Assessing the
Prospects of State
and Local Health
A study for the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human
American Public Health Association
Boston MA
Project Overview
• Purpose
• Assess current status of IT in public health
• Document recent opportunities and progress
• Develop potential next steps for policy and program officials at all levels
• Approach
• Two technical expert panel (TEP) meetings
• Environmental scan
• Three in-depth case studies based on site visits to state and local
agencies: Florida, Oregon, Michigan
Sites selected both to highlight innovation and obtain a broad understanding
of “day to day” system use
• Team: Karen Swietek, Sara Levintow, Alana Knudson, Prashila Dullabh, Cheryl
Austein Casnoff, Mike Millman (ASPE), Adil Moiduddin
Relevant Data
Private Providers:
PH Services:
e.g., TB, STD, HIV, home visiting
clinics, laboratory and case
management, Women, Infant
and Children (WIC)
Health Records:
e.g., newborn screening, vital
statistics, early hearing,
immunizations, cancer
e.g., emergency departments,
hospital infection specialists,
commercial labs, primary care
providers, behavioral health
Environmental Health:
e.g., licenses and inspection data
maintained by local public health
Models for Integration, Interoperability and Exchange
to support needs assessment, care coordination,
health care quality improvement, monitoring and
e.g., communicable diseases,
STDs, syndromic surveillance,
e.g., Ryan White, Title V,
mental health / substance
abuse programs
Social Service
e.g., Schools, Housing
Assistance, Nutrition Support,
Heating Assistance
Health Care
Medicaid Enrollment,
Eligibility and Encounters; AllPayer Claims
Red (bottom): data typically managed by state health departments
Blue: data typically managed by local health departments
Green: data typically managed by private providers
Purple: data typically managed by other social welfare agencies
“Opportunity” 1 IT
• MU enhances incentives for electronic reporting to public
health (ELR, immunizations, cancer, syndromic surveillance),
but no systematic way to upgrade state public health systems
receiving data
• PH agencies serve as care providers, but few qualify for MU
• Limited billing to Medicaid and Medicare
• Many public health nurses do not meet “eligible provider” criteria
• Relatively few PH agencies use accredited EHRs
• State Health Information Exchange and Beacon Programs
• “public health hub” for public health reporting through a single portal
• PH is at the center of efforts to reduce hospital admission for
ambulatory care sensitive conditions (e.g., SE Minnesota)
“Opportunity” 2 Reform
• ACA goals and public health functions overlap
• Coordination (case management) and prevention
• Use of “community pathway hubs” to improve
connectivity to social services
• Sharing data across public service agencies
• Role of public health in QI and health promotion
through engagement with providers
• using EHR data to profile provider quality indicators
• chronic disease registries
• quality reporting to support Medicaid demonstrations
“Opportunity” 3 Science
• A logical premise: right information to the right person at the
right time
Public health
Public health
Workflow and
data flow
• Commitment to this idea on multiple fronts
RWJF projects, “Common Ground”
Public Health Data Standards Consortium (PHDSC)
Standards and Interoperability (S&I) Framework
Integrating the Healthcare Enterprise
• Key accomplishments to date
• Specifications for reporting to cancer registries, early hearing detection and
intervention, immunization reporting
• Use of clinical document architecture (CDA) or HL7 2.5.1 messaging
• Translating advances in PH informatics “on the ground” is not easy
…Funding Issues
• Varies considerably due to varying state and local budgets
• Plurality comes in the form of program funding from state and
federal sources
• Federal funds are typically administered by the state who work with
local health departments as service providers
• IOM and others note that public health is under-funded
• Funding mechanisms constraint IT investments
• Use of operational budgets rather than capital budgets
• Lack of flexibility in use of categorical funds
• Limited sustained funding focused on encouraging systems
improvements linked to analysis of business processes, workflow and
Areas of Progress
• Use of information systems among public health agencies has evolved
in useful ways
• Increased awareness of need for public health informatics
• Increased use of some systems and electronic reporting (ELR, immunizations)
• Comprehensive understanding of public health business rules is
• Necessary for overcoming silos
• Necessary for creating a framework for wise strategic investment
• New business rules for “evolving” functions such as chronic disease surveillance
• Vision and framework for capturing data more realistic than a formal
• Vendor community and public health informatics leaders propose “modular”
solutions using a common databases or meta-data models
Winds of Change
• Population health becomes and increasing focus in health
care policy (“third part of the three aim”)
• Vision can come from multiple places
• State public health agency
• State Medicaid agency
• Public health agencies may have skills / resources required
to achieve health care objectives
• Care coordination
• Linking “high-cost” patients to important social services to improve QoL and
lower cost
• However, their traditional role within the safety net will
• Prevention and clinical safety net roles may change
Some Lessons
• Organization matters
• Level of consolidation across state and local agencies
• Integration between Medicaid and public health
• Varying issues between state and locals
• Locals in search of a “public health EHR“ + efficient ways to report
• Locals need case management and specialized clinical modules (e.g., HIV)
• State focused on monitoring, surveillance and population data
• Some public health agencies are better positioned
• Planning should occur before grant opportunities arise
• Requires advanced capacity to receive health IT incentive payments, not just
data from providers
• Basic systems documentation / education is the first step
• Many public health agencies do not have a single list of all systems being
used and their relationships
Workforce Imperative
• Public health workforce with key gaps
• Knowledge of informatics, continuous quality improvement
• Knowledge of the best use of provider generated data (e.g., EHR data)
• Capacity to coordinate with others to assure access to care
• Leadership matters
• Involvement / knowledge of national initiatives
• Combined knowledge of public health workflows and informatics
• Realistic approach balanced with vision for future investments
More Work Needed
• Documenting business case and workflow for public
health partnership with providers
• Recent funded project from ASPE will do this for 3 chronic
• Models for strategic planning and coordination
between state and local stakeholders to plan
investments as opportunities arise
• Predictable funders that encourages innovation,
flexibility and economies of scale
• Expanded training for public health practitioners
•“Real world” tests for informatics advances
Thank You!
Michael Millman
U.S. Department of Health and Human Services
[email protected]
Adil Moiduddin
NORC at the University of Chicago
[email protected]
Full Report Available Online:
Other ASPE Public Health Reports:

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