Leveraging Health IT: How can informatics

transform public health (and public health transform

health IT)?

Claire Broome, M.D.

Health Information Technology Summit

March 7, 2005

How can informatics transform public health (and vice versa)?

How can informatics transform public health? Overview of public health role Early detection and Biosense initiative Progress in HIT capacity at state and local health

departments How can public health transform health information

technology?

What is the “business” of public health?

Surveillance (disease tracking) Early outbreak detection : bioterrorist, foodborne Assess health status of population Assist in planning access to health care

Investigation of causes and transmission pattern Development of effective interventions to prevent

disease and promote health Vaccines Decision support for eye care for diabetics

Public HealthInformation

Network (PHIN)

Health Department

Public HealthLab

CDC and Other

Federal Organizations

Public

VaccinationCenter

AmbulatoryCare

Hospital orHealth Plan

Investigation Team

Law Enforcement and First Responders

RXPharmaceutical

Stockpile

Non-Clinical SourcesOTC, 911, etc.

Early Event Detection

Outbreak Management

Surveillance/Case Reporting

Connecting Lab Systems

Secure Communications

Analysis & Interpretation

Information Dissemination & Knowledge Management

Countermeasure administration and

Response

Federal Health Architecture, NHIN

& Consolidated Health Informatics

Public Health Information Network

Public Health Information Network - Vision

To transform public health by coordinating its functions and organizations with information systems that enable:

real-time data flow computer assisted analysis decision support professional collaboration rapid dissemination of information to public health,

clinical care and the public

How can informatics transform public health (and vice versa)?

How can informatics transform public health? Overview of public health role Early detection and Biosense initiative Progress in HIT capacity at state and local health

departments How can public health transform health information

technology?

Surveillance approaches for early detection of outbreaks

Informed alert health care provider notifies local or state health department 24/7 contact

“Syndromic surveillance” --healthcare databases and novel data sources (veterinary labs, retail supermarket sales, business absentee data, etc) analyzed with various aberration detection algorithms Systematic evaluation of utility of data sources, algorithms,

systems needed Disease specific health surveillance system detects an increase in

disease specific reporting National Electronic Disease Surveillance System (NEDSS)

Any “signal” irrespective of source will need confirmation, investigation

Early event detection is critical for Bioterrorism management and response

The most useful tools will be dual use; Bioterrorism capable and regularly exercised for “routine” public health activities

Multiple data sources should be co-ordinated to facilitate signal evaluation and reduce user burden

Both diagnostic and pre-diagnostic (syndromic) data exist in electronic form in many yet untapped health-related data stores

BioSense - Principles

BioSense Software System

National “safety net” – help support early event detection in major cities

An implementation of identified standards A platform for the implementation and evaluation

of different analytic approaches Connection to the CDC BioIntelligence Center to

support early detection analysis at local, state and national levels

Data Sources Currently Available

DoD – Ambulatory Care and ER Diagnoses - Up to four diagnosis codes (IDC-9-CM) identifying the reason for every US ambulatory care (including ER) visit

DoD - Procedures - Procedure codes (CPT) ordered for every U. S. ambulatory care visit

VA - Ambulatory Care and ER Diagnoses - Diagnosis codes (IDC-9-CM) for every US ambulatory care visit (including ER) in 172 hospitals and 650 outpatient clinics nationwide

VA – Procedures - Procedure codes (CPT) for every U.S. ambulatory care visit

Clinical Laboratory Tests - Clinical lab tests ordered nationally BioWatch Results - Lab result for BioWatch environmental

collectors

System Status Views for all states and all BioWatch cities

300 state and local health department user accounts

In use in CDC BioIntelligence Center

Have set up custom views for high profile events—eg G8 meeting

Detection algorithms CuSum, “Smart Scores” – implemented

SatScan - pending

“Punchcards”and Analytical

Summary

Region Selection

BioSense Home PageAnalytical Summary Information

“News” andImportantDetailed

Information

Data LoadReport

Demonstration Data

BioSense Health Indicators PageData Visualization

User Options Menus

Links to Syndrome-Specific

Display Pages

Syndrome-Specific“Consolidated”

Graphs

Demonstration Data

BioSense Health Indicators PageSyndrome-Specific Maps

Data SourceSpecific

Maps

Zip Code“Mouse Over”

DisplayZoom-In/Out

And Map Navigation

Tool

Demonstration Data

HIT could facilitate linking additional data important for early detection to Biosense

Claims clearinghouses Hospital systems and health plans Hospital information systems vendors Other national clinical testing labs Regional Health Information Organizations With local and state health departments, local

clinical care sites

How can informatics transform public health (and vice versa)?

How can informatics transform public health? Overview of public health role Early detection and Biosense initiative Progress in HIT capacity at state and local health

departments How can public health transform health information

technology?

Public Health Information Network Funding

September 2002 Public Health and Social Services Emergency Fund

$1 billion for state and local public health preparedness capacity

CDC and HRSA require in grant guidance use of standards for IT investments—www.cdc.gov/cic

September 2003, 2004 : continued state Preparedness funding

HRSA grants $498 million ; CDC $870 million All 50 states funded for continuous internet connectivity to

counties (fy1999) and surveillance planning ( fy 2000)

Moving from conceptual to real

state and local health departments have different stages of electronic systems and IT capacities

Each state/jurisdiction will need to develop specific plans Which systems to integrate What funding streams available

Central concept of PHIN is implementation of standards based interoperable systems so all Support interoperability with clinical care partners, other

states Efficient use of technical expertise, tools Plan for extensibility

How does PHIN improve local and state capacity?

Web entry: case information available to local & state health departments immediately on entry (no paper, no mail)

Supports case investigation by state and local health dept

Standardized data sent electronically to CDC Same application for over 140 diseases, replacing

disease specific “stovepipe” applications

How does PHIN accelerate disease detection by local & state health?

Electronic laboratory results reporting (ELR) from clinical diagnostic laboratories For pre-defined results of public health importance,

electronic message to health department automatically sent

Message includes structured data including test, result, provider ID, patient age, sex

Multi-jurisdiction labs, public health labs, some local labs Nebraska sees 3 fold increased number of cases

reported; data at state within days of visit instead of weeks

Status of state PHIN enhancements January 2005

Grantee capacity Impact on disease reports

In daily use

Develop or deploy

planning

Capacity for web data entry

More timely 25* 13 14

Electronic Lab Reporting (excludes lead only)

More timely

More cases

26 14 12

*application in use: 1 commercial (3 states); NEDSS Base System (10 states); custom (12 states) ,

How will public health benefit from PHIN and HIT?

Increased timeliness for early detection: ELR, Biosense Increased number of cases reported: ELR Decreased data entry burden—for health department

(web entry; data automatically entered) For partners Easier to track and manage workflow for investigators Better alerting and communications Increased analysis capacity for state and local

personnel As EHR’s and decision support mature, can implement

public health guidelines in clinical practise

How can informatics transform public health (and vice versa)?

How can informatics transform public health? Overview of public health role Early detection and Biosense initiative Progress in HIT capacity at state and local health

departments How can public health transform health information

technology?

How can public health accelerate interoperable standards based health information systems?

Public health intrinsically must exchange information with all clinical partners in a population Shouldn’t all RHIO’s have a public health participant?

Evident public value—outbreak detection, preparedness Concrete solutions for standards based interoperability – e.g.

bidirectional secure messages (ebXML) HL7 V 3 messages Implementation guides for message content—eg lab results Development of data use agreements

Public Health content & services for EHR’s

How do we get to standards based interoperable systems?

Gartner Group project on PHIN implementation – PHIN is a multi-organizational business and technical architecture Technical standards Data standards Specifications to do work

Is also a process Commitment to the use of standards Commitment to participating in development and

implementation of specifications

Improving preparedness: enhanced diagnosis and reporting

Information on clinical presentations: E-mails via states, professional societies Web sites—CDC >12,000,000 downloads CDC’s Distance Learning network 10 programs for >1,300,000

participants (fall 2001 events) Diagnostic capacity for BT and chemical agents

Laboratory Response Network—CDC & APHL-reagents & protocols from web site

Ability to contact health department 24/7 States funding for epidemiology staff, communications with

hospitals Communications platforms, alerting protocols

Public Health Information Network Tools available from CDC

Software for industry standards based bi-directional inter-institutional messaging transport (PHIN MS)

ebXML “handshake,” PKI encryption and security Technical assistance & direct assistance available

for public health partners (eg security IVV)

PHIN Vocabulary Access and Distribution Services, including web accessible Standard Reference Tables

Implementation Guides that specify data standards, message format

Example of a potentially useful “tool”: PHIN Messaging System

(PHIN-MS)Software for industry standards based inter-institutional message

transport available from CDC ebXML “handshake”, PKI encryption and security Payload agnostic (HL-7, text file, etc) Bi-directional data exchange

PHIN-MS in use by state and local partners for point to point messaging (ED and lab to state; state to CDC)

Several commercial systems planning to incorporate

integration broker

laboratory information system

How do we get there from here?

We don’t have the ideal technology, but there is much we can do NOW

Standards and tools can help Leverage funds, hardware, software, technical

expertise, experience Let’s commit to working together to transform

the public’s health!

Background Information

What does PHIN have to do with HIPAA?

HIPAA mandates national health care data standards and policies in four areas: Transaction content; unique identifiers for providers, health plans;

security; privacy PHIN architecture standards are HIPAA compliant:

supports “dual use” for security, messaging elements Approach to PHIN data standards is HIPAA compliant:

Adopting HIPAA standards where relevant eg electronic laboratory reporting in PHIN uses HIPAA claims attachment

Advocating inclusion of data elements relevant to public health with SDO’s

What does PHIN have to do with HIPAA Privacy Rule?

Privacy Rule allows current practice of sharing data with public health Rule permits health care providers to share

individually identifiable information with legally authorized public health entities for public health activities

Public health activities include surveillance (NEDSS), investigation, intervention