Issues in Public Health Informatics

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Issues in Public Health Informatics

• Rita Kukafka, DrPH, MA
• Department of Biomedical Informatics, College of
  Physicians and Surgeons
• Department of Sociomedical Sciences, Mailman
  School of Public Health
• Medical Informatics Course for Health
  Professionals
• Woods Hole, MA
• June, 2009

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Issues in Public Health Informatics

• Rita Kukafka, DrPH, MA
• Department of Biomedical Informatics, College of
  Physicians and Surgeons
• Department of Sociomedical Sciences, Mailman
  School of Public Health
• Medical Informatics Course for Health
  Professionals
• Woods Hole, MA
• June, 2009

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Session Overview

• What is public health? (brief overview)
• What is public health informatics?
• Historical context for the discipline
• Most pressing public health issues of today, and
  some examples or public health informatics
  solutions
• Opportunities (happenings and training
  opportunities)

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• First, a perspective on public health

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You might be a public health professional if you
are.

• looking to control the most basic of human
  functions, e.g., lobbying the Federal Trade
  Commission to investigate snack-food and
  soft-drink marketing or promoting a twinkie
  tax."
• worrying about eating, smoking, HIV/AIDS,
  bioterrorism, health literacy and hand washing
  all in one day.
• spending hours per day trying to define yourself,
  your work, and explaining your work to others.

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Public Health Professional

• A person educated in public health or a related
  discipline who is employed to IMPROVE HEALTH
  through a POPULATION focus

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Public Health

• 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

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10 Essential Public Health Services

• Assessment
• Monitor health status to ID community health
  problem
• Diagnose and investigate health problems and
  hazards
• Policy development
• Inform, educate people about health issues
• Mobilize community partnerships to solve health
  problems
• Develop policies and plans

• Assurance
• Enforce laws and regulations that protect health
  and ensure safety
• Link people to health services and assure care
• Assure a competent public health and health care
  work force
• Evaluate effectiveness of programs
• Serving all functions
• Research for new, innovative solutions to
  health problems

IOM, The Future of the Publics Health, 2002
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A closer look at a population based
perspective- the foundation of public health

• Disease risk is conceived of as a continuum
  rather than a dichotomy.
• No clear division between risk for disease and no
  risk for disease with regard risk factors (e.g.,
  levels of blood pressure, cholesterol, alcohol
  consumption, tobacco consumption, physical
  activity, diet and weight)
• Degrees of risk rather than just two extremes of
  exposure (i.e., risk and no risk).

The Future of the Public's Health in the 21st
Century (2002)
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Population Based Perspective (Cont)

• Most often, only a small percentage of any
  population is at the extremes of high or low
  risk. The majority of people fall in the middle
  of the distribution of risk.
• Exposure of a large number of people to a small
  risk can yield a more absolute number of cases of
  a condition than exposure of a small number of
  people to a high risk.
• Focus on the modification of risk for the entire
  population rather than for specific high-risk
  individuals is a population based strategy.

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Hypothetical distribution of overweight and
obesity in a population a high-risk
intervention strategy targeting obesity
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Distribution of Body Mass Index in the US
hypothetical shift of the distribution to lower
the mean
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Population Based Perspective

• An individuals risk of illness cannot be
  considered in isolation from the disease risk for
  the population to which he or she belongs.
• Someone in the United States is more likely to
  die prematurely from a heart attack than someone
  living in Japan, because the population
  distribution of high cholesterol in the United
  States as a whole is higher than the distribution
  in Japan.
• Applying the population perspective to a health
  measure means asking why a population has the
  existing distribution of a particular risk, in
  addition to asking why a particular individual
  got sick.
• Leads to greatest improvements in a populations
  health

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The Determinants of Population Health
The Future of the Public's Health in the 21st
Century (2002)
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Now

• A perspective on public health informatics..

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What is public health informatics?

• Systematic application of information and
  computer science and technology to pubic health
  practice, research and learning.
• (Yasnoff, 2001)
• Simply stated, it is the application of
  informatics methods and theories to solve public
  health problems

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Public Health Informatics in Perspective
Medical Informatics Methods, Techniques, and
Theories
Basic Research
Molecular and Cellular Processes
Tissues and Organs
Individuals (Patients)
Populations And Society
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Disciplines underlying informatics
Law
Management
Disciplines within public health
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Roots of Modern Public Health Informatics

• In 1854, a major cholera outbreak in London had
  already taken nearly six hundred lives when Dr.
  John Snow, using a hand-drawn map, showed that
  the source of the disease was a contaminated
  water pump.

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A Classic Story Dr. John Snow (1813-1858)

• The relevant 1854 London Streets
• Location of the Deaths from Cholera
• The position of 13 water pumps

Population based orientation rather than patient
based
Generated using CDC Epi Map 2000 for Windows, a
public domain package that can be downloaded
from http//www.cdc.gov/epiinfo/EI2000.htm)
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Today, we have a vast array of data to monitor
the publics health. 190 data sources are
currently being used to collect progress of
Healthy People 2010 health objectives for the
nation.
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Key Challenges

• Data collected categorically exist in silos,
  lacks standards and interoperability
• PH reporting is traditionally slow, not suitable
  for responding to bioterrorism and emerging
  infectious diseases
• Major gaps exist between public health and health
  care

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Examples of informatics applied to public health
practice

• Outbreak detection and response (syndromic
  surveillance)
• Public Health Enabled EHR and PHR
• Provider-Centric EHR decision support and alerts
  for preventative services, delivering health
  guidelines and recommendations
• Patient Centric EHR/PHR decision support for
  chronic disease prevention and management

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Examples of informatics applied to public health
practice

• Outbreak detection and response
• (Syndromic Surveillance)

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What is Syndromic Surveillance?

• Real-time public health surveillance using data
  that is routinely collected for other purposes

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Legal Mandate
Local health officers shall exercise due
diligence in ascertaining the existence of
outbreaks of illness or the unusual prevalence of
diseases, and shall immediately investigate the
causes of same.
New York State Sanitary Code, 10 NYCRR Chapter
1, Section 2.16(a)
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New Response Requirements

• Fast detection
• Fast science
• Fast effective communication
• Fast effective integration
• Fast effective action
• Globalization, connectivity, and speed

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Early Detection of Large Outbreaks
Symptom Onset
Severe Illness
Release
Number of Cases
Days
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Potential Syndromic Surveillance Data Sources

• Day 1- feels fine
• Day 2- headaches, fever- buys Tylenol
• Day 3- develops cough- calls nurse hotline
• Day 4- Sees private doctor flu
• Day 5- Worsens- calls ambulance
• seen in ED
• Day 6- Admitted- pneumonia
• Day 7- Critically ill- ICU
• Day 8- Expires- respiratory failure

Pharmaceutical Sales
Nurses Hotline
Managed Care Org
Absenteeism
Ambulance Dispatch (EMS)
ED Logs
Traditional Surveillance
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Practical concerns

• Trade off between sensitivity (the ability to
  detect an attack when it occurs) and the
  false-positive rate (the probability of sounding
  an alarm when there in fact is no attack).
• If every county in the United States had in place
  a single syndromic surveillance system with a 0.1
  percent false-positive rate that is, the alarm
  goes off inappropriately only once in a thousand
  days.
• 3,000 counties in the United States an average
  of three counties a day would have a
  false-positive alarm.

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Does syndromic surveillance really work?

• A line of research considers epidemiologic
  characteristics of the pathogens that terrorist
  might use
• Epidemiological characteristics of pathogens will
  impact the public health response

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The second question, and the focus of most
current research how the performance of
syndromic surveillance systems can be improved?

• Gaining access to more, different, and timelier
  data, as well as identifying data streams with a
  high signal-to-noise ratio.
• Developing sophisticated statistical detection
  algorithms to elicit more from existing data and
  more accurate models that describe patterns in
  the data when there are no outbreaks, as well as
  detection algorithms that focus on particular
  kinds of patterns, such as geographical clusters,
  in the data.
• Simulation studies to assess how quickly
  detection algorithms would detect an attack.

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Still, Varying Level of Automation for Collection
of Data

• Manual Reporting
• Telephone
• Paper
• Paper w/ electronic reporting
• Web-based
• ? Case Based Reporting (drop-in systems)
• Automated Data Collection

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Syndromic Surveillance for Bioterrorism Following
the Attacks on the World Trade Center --- New
York City, 2001
Compared the daily ratio to its cumulative
baseline by hospital, hospital cluster, or
postal-code cluster. Alarms were generated when
the SNR (daily counts of each syndrome of
interest divided by the "none of the above)
category was significantly higher for the day in
question compared with the recent past.
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Disease Syndromic Surveillancefor Hurricane
Katrina Evacuees Seeking Shelter in Houstons
Astrodome

• Rapid health assessment tool cot surveys
• Each evening at about 6 pm
• Began with paper forms -- transitioned to
  handheld (PDAs)
• Confirmed/Monitored outbreak of acute
  gastroenteritis

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BioSense
Began development in 2003 Cost 184 million,
with the remaining upgrade to cost another 314
million,
BioSense
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new ways
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Dual Benefits

• The very same infrastructure and capabilities
  used to support data capture at the point of
  care for emergency preparedness can most
  definitely be used to implement non-attack public
  health intervention.

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EMS Drug Calls
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Data are from McGinnis et al, JAMA 1993
The percentages are for all deaths Data
are from Mokdad et al JAMA 2004
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519 2024
25
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Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
2024 2529 30
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Obesity Trends Among U.S. AdultsBRFSS, 2006
(BMI 30, or 30 lbs. overweight for 5 4
person)
2006
No Data lt10 1014 1519
2024 2529 30
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Health Care Spending and Life Expectancy
UC Atlas of Global Inequality
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Clinical and Population Health Informatics
Diffusion Model
Data Interpretation
Data Interpretation
Clinical Systems
PopulationHealth
Data Analysis
Data Analysis
Information Dissemination
Data Collection
Data Collection
Two Way Information Flow
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Perhaps the greatest challenge and ultimate
benefit of improved PH infrastructure utilizing
informatics methods

• Closing the gap that exists between public health
  and health care
• .enter the EHR and PHR

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EHR/PHR

• The PHR is also relevant to population health
• It has a broader scope, encompassing the EHR-s
  and other health information that the consumer
  deems relevant that are not captured in the
  clinical setting

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• Support patient education opportunities
• Produce tailored preventive health information,
  reminders, and alerts based on personal clinical
  records
• Assist in identifying potential tailoring
  variables

• Facilitate patient-provider communication by
  providing suggestions or scripts for providers on
  how to discuss sensitive topics
• Using the EHR to allow patients to access,
  contribute to or correct their own medical record

Special Issue on Public health Informatics
(Kukafka, Yasnoff Eds.), Journal of Biomedical
Informatics 40(2007) 370-39.
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Desired Outcomes

• A Personal Health Record that incorporates public
  health priorities and cognitive research to
  empower patients in improving their preventive
  care.
• An electronic clinical decision support system
  that incorporates public health priorities and
  epidemiologic data to empower clinicians in
  providing better preventive and acute care
• Electronic health information exchange from
  clinical information systems that improves public
  health surveillance of antibiotic resistance and
  emerging health issues.

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Citywide EHR Network

• Procured best of breed EHR- eClinical Works
• CCHIT certified, modern architecture, small
  office-friendly
• 20 million contract
• Correctional health 1,200 Medicaid providers
• Preparing practices
• Network and hardware Infrastructure
• Practice readiness (HR policies, clinical
  champions, security, IT capacity, etc)
• Implementation (September 2007)
• Approximately 100 providers a month
• Preceded by baseline data collection

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EHRs Are Evolving

• EHRs with decision support can help providers
  adhere to chronic disease prevention and
  management guidelines
• In New York City, an existing EHR has been
  enhanced to include alerts and decision support
  based on 10 Steps for a healthier New York
• Medical Home
• Smoking
• Heart Health and Diabetes
• HIV Status
• Depression
• Alcohol and Drugs Dependence
• Cancer Screening
• Immunizations
• Safe Homes (Asthma, Lead)
• Maternal and Infant Health

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Tailored Lifestyle Conversations

• CDC funded to develop and pilot test a
  patient-centric electronic health record (PC-EHR)
  for chronic disease management and prevention

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Challenges Assumptions

• Good health is the patients main motivation for
  change
• Patients want to change
• Now is the time to change
• Physician knows best how the patient should change

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TLC Assumptions

• Patients do not necessarily choose to work on the
  risk factor most harmful to their health
• Since patient and provider priorities may often
  lack concordance, a transaction decision aid,
  between patient and provider presents a viable
  option to incorporate patient choice together
  with medical importance in coming to a decision
  that will accommodate both perspectives

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Benefits to Considering Patient Choice

• Better outcomes
• Higher stages of behavior change
• Stronger intention to adhere to recommendations
• Improved emotional health
• Improved overall health

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Data exchange in integrated EHR/PHR Systems
PHR Patient Entered
EHR Clinical Encounter
Lifestyle
Cognitive
Literacy
Patient
Social Support
Finance
Cultural Beliefs
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Patient Assessment

4 Health behavior modules
Psychosocial elements
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Tailored TLC Report
Sample behavioral risk graphic
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Tailored Patient Report
Sample patient decision support
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Providers Report
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Major PHI Challenges

• Re-connecting clinical medicine and public health
  practice requires an improved public health
  infrastructure and public health workforce
  training
• Thinking outside the box-
• Dual use systems that are flexible
• enough to respond to changing public health
  needs (proactive rather than responsive)

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Four universitiesColumbia University, Johns
Hopkins, University of Utah, and the University
of Washingtonnow offer fellowships in Public
Health Informatics. The programs, designed to
prepare public health leaders to apply
informatics to public health problems, are
supported by a 3.68 million grant from The
Robert Wood Johnson Foundation to the US National
Library of Medicine (NLM).
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www.dbmi.columbia.edu
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Perspective ChallengeDiverse Sets of Agencies
Partner Organizations

• Affiliated Organizations
• 115

• Agencies / Professionals
• 60 States Territories health departments
• 3000 local heath departments
• 100,000 professionals
• 50 disciplines

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The Public Health System
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• Field of public health informatics offers many
  challenges (and applications) yet to be
  discovered.

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Where are we?