes, people, and

information technology that interact to collect, store and communicate

information as needed to facilitate planning, control, coordination and

decision making for a subject matter domain across an enterprise. (See

Businessdictionary 2013; Whatis.techtarget 2013; Whitten and Bentley 2007)

The practice of informatics is essential to assuring that information systems are

successful and provide value (e.g. see Massoudi et al. 2012; Chen et al. 2007). At

the most abstract level, Public Health Informatics (PHI) is defined as ‘‘the

systematic application of information and computer science and technology to

public health practice, research, and learning’’ (O’Carroll et al. 2003). The ultimate

goals of PHI, then, are to:

• assure development and governance of information systems that can be

effectively used within the health enterprise to support routine (day to day)

information exchange

• assure that those information systems provide value to both Public Health

practitioners and their information trading partners (e.g. see Massoudi et al.

2012).

PHI is therefore focused on implementing information systems which support public

health activities that are integrated with, and supportive of, the programmatic goals

of prevention and control of disease and injury in populations (see Yasnoff et al.

2000; O’Carroll et al. 2003; Lombardo and Buckeridge 2007). To be successful and

provide value, public health related information systems must exist within an

operational informatics framework that embodies Health as an enterprise and

supports the broader community of health information exchange (e.g. see O’Carroll

et al. 2003; Kukafka and Yasnoff 2007; Gotham et al. 2010; Massoudi et al. 2012).

Figure 1 depicts a paradigm for such a public health informatics framework and,

as described below, public health emergency preparedness (PHEP) provides an ideal

714 I. J. Gotham et al.

123

use case and means to evaluate its value proposition. The framework, while

supported by technology, has as its focal point the health information exchange

community sustained by value-added information trading synergies (Fig. 1). This

information exchange community embodies the subject domains, organizations and

jurisdictions of health as an enterprise. The synergy, or value proposition, occurs

when information providers and recipients within that community each derive

benefit through bi-directional ‘trading’, or exchange, of health information. It is this

focus that drives the implementation of integrated information systems governed by

the information needs, business rules, policies, regulations, and data-sharing

agreements of the health enterprise.

Implementation of information systems is actualized by a governance process

and based on measurable value and benefit as defined by the enterprise (Fig. 1).

This process informs an agile informatics environment that is able to respond

rapidly to both planned and emergent health information system needs. This

environment is led by informaticians and health domain subject matter experts and

supported by a team of technical experts, rapid development tools, reusable services

and data (Fig. 1).

Within the context of a public health informatics framework, these information

systems support public health activities such as disease surveillance (see Chen et al.

2010; Lombardo and Buckeridge 2007) and outbreak management, laboratory

reporting, health alerting, health care quality assurance, health care resource

availability and capacity assessment, registry reporting and situational awareness. A

model for assessing the value proposition of public health information systems has

been developed by the Public Health Informatics Institute (PHII 2005). A detailed

business process and benefit analysis for interoperable immunization registry data

exchange within a health information exchange community has also been described

by Grannis, Dixon and Brand (2010). The Joint Public Health Informatics Taskforce

has proposed a ‘‘consensus framework’’ to guide collaborations across the public

health enterprise (JPHIT 2011).

The information systems within our model framework are in turn supported by

enabling services (Fig. 1) that assure an arrangement and interaction of data,

processes, people, and technology that effectively collects, stores and communicates

heath information. These enabling services provide foundational support for:

business rules and processes; effective use of information systems; derivation of

information from data; reusable core functions and processes that support multiple

information systems; as well as standardization and interoperability of data and

information.

Services supporting business rules and processes would include provision of user

account privileges and data access control management that assures confidentiality

of data while at the same time providing seamless and appropriate access to data

across information systems based on user role and need to know. Services

underwriting effective use of information and underlying systems include project

management, user training/support, common user interface and single sign-on

across all information systems. Services supporting derivation of information from

data include data analytics and visualization capabilities such as GIS, dashboards,

integrated data reporting and query services, modeling and statistical analysis

An informatics framework for public health information systems 715

123

packages. Services supporting standardization and interoperability of data and

information include those standards that assure technical, semantic and process

interoperability of health information exchange (see Benson 2012; IHE 2013).

Core functions and processes assure integration across information systems and

sustainability through reuse of common services by those systems. Examples

include:

• A common data layer service that assures all information systems have the same

integrated view of health data and use the same authoritative version of the

‘truth’.

• Common Directory services. These services include: a communications

directory service that provides role and contact information for organizations,

health providers and users; and a provider and health facility directory service

which provides attribute information on health facilities (e.g. geo-location,

staffed beds by specialty, isolation rooms, fixed equipment assets) and providers

(e.g. certifications, practice status, populations served). Both services provide a

common source of information to systems and users that is consistent, reliable

and up to date.

• Common messaging, alerting and notification services that allow the system and

its processes and users to transmit and confirm notifications to organizations,

Fig. 1 Model Public Health Informatics Framework


123

users or other processes by multiple interoperable communication venues (e.g.

voice, text, e-mail, XML).

• Common visualization and analysis services that allow users a single interface to

information for a common operational picture of health information or health

event status. The services allow information system processes to automate

updating of those common operational pictures.

• A common permissions and access control interface provides the authoritative

source for information systems to support workflow processes and access rights

by user role.

The technical infrastructure layer of this framework assures that information

systems and supportive enabling services are interoperable, based on a Service

Oriented Architecture (SOA), secure, resilient and recoverable from disasters,

highly available and able to accommodate surge in usage.

1.2 Benefit of an informatics framework and information systems to public

health emergency preparedness

The US Federal Emergency Management Agency (FEMA 2011) has established a

National Preparedness Goal (or NPG) for preventing and responding to natural

disasters and terrorist attacks. The five components of the NPG include: Prevention,

Protection, Mitigation, Response, and Recovery. These components are cyclic in

nature, with lessons learned from response and recovery actions from previous

emergency events feeding into improving the first three components. The first three

components deal with actions to be taken in advance as preparation for the potential

events through planning, drills/exercises, risk mitigation, infrastructure develop-

ment and protection. In our discussion we will consolidate these three components

into a single category: Preparedness.

Thus public health emergency preparedness (PHEP) is the capability of public

health and healthcare systems, communities, and individuals to prevent, protect

against, mitigate, quickly respond to, and recover from health emergencies,

particularly those whose scale, timing, or unpredictability threatens to overwhelm

routine capabilities. It is a state of sustainable ‘‘readiness to act,’’ for all sectors and

stakeholders, that is achieved over time as part of the essential public health

activities that health departments practice daily (see Gotham et al. 2010).

This key point is an essential component of our model informatics framework

(Fig. 1). PHEP activities/functions, if instantiated within such an extensible or ‘dual

use’ framework, can be a value proposition of information systems that are in daily

use for routine health information exchange by various health organizations,

including Public Health. Indeed, as shown in preparedness drills and exercises

(Gotham et al. 2007, 2010) and actual health events (Gotham et al. 2001, 2007,

2008), the efficacy of information systems supporting PHEP is optimized when

embedded within an established informatics framework supporting a broad-based

community of health information trading partners engaged in routine (day to day)

information exchange activities (Gotham et al. 2001, 2007, 2008, 2010).


123

National Frameworks and Emergency Support Functions (ESF) evolved as an

outcome of the NPG (see FEMA 2013). These define an extensive list of core

capabilities and functions required to support the activities involved in prepared-

ness, response and recovery. Among these are operational coordination and

communication, threat and risk assessment, active and passive surveillance,

detection, intelligence and information sharing, situational awareness and decision

support, intervention campaigns, public information, resource assessment for

response and recovery. These functions are singularly dependent on bi-directional

exchange of information among response partners that is authoritative, timely,

accurate, trusted, appropriate and up to date.

Effective information systems by our very definition are absolutely critical in

assuring the efficacy of these activities and functions. Thus effective public health

emergency preparedness requires rapid and agile leverage of integrated information

systems that are readily adoptable in supporting novel emergent situations as well as

core public health activities, such as planning and policy; surveillance; alerting;

health resource assessment and management; situational awareness, data-driven

decision support; and implementation, coordination and management of public

health response and recovery interventions. Thus we can see that our definition of

information system and our informatics framework are well suited to encompassing

the needs of emergency preparedness.

In late April 2009, NY State (NYS) initiated a statewide PHEP response to an

international health emergency: the emergence of Novel Influenza A (H1N1). The

NYS response culminated in a statewide vaccination campaign during last quarter of

2009. The established informatics framework of integrated information systems

within NYS conveyed significant advantages and provided a single point of input

and dissemination of critical information that supported the range of PHEP activities

required for an effective response to this health event. This chapter describes, and

provides, performance metrics that illustrate how a public health informatics

framework and its information systems can enhance the efficacy of all phases of a

Public Health emergency response. The chapter also provides Informatics lessons

learned from the event.

2 A well established informatics framework and dual-use information systeminfrastructure plays an important role in preparedness for an emergencyevent

2.1 Established infrastructure needs to be in place prior to an event

An element that is essential to the value proposition of our informatics framework

paradigm (Fig. 1) is the ‘dual use’ nature of information systems. That is, systems

that are familiar and in daily use by response partners for routine health information

exchange are best suited for, and constitute a key aspect of the ‘‘preparedness’’

phases (prevent, protect, mitigate) that are necessary for effective response and

recovery of an emergency event.


123

The NYSDOH informatics framework and its infrastructure have evolved over

the past 17 years to support the state department of health’s strategic approach to

information exchange within the community of its health information trading

partners. The infrastructure, or Health Commerce System (HCS), is a closed, web-

enabled portal, supporting secure information exchange activities with all regulated

health entities in NY State (Gotham et al. 2001, 2007, 2008, 2010); see Table 1. The

flow of data and information within the HCS architecture and its foundation

informatics framework (Fig. 1) are shown in Fig. 2

The information systems within the HCS support all health-related, day-to-day

information exchange activities, from vital records and health care quality assurance

and finance to disease registry and condition reporting, statewide communicable

disease and laboratory reporting, arbovirus surveillance, child health insurance

reporting, managed care, even prescription pad orders. Given this mission, the HCS

architecture is multi-tiered, highly available, and with full off-site disaster recovery

capabilities. That architecture, therefore, is a platform well suited for responding to

public health emergencies, given its architecture and routine use by partner

organizations who would be involved in the response. Thus, based on our paradigm

(Fig. 1), an array of information systems has been implemented within the HCS to

support both PHEP and routine core public health activities.

The PHEP functions and the HCS information systems used to support them are

listed in Table 2 and their data flow within the HCS system is shown in Fig. 2.

These systems support both routine and PHEP activities for health alerting;

electronic laboratory and disease reporting; syndromic surveillance; targeted health

facility patient surveillance; monitoring of health facility status [e.g., Emergency

Department (ED) traffic]; health facility resource inventories and antiviral inventory

tracking; general situational awareness; executive decision support; school-based

surveillance and medical countermeasure administration (Table 2).

Of particular note is the Health Emergency Response Data System, HERDS, an

information system that supports dynamic, real-time deployment of ongoing

surveillance reporting and ad hoc surveys (see Gotham et al. 2007, 2010; Table 2).

HERDS is used for routine electronic reporting and surveys as well as for

information exchange during emergency events. State, regional, and local health

offices all have access to HERDS data as soon as it is reported by health facilities.

Statewide data is typically available and integrated into decision support systems

within 24 h of deployment of a HERDS survey (Table 2).

2.2 Routine, ongoing use of information systems leads to an advance

preparedness advantage

The HCS PHEP information systems relevant to PHEP had been in use for years

prior to the H1N1 Pandemic event and already had been used to support statewide

responses to emergent infectious disease events, emergency disaster declarations,

health resource shortages, elevated national threat levels and high-profile national

security events (Gotham et al. 2001, 2007, 2008, 2010).

The HERDS system had been used to monitor statewide hospital bed availability

and ED patient traffic reporting since June 2003, and provides statewide, facility-


123

specific surveillance on bed availability by specialty type (e.g., adult and pediatric

medical/surgical, ICU, burn). The system has been used to monitor ED patient

registrations, and had also been used to compile and maintain an ongoing statewide

inventory of hospital assets since August 2004. The critical asset survey, deployed

via HERDS, is an exhaustive inventory of current staffed and surge capacity of beds

by specialty; special treatment capacities (e.g., trauma and burn center, hyperbaric,

decontamination); transportation capacities; durable and fixed equipment (e.g., adult

and pediatric ventilators, cardiac monitors); airborne infection isolation room

capacity; staff capacities by specialty; communication and generator capacities.

Reporting of laboratory-confirmed influenza cases, by age group, among hospital

patients, has also been maintained on HERDS since December 2004. Along with

HCS dashboard analytics on the HCS (Table 2), HERDS was instrumental in

supporting the NY State response to the national influenza vaccine shortage in 2004

(Gotham et al. 2008).

Prior to the emergence of the H1N1 event, use of HERDS had been expanded to

support routine surveillance and resource reporting by all Local Health Departments

(LHDs), nursing homes, adult and home care entities, and schools statewide.

Nursing home reporting of bed availability, critical assets, and vaccination rates for

Table 1 NYS health commerce system (HCS) demographics and usage as of July, 2009

Organization or user group Number Users

H1N1 vaccine providers 6,113 5,955

Clinical or environmental labs (Labs) 1,481 3,388

Clinics and treatment centers (Clinics) 1,498 7,369

Home and adult care facilities (adult care) 1,701 15,785

Hospitals 230

Local health departments (LHDs) 58 6,823

Medical professionals – 43,984

NYSDOH central health office 1 4,428

NYSDOH regional health offices 4 1,107

Nursing homes 663 12,287

School districts 1,311 4,259

Pharmacies 2,259 3,388

Other organizations 1,902 10,107

Usage statistics

250 applications

14,500 user logins per day

800,000 access hits per day

30 Gbytes in transactions per day

LHDs include NY City Department of Health and Mental Hygiene

Other organizations include schools, fire and EMS, federal and state agencies, tribal nations, managed

care organizations, etc. Organization counts are by physical facility. Medical Professionals include MDs

and practices, dentists, veterinarians, physician assistants, nurse practitioners


123

influenza and pneumococcal infection and other health care surveillance is captured

in HERDS, as are reports, by all types of schools, of vaccination rates and other

public health concerns. Given the established history of the framework, information

systems and the technical infrastructure, the HCS infrastructure had become an

integral component of NYS Health Department incident management processes as

well as of NY State’s all-hazards and pandemic influenza plans (see Gotham et al.

2007, 2010).

Emergency response plans and their underlying components must be tested

periodically to assess their efficacy and revised according to lessons learned. Thus

HCS and its information systems had been used as integral functions in both routine

drills and full-scale exercises (Gotham et al. 2007). In spring of 2006, NY State

Department of Health (NYSDOH) conducted a full-scale exercise simulating the

emergence of a novel influenza strain in the western region of the state (Gotham

et al. 2010). The scenario was entirely data driven, lasted a month in duration, and,

as part of NY’s pandemic influenza plan, leveraged its existing informatics

infrastructure to support the ongoing ‘‘response.’’ The information systems used by

the exercise participants to respond to the scenario included health alerting,

epidemiological surveillance, health care resource and medical countermeasure

management, and data-driven decision support through integrated dashboard

visualization. Situational awareness was provided to all of the organizational

Fig. 2 Health Commerce System (HCS) Technical Information Architecture


123

Table

2Pre-H

1N1HealthEmergency

Preparedness(PHEP)FunctionsandInform

ationSystem

susedontheNYStateHealthCommerce

System

(HCS)to

SupportThem

Generic

publichealthem

ergency

preparednessfunction

ActivitiessupportingNYSPHEPpreparedness,

response

andrecovery

Statewideinform

ationsystem

onHCSsupportingPHEPactivities

‘Health’Facilitysurveillance,

dynam

icresourcereportingand

response

Dynam

icDatareportingfrom

hospitals,nursing

homes,adultcare

facilities

andschools

for

surveillance

andem

ergency

response

Healthem

ergency

response

data

system

(HERDS—

hospital,nursinghome

andadultcare

facility

instances)

Dynam

ic,multitaskingsystem

supportinglivedatafeedsforelectronic

surveillance,surveys,resourceandassettracking,surge,

bed

availability,

patienttracking.andem

ergency

response

inhospitals

HERDS(schoolinstance)

Dynam


supportinglivedatafeedsforstate-wide

electronic

reportingofdatafrom

both

publicandprivateschools

Emergency

Department(ED)Surveillance

System

(EDSURV)

Automated

reportingofchiefcomplaintdataforem

ergency

departm

ent

admissionsforsyndromic

surveillance

NosocomialOutbreakReportingApplication(NORA)

Reporting,follow-upandcloseoutofnosocomially-acquired

infectionsfor

individual

casesoroutbreaksofcommunicable

diseaseswithin

the

hospital

andnursinghomesettings

Disease

reportingand

epidem

iological

surveillance

Reportingofcommunicable

disease

cases

communicable

disease

electronic

surveillance

system

(CDESS)

Statewidesystem

forreportingofdisease

casesforstatemandated

disease

conditionsbylocalhealthdepartm

ents

(LHD)s;includes

contact

tracing

andintegrationwithElectronic

Laboratory

Reporting

HERDS(county

instance)

Dynam


supportinglivedatafeedsforsurveillance

andsurvey

distributionandreturn

forLHDs

AlertingandCommunication

Provides

general

andtargeted

healthalertingand

notificationusingautomated

phone,

cell,fax,

e-mailandsecure

web

postings

CommunicationsDirectory

(ComDir)

Central

directory

ofrole

andcontact

inform

ationforallHCSparticipants;

maintained

bycoordinators

atparticipantHCSorganizations

Integratedhealthalertingandnotificationsystem

(IHANS)

Provides

healthalertingandnotificationusingautomated

phone,

cell,fax,

e-mail,andweb

postings;

integratedwithComDir


123

Table

2continued

Generic

publichealthem

ergency

preparednessfunction

ActivitiessupportingNYSPHEPpreparedness,

response

andrecovery

Statewideinform

ationsystem

onHCSsupportingPHEPactivities

Laboratory

reporting

Electronic

reportingofclinical

test

resultsfrom

clinical,publicandnational

commercial

labs

Electronic

clinicallaboratory

reportingsystem

(ECLRS)

Supportsautomated

andmanual

electronic

reportingofpositivetestresults

forreportable

disease

conditionsto

CDESS,includinginfluenza

Decisionsupport,datavisualization

andsituational

awareness,incident

managem

entandoperational

support

Providedecisionsupport,situational

awareness

andacommonoperationalpicture

forexecutive

decisionmakersat

local,regional

andstate

levels

Providerich

andinteractivevisualizationof

event-relateddatafrom

across

datasources

toallprogramsandorganizationsinvolved

inthe

response

effort

Providegeneral

situational

awarenessto

the

communityofHCSorganizations

Executive

dashboard

anddata

visualizer

Access-controlled

system

providinghigh-level

situational

awarenessto

key

decisionmaker

rolesacross

response

partner

organizations;integratesand

summarizes

multiple

datastream

s(H

ERDS,CDESS)into

graphical

displays

Event-specificwebsite

Aweb

site

within

theHCSprovidinginform

ationpostingsandupdates

toentire

HCScommunityduringan

event

Secure

file

view

er

Supportssecure

‘push’ofstatic

contentto

targeted

rolesandorganizations

VirtualHealthOperationsCenter(VHOC)

Access-controlled

system

usedto

supportplanning,incidentmanagem

ent

process

anddiscussionforumsbetweenorganizationsandincident

commandinvolved

intheevent

Medical

countermeasure

response

administrationandinventory

Reportingandmanagem

entofpatientdataand

medical

countermeasuresandinfluenza

vaccinations

Clinic

data

managem

entsystem

(CDMS)

Dynam

ic,form

s-based

system

forreportingandmanagem

entofanymedical

counterm

easure

orprophylacticadministeredfrom

county

clinicsorPoints

ofDistribution(PODs).Alsousedin

annual

LHD-based

seasonal

influenza

clinics

NYState

Immunizationinform

ationsystem

(NYSIIS)

Immunizationregistry,supportingmandated

reportingofvaccinationsby

medical

professionalsto

childrenages

under

19)


123

entities that might directly participate in the response or contribute resources to

facilitate the response. Exercise participants included multiple state agencies, state

and local health departments, and health care facilities.

The exercise provided the opportunity to measure the response rates and

utilization metrics for the information systems supporting PHEP activities. It

demonstrated that the presence of an established, integrated informatics framework

for health information exchange conveys significant advantages in advancing

preparedness in terms of rapid and accurate execution of requested actions and

responses within a simulated emergency event (Gotham et al. 2010). Lessons

learned from the exercise were used to improve the information system’s

capabilities for response to emergent events. The exercises and drills were of

fortuitous benefit: in early spring 2009, nearly 3 years to the day of the 2006

exercise, NYS activated its Incident Management System (IMS) in response to the

emergence of Novel Influenza A (H1N1) within the state. All of the HCS PHEP-

related information systems and informatics infrastructure was called upon to

respond to the event.

3 Background and history of events surrounding NY state response to a publichealth emergency: Novel Influenza A (H1N1)

In mid-March, 2009, the Mexican government identified 3 separate events of

increased influenza-like illness (ILI) and pneumonia along with rising death tolls

that caused it to close schools, cancel public events, and isolate ill individuals at

places of work (WHO 2009). On April 24, 2009, NYSDOH activated its Incident

Management System (IMS) in collaboration with NY City Department of Health

and Mental Hygiene as a preparatory measure in anticipation of positive test results

for what was then called Swine Origin Influenza A (H1N1) among a cluster of

respiratory illnesses within a student cohort at a NY City school (US CDC 2009a).

On Saturday, April 25, NYSDOH initiated a health alerting process, providing

initial guidance to local health and health care entities in NY. By April 26 several of

the NY City specimens had tested positive (US CDC 2009a) and by April 28, 2009,

there were 45 confirmed cases in NY (US CDC 2009b), NYSDOH IMS was in full

response mode, and all PHEP information systems were actively engaged in

supporting the response.

The rapidly advancing geographic spread of the Novel Influenza strain led the US

Government to declare the situation a public health emergency on April 26 (US

CDC 2010a). On June 11, the World Health Organization (WHO) raised the

pandemic alert level to Phase 6, signaling that a global pandemic was under way

(US CDC 2010a). As of June 11, NYSDOH’s website reported over a thousand

confirmed cases of H1N1 distributed across 40 NY counties and NY City. By late

June 2009, the disease was becoming better understood (CDC 2009c, 2010a) and

early estimates by the CDC put the total US cases at between 1.8 and 5.7 million by

late July (Reed et al. 2009). Atypically, the H1N1 influenza activity peaked in late

spring, decreased in midsummer, and increased again in fourth quarter 2009 (see

CDC 2010b). The picture was complicated by the fact that (the usual) ‘‘seasonal’’


123

influenza activity remained high throughout the summer and displayed the same

multimodal pattern of activity (see CDC 2010b). The experience reinforced the

importance of information systems and procedures for timely communication, data

collection and analysis to support science-based public health decisions in

responding to this event.

Absent a vaccine for H1N1 when the national public health emergency was

declared, the Centers for Disease Control (CDC) Strategic National Stockpile (SNS)

program began releasing inventories of antiviral medications and respiratory and

personal protective equipment to the States, including NY (US CDC 2010a). These

assets, in combination with NY State’s medical reserve cache, were forward-

deployed to supplement potential shortages in medications and infection control. In

June 2009, plans were under way to implement a national H1N1 vaccination

campaign to control the anticipated re-emergence of the disease in fall of 2009 (see

CDC 2010a). The expected availability date of the H1N1 vaccine was October 2009.

Given the short time frame and competition for resources needed for the seasonal

flu vaccine, however, it was anticipated that the supplies would be limited. In late

July 2009, the CDC’s Advisory Committee on Immunization Practices (ACIP)

released guidance on H1N1 vaccination administration based on the disease

characteristics, concern over the potential for increased severity upon re-emergence,

and limited availability of vaccine at the start. The guidance assigned priority to

specific groups of individuals to receive the vaccine, including health care workers

(see CDC 2010a). As in the 2004 vaccine shortage (Gotham et al. 2008), States were

given local autonomy to sub-allocate CDC allocations. States would identify

vaccination providers by priority group, determine the provider sub-allocation, and

electronically place orders for specific products with the CDC; the CDC would ship

the product to the designated provider through an independent agent.

4 PHEP activities and information systems supporting response to the event

The general pattern of PHEP activities and information system use during the

response phase of the event lifecycle related to the emergence of H1N1 was similar

to that which occurred during the emergence of West Nile Virus in NY State in

1999 (see Gotham et al. 2001). The overall PHEP response to the novel influenza

event occurred in three phases spread out over a period of 9 months. In analogy with

a foot race: Phase 1 was a sprint, immediately followed by a long distance marathon

(Phases 2 and 3).

The initial response phase occurred from late April through mid-June 2009.

During that time, NY State had to rely on the Pandemic flu plan, HCS information

systems and informatics infrastructure that existed at the time. In the second phase

(June to mid-September 2009), more was known about the disease, its activity

ebbed and Federal vaccine response plans were in process.

In Phase 2 (June to mid-September 2009), PHEP activities involved continued

monitoring and surveillance of disease activity for any changes in status in the

community and health care settings. This phase also involved intensive planning

and information system development/modification activities to prepare for the re-


123

emergence of the disease in fall 2009 and for a statewide vaccination campaign to

start in October when that countermeasure would become available. The planning

and information system development activities were based on lessons learned from

Phase 1, NY State health executive governance policies and needs (Fig. 1) and

federal vaccine response plans and policies.

The third phase involved implementation of the response plan, which included

the H1N1 vaccine campaign as a public health intervention to control the spread of

the disease (September 2009 to January 2010). Table 3 lists the public health

activities, the HCS information systems supporting them, and how they were used

throughout the phases of response.

4.1 Phase 1: established information systems supported the initial response

to the emergency health event

The initial response required intensive health alerting and communication of

situational awareness to, and among, response partners in the health community;

rapid gathering and distribution of data related to surveillance and assessment of

disease severity, geographic spread, and antiviral resistance; assessment of the

impact on health care resources; control and mitigation of infection in the health

care and community settings; management and distribution of antiviral counter-

measures and respiratory and personal protective equipment.

There was an immediate imperative for situational awareness and guidance from

a single authoritative source that could provide rapid distribution of guidance,

advisories and updates and related communiques statewide to the global HCS

community (Figs. 1, 2; Table 1), including all Local Health Departments (LHDs),

acute care and long-term care facilities, clinical laboratories, and health providers.

The Integrated Health Alerting and Notification System (IHANS) and event-specific

website within the HCS system provided the methodology for distribution of these

materials (Table 3) and the HCS health information exchange community provided

the venue (Figs. 1, 2; Table 1).

Access to event-specific information was also important: laboratory and case

reporting of suspect and confirmed cases were supported by existing HCS systems

(Tables 2, 3, see ECLRS and CDESS). Syndromic Surveillance was maintained

through the HCS Emergency Department Surveillance System (Tables 2, 3, see

EDSURV). Healthcare-based outbreaks were monitored via the Nosocomial

Outbreak Reporting Applications (see NORA, Tables 2, 3). The HERDS system

(Tables 2, 3) was leveraged to provide heightened surveillance on increases in

patients presenting with febrile or Influenza-Like Illness (ILI) at hospitals;

assessment of impact on health care status (e.g., ED traffic); assessment of critical

healthcare resource inventories (e.g., Personal Protective Equipment and antiviral

medications); tracking of antiviral medications distributed to the state through the

Strategic National Stockpile (SNS); and assessment of vendor-managed inventories

of antiviral medications available through pharmacy chains.

Additional baseline information was also required, including seasonal influenza

surveillance data from acute health care facilities; inventories of fixed health care

assets from acute and long-term care facilities (e.g., ventilators, airborne isolation


123

infection rooms); and bed availability. As the demographics of the viral infections

became better understood, guidances regarding school closings and absenteeism

were distributed via the health alert system and event website (Table 3). School

absenteeism surveillance, required to make decisions regarding school closings, was

implemented through the HERDS system (Table 3), allowing all schools across NY

State to report this data and receive event information in exchange. The dynamic

nature of the HERDS information system allowed for real time creation of reports

for each of these needs, with information provided on appropriate levels to the

decision makers across the HCS domain of response partners (see Tables 2, 3;

Gotham et al. 2007)

Situational awareness and decision support were paramount for the executive

policy and decision makers across the domains of the health information enterprise

of the HCS community. Data feeds from surveillance, health care resource

monitoring, and health care facility status were integrated into the HCS executive

dashboard and data visualization system as well as a Virtual Health Operations

Center (Tables 2, 3) to provide situational awareness and decision support for

executives within the Incident Management System (IMS) (Table 3, see also

Gotham et al. 2010).

Thus the existing HCS information systems supported the response to the initial

phase of the emergency response. However, the marathon phase of the response was

about to begin.

5 Phase 2: an established informatics framework enabled agile developmentof new or modified information systems to support recovery, planningand preparedness for disease re-emergence and countermeasure intervention

The second phase of the H1N1 event encompasses both the ‘‘recovery’’ phase of the

event lifecyle, that is, recovery from Phase 1 and re-initiation of the cycle into

‘‘preparedness’’ for what, at the time, was envisioned as Phase 3: re-emergence of

the disease and medical countermeasures against it. One component of Phase 2

involved ongoing monitoring and surveillance of disease activity for any changes in

status in the community and health care settings as well as alerting and situational

awareness reporting. These activities were supported by the existing HCS

information systems (Tables 2, 3). A second component of Phase 2 involved

engaging in intensive planning activities to prepare for the re-emergence of the

disease and a vaccine countermeasure campaign in fall 2009.

Federal policies, distribution plans, reporting mandates, as well as lessons

learned locally from Phase 1 by NY State dictated that completely new intervention

and surveillance plans had to be developed to support a federally-brokered, state

fiduciary-based vaccination campaign. The campaign was slated to start that

October when federal entities would make the vaccine available to providers and

states. The existing PHEP systems, such as HERDS, were well tuned to the

information needs of an emergent event of short duration. The existing Immuni-

zation Registry and clinic data management system were well suited to monitoring

administration of vaccines by providers and mass vaccination clinics (Tables 2, 3).


123

Table

3Publichealthem

ergency

preparedness(PHEP)activitiesandNYState

healthcommerce

system

(HCS)inform

ationsystem

ssupportingtheem

ergency

response

toH1N1

PHEPfunctionanddata/inform

ation

sources

ActivitiessupportingPHEPresponse

HCSinform

ationsystem

Planningandincidentmanagem

ent

State,regional

andlocalhealth

officials

Supportelectronic

collaborationfordevelopment,

distributionandcommentonresponse

plansas

they

evolved

betweenJuneandAugust2009

SupporttheNYSHealthIncidentCommandSystem

(ICS),throughelectronic

collaboration,mission

assignments

andsituationreports

Virtual

healthoperationscenter(V

HOC)

Epidem

iologic

surveillance

Hospitalsstatew

ide

Monitorhospital

admissions/deathswithlaboratory

confirm

edseasonal

influenza

byagegroup

Monitorhospital

admissions/deathsdueto

acute

febrile

respiratory

illnessbyage

MonitorInfluenza-likeillness(ILI)symptomsfor

emergency

departm

ent(ED)admissions(N

YCity)

HERDS—

hospital

instance

Conduct

ED

syndromic

surveillance

based

onchief

complaintdataonED

admission

Emergency

departm

entsurveillance

(EDSURV)

Schools

andschooldistricts

statew

ide

Collectstudentandfacultyabsenteeism

from

schools

andschooldistrictsin

supportofnovel

andseasonal

influenza

surveillance

HERDS—

schoolinstance

LocalHealthdepartm

ents

(LHDs)

statew

ide

Statewideelectronic

communicable

disease

case

reportingbyLHDs—

novel

influenza

case

reporting

from

sentinel

facilities

Communicable

disease

electronic

surveillance

system

(CDESS)

Clinical

laboratories

(National,

Privatein

State

andHospital)

Automated

reportingofpositivetest

resultsforre-

portabledisease

conditions,integratedwithCDESS—

PositiveInfluenza

testresultsbytype,includingnovel

influenza

Electronic

clinical

laboratory

reportingsystem

(ECLRS)


123

Table

3continued


ation

sources


HCSinform

ationsystem

Nursinghomes

andhospitals

Reportingofnosocomiallyacquired

infections;areasof

thefacility

involved,number

anddispositionof

affected

patients,andinfectioncontrolmeasurestaken

tocontain

andmanagetheoutbreak

Nosocomialoutbreak

reportingapplications(N

ORA)

Monitorandtrack

healthcare

facility

status,resourceutilizationandavailability,

surgecapacity

Hospitals

Inventory

statew

idehospital

assets

andequipment

deemed

essential

toem

ergency

response

(e.g.

pharmacyinventory,diagnostic

equipment,life

supportequipment,supplies,personal

protective

equipment(PPE),airborneinfectionisolationrooms

(AIIR))

Monitorhospitalbed

availabilitybystaffedservice(e.g.

adult/pediatric:medical

surgical,ED,IntensiveCare

Unit(ICU))

Monitorevent-relatedhospital

resourceutilization(e.g.

ventilators)andfacility

stress

status(facility

emergency

planactivated,diversionstatus,surge

strategiesactivated)

HERDS—

hospital

instance

Longterm

care

facilities

Inventory

statew

idenursinghomeassetsandequipment

deemed

essential

toem

ergency

response

(e.g.

pharmacyinventory,diagnostic

equipment,life

supportequipment,supplies,PPE)

Monitornursinghomebed

availabilitybystaffed

service

HERDS—

nursinghomeinstance

AlertingandCommunication


123

Table

3continued


ation

sources


HCSinform

ationsystem

Global

HCScommunity(see

Table

1)

Distribute

general

notificationsandalerts

regarding

novel

influenza

disease

status,vaccineavailability,

infectioncontrol,stateandfederal

guidance

toHCS

community

Integratedhealthalertingandnotificationsystem

(IHANS)and

communicationsdirectory

(ComDir)

Targeted

healthresponse

partners

(LHDs,hospitals,longterm

care

facilities,medical

professionals)

Customized

organization—androle-specificdistribution

ofevent-relatedalerts,advisories

andupdates:e.g.

response

andinfectioncontrolandexposure

protocols;case

definitions;vaccinationpriority

groups;vaccineefficacy

inform

ation;em

ergency

waiver

inform

ation

H1N1vaccinationproviders

(medical

professionals,LHDs,

healthfacilities

andother

organizationsadministeringH1N1

vaccineto

targeted

priority

populations)

Targeted

individual

andmasscommunicationof

inform

ation,updates

andadvisories

relatedto

the

novel

infuenza

vaccineadministrationcampaign:e.g.

ordering,order

status,reportingofadministered

doses,priority

groupadministration,andallocation

protocols

Publichealthintervention:statewidevaccinecampaign:medicalcounterm

easure

managem

ent,vaccineordering,managem

ent,distribution,administrationandreporting

H1N1vaccinationprovidersordering

vaccine

Registerto

order

vaccine,place

vaccineorders,receive

vaccineallocationinform

ation,checkorder

status

Vaccineorderingandmanagem

entsystem

(VOMS)

Medical

practitioner

orpracticeor

healthfacility

aggregate

administereddosesreporting

Weekly

reportingofaggregatevaccinedoses

administeredvia

phoneorweb

applicationby

practitionersandhealthfacilities

forreportingpriority

populationgroupvaccinations

Medical

practitioner

orpractice

patient-level

administereddoses

reporting

Reportnumbersofpatient-level

vaccinationsfrom

provider

office

based

settings

New

York

State

ImmunizationInform

ationSystem

(NYSIIS)

LHD

Clinics/PointsofDispensing

(PODs)

Reportnumbersofpatient-level

vaccinationeventsand

inform

ationat

county-based

massvaccinationclinics

Clinic

DataManagem

entSystem

(CDMS)


123

Table

3continued


ation

sources


HCSinform

ationsystem

Hospital,nursinghomeandadult

care

healthcare

workers

Assessvaccinationratesforseasonal

andnovel

influenza

amonghealthcare

workersat

health

facilities

HERDS—

hospital,nursinghomeandadultcare

facility

instances

State

executivedecisionmakersand

incidentmanagem

entstaff

Allocatelimited

supplies

ofevent-relatedvaccineto

fill,

orpartially

fill,provider

ordersbased

ongeographic

location,coverageofpriority

populationsserved

by

providers,order

history

andmultiple

other

eventand

disease-related

factors

VOMS

State

incidentmanagem

entstaffand

LHDs

Tracking,reportingandinventory

ofmedical

counterm

easures,equipmentandsupplies

deployed

duringhealthem

ergency

from

stateandfederal

stockpiles

Medicalem

ergency

response

inventory

trackingsystem

(MERITS)

Situationalawarenessanddecisionsupport

Global

HCScommunity(see

Table

1)

Providehighlevel

situational

awarenessregardingthe

eventto

healthresponse

partnersandusersoftheHCS

system

,includingdisease

severity,extent,prevalence;

vaccinecampaignstatus,stateguidance

onexposure

precautions,overviewsofresponse

plans,federal

guidance

onpriority

groupvaccinationpriorities

H1N1event-specificweb

site

Executivedecisionmakersand

incidentmanagem

entstaffingat

stateandregional

healthoffices

andLHDs

Supportvaccineallocationprocess

andsituational

awareness,providingorganizationandrole

appropriateaccess

tointegratedviewsofnovel

influenza

surveillance

data(hospital

admissions,

syndromic

surveillance,schoolabsenteeism

,lab

reports);event-relatedhealthfacility

resourcedata

(bed

availability,ventilatorutilization,facility

PPE

supplies,etc.);vaccinecampaigndata(e.g.summary

inform

ationonprovider

registrations,vaccineorders,

vaccineshipments,vaccinationadministrationsby

priority

group,geographic

extent,populationdensity)

Executivedashboardanddatavisualizer

system


123

However, no system existed to support transactional placement of vaccine orders,

order and inventory tracking, and reporting for orders placed to the CDC. Further,

there was no integrated allocation system to implement the state’s requirements for

distribution and reporting. The situational awareness and decision support

capabilities of the HCS also had to be attuned to this information flow in order to

allow decision makers to assess need based on federally mandated priority

populations, place orders for vaccine supply, and report the number of vaccines

administered.

As described in our definition of information systems and our informatics

framework (Fig. 1), people and processes form an important infrastructure

component of each paradigm. Our model informatics framework includes a

governance process which informs an agile informatics team of the needs of the

enterprise, the team being tasked with the responsibility of developing and

implementing the information system to meet them.

Thus, NY State maintains a staffing infrastructure of subject matter experts in

technology, project management, informatics and health knowledge domains who

make up an informatics team (see Fig. 1 for roles on that team). That team was

tasked with the responsibility for design, development, and implementation, by

October 1, 2009, of the systems required to order, manage, track inventory, and

report the status of vaccination campaigns. Additionally, all data feeds from these

new systems and existing information systems had to be integrated into the

executive dashboard (Tables 2, 3) to enable a common operational picture to

provide situational awareness as well as decision support in ordering, prioritizing

and distributing vaccine among the NYS population.

The governance structure was centered around a series of Health Knowledge

domain executive workgroups created to cover all programmatic information

system needs for the response. The Informatics team participated as an integral

component on all of these programmatic workgroups and was tasked with the

responsibility of developing the informatics component of the plan: a compre-

hensive approach to support (1) incident management; (2) vaccination campaign;

(3) epidemiologic surveillance; (4) monitoring health care facility status,

resource utilization and availability, surge capacity; (5) community mitigation;

(6) alerting and communication; (7) situational awareness and decision support

(see Tables 2, 3).

Executive workgroup products–objectives, response triggers, guidance, policy,

protocols, and operational documents–were created and posted within a Virtual

Health Operations Center (VHOC) within the HCS system (Table 3). The VHOC

information system provided a vehicle to share and collaborate on plan development

with external response partners within the information exchange community of the

HCS. The VHOC also supported the IMS process through electronic tracking of

assignments and collaborative production of daily reports (Situation Reports) for

executive consumption.

A key deliverable of the Informatics team was to formulate a cohesive and

comprehensive Master Data Management Plan (MDMP). An MDMP was essential

to establishing a single integrated and authoritative source of information to the data

layer services that would support the Information Systems to be used in the response


123

(e.g. see Figs. 1, 2). This effort was largely focused on identifying the data elements

that were well defined and reliable; used a standard vocabulary; could be obtained

without overburdening the data providers; were needed to support state and local

executive decision making and situational awareness and to present a common

operational picture to the IMS staff; and would lead to information products that

offered value back to the data provider. Defining data sharing and access rules and

other key metadata elements was also included in the plan. A data dictionary was

developed and linked to electronic data collection templates for deployment in the

HERDS systems. Each template was tailored to the needs of agreed-upon scenarios

of disease severity.

The informatics forum for developing the MDMP included participants from

organizations that cross-cut the information exchange community on the HCS:

NYSDOH health care and public health subject matter experts (SMEs), New York

City Department of Health and Mental Hygiene (NYCDOHMH) local public health

agency programs, LHDs, hospital associations, and long-term care facilities. The

result of this effort was a well-defined and realistic MDMP that was supported by

the health care and local health response partners. The MDMP also addressed the

need for school closure and absenteeism surveillance. The informatics workgroup

used a similar approach working with NYSDOH epidemiologists, the NYS

Education Department, LHDs, and representatives from schools and school districts

to design a plan for schools to report absenteeism via the HERDS information

system. The data collected from these reporting streams would, as part of the plan,

be integrated into the HCS executive dashboard visualization system to provide a

common operational picture and situational awareness to executive staff and the

IMS.

The informatics team engaged an agile project management approach to

developing and implementing a Vaccine Ordering and Management System

(VOMS). The process started with a ‘‘top-to-bottom’’ business analysis of existing

vaccine ordering and distribution protocols and procedures to gather requirements

and assess how technology could improve workflow and streamline the process and,

further, allow the flexibility needed for rapid responses to changes in vaccine supply

and demand at the national, state, or local level. The ability to react to, and

accommodate, changes in the VOMS system was essential as the vaccination

campaign itself presented complex and rapidly evolving state and federal

requirements. An overview of the information and process flow of the vaccine

campaign is shown in Fig. 3. VOMS requirements dictated that the system must:

• Allow vaccination provider organizations to register electronically and to

acknowledge their agreement to federally mandated conditions, place orders,

receive order status updates, and make changes in orders online

• Allow local health departments to assess provider rankings in priorities

• Support a data-driven allocation process

• Place orders with the Centers for Disease Control

• Accept reports from providers of vaccine doses administered to priority

populations as identified in federal guidance


123

• Be operational before October 19, 2009, when supplies of the vaccine would be

available to fill state orders

The third phase involved implementation of the response plan, which included the

vaccine campaign as a public health intervention to control the spread of the disease

(September 2009 to January 2010). A common operational picture of disease

surveillance data, health care facility status and resources, vaccine ordering and

administration status, and infection control actions had to be made rapidly available

to policy makers and response partners. The influenza vaccine countermeasure

would be made available to vaccination providers according to the federal

government’s prioritization recommendations. State allocation decisions would be

informed by multiple data sources, including: surveillance, healthcare status, and

reports of administered doses from mass clinics, school-based clinics, hospitals,

community health centers, and private providers.

5.1 Phase 3: implementation of information systems supporting the revised

response plan and vaccine countermeasure campaign

The third phase involved implementation of the revised Phase 2 response plan. The

goal was to establish and sustain a ‘long-term’ public health intervention campaign

designed to control the spread of the disease (September 2009 to January 2010). The

plan dictated the absolute need for decision makers and response partners across the

HCS community to have real-time access to a common operational picture of

disease surveillance data, health care facility status and resources, vaccine ordering

and administration status, and infection control actions. The influenza vaccine

orders placed with the CDC by the States would be made available to vaccination

providers according to the federal government’s prioritization recommendations and

the States’ allocation plans. Therefore, NY State orders to the CDC for vaccine and

its allocation supplies must be informed by multiple data sources, including:

surveillance, healthcare status, and reports of administered doses from mass clinics,

school-based clinics, hospitals, community health centers, and private providers.

5.1.1 Epidemiologic surveillance information systems

Using the MDMP, NYS implemented enhanced influenza surveillance activities by

leveraging its existing information systems tracking both severity and extent of both

novel influenza and seasonal influenza (see Tables 2, 3). These systems included:

Electronic lab reporting system, HERDS, communicable disease case reporting, and

syndromic surveillance. Thus, given the the long history of HCS’s information

systems, surveillance data collected in previous years could be used as baselines for

comparison against any changes in seasonal trends in activity or patient attributes in

the data collected during Phase 3 (see Fig. 4).

The HERDS school surveillance information system was activated to provide a

tool for schools and LHDs to collect and track absenteeism data in a consistent way

across the state, to facilitate monitoring of potential increases in illness, and to

provide objective data to support local decision making regarding possible


123

community mitigation actions, such as school closures. All related data feeds from

these surveillance activities were integrated into the executive dashboard decision

support system, informing the vaccination campaign as well as assisting in

providing a common operational picture of disease extent across the state (see

Figs. 4, 5).

5.1.2 Information systems monitoring and tracking health care facility status,

resource utilization and availability, surge capacity

The MDMP called for a staged approach to monitoring health facility status and

resource utilization or shortfalls across the continuum of acute and long-term care

facilities, based on severity of the disease (Tables 2, 3). The intent was to monitor

status, assess the level of ‘‘stress’’ the facilities were experiencing due to hospital or

ED admissions, and activate IMS intervention processes to allocate physical or

staffing resources if needed to help maintain the ability of facilities to provide

routine care or respond to even greater demands. The HERDS system was used to:

• Track bed availability and utilization, by service category (e.g., adult/pediatric

ICU, medical/surgical, monitored, isolation), in comparison to the total staffed

beds at health care facilities

Fig. 3 Interrelation and Information Flow between Information Systems Supporting the VaccinationCampaign


123

• Track supplies of personal and respiratory protective equipment

• Track critical life support equipment (e.g., ventilators)

• Track pharmacy supplies

• Assess facility stress levels as indicated by activation of surge plans, emergency

operations centers, diversion status, cancellation of elective procedures, etc.

• Assess health care worker shortages

The data feeds from both acute care and long-term care facilities were also

integrated into the executive dashboard (see Fig. 5) to inform the IMS leads and

also the vaccination campaign.

5.1.3 Information systems supporting the vaccination campaign

The complex data and workflow needed to support the VOMS system as well as

other supportive information systems (Fig. 3) were integrated using the SOA and

reusable core services within NY’s framework (Figs. 2, 3). This allowed NY State

to effectively take orders for vaccine from providers, allocate them according to

ACIP priority groupings, place orders with the CDC and track all portions of the

transaction. Using the executive dashboard decision support system (Fig. 5) with

information integrated in real time from the provider registrations and orders from

allocated H1N1 vaccine doses and types from the CDC, NYSDOH was able to

allocate the available doses of vaccine to appropriate providers and target the groups

recommended by ACIP to receive vaccine.

Once allocated, vaccine orders were transmitted electronically to CDC for

distribution to providers either directly from CDC or via state or local health

departments. NYSDOH also automatically tracked each vaccine shipment and

Fig. 4 Hospital patients testing positive for influenza virus, New York State, October 2007–May 2010


123

provided information to state and local health officials for distribution planning and

tracking and to providers via the Order History Report for immunization scheduling

and coordination with patients. After vaccine was administered, providers were

required to report the number of administered doses via one of three mechanisms:

H1N1 Vaccine Administered Doses Reporting System, which utilized a dual phone

and web data entry interface, Clinical Data Management System for mass

Fig. 5 Example of NYSDOH Executive Situational Awareness Dashboard and Data Visualizer System


123

vaccination clinics hosted by local health departments, and NYS Immunization

Information System (Tables 2, 3). If providers needed to redistribute vaccine to

others, they could also report through a web interface so the data could be used for

both allocation and tracking purposes. Based on the MDMP, all information from

these systems were integrated into a centralized data layer so they could be analyzed

and visualized for operational decision support and situational awareness via the

executive dashboard and other visualization tools (Fig. 5).

5.1.4 Situational awareness and decision support

The MDMP developed by the Informatics team provided the framework for assuring

the effectiveness of data-driven decisions throughout the Phase 3 response. The

Executive Dashboard and Data Visualizer tool (Tables 2, 3) provided a single,

seamless, and highly visual interactive interface for executive decision makers and

IMS managers to have access to a common operational picture based on

standardized and agreed-upon data elements and visual objects (Fig. 5). The

dashboard provided summary information as well as interactive drill-down into

aggregated and time-series data views from HERDS, laboratory surveillance

systems, syndromic data, hospital resource availability, bed utilization, school

absenteeism, and vaccine ordering and administration for state and local health

officials.

Access to these data informed the vaccine allocation process, providing all

information necessary to formulate, execute, and communicate executive and

operational decisions in vaccine management, allocation, and distribution across

providers, jurisdictions, and DOH programs. Of key importance was that all

decision makers and supporting analysts used a common operational picture and

standard data sets on which to base their decisions and actions. Resulting data-

driven executive policies, vaccine administration and reporting procedures, and

other patient care–related information regarding the vaccination campaign were

flash-transmitted to a cohort of some 5,500 vaccination provider organizations via

the IHANS system (Tables 2, 3). Information about the response and vaccination

campaign was regularly made available to the HCS health information exchange

community via the event-specific website (Tables 2, 3). Information on the website

included daily vaccine campaign status reports of doses ordered, allocated, shipped,

and administered for all local health departments.

6 Value of an informatics framework and information systems in supportingemergency preparedness and response

We have discussed the role of a model Informatics Framework and the information

systems it encompasses in providing value throughout the cycle of Public Health

Emergencies: Preparedness, Response and Recovery (Figs. 1, 2). The final stage,

recovery, is considered in Sect. 4. In this section we review some of the beneficial

outcomes of this Framework.


123

6.1 Preparedness benefit: well established and routinely used informatics

framework

NY State’s existing informatics framework conveyed the following advantages in

responding to the novel influenza event:

• The dual use nature of the HCS and its information systems entrained and

cultured a community of electronic heath information exchange partners that

cross-cut health organizations across the state. Thus all needed response partners

were already using the HCS systems and their role and contact information was

captured in the communications directory at the time of the event (Tables 1, 2, 3).

• Lessons learned from a history of responding to health events such as West Nile

Virus, 9/11, natural disasters, and health care resource shortages allowed

systems to evolve to support routine and emergency use (e.g. Gotham et al.

2001, 2007, 2008). Thus NY State had the information systems in place to

respond immediately to the health event.

• existing information systems not only allowed for rapid response to the event but

also provided a history of baseline data for monitoring changes in trends during

the event.

• Ongoing exercises and drills that use and test the informatics framework and its

information systems resulted in both user and information system preparedness

to respond to the health event (see Gotham et al. 2010).

• A governance process and an existing and experienced team of experts in

informatics, health domain subjects, project management and information

technology enabled NY State to rapidly develop and modify information

systems and MDMP to meet the information and planning needs of the longer

term response to the health event. The existence of the HCS information

exchange community provided a source of health organizations able to

contribute to the MDMP as well as provide input into the development of

new information systems based on their knowledge and use of the existing HCS

systems.

6.2 Response benefit: health alerting and notification: rapid communication

of critical event-related information across response partners

The Integrated Health Alerting and Notification System provides general and

targeted health alerting and notification, using multiple communications modalities:

automated phone, cell, e-mail notifications with acknowledgements (Tables 2, 3;

Fig. 2) (see Le et al. 2010). Routine health alerting drills are conducted with local

health departments and health facilities assure proficiency in its use (see Gotham

et al. 2007, 2010; Le et al. 2010). The IHANS serves multiple purposes during an

emergency response: (1) notifying targeted organizations as to new health alert

postings or materials posted on the event website within the HCS (see below); (2)

direct distribution of documents and information to targeted HCS organizations; (3)

notifying targeted organizations of surveys activated within the HERDS systems. In

the initial weeks of the novel influenza response (April 24–June 1, 2009) the IHANS


123

was used to transmit 309 separate event-related notifications to an aggregate total of

396,014 users. The targeted organizations included LHDs, hospitals, nursing homes,

adult and home care organizations. Table 4 presents representative examples of

average time to alert pickup by key HCS organizations during the initial phases of

the PHEP response.

6.3 Response and recovery benefit: decision support, situational awareness:

informing decision-makers, response partners and the health information

exchange community in general

Situational awareness for the HCS community was provided via two mechanisms:

(1) health alert postings within the HCS Health Alert Network (HAN) Viewer

system; and (2) an event-specific website within the HCS portal itself. IHANS is

used to notify targeted HCS groups that new postings are available. As described

earlier and indicated in Table 1, the HCS portal is a diverse information exchange

platform. The NYSDOH response protocol for a health event is to establish an

event-specific website within the HCS portal system (Tables 2, 3; Gotham et al.

2010). This site is the focal point for access to all event-related postings,

applications, information, and data. This includes links to the HCS Health Alert

Viewer as well as to collections of electronic documents. The documents posted in

the HAN Viewer and the website included case definitions, infection control

protocols, clinical and treatment guidance, specimen handling and biosafety

procedures, laboratory testing protocols; school closing and surveillance recom-

mendations; guidance for EMS workers and facility-specific guidance for long-term

care, educational, child care, and correctional facilities and summer camps.

Between April 24 and June 1, 2009, some 482,681 event-related documents were

downloaded by 32,185 distinct HCS users from the Alert Viewer and event website.

Table 5 presents the document access distribution among key organizations from

April 24 through December 31, 2009. Over this period of time, over 45,000 users

downloaded approximately 1.3 million documents from HCS. On average, 70 % of

these users were repeat users, defined as having downloaded materials on 3 or more

separate days. LHDs were the highest user group in terms of both volume of

documents downloaded and percent of repeat users. Medical practitioners as a group

constituted the greatest number of users accessing event-related materials.

6.4 Preparedness, response and recovery benefit: flexible and dynamic

surveillance, visualization and reporting systems deployed and in routine

use across the organizations within the health information exchange

community: immediate responsiveness to information needs for any event

or routine health program initiative

The HERDS system is completely dynamic and does not require programing to

develop and deploy information gathering and reporting applications (see Gotham

et al. 2007). This information system was used throughout the response to support a

wide array of ongoing and customized information and data collection needs

dictated by the event and the phase of the response to the event. It supported event-


123

related data reporting required for epidemiologic surveillance, reporting of resource

and bed availability, assessment of facility stress level due to patient influx, and

oversight of vaccination rates in the healthcare setting (Tables 2, 3). The system was

used for data exchange by facilities ranging from acute care hospitals to long-term

care facilities and schools, and it simultaneously supported customized surveillance

needs of the NYCDOHMH. As HERDS has been in use since 2003–2004 for

periodic reporting of bed availability, critical assets, and seasonal influenza testing

by hospitals, the NYSDOH had historical trend data to provide baseline information

for comparison against the evolving seasonal and H1N1 influenza patterns. For

example, hospital reporting of patient admissions with laboratory-confirmed

influenza (any type) showed a dramatic shift in pattern during the spring and fall

of 2009 over previous years (Fig. 4). The integrated information architecture of the

HCS system (Figs. 1, 2) assures that the diverse data streams flow into a central data

repository and are available for visualization and provision of a common operational

picture via a single dashboard system (Fig. 5; see also Gotham et al. 2010). Table 6

presents the composite access transactions against HERDS instances for hospitals,

nursing homes, and schools from April 24 through December 31, 2009. Over this

period of time, there were over 6.6 million access transactions (submitting data or

retrieving reports) by over 14,000 users. On average, across all organizations 43 %

of these users were repeat users, accessing the system on 3 or more days.

6.5 Preparedness and response benefit: existing informatics framework assures

rapid, effective response to new information systems needs: case study-

vaccine ordering and administration system

The Vaccine Ordering and Management System (VOMS) was required to manage

the ordering and distribution of vaccine, short in supply, and to assure that the

majority of organizations providing vaccinations to the federally designated priority

groups met certain requirements. The information system required linkage of a

complex information and process workflow (Fig. 3). Physicians were required to

register to order the H1N1 vaccine, to report the number of patients they serve in the

priority population groups, and to attest their agreement (electronically) to a

federally required vaccine receipt agreement. It was critical that the majority be

registered and able to place orders in advance of the availability of vaccine (October

19, 2009) to allow NYSDOH executive decision makers the ability to execute the

allocations according to provider attributes (e.g. priority populations served) and

other critical information available from the common operational picture presented

in the dashboard system (Figs. 2, 4, 5).

A shortage of vaccine and delays in production at the onset of the campaign

created unanticipated demand and increased pressure to distribute limited supplies

of vaccines. These events had a significant impact on planning assumptions. Rapid

and frequent changes in business rules were required during the development of the

Vaccine Ordering and Management System (VOMS). Nevertheless, given the rapid

development environment within NYS informatics framework, combined with the

adoption of agile methodology, the process—requirement gathering, business rule

definition, and technical development of VOMS—was completed in only 1 month.


123

Table

4Exam

ple

healthalertresponse

ratesfornovel

influenza

(H1N1)events

Exam

ple

one

Exam

ple

two

Exam

ple

three

Exam

ple

four

Exam

ple

five

Exam

ple

six

Target

organization

LHDs

Hospitals

LHDs

NursingHomes

LHDs

HomeHealth

Agencies

Date/time

initiated

April28,2009

10:10a.m.

May

1,2009

15:32p.m

.

May

2,2009

15:10p.m

.

May

1,2009

8:21a.m.

April26,2009

18:59p.m

.

April30,2009

20:28p.m

.

Purpose:

Initiate

LHD/NYSDOH

epidem

iolog-icalbriefings

ActivateHERDSSurvey

Baseline

PPEandSupplies

AlertLHDsto

SNSasset

distribution

Guidance:

Patientand

Staff

Carein

LongTerm

CareSetting

for‘‘Swine

Influenza’’

Initial‘‘Swine

Flu’’briefing

withLHD

Officialsand

hospitals

NYSDOH

Swine

Influenza

A

(H1N1)

inform

ationand

Q/A

sessions

forLTC

providers

Urgency

level:

Alert;highesturgency

Alert;highesturgency

Alert;highest

urgency

Advisory

HighAdvisory

Advisory

Contact

Mode:

Phone,

Email

Phone,

Email

Phone,

Email

Email

Phone;

Email

Email

Confirm

ation

rate:

100%;LHDs(59);

NYCDOHMH;NYSDOH

regions(6);

96%;NYShospitals(256/267)

100%;LHDs

(59);

NYCDOHMH;

NYSDOH

regions(6)

92%

Nursing

Homes

(597/

652)

100%

LHDs

(59);

NYCDOHMH;

NYSDOH

regions(6);

91%

hospitals

(200/219)

81%

Home

Health

Agencies

(230/

283)

Confirm

ation

stats:

Mean;min;

max;mode

10;4;50;6(m

inutes)

62;13;291;19(m

inutes)

9;4;25;4

(minutes)

70;10;589;13

(minutes)

247;10;1048;

166(m

inutes)

604;15;1000;

N/A

(minutes)


123

Tab

le4continued Exam

ple

one

Exam

ple

two

Exam

ple

three

Exam

ple

four

Exam

ple

five

Exam

ple

six

Rolesalerted:

LHD:Commissioner/PH

Dir;

PHEPEpidem

iologyContact;

PHEPPrimaryContact;

Communicable

Disease

InvestigationStaff;LeadEpi;

Dir.Disease

Control;Dir

PatientServices;

NYSDOH

Region:Im

munization

Coord;LeadEpi;Regional

Epi;

Dir.,Disease

Control

Hospital:ChiefExecutive

Officer;Bioterrorism

Coordinator;Designated

Pharmacist;Emergency

Response

Coord;HERDSData

Manager;HERDSData

Reporter;HERDSSurvey

Reporter

LHD:

Commissioner/

PH

Dir;SNS,

Coord;On-

Duty

PH

Officer;

NYSDOH

Region:Dir,

Regional

Office

NursingHome

Administrator;

Director,

Nursing;

Emergency

Response

Coordinator;

HPN

Coord;

NursingHome

DataReporter;

PlantManager

LHD:

Commissioner/

PublicHealth

(PH)Director

(Dir);

Incident

Command-

LHD;Public

Inform

ation

Officer

NYSDOH:PHEP

Education/

TrainingCoord;

PHEPCoord;

State

HAN

Coord

HHA:

Administrator;

Emergency

Preparedness

Coord;HPN

Coord

LHD

LocalHealthDepartm

ent,NYSDOH

New

York

State

Departm

entofHealth,NYCDOHMH

New

York

CityDepartm

entofHealthandMentalHygiene,

HERDS

HealthEmergency

Response

DataSystem

,PPEPersonalProtectiveEquipment,SNSStrategicNationalStockpile,NYSNew

York

State,PHPublicHealth,Dir.Director,

PHEPPublicHealthEmergency

Preparedness,EpiEpidem

iologist,Coord

Coordinator,HANHealthAlertNetwork,HPNHealthProvider

Network,HHAHomeHealth

Agency


123

The process of registration and order placing for vaccine was expedited by the fact

that 95 % of the vaccination provider organizations were existing members of the

HCS system and had used it for other applications. Owing to the existing HCS

infrastructure, its experienced user community, and the agility of VOMS, approx-

imately 80 % of vaccine providers were registered in VOMS and placing orders by

October 20, when H1N1 vaccine was available at the federal level for distribution. As

shown in Fig. 6, a total of 5,509 provider organizations registered over the course of

the event. Eighty percent of the providers had registered prior to the deadline and had

placed orders with the state for some 750,000 doses. By the end of the year the

providers had placed orders for nearly 13 million doses of vaccine (Fig. 6).

7 Conclusions and lessons learned

The presence of an established integrated informatics framework for health

information exchange and PHEP in NY State conveyed significant advantages in

Table 5 H1N1 Influenza-related Documents Downloaded from Event Website and Integrated Health

Alerting and Notification System (IHANS) by NYSDOH Health Commerce System (HCS) Organizations

(April 24 through December 31, 2009)

Organization

type

Organizations

downloading

Documents downloaded

(total = 1,321,580)

Users downloading documents

(total = 45,172 repeat

users = 31,797)

Percent registered

with HCS

Percent total downloads Percent total

downloading

Percent

repeat users

Laboratories 73 2.7 5.9 72

Clinics 41 2.3 2.6 75

Adult care 82 14.9 9.5 85

Hospitals 100 14.0 12.0 80

LHDs 100 20.2 6.7 87

Medical

professionals

42 16.9 36.0 55

NYSDOH

central

100 5 3.0 81

NYSDOH

regional

100 3.4 2.1 80

Nursing

homes

98 13.8 9.2 85

School

districts

75 4.5 8.8 68

Pharmacies 50 1.5 2.8 81

Other na 0.9 0.4 69

Documents include guidance, alerts, updates, advisories, infection control protocols and other com-

muniques related to the event. Percent repeat users: percent of users who accessed documents on 3 or

more separate days

LHD Local Health Departments including NY City Department of Health and Mental Hygiene, NYSDOH

NY State Department of Health


123

preparedness and response to H1N1. The final stage of managing an emergency

event is Recovery, which includes ‘‘evaluation of the incident to identify lessons

learned’’. The data collected and reported through the HCS has made this analysis

possible.

The key preparedness objectives achieved during the emergency event include:

(1) rapid alerting, communication and distribution of guidance and other materials

to a broad community of response partners; (2) rapid and flexible deployment of

customized surveillance and resource assessment activities across a wide array of

organization types; (3) establishment and maintenance of situational awareness

across response partners; (4) integration of data from various sources to support

executive decision makers; (5) support of the PHEP planning and implementation

process for response; (6) support for a statewide public health intervention, the 2009

H1N1 vaccination campaign.

Lessons learned from the event response include:

• Existing informatics infrastructure is essential to preparedness for emergency

events. NY State’s PHEP readiness to leverage its informatics infrastructure to

respond to the emergence of this novel influenza virus was enhanced by (1)

incorporating its use as part of the agency’s pandemic flu plan and (2) having

used it as an integral component of exercises and drills. During the full-scale

novel influenza exercise of Spring 2006 (Gotham et al. 2010), NY State used its

information infrastructure to meet most of the information and alerting needs

that ultimately were required in the real-life event 3 years later. Lessons learned

from the exercise were used to enhance capacities and procedures needed to

improve the effectiveness of the infrastructure.

• Adopt a model informatics framework that is based on dual use and value chain

synergies accrued from an information exchange community as its focus. PHEP

readiness is optimized when supportive information systems are embedded

within an established, dual-use, informatics framework, such as the NYSDOH

HCS system, which supports a broad-based community of health information

trading partners engaged in routine information exchange, as the information

trading partners become response partners in PHEP events. For example, 95 %

of the vaccine provider organizations that served the ACIP-defined priority

populations and that needed to access VOMS to register for and order H1N1

vaccine were existing HCS users, familiar with the system and with prior

experience accessing event-related information on the HCS.

• Consider ways in which current information systems may be adapted to

emergency needs. The dual-use concept also extends to application systems

within such a framework. Systems, such as HERDS (Gotham et al. 2007), that

support rapid, integrated, and flexible deployment of ongoing surveillance or

surveys across the universe of health care facilities and other partners are ideally

suited to respond to emergent PHEP events. Deploying dynamic, multiuse

systems (i.e., HERDS)—as opposed to single-purpose, monolithic systems—for

reporting of routine public health ‘‘survey’’ data allows those multiuse systems

to incorporate PHEP reporting rapidly, when needed, because the reporting

organizations are already familiar with the user interface and operational needs


123

Table 6 HERDS Usage by NYSDOH Health Commerce System (HCS) Organizations Across All

Facility Instances for Hospital, Nursing Homes and Schools (April 24 through December 31, 2009)

Organization type Access transaction hits

(total = 6,655,304)

Users accessing HERDS (total = 14,110

repeat users = 6,067)

Percent total transactions Percent total

accessing

Percent repeat

users

Hospitals 9.5 17.9 48

LHDs 3.8 6.4 40

Medical

professionals

2.3 7.8 15

NYSDOH central 2.4 3.2 31

NYSDOH regional 2.0 2.9 40

Nursing homes 41.0 33.6 60

School districts 39.0 28.2 55

NYSDOH and LHDs access HERDS solely to gain access to data reported by reporting entities (Hos-

pitals, Nursing Homes, Schools). Reporting entities access HERDS for both data reporting and access to

data. Percent repeat users: percent of users who accessed documents on 3 or more separate days

LHD Local Health Departments including NY City Department of Health and Mental Hygiene, NYSDOH

NY State Department of Health, HERDS Health Emergency Response Data System

Fig. 6 H1N1 vaccine providers registered and orders submitted, vaccine order management system,New York State, 9/25–12/31, 2009


123

of the system. Thus NY State was able to deploy specialized reporting across a

wide variety of PHEP response partner organizations at short notice.

• Reach across institutional and organizational boundaries. Ubiquitous deploy-

ment of dual-use applications is also critical. In PHEP events in the past

(Gotham et al. 2008), NY State had not yet completed deployment of these

systems across the universe of HCS organizations, resulting in data management

barriers. The lessons learned from past PHEP events energized NY’s efforts to

deploy HERDS across key HCS organizations, providing the platform that

allowed NY rapidly to implement surveillance and resource assessment across

all needed PHEP partners. Dynamic, multiuse data reporting systems are ideal

for rapid extension of influenza surveillance beyond the traditional healthcare

settings; an example is NYSDOH’s use of HERDS for school absentee

surveillance.

• People and processes are critical assets for rapid and effective information

systems; develop an enterprise culture that invests in, nurtures and sustains this

infrastructure. Subject matter experts that can work as part of an organized team

and cross-cut the agile informatics environment as depicted in Fig. 1 are critical

assets to the enterprise and an essential component of our model informatics

framework. As shown in the Phase 2 response period of H1N1, the governance

process and the informatics team infrastructure of subject matter experts (Fig. 1)

were informed of, and acted on, the value-based information systems needs of

the enterprise and assured that the emergent needs of the response were met in a

timely and effective manner.

• Be ready to expand the existing information systems on short notice. The success

of the H1N1 vaccination campaign can be attributed to the flexibility of the

informatics framework implemented at NY State (Figs. 1, 2). Dynamic

applications such as HERDS allow real-time development and deployment of

information reporting applications for emergent health program needs as well as

emergency events (see Gotham et al. 2001). Architecting core reusable services

and data layers (Figs. 1, 2) facilitates rapid implementation of new information

systems that are easily integrated into process and data flows or other

information systems and use the same authoritative source of data.

• Invest the effort in Master Data Management Plans and data-sharing

agreements BEFORE the emergency event. Finally, and most important, is the

Master Data Management Plan (MDMP), including at its core well-defined and

accepted data sharing and access agreements. NY has been involved in many

first-time PHEP events: emergence of West Nile, the 9/11 attacks, the Northeast

power outage, and others. Repeatedly and predictably, absent an MDMP, the

initial ‘‘heat’’ of the emergency drives executive leadership to sequester

information vitally needed to promote situational awareness. There are many

facets to an MDMP, but one key component defines, in advance and in

collaboration with ALL partners in the information exchange community, the

agreed-upon information to be provided to persons in appropriate roles, at the

appropriate time, at the appropriate levels of data quality required for an

effective response. The least optimal time for discussing, negotiating, and

implementing these agreements is just after an emergency has occurred. An


123

operational MDMP is essential for launching an effective response to public

health emergencies. The MDMP is part and parcel of the enterprise governance

process which assures that the enterprise (the health information exchange

community) prioritizes information system needs and investments based on

value or benefit to be received from that investment.

Acknowledgments We are indebted to Robert L. Burhans, Former Director of Health Preparedness,

and Dr. Dale Morse, MD, Former Director Office of Science, at NYSDOH for their leadership and

support. We also acknowledge the New York State Association of County Health Officials and the

hospitals and local health departments of NY State for their contributions to the successful response of

New York State to public health events. This publication was supported by Cooperative Agreement

Numbers U50/CCU223671 and U90/CCU216988 from the U.S. Centers for Disease Control and

Prevention (CDC) and by Cooperative Agreement Number 6U3RHS05934 from the U.S. Health

Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors

and do not necessarily represent the official views of CDC or HRSA.

References

Benson T (2012) Principles of health interoperability HL7 and SNOMED. In: Benson T (ed) Health

information technology standards, 2nd edn. Springer-Verlag, London

Businessdictionary (2013) Information system definition. http://www.businessdictionary.com/definition/

information-system.html. Accessed 28 Sept 2013

Chen J, Fuller S, Friedman C, Hersh W (2007) Medical informatics: knowledge management and data

mining in biomedicine. Springer, New York

Chen H, Zeng D, Yan P (2010) Infectious disease informatics: syndromic surveillance for public health

and bio-defense. Springer, New York

Federal Emergency Management Agency (FEMA) (2011) National preparedness goal. http://www.fema.

gov/media-library-data/20130726-1828-25045-9470/national_preparedness_goal_2011.pdf. Acces-

sed 10 Feb 2013

Federal Emergency Management Agency (FEMA) (2013) National response framework. http://www.

fema.gov/national-response-framework. Accessed 10 Feb 2013

Gotham I, Eidson M, White D, Wallace B, Chang H, Johnson G, Napoli J, Sottolano D, Birkhead G,

Morse D, Smith P (2001) West Nile virus: a case study in how New York state health information

infrastructure facilitates preparation and response to disease outbreaks. J Public Health Manag Pract

7(5):75–86

Gotham I, Sottolano D, Hennessy M, Napoli J, Dobkins G, Le L, Burhans R, Fage B (2007) An integrated

information system for all hazards health preparedness and response, New York State Health

Emergency Response Data System (HERDS). J Public Health Manag Pract 13(5):487–497

Gotham I, Le L, Sottolano D, Schmit K (2008) Public health preparedness informatics infrastructure. A

case study in integrated surveillance and response: 2004–2005 national influenza vaccine shortage.

In: Zeng D, Chen H, Rolka H, Lober W (eds) BioSecure 2008. LNCS 5354, pp 42–55

Gotham I, Sottolano D, Le L, Primeau M, Santilli L, Johnson G, Ostrowski S, Hennessey M (2010)

Design and performance of a public health preparedness informatics framework: evidence from an

exercise simulating influenza outbreak. Chapter 18. In: Castillo-Chavez C, Chen H, Lober W,

Thurmond M, Zeng D (eds) Infectious disease informatics and biosurveillance: research, systems,

and case studies. Springer, New York, pp 406–437

Grannis S, Dixon B, Brand B (2010) Data exchange, and Brand B. Leveraging immunization data in the

e-health era. Exploring the value, tradeoffs, and future directions of immunization. A joint

publication of the Public Health Informatics Institute and the Regenstrief Institute. http://www.phii.

org. Accessed 10 Feb 2013

Joint Public Health Informatics Taskforce (2011) JPHIT’s consensus framework. http://jphit.org/

resources/. Accessed 10 Mar 2013

IHE (2013) Integrating the health enterprise. http://www.ihe.net. Accessed 10 Jan 2013

Kukafka R, Yasnoff W (2007) Public health informatics. J Biomed Inform 40:365–369


123

http://www.businessdictionary.com/definition/information-system.html

http://www.businessdictionary.com/definition/information-system.html

http://www.fema.gov/media-library-data/20130726-1828-25045-9470/national_preparedness_goal_2011.pdf

http://www.fema.gov/media-library-data/20130726-1828-25045-9470/national_preparedness_goal_2011.pdf

http://www.fema.gov/national-response-framework

http://www.fema.gov/national-response-framework

http://www.phii.org

http://www.phii.org

http://jphit.org/resources/

http://jphit.org/resources/

http://www.ihe.net

Le L, Sottolano D, Gotham I (2010) Integrated health alerting and notification: a case study in New York

State. Chapter 17 In: Castillo-Chavez C, Chen H, Lober W, Thurmond M, Zeng D (eds) Infectious

disease informatics and biosurveillance: research, systems, and case studies. Springer, New York,

pp 382–404

Lombardo J, Buckeridge D (2007) Disease surveillance: a public health informatics approach. Wiley,

New Jersey

Massoudi B, Goodman K, Gotham I, Holmes J, Lang L, Miner K, Potenziani D, Richards J, Turner A, Fu

P (2012) An informatics agenda for public health: summarized recommendations from the 2011

AMIA PHI conference. J Am Med Inform Assoc 19:688–695

O’Carroll P, Yasnoff W, Ward M, Ripp L, Martin E (2003) Public health informatics and information

systems. Springer, New York

PHII (2005) Towards measuring value: an evaluation framework for public health information systems.

Public Health Informatics Institute Research Brief. http://www.phii.org/sites/default/files/resource/

pdfs/TowardsMeasuringValueBrief.pdf. Accessed 10 Feb 2013

Reed C, Angulo F, Swerdlow D, Lipsitch M, Meltzer M, Jernigan D et al (2009) Estimates of the

prevalence of pandemic (H1N1) 2009, United States, April–July 2009. Emerg Infect Dis

15(4):2004–2007

US Centers for Disease Control and Prevention (2009) Swine-origin influenza A (H1N1) virus infections

in a school—New York City, April 2009. MMWR Dispatch 58(Dispatch):1–3

US Centers for Disease Control and Prevention (2009b) Update: infections with a swine-origin influenza

A (H1N1) virus—United States and Other Countries, April 28, 2009. MMWR Wkly

56(16):431–433

US Centers for Disease Control and Prevention (2010) The 2009 H1N1 pandemic: summary highlights,

April 2009–April 2010. http://www.cdc.gov/h1n1flu/cdcresponse.htm. Accessed 28 Sept 2010

US Centers for Disease Control and Prevention (2009) Report to advisory committee on immunization

practices (ACIP). Atlanta, GE June 24, 2009. www.cdc.gov/vaccines/recs/acip/downloads/min-

jun09.pdf. Accessed 28 Feb 2010

US Centers for Disease Control and Prevention (2010b) Update: influenza activity—United States,

2009–10 season. MMWR Wkly 59(29):901–908

Yasnoff W et al (2000) Public health informatics: improving and transforming public health in the

information age. J Public Health Manag Pract 6(6):67–75

Whatis.techtarget (2013) Definition IS (Information System or Information Services). http://whatis.

techtarget.com/definition/IS-information-system-or-information-services, Last accessed 9/28/2013

Whitten J, Bentley L (2007) Systems analysis and design methods, 8th edn. New York: McGraw-Hill,

Irwin

World Health Organization (2009) Influenza-like illness in the United States and Mexico. http://www.

who.int/csr/don/2009_04_24/en/index.html. Accessed 28 Feb 2010


123

http://www.phii.org/sites/default/files/resource/pdfs/TowardsMeasuringValueBrief.pdf

http://www.phii.org/sites/default/files/resource/pdfs/TowardsMeasuringValueBrief.pdf

http://www.cdc.gov/h1n1flu/cdcresponse.htm

http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun09.pdf

http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun09.pdf

http://whatis.techtarget.com/definition/IS-information-system-or-information-services

http://whatis.techtarget.com/definition/IS-information-system-or-information-services

http://www.who.int/csr/don/2009_04_24/en/index.html

http://www.who.int/csr/don/2009_04_24/en/index.html