Semi-retired, I am trying to organize some memories about what has felt like a pretty remarkable life. Posting them on this website allows friends, family and colleagues to leave embellishments or to correct inevitable errors of memory, fact and attribution. I hope you enjoy the first story describing how in 1977 activists at Stanford University contributed to the fall of apartheid in South Africa.
I stepped away from this website and closed my consulting business in 2017 when I joined what is now the Public Health Institute at Denver Health, supervising epidemiology, emergency response and informatics innovation. After responding to COVID-19, hepatitis A and fentanyl epidemics I’ve semi-retired. I am now donating my time to CDC/associations to establish public health Fast Healthcare Interoperability Resources (FHIR) and the International Joint Commission to prepare for climate change health effects along US-Canada boundary waters.
I’ll post about current activities here, and will likely add some remembrances too. I hope others’ comments will help repair any false memories, of which there are likely to be a few!
Thanks to all who remain part of my professional and personal cadre.
How do changes in the environment affect human behavior and human health? Even events as traumatic as the 2010 Deep Horizon oil rig disaster left few fingerprints of mental or behavioral effects using traditional public health survey technology. Are there few effects, or do traditional methods fail to discern them? The inability of hypothesis-driven surveys to yield medical diagnoses doesn’t mean that families’ health behaviors, social or economic well-being and connection to the gulf haven’t changed in meaningful ways.
Sudden changes to local waters can create big effects. The 1993 Milwaukee cryptosporidium outbreak (from Lake Michigan drinking water) killed nearly 100 people and left an entire city on edge for years every time it rained heavily. 2014’s sudden, if temporary, loss of municipal drinking water in Toledo, OH (due to harmful algal blooms) and Charleston, WV (due to a chemical spill) indicate how fragile human health and community well-being are in the face of sudden environmental changes (which will increase with anthropomorphic climate change). Gradual changes in environmental quality, such as mercury and PCB contamination of fish and rising beach closings from sewage pollution affect large populations and major economic activities, but their effects are harder to assess.
Does environmental degradation spur diarrhea or depression, anxiety or apathy, fishing or flight? What is the time course and effect size of different types of events on both human health and human attitudes? Historians and archeologists try to answer such questions using old letters, diaries and physical evidence. Today massive new caches of information have become far more immediately available as each of us leaves a near-real time internet trail of observations (posts, photos), emotions (“likes”, emoticons and “flameouts”), actions (consuming, advocating), location changes (visiting, avoidance, in- or out-migration) and physiologic measurements (from our FitBits and Apple watches). These data are now time-stamped, geo-positioned, #hashtagged and otherwise encrusted with useful metadata. Methods to create, mine and understand such massive, untidy data are evolving as rapidly in civil society/non-profit organizations, marketing firms, and technology start-ups as in academia or government.
I was recently honored to be named US co-chair of the Health Professional Advisory Board (HPAB) of the International Joint Commission (IJC), a treaty-based organization that has been preventing and resolving US-Canada conflict over our thousands of miles of shared shorelines and waters since 1907. IJC has issued a Request for Information (due July 24, 2015) asking businesses, civil society organizations, academics, government agencies and individuals to describe or propose how to use social networking and similar internet information to study changes in human health and behavior contemporaneous with environmental change in our boundary waters. Please forward this Request for Information to anyone who might be able to contribute.
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.)
The clock is running for public health advocates to advise what should be included in Stage 3 of the Electronic Health Records (EHR) Incentive Program (“Meaningful Use” (MUse)).
January 14, 2013 is the deadline for comment on the Health IT Policy Committee’s recommendations for Stage 3.
- A key issue is whether EHRs should be certified in Stage 3 to generate electronic public health reports using a new, standardized approach. The Public Health Reporting Initiative is finalizing both a harmonized data element profile and a Clinical Document Architecture implementation guide in the next few weeks.* These are based largely on the Cancer Registry reporting standard that appears in Stage 2 MUse rules and on implementations already in place for the National Healthcare Safety Network (NHSN) and recommended for Stage 3. Adopting the PHRI approach need not require change to existing MUse reporting activities like electronic laboratory reporting, immunization registries or syndromic surveillance. However, it provides a reusable, modular, and extensible methodology that could be leveraged by these and many other types of reporting (for example, communicable disease case reports, product safety reports, birth and death reports) into the future.
- The public health (and health IT) communities should examine the PHRI documents to decide if they represent an achievable step toward more generic interoperability between EHR and public health surveillance systems. If so, they will have to make their voices heard during the comment period, because MUse Stage 3 certification is NOT recommended by the HIT Policy Committee (rather, it is recommended for some future, unspecified time).
- The Centers for Disease Control and Prevention (CDC), which funds much US public health surveillance, needs to decide and announce whether it will support pilot implementations, full-scale implementation, and health department migration to the new approach going forward.
- The Office of the National Coordinator and CDC need to ensure that PHRI products are harmonized with similar initiatives across the ONC Standards and Interoperability Framework, and curated and maintained over time.
- Other important issues in the Stage 3 recommendations include EHR data capture of information like occupation and disability; whether NHSN hospital reporting should be included as a new objective; and whether additional public health registries should be offered as choices in the incentive program.