Assessing the
Prospects of State
and Local Health
Department
Information
Technology
Infrastructure
A study for the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human
Services
American Public Health Association
Boston MA
11/3/2013
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
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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
surveillance.
Surveillance:
e.g., communicable diseases,
STDs, syndromic surveillance,
BRFSS
Program
Management:
e.g., Ryan White, Title V,
mental health / substance
abuse programs
Social Service
Records:
e.g., Schools, Housing
Assistance, Nutrition Support,
Heating Assistance
Health Care
Administrative
Records:
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
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“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)
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“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
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“Opportunity” 3 Science
• A logical premise: right information to the right person at the
right time
Public health
mission
Public health
activities
Workflow and
data flow
Systems
requirements
• 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
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…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
needs
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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
• 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
architecture
• Vendor community and public health informatics leaders propose “modular”
solutions using a common databases or meta-data models
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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
change
• Prevention and clinical safety net roles may change
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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
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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
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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
illnesses
• 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
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Thank You!
Michael Millman
U.S. Department of Health and Human Services
Michael.Millman@hhs.gov
Adil Moiduddin
NORC at the University of Chicago
Moiduddin-adil@norc.org
Full Report Available Online:
http://aspe.hhs.gov/sp/reports/2013/PublicHealthInformatics/hitech_rpt.cfm
Other ASPE Public Health Reports: http://aspe.hhs.gov/sp/reports/
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