GOVERNMENT, POLITICS, AND LAW

Opportunity Forged by Crisis

Public Health Surveillance and Meaningful Use Regulations:A Crisis of OpportunityLeslie Lenert, MD, MS, and David N. Sundwall, MD

The Health Information Tech-nologyforEconomicandClinicalHealth Act is intended to en-hance reimbursement of healthcare providers for meaningfuluse of electronic health recordssystems. This presents both op-portunities and challenges forpublic health departments.To earn incentive payments,

clinical providers must ex-change specified types of datawith the public health system,such as immunization andsyndromic surveillance dataand notifiable disease report-ing. However, a crisis loomsbecause public health’s infor-mation technology systemslargely lack the capabilities toaccept the types of data pro-posed for exchange.Cloud computing may be

a solution for public health in-formation systems. Throughshared computing resources,public health departmentscould reap the benefits of elec-tronic reporting within federalfunding constraints. (Am J Pub-lic Health. 2012;102:e1–e7. doi:10.2105/AJPH.2011.300542)

You never want to let a seriouscrisis go to waste. . . . It’s anopportunity to do things youcould not do before.

—Rahm Emmanuel, formerWhite House chief of staff

Public health faces an impend-ing crisis in health informationtechnology. The Health Informa-tion Technology for Economicand Clinical Health (HITECH)Act1 aims to automate health re-cords in the United States. Theadministration of President BarackObama, continuing an effortlaunched by President George W.Bush, supports the measure, whichis administered by the Of!ce ofthe National Coordinator (ONC) forHealth Information Technology.This program provides fundingof up to $30 billion to facilitateadoption of health informationtechnology, most of it for directreimbursements to cliniciansand hospitals as an incentivefor adoption. The efforts of ad-vocates on the ONC’s HealthPolicy Advisory Committee ledto inclusion in the initial federalregulations for reimbursementof expenses related to medicalrecords adoption speci!cationsdesigned to enhance 2-way com-munications between the clini-cal and public health sectors.Initial requirements specify

transmission of data to publichealth departments on eitherimmunizations or syndromic sur-veillance by individual health careproviders, noti!able conditions orsyndromic surveillance by hospi-tals, and speci!c data where re-quired by state law.2 Providers arealso required to provide data to theCenter for Medicaid and MedicareServices on a variety of qualityindicators that may have publichealth implications, such as rates ofdelivery of smoking cessation in-terventions and the degree of con-trol of hypertension in a providerspractice. Unfortunately, the pro-gram has created unfunded man-dates that worsen !nancial strainson state and local health depart-ments.

Providers who meet meaningfuluse speci!cations,3 as further de-!ned in rulemaking, are eligiblefor payments of up to $44000per Medicare provider and up to$63000 per Medicaid provider.1

However, if providers ignore thisrule, beginning in 2015 substantialpenalties (starting at 1% reductionin reimbursement and increasing to5% by 2020) will be imposed. Thelegislation provides for the secre-tary of the US Department ofHealth and Human Services tomake the criteria for meaningful

use of electronic health recordsmore stringent and extensive asthe program evolves. Federalrulemakers divided meaningfuluse into stages 1, 2, and 3; criteriafor stage 2 are targeted to be fullyimplemented by 2014 and forstage 3 to begin in 2015.4 Becausethe meaningful use regulatoryframework extends beyond initialadoption to ongoing use of elec-tronic health record systems, itprovides a strong lever to encour-age clinical care providers to in-tegrate their information "owswith public health departments.

Meaningful use regulationspose a signi!cant challenge forpublic health of!cials: they requirepublic health institutions to beable to receive data transmissionsin forms speci!ed by ONC. Thisis likely to become a substantialproblem because of the manytypes of health information tech-nology (IT) systems, the number ofdifferent providers, the relativeimmaturity of standards, and thecosts of becoming compliant withthese requirements. If publichealth departments are not ableto support connectivity, healthcare providers and hospitals intheir jurisdiction are exemptedfrom requirements to provide datato these departments.2

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Furthermore, meaningful userequirements are designed toevolve rapidly: in stage 2, sched-uled to begin in 2014, publichealth departments are expectedto be able to receive data regularlyfrom clinical providers for noti!-able conditions, immunizations,and syndromic surveillance. Instage 3, beginning in 2015, elec-tronic health records systemswith new capabilities, such as theability to work with public healthalerting systems and on-screen“buttons” for submitting case re-ports to public health are envi-sioned.4 Public health departmentswill be required not just to upgradetheir systems once, but also to keepup with evolving changes in theclinical care system prompted bymeaningful use regulations.

The size of the task facing pub-lic health departments to managereceipt of data from the clinicalcare system is daunting. Withmore than 5000 individual hos-pitals (>3700 independent hospi-tals)5 and more than 230000physician practices in the UnitedStates,6 each of whichmight requirea unique connection to 1 or morepublic health departments at thestate and local levels, the task ofbuilding an integrated infrastruc-ture is signi!cant. Even with antic-ipated consolidation of practicesand hospitals through health infor-mation exchanges, it will be costlyand dif!cult. Furthermore, the re-quirement for continual evolutionof the types of communicationsproposed for meaningful use addsto the problem. Each connectionbetween public health departmentsand clinical care providers mayneed to be revised several times asrequirements evolve. Where are

state and local public health de-partments to !nd the funds to adapttheir IT systems to this massive andconstantly evolving data stream?

Data from a recent survey bythe Association of State and Ter-ritorial Health Of!cers suggestthat public health departmentsare ill prepared to meet even theinitial requirements for surveil-lance systems.7 Fewer than 45%of state health departments re-ported being ready to test receivingmeaningful use data on syndromicsurveillance. Rates of reportedreadiness for testing of noti!ablediseases and immunization datawere higher, but additional work isneeded. The most common ob-stacle, as might be expected (37of 48 respondents), is a lack offunding. The bene!ts of upgradingto be able to receive messagesfrom meaningful use are not clear:one survey respondent said,

Updating our [ELR] infrastruc-ture . . . will cost over $100000including re-certi!cation. . . .Updating . . . will not provide anyreal bene!t to us as the PublicHealth Department.7(p13)

Local health departments likelyface even greater challenges inresponding to meaningful use. Arecent National Association of Cityand County Health Of!cials sur-vey of local health departmentsfound that 72% identi!ed insuf!-cient funding among their top 3barriers to system development.8

However, money is not the onlyproblem. Lack of time or resourcesto divert from current programsand responsibilities was a top bar-rier to system development for55% of survey respondents.

A further problem is growth inthe volume of data that will come

to the public health systems. Esti-mates from the Indiana HealthInformation Exchange suggest thatautomation of reporting for noti!-able diseases will increase thevolume of reported diseases about4 to 10 times over that of man-ual reporting.9 New systems andwork "ows will be needed to pro-cess these reports, for example,automating access to electronicmedical records to facilitate caseinvestigation. Increases in the vol-ume of data for syndromic systemscould be much greater. Many localagencies with functional systemsonly receive syndromic data froma few hospitals in their jurisdiction.

Demands on immunizationregistries also will increase, be-cause providers are essentiallymandated to report immuniza-tions to registries, potentiallyoverwhelming existing infra-structure. New kinds of capabil-ities are also envisioned for laterstages of meaningful use, such aslinking electronic health recordswith chronic disease registries,buttons for reporting of noti!ablediseases, and vaccine forecast-ing.4 Therefore, public healthreadiness for meaningful use re-quires more than a 1-time invest-ment: it requires ongoing upgradesof public health infrastructure.

LACK OF INFORMATIONTECHNOLOGY FUNDING

The authors of the HITECHAct envisioned the need, and au-thorized funding, for governmentinfrastructure to work with theenhancements to the private sec-tor systems funded throughHITECH.10 However, it is appar-ent that funding for public health IT

infrastructure has not been a prior-ity for ONC or even the Centers forDisease Control and Prevention(CDC). During the transition periodbetween administrations, CDCdeveloped a plan for substantial(>$149 million) funding of publichealth IT infrastructure improve-ments from HITECH.11 However,this proposal was withdrawn, andONC redirectedmost of the moneyspreviously considered for publichealth IT infrastructure to otheruses. Approximately $30 millionof HITECH funding has gone topublic health, including $12 mil-lion for upgrading immunizationregistries, $5 million for publichealth laboratory interoperability,and $5 million to a program led bySurescripts to link 500 hospitallaboratories to health depart-ments.12 But these initiatives do notfund health department integrationof the data into their systems. Cur-rent funding covers only a smallfraction of what CDC had estimatedin 2008 was needed to preparehealth departments for the chal-lenges of integration with a healthcare system that relies on electronichealth records.13

Public health had a secondchance to garner appropriateddollars to meet IT infrastructureneeds for meaningful use with thepassage of the Patient Protectionand Affordable Care Act,14 whichauthorized spending of up to $700million on public health infrastruc-ture, including IT infrastructure. Ofthe authorized moneys, CDC dis-bursed about $70 million in 2010for infrastructure improvementgrants. Amounts for informaticsinfrastructure support were rela-tively small in the initial award.Additional funding for informatics

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is available to support publichealth infrastructure for meaning-ful use through the ElectronicLaboratory Capacity grant pro-gram ($40 million in 201115),although this program is alsointended to serve many otherpublic health infrastructure needs.

CRISIS

These choices and prioritieshave created a serious challengefor public health of!cials at thelocal, state, and national levelswho try to uphold public health’send of meaningful use require-ments. The HITECH Act couldincrease availability of data fromthe clinical care system to publichealth, but the needs for expansionof the capabilities public health in-formation technology systems aregreat and the funding to meet theseneeds is relatively small. Allowingthe health care system to evolvewithout public health integrationwill have serious consequences forcommunities.

Furthermore, even if federalfunds were available to supportpublic health integration with theclinical care system, public healthbusiness processes for IT are in-adequate to the task of integratingwith a fast-paced interoperable na-tional program. Even if funding forgrant programs could be found,the process of meeting evolvingrequirements of meaningful use isill suited to traditional CDC-fundedgrant programs. Such mechanismswould require states not only tocompete for eligible funds, butthen to design systems and selectvendors for ongoing efforts, whilealso working with local (city andcounty) health of!cials who want to

maintain autonomy along with in-teroperability. The result could beunnecessary variability betweensystems and, perhaps more impor-tant, prolonged development pro-cesses with uncertain prospects forsuccess. The current approach topublic health IT infrastructure de-velopment is unlikely to be agileenough to be relevant to the rap-idly moving meaningful use time-line. A new approach is needed.

A POSSIBLE SOLUTION

If public health practitioners !ndthe will to work together, they cantake advantage of a solution thatoffers greater capabilities and couldeven save money. This solutionwould involve the conversion ofpublic health information manage-ment activities, particularly thosethat interface with the health caresystem, to cloud computing.

Cloud computing has many vari-ants, but its foundation is a migrationof software platforms away frominstallations on a desktop or serverin a local facility to remote hosting,potentially at several sites, linked bythe Internet.16 TheNational Instituteof Standards and Technologyde!nes cloud computing as

a model for enabling ubiquitous,convenient, on-demand networkaccess to a shared pool of con-!gurable computing resourcesthat can be rapidly provisionedand released with minimal man-agement effort.17(p6)

Features of cloud computing in-clude customizability for individualusers, fault tolerance and disasterresilience, scalability in perfor-mance on demand, and freedomfrom infrastructure costs for theuser. Cloud computing can also

integrate technologies that can fa-cilitate sharing of data across userswhile allowing owners to maintaincontrol of their data. Examples ofcloud computing services availabletoday are tools such as Googledocs, social networking applica-tions such as Facebook andLinkedIn, and business applica-tions such as Salesforce.

Cloud computing has variousservice models. The most familiarmode is Software as a Service(SaaS). Users share either a singlecopy of a software program(Facebook) or the infrastructurethat provides access to multipleversions of a software program(e.g., 1 for each organization usingthe cloud resource). The optionthat is most relevant to publichealth, in our opinion, is Platformas a Service (PaaS).17 PaaS allowsusers to share a common library ofprograms, including software-authoring tools and databases.Users own a full version of theirenvironment, in which they canbuild customized programs asthey choose. The operating systemand other networking features areclones of each other, minimizingproblems with incompatible con!g-urations and reducing the level ofexpertise needed to achieve inter-operability.

Security in a cloud environ-ment depends on existing meth-ods: virtual private networks toencrypt data transmissions, !re-walls to keep unauthorized usersfrom accessing systems, andmethods of authentication ofusers, such as smart cards andbiometry.18 Cloud applications canmeet Health Insurance Portabilityand Accountability Act security re-quirements.19 Multiple electronic

health record vendors have adop-ted cloud solutions that are in dailyuse for managing con!dential pa-tient data. However, in addition tothe usual security measures, cloudsystems have to protect against in-troduction of software that breaksdown the software barriers be-tween different users’ programs anddata.18 This is best done in collab-oration with cloud clients with opensecurity models and principles.However, it may be dif!cult for oneclient to prevent sophisticated at-tempts at intrusion by another. Acloud service restricted to publichealth departments would offerreasonable levels of security, atsuf!cient size to control costs.

Although it is highly desirable foreach public health jurisdiction tomaintain its autonomy, the idea thateach one needs to maintain a sepa-rate IT infrastructure to achievethat autonomy is obsolete. It iseminently feasible to offer the soft-ware systems needed by publichealth departments through cloudservices. An early example of theuse of cloud computing approachesin public health was the NationalElectronic Disease SurveillanceSystem (NEDSS) Base System Ap-plication Service Provider version.20

Under this program, CDC offeredstates the opportunity to access itsNEDSS Base System software usinga Web-based SaaS model usingwhat would now be described as aprivate cloud approach. States couldsubscribe to the NEDSS Base Sys-tem software, with each state havingits own version that was customizedto its needs, with the sharing ofinfrastructure and support costs forthe private data center with CDC.CDC also has recently developeda SaaS public cloud system for its

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redesign of BioSense to bettersupport meaninful use data re-quirements.21

CLOUD COMPUTING FORINTEROPERABILITY

In addition to the new problemsposed by meaningful use, publichealth departments continue toface the obstacle of data silosacross organizations and pro-grams. Local jurisdictions use sys-tem barriers to prevent interfer-ence by states, and states do thesame to prevent interference byCDC. This practice needs to bereplaced by an interoperable sys-tem. Of course, such a system re-quires governance to create a col-laborative functional environment.Software systems should allowstate and local health departmentsto work collaboratively. Segregat-ing data by application area makesno sense, as illustrated by the 2types of surveillance systems mostaffected by meaningful use: syn-dromic surveillance and noti!abledisease surveillance (the !rst lineof public health defense). Asidefrom historical precedent, no rea-son exists to separate the datafrom these surveillance systems.

A Public Health Cloud

Community

Our proposal is intended to (1)create capabilities for publichealth to meet evolving meaning-ful use requirements, (2) integrateinformation supply chains forpublic health systems, (3) createa free market that will continu-ously improve public health sys-tems, and (4) enhance ef!ciencyand reduce costs. To achieve theseends, we plan to develop a PaaS

community cloud for publichealth, which would eventuallyreplace the entire suite of CDC-supported applications scatteredover multiple computer systems inhealth departments with a singleintegrated suite of programs run-ning in a cloud environment. Asillustrated in Figure 1, the platformwill have 2 components: a set ofcore services for public health de-partments and a set of applicationsthat would use the core servicesto provide public health functions.

Core services would be devel-oped through an open-source ap-proach that would allow healthdepartments, CDC, and softwaredevelopers to collaborate on tools.Components would include data-base software, a master patientindex software program (whichwould provide a uniform patient

identi!er across applications), in-teroperability tools (e.g., Direct 22

and PHIN MS23), tools to supportdistributed queries of databasesacross health departments for col-laboration during outbreaks (e.g.,Public Health Grid24,25), decisionsupport tools for vaccine forecast-ing26 and public health alerts27

(e.g., openCDS28), and software de-velopment tools to speed develop-ment of applications (e.g., CDC’sPHIN Vocabulary Access and Dis-tribution Service29). These servicescould support a broad range offunctions required for meaningfuluse, including proposed stage 2 and3 functionality.

Sitting on top of core serviceswould be a set of applications builtby either vendors or health de-partments (Figure 2). These appli-cations would replace existing

software systems for public healthfunctions such as the NEDSS BaseSystem or a state immunizationregistry. Either CDC or a privatebody, through a process similarto ONC certi!cation of electronichealth records,30 would certifyeach application to ensure that itwould perform required publichealth functions, pose no securitythreat to other applications or othercloud users, and be interoperable.

The proposed model separatesthe data models and data storagefrom the software that implementsmany of the required functions ofpublic health applications. A kindof application (app) store would becreated where public health de-partments could choose among cer-ti!ed apps for speci!c departmentalfunctions and even switch apps be-tween vendors without loss of data.31

Note. CDC =Centers for Disease Control and Prevention; PH= public health.

FIGURE 1—Architecture of a Platform as a Service public health cloud platform with core services and

interchangeable applications to use those services to provide public health functions.

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This functionality would enhancecompetitiveness and innovation inpublic health software while reduc-ing costs for software developmentand preventing vendors from lock-ing health departments into theirsystems. It also would allow ven-dors to create new types of softwareprograms that combine the func-tionality of systems that currentlysegregate data in silos (e.g., mergingof syndromic surveillance and no-ti!able disease investigation appli-cations), promoting innovation.

Public health applications andcore services would be madeavailable to health departmentsfrom a shared community PaaScloud. Each department would beable to lease or build customizedsoftware solutions. Because

solutions would share a commondata model and interoperabilityservices, exchange of data be-tween jurisdictions and CDCwould be greatly facilitated.

Financing

CDC spends more than $150million annually on external soft-ware systems.32 The majority ofthat money should be convertedover time to state and local grantsfor purchasing PaaS cloud services,including access to departments9choice of certi!ed applications. If allexternally facing CDC softwaresystems could be converted to PaaS,annual funding might total as muchas $0.50 per person in the popula-tion served by a health department,divided between state and local

jurisdictions, to help support theleasing of applications and access tothe PaaS platform.

This funding seems suf!cient tocreate a vibrant market for publichealth software systems, wherevendors would compete to offerimproved functionality and high-quality service to state and localhealth departments. If vendors9systems proved to be unreliable orotherwise of poor quality, the coreservice platform would makeswitching to another vendor easy.

The programs with the greatestneed for rapid evolution to keepup with meaningful use regula-tions are the Immunization Infor-mation System (IIS) and theNEDSS and BioSense programs.The NEDSS program supports

public health integration with thehealth care system for noti!ableconditions. The BioSense programsupports public health integrationwith the health care system forpurposes of syndromic surveil-lance. Together, appropriationsfor these 2 programs total about$58 million annually (in the CDC’s2010 budget33). Funding for IISsoftware support is bundled withsupport for operation of immuniza-tion registries and is therefore dif!-cult to assess but probably sub-stantial (in the range of millions ofdollars per year).

This core funding would sup-port creation of the platform, or-ganization of an app store forintegrated syndromic and noti!-able disease surveillance, purchaseof immunization registry software,and initial grants for licensing ofsoftware. CDC would conducta competition to certify vendors tocompete for eligibility to supplystates and local governments withthe combined systems. Speci!ca-tions would encompass meetingmeaningful use criteria as wellas interoperability between federal,state, and local agencies and withthe health care system. Vendorswould be certi!ed to provide in-teroperability across levels of publichealth. Perhaps most important,vendors would manage connectiv-ity for meaningful use, guaranteethat data could be accepted, andadapt and evolve systems as mean-ingful use requirements evolve.

CONCLUSIONS

In a fully functioning publichealth cloud community, state andlocal health departments wouldhave their choice of certi!ed

Note. CDC = Centers for Disease Control and Prevention; PH =public health.

FIGURE 2—Platform as a Service public health cloud with 3 public health departments, each with its own

copy of the platform with different applications based on the same core services.

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interoperable integrated applica-tions. Each jurisdiction couldchoose its own vendor and migrateannually, promoting competitionand further re!nement of software.Applications would be able to ex-change both case reports and morecomplex data with each other. Stateand local jurisdictions could differbut work together through dataexchange in the cloud. The limitednumber of connections would fa-cilitate data exchange. The vendorsof these applications would workto meet meaningful use require-ments, and software could rapidlyevolve. The pace of connections tothe clinical care system would befast—only a few central connectionsto vendors supporting public healthcloud systems would be required.Connections to CDC would notchange greatly. States would notifyCDC of cases at appropriate timeswith transmission of data fromtheir cloud vendor. Integrated sup-port for distributed queries anda common data model would makesharing of data across jurisdictionsfor surveillance relatively easy.

The advantages of a cloud ap-proach are signi!cant: publichealth would have a new com-puting infrastructure to supportconnections with health care formeaningful use. Remote hosting andshared systems would overcomethe problem of insuf!cient fundingand infrastructure for publichealth systems. Individual juris-dictions could choose their pre-ferred system from a list of certi-!ed approved vendors. Systemswould be interoperable, facilitat-ing exchange of data betweenfederal, state, and local govern-ments, because a uniform certi!-cation process would require this.

Vendors of clinical data systemswould have a limited number ofpublic health information systemsto target and could more readilybuild systems to interface withpublic health, lowering costs andspeeding adoption. The devel-opers of public health systemswould have a reliable market fortheir products, making invest-ments in innovation possible andadvancing the !eld as a whole.

Although the autonomy of in-dividual jurisdictions has beensacrosanct in public health,extending this principle to the de-sign and implementation of com-puter systems for public health hascreated a largely unworkable na-tional system. The present crisiscreates an opportunity for changefor the better. To reap the rewardsof new data sources created bymeaningful use regulations, and ofnew integrated systems that offergreater capabilities, public healthneeds to embrace change in how itdevelops and manages its IT sys-tems. In light of the absence ofnew resources to fund publichealth IT and the economies ofscale created by cloud computing,practitioners should choose tomove collectively to a new modelof shared infrastructure that cankeep pace with the evolution ofthe health care systems IT; other-wise it will become more isolatedfrom and less relevant to the clin-ical care system. Free-marketcompetition that creates large-scaleshared cloud-computing resourcesthat are certi!ed for both func-tionality and interoperability is theonly realistic route for public healthto achieve universal connectivity tothe health care system in themeaningful use era. j

About the AuthorsLeslie Lenert is with the Department ofMedicine, and David N. Sundwall is withthe Department of Family and PreventiveMedicine, School of Medicine, University ofUtah, Salt Lake City.Correspondence should be sent to Leslie

Lenert, MD, Dept of Medicine, 30 North1900 East, Room 4c104, Salt Lake City,UT 84132-2406 (e-mail: Leslie.Lenert@gmail.com). Reprints can be ordered athttp://www.ajph.org by clicking the“Reprints/Eprints” link.This article was accepted October 3,

2011.

ContributorsL. Lenert conceptualized and wrote initialversions of the article and contributedto subsequent revisions. D. N. Sundwallcontributed to the conceptual developmentof initial versions of the article and pro-vided helpful commentary on subsequentdrafts.

AcknowledgmentsWe thank Kathleen Handziuk for hereditorial assistance.

Human Participant ProtectionNo protocol approval was required be-cause no human participants were in-volved.

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