Public Health Informatics

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Public Health Informatics

• John W. Loonsk, MD FACMI
• Director of Interoperability and Standards
• Office of the National Coordinator
• for Health Information Technology
• Woods Hole - October 2008

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Public Health Informatics - Agenda

• Public health
• Surveillance
• And the National HIT Agenda
• Public Health Informatics Discussion Scenarios
• Wrap-up

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Public Health

• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in
  recovery
• Assures the quality and accessibility of health
  services

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Who is Public Health?

• Infection control officer in a hospital
• Epidemiologist
• State health officer
• Public health labratorian
• Restaurant health inspector
• CDC, FDA, CMS
• Emergency health care provider
• Academic researcher
• Communication officer
• Medical informaticians
• Etc.

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Potential of Public Health Informatics

• Enhance public health outcomes
• Extend the reach of the limited number of public
  health professionals
• Better protect the population
• Automate public health outcomes in clinical care
  practice
• Work directly with consumers to enhance
  prevention

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Data are from McGinnis et al, JAMA 1993
The percentages are for all deaths Data
are from Mokdad et al JAMA 2004
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Public Health Cycle

• Surveillance
• Monitoring

• Clinical care
• Population health

• Analysis
• Research

• Patients / consumers
• Clinicians
• Health policy

• Prevention and Treatment
• Education and guidelines

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Public Health Information Network Functions - 2006

• Event detection and monitoring support of
  disease and threat surveillance, national health
  status indicators
• Analysis facilitating real-time evaluation of
  live data feeds, turning data into information
  for people at all levels of public health and
  clinical care
• Information resources and knowledge management -
  reference information, distance learning,
  decision support
• Alerting and communications transmission of
  emergency alerts, routine professional
  discussions, collaborative activities
• Response management support of isolation,
  prophylaxis, vaccination, etc.

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Public Health Surveillance and IT

• Public Health Surveillance - The ongoing,
  systematic process of collecting, analyzing and
  using data on specific health conditions and
  diseases.
• Monitoring vs. surveillance
• Notifiable disease vs. specific surveillance
  issues
• Biosurveillance
• Disease specific systems and the integrated
  surveillance problem

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Public Health Data Flow
Public Health Money Flow

• Clinical sites, such as local hospitals
• Local health departments
• State health departments
• National Centers for Disease Control and
  Prevention and others

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Disease Surveillance

• Initial detection find first event
• Situational awareness and subsequent detection
  identifying other possible cases, including
• Quantification how many people are ill?
• Localization where is it taking place?
• Investigation demographics, etiology,
  conveyance
• Outbreak management confirming true cases,
  tracking who was exposed and managed

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One Way to Slice Surveillance

• Traditional Case Reporting
• Requires clinician to report case
• Most reporting steps are phone or paper- based
  and manual
• Most reportable disease cases are not reported
• Lab result is sometimes pathoneumonic

Case Report Name Jane Age 46 Sex
Female Weight____ Height_____ Temp_____ BP_______
Public Health Case Reports
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All Hazards Detection and Response Data
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Situational Awareness and West Nile

• Clinical care data supportive of many information
  needs even after an event has been identified

West Nile Virus NYC - 1999
3
Epi investigation started
2
Unreported
Number of cases
cases
1
Reported
cases
0
8-Aug
15-Aug
22-Aug
Date of Admission
NYC DOHMH Marci Layton
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Biosurveillance Data Needs
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Public Health, Interoperability and Electronic
Medical Records(Other Examples)

• Reminders for immunization schedules and
  preventative services
• Populate registries for trauma, burn, poisoning,
  cancer, birth, death, birth defect, immunization,
  etc.
• Deliver health guidelines and recommendations
• Characterize at risk groups, evaluate impact of
  intervention measures
• Identify disease and injury trends, manage
  chronic disease outcomes, adverse events
• Identify social determinants of health

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• Interoperability and the National HIT Agenda

Broad Use of Standards
Verification in Systems
Data and Technical Standards And Specs
Priorities and Context for Use
Availability
Interoperability
Interoperability

• Challenges to use of interoperability
• Few incentives for exchanging information
• When value of exchanging is high, it costs to
  not use standards etc.
• Many incentives for not exchanging information
• Implicit data ownership and propriety business
  needs
• Patient confidentiality issues
• Integration services profits
• Existing non standards-based systems
• HIPAA and other legal angst
• Historically was a problem with the
  availability of definitive, detailed and
  testable standards

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National HIT Agenda

• Priorities
• American Health Information Community
• Business needs and priorities
• Use Cases

• Networking
• NHIN - network of networks
• Architecture specifications

• Standards
• Healthcare Information Technology Standards Panel
• Recognized standards

• Policies
• State laws and regulations State Alliance
• Health Information Security and Policy
  Collaboration

• Certification
• Certification Commission For Healthcare
  Information Technology
• Criteria development
• Testing

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AHIC Priorities Roadmap
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Standards in the National HIT Agenda
American Health Information Community
Priorities (AHIC)
Healthcare Information Technology Standards
Panel (HITSP)
Secretary Currently Accepted 60 (2007)
Use
Interoperability
Cases
Specifications
One Year - Testing and Implementation
Certification Commission for Healthcare
Information Technology (CCHIT) (Stark and
Anti-kickback)
Secretary Currently Recognized 52 (2006)
Verified
Federal Systems and Healthcare Contracts
(Executive Order 13410)
Use
Nationwide Health Information Network (NHIN)
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The New Public Health Normal
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Public Health EmergencyInformatics

• Emergent needs and the public health culture
• Dual use infrastructure
• Build before the emergency
• Heavy needs stress manual processes
• After action window of opportunity for workflow
  changes and technology adoption

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Anthrax Attacks

• White powder in envelopes
• Academic -gt emergency public health
• Limited number of cases
• Respiratory
• Cutaneous
• Local, state and federal involvement
• Lab testing
• Massive coordination and communication issues

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Informatics Needs of a Major PH Event
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Anthrax Informatics

• Connectedness
• Lab results and lab capacity
• Emergency operations support
• Incident level data
• Communications
• Secure public health
• Public
• Emergency room situational awareness
• not initial event detection
• Who to prophylax?

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SARS

• Highly infectious, unknown severe respiratory
  illness
• Local, state and federal involvement
• Not reportable disease
• Changing case definition
• Isolation and quarantine effective

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Contact Tracing

• Outbreaks about relationships
• Lab results to possible cases
• Person to person
• Vector to person
• Location to person

SARS cases in Singapore
Bogatti SP. Reprinted in MMWR 5-9-03
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Realities of Outbreak Investigation and
Management

• Frequently no information system in place
• Multiple spreadsheets or equivalents are
  initiated
• Similar data not in use
• State, local and federal partners do not
  completely share data
• Complex information relationships are documented
  late in the event
• Evolving investigation questions and case
  definition changing
• There is manual data management, analysis and
  reporting

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SARS Informatics

• Case reports
• Dynamic
• Surveillance data
• Always needed
• Variable but can use standards
• Unanticipated
• Case counts and the press
• Contact tracing
• Isolation and quarantine systems
• Evolution of an outbreak possible case -gt
  confirmed case -gt multiple cases -gt registries
  and retrospective research
• Similarities in West Nile I and II and Monkeypox

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Monkeypox

• Stores
• Rodents
• People

Animal ID Species Color 643M32
Monkey Brown 765D89 Dog Black
Case Name Age Gender 123896 E.Doe 32
Male 765432 I. Bye 55 Female
Specimen Type Collected 2347801
Serum 6/30/03 7832349 Blood 6/15/03
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WNV Transfusion Tables

• Donors
• Blood products
• Organs
• Recipients

Laboratory Specimen
Specimen ID Case ID Type Collected
2347801 117 Serum
6-15-04 7823349 234 Tissue 6-16-04

Blood Product
Epi - Human
Unit ID Site ID Type
Processed 2347503 129 Red
cells 6-30-04 7823349 245
White cells 6-29-04
Patient ID Case ID Age
Gender 123896 117 32
Male 765432 234 65
Female
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Smallpox Vaccine Program

• Public health program to vaccinate emergency care
  clinicians
• Who should be vaccinated and who should not?
• Investigational vaccine and data privacy
• Clinic workflow and mass distribution
  considerations
• Active surveillance for adverse events

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Countermeasure and Response Administration

• Support delivery of prophylaxis, vaccination and
  management of isolation and treatment
• Optimization and management of response is very
  data intensive
• Computer systems are necessary to monitor the
  effectiveness and completeness of response

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Smallpox Vaccine Program Informatics

• CDC system to support investigational vaccine
  administration
• Who to vaccinate, vaccine lot, diluent
• Data privacy
• State systems
• Vaccinated -gt active surveillance
• Not supported by existing passive system

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Flu Vaccine Shortage

• One of two major vaccine manufacturers has
  vaccine recalled
• Discrepancy between vaccine need nationally and
  distribution of remaining manufacturer
• Ordering, apportionment and distribution becomes
  a public health issue
• Shortage triggered even greater demand

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Flu Vaccine Shortage Informatics

• CDC flu finder system with Aventis Pasteur
• Routine aspects of supply ordering, apportionment
  and management management applied nationwide
• Availability of supply

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Katrina

• Hurricanes forced displacement of large numbers
  of evacuees
• At risk populations
• No medical records
• Care provided in shelters and auditoriums
• Conditions fostered disease outbreaks

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Katrina - Informatics

• Medical record access
• Medication lists in prescription brokering
  services
• Reorient data, access and authorization for
  emergency care providers, not timely
• VA shared system demonstrated value of redundant
  infrastructure

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Other Public Health Informatics Activities

• Population Registries
• Vaccination, cancer, disease management
• Maternal and child health
• Alerting and communication
• Geographic Information Systems
• Personal health records and prevention

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