Public Health Informatics

1
Public Health Informatics

• Rita Kukafka, DrPH, MA
• Department of Biomedical Informatics, College of
  Physicians and Surgeons
• Department of Sociomedical Sciences, Mailman
  School of Public Health
• Medical Informatics Course for Health
  Professionals
• Woods Hole, MA
• September, 2006

2
Session Overview

• What is public health?
• What is public health informatics?
• Historical context for the discipline
• Challenges and Solutions
• How public health connects to consumer health and
  the personal health record

3

• First, a perspective on public health

4
You might be a public health professional if you
are.

• looking to control the most basic of human
  functions, e.g., lobbying the Federal Trade
  Commission to investigate snack-food and
  soft-drink marketing or promoting a twinkie
  tax."
• worrying about eating, smoking, HIV/AIDS,
  bioterrorism, health literacy and hand washing
  all in one day.
• spending hours per day trying to define yourself,
  your work, and explaining your work to others.

5
What is a public health professional?

• ..A public health professional is a person
  educated in public health or a related discipline
  who is employed to improve health through a
  population focus

6
What is public health?

• "what we, as a society, do collectively to assure
  the conditions in which people can be healthy
• the specialty emphasizing prevention, with the
  object of its work being populations, in contrast
  to the historical role of medicine, dentistry,
  and other clinical disciplines that focus on
  healing, with the object of their work being
  individuals

7
Now

• A perspective on public health informatics..

8
What is public health informatics?

• Systematic application of information and
  computer science and technology to pubic health
  practice, research and learning.
• (Yasnoff, 2001)

9
Public Health Informatics added to MeSH
(Medical Subject Headings) very recently in 2003
10
As of (May 2006)
11
(No Transcript)
12
www.dbmi.columbia.edu
13
Four universitiesColumbia University, Johns
Hopkins, University of Utah, and the University
of Washingtonnow offer fellowships in Public
Health Informatics. The programs, designed to
prepare public health leaders to apply
informatics to public health problems, are
supported by a 3.68 million grant from The
Robert Wood Johnson Foundation to the US National
Library of Medicine (NLM).
14
Disciplines underlying informatics
Law
Management
Disciplines within public health
15

• More than automating existing activities.
• Enables new approaches
• Promise is in engineering innovative new ways to
  protect and promote the publics health using the
  power of information science and technology

16
Automate the way we currently do business

• Consider notifiable disease surveillance
• Hospital maintains their records, and also mails
  initial disease report form to LHD there, PH
  nurse completes form, and mails it to state
  epidemiologist or
• Same as above, but PH nurse completes an on-line
  form, e-mails it to state epidemiologist

17
Change the way we currently do business

• Again, notifiable disease surv. example
• Hospital maintains their own information systems
  as usual
• State epidemiologist uses Internet to
  simultaneously query multiple hospital data
  systems in real time.

18
Principals of public health informatics

• Public health informatics shares with medical
  informatics an underlying science with
  associated methods, techniques and theories.

19
Public Health Informatics in Perspective
Medical Informatics Methods, Techniques, and
Theories
Basic Research
Molecular and Cellular Processes
Tissues and Organs
Individuals (Patients)
Populations And Society
20
Four Underpinning Principles

• The primary focus of public health is to promote
  the health of populations and not the health of
  specific individuals.
• The primary strategy of public health is
  prevention of disease and injury by altering the
  conditions or the environment that put
  populations at risk.
• Public health professionals explore the potential
  for prevention at all vulnerable points in the
  causal chains leading to disease, injury, or
  disability public health activities are not
  restricted to particular social, behavioral, or
  environmental contexts.
• Public health interventions typically reflect the
  governmental context in which public health is
  practiced.

21
(No Transcript)
22
The Prevention Continuum
Primary
Secondary
Tertiary Prevention
Health Promotion Screening

Disease Management
Disease Free Subclinical
Disease Clinical Disease
A
B
C
Well

Premature/Preventable

Mortality


TIME
23
Roots of Modern Public Health Informatics

• In 1854, a major cholera outbreak in London had
  already taken nearly six hundred lives when Dr.
  John Snow, using a hand-drawn map, showed that
  the source of the disease was a contaminated
  water pump.

24
A Classic Story Dr. John Snow (1813-1858)

• The relevant 1854 London Streets
• Location of the Deaths from Cholera
• The position of 13 water pumps

Population based orientation rather than patient
based
Generated using CDC Epi Map 2000 for Windows, a
public domain package that can be downloaded
from http//www.cdc.gov/epiinfo/EI2000.htm)
25
Today, we have a vast array of data to monitor
the publics health. 190 data sources are
currently being used to collect progress of
Healthy People 2010 health objectives for the
nation.
26
(No Transcript)
27
Key Challenges

• Data collected categorically exist in silos,
  lacks standards and interoperability
• PH reporting is traditionally slow, not suitable
  for responding to bioterrorism and emerging
  infectious diseases
• Major gaps exist between public health and health
  care

28
Examples of informatics applied to public health
practice

• Syndromic Surveillance

29
What is Syndromic Surveillance?

• Real-time public health surveillance using data
  that is routinely collected for other purposes

30
Legal Mandate
Local health officers shall exercise due
diligence in ascertaining the existence of
outbreaks of illness or the unusual prevalence of
diseases, and shall immediately investigate the
causes of same.
New York State Sanitary Code, 10 NYCRR Chapter
1, Section 2.16(a)
31
New Response Requirements

• Fast detection
• Fast science
• Fast effective communication
• Fast effective integration
• Fast effective action
• Globalization, connectivity, and speed

32
Goals

• Early detection of large outbreaks
• Characterization of size, spread, and tempo of
  outbreaks once detected
• Monitoring of disease trends

33
Early Detection of Large Outbreaks
Symptom Onset
Severe Illness
Release
Number of Cases
Days
34
Characterization of Outbreak
Symptom Onset
Severe Illness
Number of Cases
Days
35
Which Scenario will happen?

• Depends on
• agent
• quality and quantity,
• method of dispersion,
• population characteristics
• Which scenario will occur is unknowable
• We should be prepared for both possibilities

36
Collection of Clinical Data

• Manual Reporting
• Telephone
• Paper
• Paper w/ electronic reporting
• Web-based
• ?Case Based Reporting (drop-in systems)
• Automated Data Collection

37
Syndromic Surveillance for Bioterrorism Following
the Attacks on the World Trade Center --- New
York City, 2001
Compared the daily ratio to its cumulative
baseline by hospital, hospital cluster, or
postal-code cluster. Alarms were generated when
the SNR (daily counts of each syndrome of
interest divided by the "none of the above)
category was significantly higher for the day in
question compared with the recent past.
38
Potential Syndromic Surveillance Data Sources

• Day 1- feels fine
• Day 2- headaches, fever- buys Tylenol
• Day 3- develops cough- calls nurse hotline
• Day 4- Sees private doctor flu
• Day 5- Worsens- calls ambulance
• seen in ED
• Day 6- Admitted- pneumonia
• Day 7- Critically ill- ICU
• Day 8- Expires- respiratory failure

Pharmaceutical Sales
Nurses Hotline
Managed Care Org
Absenteeism
Ambulance Dispatch (EMS)
ED Logs
Traditional Surveillance
39
(No Transcript)
40
Public Health Information Network (PHIN)

• CDCs national initiative to implement a
  multi-organizational business and technical
  architecture for public health information
  systems.
• Initial work toward the adoption and
  implementation of standards-based, integrated,
  and interoperable information technology (IT)
  systems
• Now moved toward defining PHIN functions and
  specifications
• PHIN Preparedness Initiative focuses on
  certifying systems against function, technical
  and operational requirements

41
(No Transcript)
42
PHIN Components for Disease Surveillance
Traditional Surveillance
Syndromic Surveillance
Public Health Information Network (PHIN)
Environmental
Surveillance
Internet
Emergency Communications
detection
response
43
Informatics methods can be applied at all these
points
Health Department Information Systems

Analysis Alerting Visualization
Sources of surveillance data
Reduced mortality, morbidity
Decision Making
Database
Action
e.g., Algorithms Visualization Tools Decision
support
RODS Lab
44
(No Transcript)
45
(No Transcript)
46
GIS in surveillance and public health practice
Turn data into meaningful decision support

• Improved decision making
• Improved service and health outcomes
• Reduced health inequalities
• Reduced costs

• Service benefits
• Better understanding of current situations
• Planning/targeting
• appropriate interventions
• Prioritizing, monitoring and
• tweaking interventions
• as necessary

47
GIS in MeSH 2006
48
PubMed (May 2006)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
Adult (15-49) HIV Prevalence Rate ()
1985
2005
53
(No Transcript)
54
Perhaps the greatest challenge and ultimate
benefit of improved PH infrastructure utilizing
informatics methods

• Closing the gap that exists between public health
  and health care
• .enter the EHR and PHR

55
Bilateral real-time communication between public
health and clinical information systems

• Benefits
• Enables public health interventions at
• the point of care
• Decision support to providers on
• Preventive practices based on patient
  characteristics
• Tailored patient education on current
  medications, medical problems and conditions,
  tests and procedures.
• Ability for patients to control and
• maintain their own health data

Public Health
Clinical Care
56
Other emerging applications in public health
informatics a schematic view
Clinical services
Telehealth
Clinical/Medical Informatics
C
Primary focus
A
Consumer Health Informatics
Public Health Informatics
B
Population health
A represents tools for population health such as
syndromic surveillance epidemiology databases B
represents health promotion or disease prevention
tools
57
Duel Benefits

• The very same infrastructure and capabilities
  used to support data capture at the point of
  care for emergency preparedness can most
  definitely be used to implement non-attack public
  health intervention.

58
Data are from McGinnis et al, JAMA 1993
The percentages are for all deaths Data
are from Mokdad et al JAMA 2004
59
(No Transcript)
60
EMS Drug Calls
61
Examples of informatics application to modify
high risk health behavior

• A Tailored Intervention to Link Primary Care
  Practices with Community Health Resources
• Tailored intervention to link patients wishing
  to make behavior changes to an existing web-based
  resource that provides local support and
  educational materials. Patients will be directed
  to this resource via a health promotion Rx

62
Tailoring system program
63

• Modular Lifestyle Intervention Tool (MLIT)A
  handheld clinical decision support tool to assist
  clinicians in providing patient-tailored
  counseling at the point of care. Practices will
  adopt smoking and BMI as vital signs, which cue
  the clinician to address the target behavior and
  use the software.

64

• Testing PDA-Based Interventions for Smoking and
  Unhealthy DietTwo evidence-based, best practice
  protocols mounted on PDAs will be used to guide
  patient interventions around smoking and diet.
  Community health advisors will be used to promote
  and support patients attempting change.

65

• Using Behavior-change Action Plans during the
  Primary Care Visit
• Incorporate behavior change action plans into
  routine visits and follow with six-month patient
  self-assessment questionnaire and clinician
  action plan assessment questionnaire.

66
Major PHI Challenges

• Re-connecting clinical medicine and public health
  practice
• 21st century disease surveillance Integrated PH
  Information Systems
• Pressing Challenge
• Thinking outside the box-
• Duel use systems that are flexible
• enough to respond to changing public health
  needs

67
Perspective ChallengeDiverse Sets of Agencies
Partner Organizations

• Affiliated Organizations
• 115

• Agencies / Professionals
• 60 States Territories health departments
• 3000 local heath departments
• 100,000 professionals
• 50 disciplines

68
The Public Health System
69

• Field of public health informatics offers many
  challenges (and applications) yet to be
  discovered.

70
Where are we?