Category Archives: Health Information Exchange

Rx for Ebola: Protect the Perimeter with Decision Support and Surveillance

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A man walks into an emergency room with a globally notorious febrile illness wanted for mass killings in other countries.  Instead of being diagnosed and treated, he is released back into the community, continuing to expose health workers and community members without warning.   While this may sound like the September 2014 Ebola virus fumble in Dallas, it was also the scenario that drove the SARS epidemic in 2002-3 when, as today in Africa, health care facilities were a major node of transmission.

Back then, a small cadre of techies and local public health workers developed a scalable process of perimeter screening at emergency departments that fed into a public health surveillance system (the SARS Surveillance Project).   Front line health care workers welcomed a simple decision tool to distinguish routine fevers from possible SARS, allowing them to initiate infection control to protect themselves and their patients.  Health departments received immediate notification of suspect cases and daily trends of respiratory febrile illness.   In a matter of days the system was operational in Milwaukee, and within a few weeks across parts of Ohio, Colorado and Texas too.

The system might be considered laughably simple today (yes, it involved paper, pencil and arithmetic).  It was slapped together with tools at hand and without federal funding.  Nevertheless it scaled far faster than the anticipated SARS epidemic.  (We never found a SARS case, nor were there cases to find in our jurisdictions.)  The Dallas experience proves that a similar approach is needed today.   I hope our old publication might prove useful to today’s Ebola virus fighters.

We failed to get CDC to pick up or even endorse the project.  It fell victim to the “not invented here” syndrome.  (Although we showed we could rapidly scale to EDs serving more than a quarter of the US population, the last conversation ended with “We already work with an emergency department in California, thank you very much” [emphasis mine]).*

A larger question is: are we better equipped to scale up such a system today after US$ billions of investment into health information technology?   The short-term answer is “No”, outside some local centers of excellence.    But there is little reason we couldn’t get there with a little strategic leadership and investment.

Imagine that CDC translates Ebola suspect case definitions (symptoms, signs, travel, sick contacts) into standardized HIT data elements.  Imagine these are loaded into a standards-compliant rules repository accessible to electronic health record systems (EHRs).   Imagine that EHR systems upload these rules to alert triage personnel to ask 4-6 brief questions of febrile patients.   Imagine that responses suggesting Ebola trigger immediate infection control and public health reporting.  Imagine that patients, healthcare workers and the community are protected pending definitive diagnosis.  Imagine that emergency response receives the gift of a head start on the possible emergence of a generation of new cases.

In recent years the pieces of this more automated solution have been largely completed but not assembled and applied: widespread certified EHR use; specifications for capturing most of the needed data elements; methods to distribute clinical decision support rules; specifications for electronic public health reporting.   With a focused vision and public health investment an adaptable system that combines “situational” EHR decision support with surveillance could be achieved fairly rapidly.  In the meantime, I’m told, paper, pencil and basic http are still available to replicate the 2002 approach.

 

*(In fairness it must be told I joined CDC 8 years later, and during my two years there agency budgets for the public health use of health information technology markedly shrank.  Thus I must share responsibility for the current state, despite efforts to the contrary.)

 

A Trip in the Time Machine

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What information management capabilities will future US health departments need?  Shaun Grannis (Regenstrief Institute), Torney Smith (Spokane Regional Health Department), David Ross (Public Health Informatics Institute) and I were asked to gaze over the horizon during a 2012 Public Health Accreditation Board think tank.  Our work was recently published online-ahead-of-print by the American Journal of Public Health.

We looked first at potential changes in health department function suggested by the Patient Protection and Affordable Care Act (“ACA”).  Some argue that health departments might exit direct individual health services, as uninsured populations fall and Accountable Care Organizations rise.   Perhaps health departments will no longer need to track individual clients and services?  On the other hand, others have proposed expanded health department roles in community-based preventive services.  Billing for individual services like vaccination is becoming more important than ever for department revenues.   Millions will remain uninsured even after ACA implementation, health departments will continue to track cases of reportable illness and injury, and will remain accountable for transparent and up-to-date data on population health trends.  In balance we found arguments that most health departments could jettison the responsibility for collecting and protecting individual health information unconvincing.  It is likely that faster, better and safer information management is needed instead.

We also looked at projected technology changes.  Perhaps health departments won’t need to collect surveillance data when interconnected electronic health records might make such data searchable on demand?  The slow pace of interoperability initiatives, and the likely demand that health performance data be independent, transparent and accountable made us skeptical that simply “grazing on others’ data” will be meet all needs within several decades.  Meanwhile numerous other information sources, for example data recorded by citizens and sensors, will probably be added to the floods of data obtained from health care providers.

Inevitably, then, most health departments will be subject to a growing glut of electronic information like other health organizations.  Indeed, if they will fulfill their mandates and avoid shrinking into vestigial remnants, they must manage information and knowledge more competently than ever before.   The good news is that as connectivity, standardization and cloud capabilities improve, it will be easier for individual local and state health departments to lease shared information systems rather than manage them locally.  By collaborating on such shared systems they will be able to focus more on how they want to use information to protect and improve the public’s health, and less on managing hardware and software.   However, this vision depends on goal-oriented collaboration and planning between local, state and federal agencies.

Every public health department will need certain capabilities to navigate the course ahead, making these capabilities appropriate for consideration in the process of health department accreditation.  We hope our article and will initiate lively discussion on what such capabilities should look like.  What do you think?

A High Altitude View of US Public Health Systems

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The long-awaited second edition of Springer-Verlag’s Public Health Informatics and Information Systems was released this winter under the able editorship of JA Magnuson and Paul Fu.  I was privileged to write a chapter on US public health information systems, and took the perspective of a newcomer asking: “How did US systems come to be this way?”

That states perform surveillance, vital registration and other functions in divergent ways using non-interoperable systems is an artifact of an decentralized eighteenth-century constitution that delegated public health authority to state, not national government.   Today this lack of standardization is a source of aggravation in the face of increasing HIT interoperability driven by Meaningful Use and EHR certification.   The federal government has levers to increase standardization in public health just as it does in health care, including facilitating inter-state consensus, adopting industry standards, and making their use a condition of funding.  Inconsistency of priority, direction and funding over the past two decades has failed to deliver standardization now when it is most urgent.

Despite this, I was able to direct emerging informaticians to the products of several recent attempts to standardize public health business processes, vocabularies, and data formats across system domains as varied as chronic disease surveillance, immunization management, newborn screening, vital statistics and communicable disease surveillance.  I like to think there will be less “wheel re-invention” as a consequence.

On the other hand I was disappointed to see how few of these are reflected in the current CDC Public Health Information Network website.  PHIN ideally would provide “one source of truth” regarding standardized information exchange for health departments. If the website is any indication the plan to resuscitate national efforts for public health interoperability has stalled once more.   It would be wonderful if the textbook’s 3rd Edition could direct learners with confidence to a federal source for public health information exchange and interoperability specifications and profiles.

I’m delighted to see that my chapter is among those most often accessed online.  Nevertheless, I cannot help but hope that rapid progress in US public health information systems will push it quickly out of date!

Network with ATL Colleagues: INTERFACE Weds. APRIL 2, 2014

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NTERFACE:ATL networking event WEDNESDAY, April 2nd from 6:30-8:00 pm at Marriott Courtyard lobby bar

Please join my INTERFACE:ATL networking event THIS WEDNESDAY, April 2nd from 6:30-8:00 pm at the Marriott Courtyard lobby bar, 130 Clairemont Ave. in Decatur.
Meet health informatics peers to learn who’s doing what. Several state epidemiologists will likely be on hand. Free to attend, pay own food and drink. See you Wednesday!

Atlanta Networking Sept. 19

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Please share as desired with those interested in health informatics.   I look forward to seeing you in Decatur September 19.

Stage 2 MU Guidance for Health Departments Published, Funding Lags

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The first year of Stage 2 Meaningful Use requirements is coming up fast (October, 2013).  Meaningful use participants will need to achieve ongoing submission of public health reports to health departments.  A multi-organizational taskforce has issued guidance materials for local and state health departments to help them 1) declare their readiness to receive data from eligible professionals (EPs) and hospitals (EHs); 2) establish systems whereby EPs and EHs register their intent to submit data; 3) on-board data submitters; and 4) provide necessary acknowledgement of on-going data submission.  That’s a lot to get ready for!  (Some health departments are also acquiring electronic health record (EHR) systems and will themselves need to demonstrate that they are meeting other Meaningful Use objectives as well.)

Unfortunately, as in earlier years, the President’s FY 2014 proposed budget fails to include dedicated funding to help health departments exchange information with EHR systems (with the notable exception of the National Healthcare Safety Network, which is not part of Stage 2 Meaningful Use regulations).  State health departments are heavily dependent (45%) on federal funding, especially from the Centers for Disease Control and Prevention (CDC).  While several CDC funding programs encourage recipients to use funds for achieving connectivity for Meaningful Use Population and Public Health objectives, CDC’s proposed budgets for programs that would support meaningful use objectives (like immunization and emergency preparedness) would shrink in 2014.  Health departments may indirectly benefit from increased funding for ONC if it facilitates health information exchange, and in a few states partial funding for public health information exchange is addressed in state Medicaid plans.  Most affected health departments will need to make do with existing or shrinking resources as Stage 2 ratchets up expectations.

The ONC’s budget proposal (page 33) seems to suggest that ONC is establishing a dashboard of public health participation in meaningful use information exchange.  This would be an important indicator for policy-makers and public health advocates to watch.

Who will you meet? Food, drink, informatics networking in DC near TEDMED April 18

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Join our first Washington DC area INTERFACE networking salon for those interested in improving public health through informatics.   After work, just blocks from TEDMED 2013 –there’s no telling who you’ll meet!  Join us Thursday, April 18 from 5:30-7:00 pm at the Notti Bianche bar inside GW University Inn, 824 New Hampshire Blvd NW.   Just steps from the Foggy Bottom Metro.  No charge; excellent food and drink available for purchase.   RSVP at sfoldy@sbcglobal.net.  Pass it on!

Meaningful Use and the Learning Health System-HIMSS

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At the 2013 Health Information Management Systems Society (HIMSS) meeting in New Orleans on March 3 I’ll provide guidance to the Physician IT Seminar on how to convert Meaningful Use advances in electronic health records and health information exchange into real learning opportunities to improve care and health.  The Institute of Medicine’s vision for a Learning Health System is “by 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.”  How do the Meaningful Use rules carry us closer to this goal?

I’ve diagrammed critical elements for a learning health system, below.  At its base, and most critically, the electronic health record (EHR) captures information.  This may be entered by clinicians, or received from either patients or other health care providers.  This use of the EHR to “learn about the patient” is fundamental to all other improvements in care.

Various objectives in Stage 1 and 2 Meaningful Use require data capture.  They also require that EHRs be able to exchange information with other clinicians and to some extent with patients.  Meaningful Use objectives also require public health reporting, quality reporting, and decision support, each setting the stage for still more sophisticated learning.

Today, naturally, many providers are obsessed with the implementation of the Meaningful Use objectives and the receipt of incentive payments.  But it is never too soon to consider how these EHR objectives can be pressed into the service of “accurate, timely, and up-to-date clinical information and… the best available evidence.” It is already happening.   For example, in late 2012 a mysterious surge in fungal meningitis cases was detected in Tennessee, and was rapidly traced to certain lots of injection steroids produced by the New England Compounding Center.  Little was known about how to treat the predominant fungus,  Exserohilum rostratum.  Investigators used electronic health record reviews to rapidly identify exposed patients, and to track the success of treatment.   A rapid decline in case mortality among infected persons resulted within just two weeks.  That is truly a learning health system in action.*

Information alone does not bring about learning.  Learning requires a “central nervous system” to process incoming information in light of other knowledge.   Public health agencies, like local and state health departments, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA) are examples of such “central nervous systems.”  But a good brain is useless without being attached to sensory and motor organs.   The Exserohilum rostratum outbreak helps show the Meaningful-Use-certified EHR is beginning to serve a valuable sensory function.   Equipped with decision support tools, it is destined to be a powerful motor organ as well.

 

*Thanks to the American Medical Informatics Association Public Health Informatics Workgroup for a great webcast on informatics use and needs associated with this outbreak.

Stage 2 Meaningful Use begins this year. Is public health ready?

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Thousands of eligible professionals and hospitals will have to meet Stage 2 requirements for the Electronic Health Record (EHR) Incentive Program (“Meaningful Use”) in the coming year.  Some hospitals may seek to attest to Stage 2 objectives as soon as 12 months from now.  For healthcare providers, failure to achieve objectives can put thousands or millions of dollars of incentive payments at risk.  Will health departments be ready to meet them half way in information exchange?  The answer depends on whether they are preparing now.  Absent a strong project plan in the next few months, the answer may be “no”.

Here is a checklist for health departments to consider:

1. Are you prepared for MORE DATA?  The standard for Stage 2 rises to on-going data submission, rather than just sending a test message.   Are you ready to receive, parse and use steady streams of data from many healthcare providers?  Health departments can still manage the pace of on-boarding new providers, but must do so in a way that does not put providers at risk (see points 6 and 7).

2. Are you ready to accept MORE TYPES of reporting from each provider?  In Stage 1 providers could select only one of several “menu” public health objectives.  Some menu options in Stage 1 are now required (“core”) in Stage 2.  For example, hospitals must submit ALL OF immunization data,  electronic laboratory reporting and syndromic surveillance reports to health departments ready to accept them.   Eligible professionals must submit immunization data AND  select from other menu objectives (including several public health options) to obtain their incentive.

3. Are you prepared to use HL7v2.5.1 messages for immunizations and syndromic surveillance?  Two standards to choose from in Stage 1 created confusion and frustration, so there is only one standard for each Stage 2 objective.   However…

4. Are you willing to GRANDFATHER providers that have achieved on-going submission of HL7v2.3.1 messages in Stage 1?  This option is up to the health department, and can help you avoid having to re-on-board those providers already successfully submitting data using HL7v2.3.1.  Any new data providers must use v2.5.1 however.

5. Will you accept CANCER REGISTRY data documents using the Clinical Document Architecture standard specified in Stage 2? Do you intend to sponsor any other SPECIALIZED REGISTRIES in 2014?   These are new “menu” options for Eligible Professionals.

6. Do you have a plan to publicly DECLARE READINESS of what public health reporting objectives you will offer for Eligible Professionals and Eligible Hospitals during each reporting period?  Because providers need timely and definitive information, Stage 2 rules now allow providers to claim EXEMPTION from public health meaningful use objectives if such a declaration is not publicly available for their jurisdiction.  (Public health departments need not receive data for any or all objectives, but if they wish providers to be motivated by Meaningful Use incentives to submit data, they must publicly state in advance of each reporting period which objectives will be accepted.)  A closely related issue: if more than one jurisdiction in a state receives Meaningful Use data submission (for example, if there are both local and state level syndromic surveillance or immunization information systems) are state and local departments planning to COMMUNICATE CLEARLY  which exchange opportunities and requirements apply to which jurisdictions?

7. How will you manage Eligible Professionals and Eligible Hospitals that intend to initiate data submission during each reporting period?  Stage 2 rules require providers to REGISTER their intent to submit data with the appropriate health department.   The health department need not then immediately on-board the provider, but has the option to later disqualify a registered provider from receiving incentives if it fails to respond within 30 days to two written requests to take action (i.e., to begin sending test data, or to adjust transmission, structure or vocabulary to the required standards).

8. Do you intend to DESIGNATE a Health Information Exchange to receive some public health data submissions?  To ensure good end-to-end transmission of reports, HIEs cannot claim to substitute for health departments unless they are designated to do so.

9. Is there CLOSE COORDINATION and a RESPONSIBLE OVERALL MANAGER linking planning with each of the affected surveillance programs (and jurisdictions), the state HIT coordinator, Medicaid director and HIT Extension Center?

[And 10. for health departments using EHRs and enrolled in the EHR Incentive Program: Will my EHR migrate to 2014 edition certification standards, and can we meet Stage 2 objectives to earn our incentive?]

Obviously, serious planning is needed.  Some health departments may be asking: is all this worth the effort?  It is critical to remember that:

1. Meaningful use is establishing the de facto standards that will be used for information exchange in the future.  The faster health departments adopt the new national standards and on-board data submitters, the faster they can be automating data management and the detection and management of critical events.   This can serve both effectiveness AND efficiency.  National data and exchange standards will foster the ability of vendors and development of systems to aid health departments with these tasks.

2. Before long, most providers will have electronic health records that are all certified to capture and transmit information in standardized ways.   Onerous reporting processes for providers, and incomplete reporting to health departments, can both be addressed to the benefit of both through automation.  

3. Health departments can decide the pace at which they enroll providers in Meaningful-Use-specified data exchange.  Health department participation is optional, but Meaningful Use incentives (and later, penalties) will induce providers to begin submission whenever the health department is ready.   What the new Stage 2 rules demand in return is that health departments communicate clear plans and requirements to providers.  It is the latter who then face financial loss if objectives aren’t met.

4. The new rules continue to support the idea of “queuing providers” and on-boarding them at the pace the health department can tolerate.  Once providers are registered, they are not at risk of losing their incentive UNLESS they fail to respond timely (30 days) to requests from the health department.  The health department can invite registered providers to initiate data exchange at whatever pace is practical, and neither party “gets hurt.”

5. Stage 3 will likely move beyond surveillance to improving preventive care delivery.  For example, immunization information systems (which by Stage 3 will be bulging with information submitted by hundreds of thousands of healthcare providers) will likely be able to alert professions to immunizations patients lack, using the EHR during the context of care.

It may be a tough slog now, but there’s much to gain at the far end!

Fortunately, a Stage 2 Task Force of affected public health associations has formed under the leadership of the Joint Public Health Informatics Task Force, the Centers for Disease Control and Prevention (CDC), and the Office of the National Coordinator for Health Information Technology (ONC).  It will soon be issuing fact sheets and other tools, which will likely be distributed at the NACCHO ePublic Health Blog among other modalities.