Claire Broome, M.D. Health Information Technology Summit March 7, 2005

1. Leveraging Health IT: How can informatics transform public health (and public health transform health IT)? Claire Broome, M.D. Health Information Technology Summit March 7, 2005

2. How can informatics transform public health (and vice versa)? • How can informatics transform public health? • Overview of public health role • Early detection and Biosense initiative • Progress in HIT capacity at state and local health departments • How can public health transform health information technology?

3. What is the “business” of public health? • Surveillance (disease tracking) • Early outbreak detection : bioterrorist, foodborne • Assess health status of population • Assist in planning access to health care • Investigation of causes and transmission pattern • Development of effective interventions to prevent disease and promote health • Vaccines • Decision support for eye care for diabetics

4. Public Health Lab Hospital or Health Plan CDC and Other Federal Organizations Investigation Team Health Department Ambulatory Care R X Pharmaceutical Stockpile Non-Clinical Sources OTC, 911, etc. Vaccination Center Law Enforcement and First Responders Public Public Health Information Network (PHIN)

5. Public Health Information Network • Early Event Detection • Outbreak Management • Surveillance/Case Reporting • Connecting Lab Systems • Secure Communications • Analysis & Interpretation • Information Dissemination & Knowledge Management • Countermeasure administration and Response Federal Health Architecture, NHIN & Consolidated Health Informatics

6. Public Health Information Network - Vision To transform public health by coordinating its functions and organizations with information systems that enable: • real-time data flow • computer assisted analysis • decision support • professional collaboration • rapid dissemination of information to public health, clinical care and the public

7. How can informatics transform public health (and vice versa)? • How can informatics transform public health? • Overview of public health role • Early detection and Biosense initiative • Progress in HIT capacity at state and local health departments • How can public health transform health information technology?

8. Surveillance approaches for early detection of outbreaks • Informed alert health care provider notifies local or state health department 24/7 contact • “Syndromic surveillance” --healthcare databases and novel data sources (veterinary labs, retail supermarket sales, business absentee data, etc) analyzed with various aberration detection algorithms • Systematic evaluation of utility of data sources, algorithms, systems needed • Disease specific health surveillance system detects an increase in disease specific reporting • National Electronic Disease Surveillance System (NEDSS) • Any “signal” irrespective of source will need confirmation, investigation

9. BioSense - Principles • Early event detection is critical for Bioterrorism management and response • The most useful tools will be dual use; Bioterrorism capable and regularly exercised for “routine” public health activities • Multiple data sources should be co-ordinated to facilitate signal evaluation and reduce user burden • Both diagnostic and pre-diagnostic (syndromic) data exist in electronic form in many yet untapped health-related data stores

10. BioSense Software System • National “safety net” – help support early event detection in major cities • An implementation of identified standards • A platform for the implementation and evaluation of different analytic approaches • Connection to the CDC BioIntelligence Center to support early detection analysis at local, state and national levels

11. Data Sources Currently Available • DoD – Ambulatory Care and ER Diagnoses - Up to four diagnosis codes (IDC-9-CM) identifying the reason for every US ambulatory care (including ER) visit • DoD - Procedures - Procedure codes (CPT) ordered for every U. S. ambulatory care visit • VA - Ambulatory Care and ER Diagnoses - Diagnosis codes (IDC-9-CM) for every US ambulatory care visit (including ER) in 172 hospitals and 650 outpatient clinics nationwide • VA – Procedures - Procedure codes (CPT) for every U.S. ambulatory care visit • Clinical Laboratory Tests - Clinical lab tests ordered nationally • BioWatch Results - Lab result for BioWatch environmental collectors

12. System Status • Views for all states and all BioWatch cities • 300 state and local health department user accounts • In use in CDC BioIntelligence Center • Have set up custom views for high profile events—eg G8 meeting • Detection algorithms • CuSum, “Smart Scores” – implemented • SatScan - pending

13. BioSense Home Page Analytical Summary Information Region Selection Demonstration Data “Punchcards” and Analytical Summary “News” and Important Detailed Information Data Load Report

14. BioSense Health Indicators Page Data Visualization Demonstration Data User Options Menus Syndrome-Specific “Consolidated” Graphs Links to Syndrome-Specific Display Pages

15. BioSense Health Indicators Page Syndrome-Specific Maps Demonstration Data Zip Code “Mouse Over” Display Zoom-In/Out And Map Navigation Tool Data Source Specific Maps

16. HIT could facilitate linking additional data important for early detectionto Biosense • Claims clearinghouses • Hospital systems and health plans • Hospital information systems vendors • Other national clinical testing labs • Regional Health Information Organizations • With local and state health departments, local clinical care sites

17. How can informatics transform public health (and vice versa)? • How can informatics transform public health? • Overview of public health role • Early detection and Biosense initiative • Progress in HIT capacity at state and local health departments • How can public health transform health information technology?

18. Public Health Information Network Funding • September 2002 Public Health and Social Services Emergency Fund • $1 billion for state and local public health preparedness capacity • CDC and HRSA require in grant guidance use of standards for IT investments—www.cdc.gov/cic • September 2003, 2004 : continued state Preparedness funding • HRSA grants $498 million ; CDC $870 million • All 50 states funded for continuous internet connectivity to counties (fy1999) and surveillance planning ( fy 2000)

19. Moving from conceptual to real • state and local health departments have different stages of electronic systems and IT capacities • Each state/jurisdiction will need to develop specific plans • Which systems to integrate • What funding streams available • Central concept of PHIN is implementation of standards based interoperable systems so all • Support interoperability with clinical care partners, other states • Efficient use of technical expertise, tools • Plan for extensibility

20. How does PHIN improve local and state capacity? • Web entry: case information available to local & state health departments immediately on entry (no paper, no mail) • Supports case investigation by state and local health dept • Standardized data sent electronically to CDC • Same application for over 140 diseases, replacing disease specific “stovepipe” applications

21. How does PHIN accelerate disease detection by local & state health? • Electronic laboratory results reporting (ELR) from clinical diagnostic laboratories • For pre-defined results of public health importance, electronic message to health department automatically sent • Message includes structured data including test, result, provider ID, patient age, sex • Multi-jurisdiction labs, public health labs, some local labs • Nebraska sees 3 fold increased number of cases reported; data at state within days of visit instead of weeks

22. Status of state PHIN enhancements January 2005 *application in use: 1 commercial (3 states); NEDSS Base System (10 states); custom (12 states) ,

23. How will public health benefit from PHIN and HIT? • Increased timeliness for early detection: ELR, Biosense • Increased number of cases reported: ELR • Decreased data entry burden—for health department (web entry; data automatically entered) For partners • Easier to track and manage workflow for investigators • Better alerting and communications • Increased analysis capacity for state and local personnel • As EHR’s and decision support mature, can implement public health guidelines in clinical practise

24. How can informatics transform public health (and vice versa)? • How can informatics transform public health? • Overview of public health role • Early detection and Biosense initiative • Progress in HIT capacity at state and local health departments • How can public health transform health information technology?

25. How can public health accelerate interoperable standards based health information systems? • Public health intrinsically must exchange information with all clinical partners in a population • Shouldn’t all RHIO’s have a public health participant? • Evident public value—outbreak detection, preparedness • Concrete solutions for standards based interoperability – e.g. • bidirectional secure messages (ebXML) • HL7 V 3 messages • Implementation guides for message content—eg lab results • Development of data use agreements • Public Health content & services for EHR’s

26. How do we get to standards based interoperable systems? Gartner Group project on PHIN implementation – PHIN is a multi-organizational business and technical architecture • Technical standards • Data standards • Specifications to do work Is also a process • Commitment to the use of standards • Commitment to participating in development and implementation of specifications

27. Improving preparedness: enhanced diagnosis and reporting • Information on clinical presentations: • E-mails via states, professional societies • Web sites—CDC >12,000,000 downloads • CDC’s Distance Learning network 10 programs for >1,300,000 participants (fall 2001 events) • Diagnostic capacity for BT and chemical agents • Laboratory Response Network—CDC & APHL-reagents & protocols from web site • Ability to contact health department 24/7 • States funding for epidemiology staff, communications with hospitals • Communications platforms, alerting protocols

28. Public Health Information Network Tools available from CDC • Software for industry standards based bi-directional inter-institutional messaging transport (PHIN MS) • ebXML “handshake,” PKI encryption and security • Technical assistance & direct assistance available for public health partners (eg security IVV) • PHIN Vocabulary Access and Distribution Services, including web accessible Standard Reference Tables • Implementation Guides that specify data standards, message format

29. Example of a potentially useful “tool”: PHIN Messaging System (PHIN-MS) Softwarefor industry standards based inter-institutional message transport available from CDC • ebXML “handshake”, PKI encryption and security • Payload agnostic (HL-7, text file, etc) • Bi-directional data exchange PHIN-MS in use by state and local partners for point to point messaging (ED and lab to state; state to CDC) Several commercial systems planning to incorporate integration broker laboratory information system

30. How do we get there from here? • We don’t have the ideal technology, but there is much we can do NOW • Standards and tools can help • Leverage funds, hardware, software, technical expertise, experience • Let’s commit to working together to transform the public’s health!

31. Background Information

32. What does PHIN have to do with HIPAA? • HIPAA mandates national health care data standards and policies in four areas: • Transaction content; unique identifiers for providers, health plans; security; privacy • PHIN architecture standards are HIPAA compliant: • supports “dual use” for security, messaging elements • Approach to PHIN data standards is HIPAA compliant: • Adopting HIPAA standards where relevant eg electronic laboratory reporting in PHIN uses HIPAA claims attachment • Advocating inclusion of data elements relevant to public health with SDO’s

33. What does PHIN have to do with HIPAA Privacy Rule? • Privacy Rule allows current practice of sharing data with public health • Rule permits health care providers to share individually identifiable information with legally authorized public health entities for public health activities • Public health activities include surveillance (NEDSS), investigation, intervention