Public Health in Health Information Exchanges White Paper

Return to Case Management White Paper

What is Public Health

Public Health Functions

• 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

Essential Public Health Services

• Monitor health status to identify community health problems
• Diagnose and investigate health problems and health hazards in the community
• Inform, educate, and empower people about health issues
• Mobilize community partnerships to identify and solve health problems
• Develop policies and plans that support individual and community health efforts
• Enforce laws and regulations that protect health and ensure safety
• Link people to needed personal health services and assure the provision of health care when otherwise unavailable
• Assure a competent public health and personal health care workforce
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services
• Research for new insights and innovative solutions to health problems

Organizational Structure

• US Public health as a health care provider
• US Public health as an agency
• US Public health as a Research/Academic Institution [Tim Carney]
• International perspectives (canada?, france?)

References

• Public Health in USA
• other

Activities

Activity List:

• Case Management – what individual does to manage the disease
  • Disease Management – a aggregate analysis of care delivery for a disease entity
    • Chronic Diseases Management (Asthma , Diabetes , COPD, Heart, obesity)
• Decision Support
• Bioterrorism Preparedness/surveillance
• Community Record (creation and maintaince)
• Maternal and Child Health
• School Health
• Environmental health (abatement, asbestos)
• Health Education
• Preventive care services
• PHR Perspectives (significance to an infdividual patient) [Dave McCord]
• Public Health Informatics & Emergency Response [ Jennie Lou]
• Patient Safety [Xu Wu]

Links:

• Public Health Activity Examples, in USA
• other

Stakeholders

• Safety-net clinics
• Healthcare providers (private)
• Local Health Department
• State Health Department
• Other Governmental Agencies (e.g. DOE/CDC/HHS)
• Other healthcare providers (e.g. hospitals, labs, RX, Nursing home, home health)
• Medicaid/Social Services case workers
• Disease Management Departments
• Emergency responders

Workflows and Processes

Scope

Clearly state the scope of what we are addressing in this paper.

• data types
• Send/assess/policy
• Screening/biosurveillance
• Send/feedback/clinical care intervention (closed loop process)
  • PH agent
  • Clinical care provider
  • Outbreak/emergency
  • Oversight (e.g. sicklecell – nationwide screening; group with abnormal result; then intervene)

Existing processes and technologies

State (regional) efforts

• e.g., immunization registries [Alien Kirnak],
• disease registries (e.g., cancer registries [Sandy Thames],
• EMS-Trauma Systems [Chris Tilden],
• public health laboratories,
• vital registration [Marjorie Greenberg/Michelle Williamson] etc.
• france?

Interstate (inter-regional) efforts

• e.g., Great Lakes region interstate collaboration, etc.;

National efforts

• USA: e.g., EpiInfo, NEDSS, EPHTN, Surveys [Karen Lipkind], etc.
  • Organizations: AHIC, HITSP, HISPC, CCHIT, NHIN prototypes projects, PHIN, Other….
• (efforts from other nations: Canada?, Germany? Other?),

International Efforts

• ??

Cooperation with Clinical Care

• Connecting Communities for Better Health projects
• AHRQ HIT demonstration projects
• RWJ InformationLinks projects [Chris Tilden, Dave Ross – to be approached]
• RWJ Common Ground projects [Chris Tilden, Dave Ross – to be approached]

Interoprability Efforts

• NYC - Community Health Centers & Health Department
• PHDSC Interoperability Prototype, 2005
• IBM Laboratory Demonstration Project
• Other????

Example (Ideal) Scenario

• Today – paper based: Workflow for school health scenario
  • Parent requests form vs Provider fills in health form
  • Provider signs health form
  • Provider gives form to parent to bring to school

• Future: for school health scenario
  • Parent provides RHIO consent for release restrictions to school system (BPPC)
  • Parent provides RHIO consent for release of school health record to system
  • Provider/EHR generates School Health Form including DSG
  • Provider EMR submits school health form to RHIO (DOE?) (Provide and Register)
  • School nurse retrieves health form from RHIO into local school EMR (document Consumer)
  • School nurse EMR generates walkin visit medical summary (XDS-MS)
  • EMR sends medical summary to RHIO (Provide and Register)
  • (School attendance system generates school attendance data)
  • Local public health retrieves Medical data from RHIO school and medical system submissions (document consumer) (?Aggregate Data Retrieval)
  • Local public health analyses data for trend analysis
  • Condition detected through trending (e.g. flu) Case investigation
  • Intervention
    • Communication with parent
    • In-school services to mitigate illness (e.g. vaccination)
    • In-school Education (opportunity?)

Technical Requirement Definitions

1. Express the criteria: This is the data definition used to determine that a patient qualifies for a particular PH program. The program has a well defined population to serve, though the population may be difficult to identify. Examples:
   • Newborn Screening – all newborns born in that state (birth)
   • Newborn Follow-up – newborn with a positive newborn screening test (lab result)
   • Immunization – all children in that state (Medicaid enrollment)
   • Cancer Registry - all patients with positive test for cancer (lab result)
2. Identify a patient meeting certain criteria (compositional) – patient level:
   • This is the identification of patients that qualify for a particular PH program. How this happens varies greatly within PH. Patient identification comes from referrals that include private and public clinics as well as other agencies. Incoming lists may require human review and further clarifications. Examples:
     • Newborn Screening – all birthing centers, safe haven medical facilities
     • Newborn Follow-up – public health laboratory
     • Immunization – private and public clinics, Medicaid enrollment lists
   • Also important in many PH programs is the continued evaluation of patients in the registry that continue to meet the program’s defined population requirements. Ex. Age, Address, Income, Insurance. Examples:
     • Newborn Follow-up – confirmation of laboratory diagnosis age birth to adult (18) living in state
3. Reporting data: This is the registry creation of patients that qualify for a particular PH program and interventions provided. Examples:
   • Newborn Screening – public health laboratory value, confirmation of laboratory diagnosis, ongoing treatment reports
   • Immunization – immunization given, waived, or refused
4. Data Review/feedback: This is the processing of the reporting data for compliance, completeness, and accuracy. Compliance is evaluating that the reports expected are received in a timely manner and match to patients known to be included in the program registry. A report received for a patient not in the registry would need to be evaluated for inclusion in the program. Completeness is identifying missing or weak content that needs follow-up. Accuracy is correctness of the data if determinable.
5. Analysis/Evaluate
6. Mapping (harmonizing semantics and concepts)
7. Validation (data integrity, correctness… QA)
8. Aggregation/reporting (communicate aggregated report – probably different by topic)
9. Communication (of raw data, of analyzed/aggregated data, of feedback/alerts, Sharing)
   1. Care coordination
   2. Population based
10. Clarification (data reported – need clarification on meaning of the data – or additional supporting data)
11. feedback
12. Iterations
    1. reset
13. Workflow
    1. Oversight of successful fulfillment of process
14. Guidance

Simmilarities to Quality and Clinical Trials

• Identify Cohort/populations fitting a similar criteria
• Select Cohort
• Overlaps (e.g. PH/Quality: HCUP/HEDIS, Pharmacovigillence - quality)

Differences with Quality and Clinical Trials

• E.g. PH Environmental subject of care (water, building…)
• Privacy Requirements (constraints)

Goals

Collaborative Goals

This section will describe the organizational goals of this joint collaboration (what “people”-related things we want to accomplish).

1. Engaging public health community in the development of the technical specifications for interoperable clinical and public health systems: IHE Profile Proposals for 2007-2009
   1. Identify public health domain/programs for the development of profiles – more on this in the next section
2. Educating the community (vendors, public health, etc.) on the new profiles or profile extensions for public health.
3. Encourage adoption of our joint technical output in the community (both public and private)
   1. Roadmap for public/private collaboration: Building health information exchanges between clinical care and public health
   2. Harmonizing state policies and regulations

Technical Goals

This section will describe the goals related to new/existing technology that needs to be created/employed

1. Proposed timeline (or prioritization list)
   1. Identify common (public health domain independent) core technologies that need to be established as profiles (or profile extensions, in the case that a profile exists that can satisfy a particular technical goal).
   2. Identify public health domain/programs for the development of profiles
2. Developing functional requirements and specifications (profiles) for interoperable clinical-public health systems
   1. Data content harmonization across public health systems
      1. Document and message based
   2. Data sharing workflows
      1. Document and message based
   3. Notification/Surveillance
   4. Privacy and security
   5. public health specific domain considerations
      1. ex. Immunization, Reportable Conditions, etc.
   6. etc?
3. Survey of existing international Standards and IHE profiles – This section will contain a list of standards, existing IHE profiles, etc. that will be under consideration for use in achieving the aforementioned technical goals.
   1. Data content harmonization
      1. Document: HL7 CDA, CEN?, X-forms
      2. HL7 v2.x and v3 messaging
      3. SNOMED, LOINC, CSTE? Other terminologies?
      4. Existing IHE content profiles: XDS-MS, XDS-Lab, XDS-I, XDS-Lab for public health (in progress), etc.
      5. Work done by HITSP?
   2. Data sharing
      1. IHE Laboratory technical framework
      2. XD* - Cross Enterprise Document Sharing
      3. RFD - Retrieve Form for Data Capture (RFD)
      4. QED – query for existing data (in progress)
      5. Work done by HITSP?
   3. Notification
      1. NAV – Notification of Availability
      2. Work done by HITSP?
   4. Privacy and Security
      1. ATNA – Audit trail and node authentication
      2. XUA – Cross-Enterprise user authentication
      3. Work done by HITSP?
   5. public health specific domain considerations
      1. ex. Immunization, Reportable Conditions, etc.
      2. Decision support (HL7 and OMG collaboration)
      3. Work done by HITSP?
   6. Etc.