A study for the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services

American Public Health Association Boston MA11/3/2013

Assessing the Prospects of State and Local Health Department Information Technology Infrastructure

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• 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

• ,

Project Overview

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Relevant Data

Red (bottom): data typically managed by state health departmentsBlue: data typically managed by local health departmentsGreen: data typically managed by private providersPurple: data typically managed by other social welfare agencies

Models for Integration, Interoperability and Exchange to support needs assessment, care coordination, health care quality improvement, monitoring and

surveillance.

PH Services:e.g., TB, STD, HIV, home visiting

clinics, laboratory and case management, Women, Infant

and Children (WIC)

Environmental Health:e.g., licenses and inspection data maintained by local public health

Surveillance:e.g., communicable diseases, STDs, syndromic surveillance,

BRFSS

Program Management:

e.g., Ryan White, Title V, mental health / substance

abuse programs

Private Providers: e.g., emergency departments, hospital infection specialists, commercial labs, primary care providers, behavioral health

Health Care Administrative

Records:Medicaid Enrollment,

Eligibility and Encounters; All-Payer Claims

Health Records:e.g., newborn screening, vital

statistics, early hearing, immunizations, cancer

Social Service Records:

e.g., Schools, Housing Assistance, Nutrition Support,

Heating Assistance

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• 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)

“Opportunity” 1 IT

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• 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

“Opportunity” 2 Reform

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• A logical premise: right information to the right person at the right time

• 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

“Opportunity” 3 Science

Public health mission

Public health activities

Workflow and data flow

Systems requirements

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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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• 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

Areas of Progress

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• 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

Winds of Change

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• 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

Some Lessons

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• 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

Workforce Imperative

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• 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

More Work Needed

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Michael MillmanU.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/

Thank You!