1. Introduction to Public Health Informatics William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services National Conference on Tobacco or Health November 20, 2002

2. 2 2 Overview n New IOM recommendations n Role of information technology (IT) in public health n Barriers to public health IT n National Health Information Infrastructure n What is public health informatics? n Role of informatics in promoting healthy communities n New IOM recommendations n Role of information technology (IT) in public health n Barriers to public health IT n National Health Information Infrastructure n What is public health informatics? n Role of informatics in promoting healthy communities

3. 3 3 Public Health Informatics: IOM Recommendations, 2002 n Informatics should be included in the curriculum of all MPH programs. (Educating Public Health Professionals for the 21 st Century, IOM, November, 2002) n “The Secretary of HHS should facilitate the development and implementation of the National Health Information Infrastructure (NHII) under the leadership of the Secretary of HHS.” (The Future of the Public’s Health in the 21 st Century, IOM, November, 2002) n Informatics should be included in the curriculum of all MPH programs. (Educating Public Health Professionals for the 21 st Century, IOM, November, 2002) n “The Secretary of HHS should facilitate the development and implementation of the National Health Information Infrastructure (NHII) under the leadership of the Secretary of HHS.” (The Future of the Public’s Health in the 21 st Century, IOM, November, 2002)

4. 4 4 Information is the Core of Public Health n Public health has been using information systems for many years n Full potential of information technology has yet to be realized l Missed opportunities n Public health is facing serious challenges l Bioterrorism preparedness & response l Increasing antibiotic resistance l Emerging infectious diseases n Public health has been using information systems for many years n Full potential of information technology has yet to be realized l Missed opportunities n Public health is facing serious challenges l Bioterrorism preparedness & response l Increasing antibiotic resistance l Emerging infectious diseases

5. 5 5 Public Health Informatics n Definition: the systematic application of computer & information science and technology to public health practice, research, and learning n Key to effective use of information technology in public health n Definition: the systematic application of computer & information science and technology to public health practice, research, and learning n Key to effective use of information technology in public health

6. 6 6 Public Health Practice Today Illustration courtesy of John Lumpkin, MD, MPH

7. 7 7 Barriers to IT in Public Health A. Information n Surveillance data l Only 15-20% of reportable cases reported l Delays of days to weeks l Not typically in electronic form n Other relevant data not electronically available l Environmental, injury, etc. l Guidelines l Contacts l Training materials n Surveillance data l Only 15-20% of reportable cases reported l Delays of days to weeks l Not typically in electronic form n Other relevant data not electronically available l Environmental, injury, etc. l Guidelines l Contacts l Training materials

8. 8 8 Barriers to IT in Public Health B. Infrastructure n Information technology l Local health departments with high- speed continuous internet connections – 48.9% (NACCHO, 1999) – 68.3% (CDC, 2001) n Workforce l 83% of local health departments indicate that computer training is a key need (NACCHO, 1996) n Information technology l Local health departments with high- speed continuous internet connections – 48.9% (NACCHO, 1999) – 68.3% (CDC, 2001) n Workforce l 83% of local health departments indicate that computer training is a key need (NACCHO, 1996)

9. 9 9 What is National Health Information Infrastructure (NHII)? n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n NOT a central database of medical records n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n NOT a central database of medical records

10. 10 What will NHII enable? 1.Test results and x-rays always available  eliminate repeat studies 2.Complete medical record always available 3.Decision support always available: guidelines & research results 4.Real-time aggregation to detect patterns (e.g. bioterrorism detection) 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records 1.Test results and x-rays always available  eliminate repeat studies 2.Complete medical record always available 3.Decision support always available: guidelines & research results 4.Real-time aggregation to detect patterns (e.g. bioterrorism detection) 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records

11. 11 Three Domains of NHII Personal/ Consumer Clinical Community/ Public Health NHII

12. 12 Elements of NHII (1 of 3) n Standards: Messaging & Content l Foundation for remainder of NHII n Electronic Medical Record (EMR) Systems l Hospital l Outpatient n Consumer Health Information Systems l Personal health record l Electronic patient-provider communication l Support groups l Authoritative information n Standards: Messaging & Content l Foundation for remainder of NHII n Electronic Medical Record (EMR) Systems l Hospital l Outpatient n Consumer Health Information Systems l Personal health record l Electronic patient-provider communication l Support groups l Authoritative information

13. 13 Messaging Standards n What information is requested n Where is the information in the message n Example: “phone number” message l Pick up phone l Listen for dial tone l Dial number – If first digit is 1, then long distance, otherwise local n What information is requested n Where is the information in the message n Example: “phone number” message l Pick up phone l Listen for dial tone l Dial number – If first digit is 1, then long distance, otherwise local

14. 14 Content Standards n A common, agreed-upon, detailed vocabulary for all medical terminology n Without a standard: l “high blood pressure” l “elevated blood pressure” l “hypertension” n With a standard l C487231, hypertension l Unambiguous meaning for both sender and receiver n A common, agreed-upon, detailed vocabulary for all medical terminology n Without a standard: l “high blood pressure” l “elevated blood pressure” l “hypertension” n With a standard l C487231, hypertension l Unambiguous meaning for both sender and receiver

15. 15 Elements of NHII (2 of 3) n Ancillary health care systems l Pharmacy l Laboratory l Physical therapy l Home health l Public health reporting n Communication/networking systems l Information moves with patient l Integrated information from all types of providers l Electronic consultation (telemedicine) n Ancillary health care systems l Pharmacy l Laboratory l Physical therapy l Home health l Public health reporting n Communication/networking systems l Information moves with patient l Integrated information from all types of providers l Electronic consultation (telemedicine)

16. 16 Elements of NHII (3 of 3) n Decision Support & Education l Professional l Consumer n Confidentiality protections l Information available on need-to-know basis l Authentication of all users l Encryption of data in transit l Audit trails of all usage l Penalties for violations n Decision Support & Education l Professional l Consumer n Confidentiality protections l Information available on need-to-know basis l Authentication of all users l Encryption of data in transit l Audit trails of all usage l Penalties for violations

17. 17 Benefits of NHII n Monitor and Protect Public Health (e.g. rapid disease detection) n Improve Patient Safety l IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS) l Estimated cost of medication errors alone is over $76 billion/year n Improve Quality of Care n Effectively Share Decision Support n Understand Health Care Costs n Better-informed Health Care Consumers n Monitor and Protect Public Health (e.g. rapid disease detection) n Improve Patient Safety l IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS) l Estimated cost of medication errors alone is over $76 billion/year n Improve Quality of Care n Effectively Share Decision Support n Understand Health Care Costs n Better-informed Health Care Consumers

18. 18 Why hasn’t NHII already been done? n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Lack of incentives for information sharing n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Lack of incentives for information sharing n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage

19. 19 NHII activities in HHS n Senior Advisor, NHII l Inform – Disseminate NHII vision – Catalog NHII activities – Disseminate “lessons learned” l Collaborate with Stakeholders l Convene – National meetings on NHII – Start in 2003 l Voluntary process – no new regulations n Senior Advisor, NHII l Inform – Disseminate NHII vision – Catalog NHII activities – Disseminate “lessons learned” l Collaborate with Stakeholders l Convene – National meetings on NHII – Start in 2003 l Voluntary process – no new regulations

20. 20 Barriers to IT in Public Health C. Informatics n Public Health Informatics is the systematic application of computer & information science and technology to public health practice, research, and learning n Management skills l IT projects expensive and high risk l Interdisciplinary teams required l New skills needed by public health managers n Public Health Informatics is the systematic application of computer & information science and technology to public health practice, research, and learning n Management skills l IT projects expensive and high risk l Interdisciplinary teams required l New skills needed by public health managers

21. 21 Public Health Informatics Topics 1. Information Architecture* 2. Avoiding Information Technology Disasters* 3. Networking & the Internet 4. Databases & Database Design 5. Standards 6. Privacy, Confidentiality, & Security 7. Computer Expertise 1. Information Architecture* 2. Avoiding Information Technology Disasters* 3. Networking & the Internet 4. Databases & Database Design 5. Standards 6. Privacy, Confidentiality, & Security 7. Computer Expertise

22. 22 1. Information Architecture n Information systems are complex (like a building) n Detailed plans required l Alignment of parts l Flow of data n Information flow, storage, processing n Interfaces to users, other systems n Independent layers n Organizational discipline and control n Information systems are complex (like a building) n Detailed plans required l Alignment of parts l Flow of data n Information flow, storage, processing n Interfaces to users, other systems n Independent layers n Organizational discipline and control

23. 23 Imagine building a house … n without any architectural plans n with only general sketches as to how it’s supposed to look, or only detailed diagrams for wiring, plumbing, etc. n with each subcontractor doing whatever they thought best, without consulting with the owner or other contractors n with no specialized functions for the rooms (e.g., every room has its own little stove, bed, bathtub…) n where the house had to be torn down to remodel one room … S.O.P for building information systems in public health. n without any architectural plans n with only general sketches as to how it’s supposed to look, or only detailed diagrams for wiring, plumbing, etc. n with each subcontractor doing whatever they thought best, without consulting with the owner or other contractors n with no specialized functions for the rooms (e.g., every room has its own little stove, bed, bathtub…) n where the house had to be torn down to remodel one room … S.O.P for building information systems in public health.

24. 24 Information Architecture n A metaphor for a systematic approach to building enterprise-wide information systems. n Information architecture refers to the totality of the data, processes, and technology used in a given enterprise, and the relations between them. n It includes databases, applications, standards, procedures, hardware, software, networks, etc. n A metaphor for a systematic approach to building enterprise-wide information systems. n Information architecture refers to the totality of the data, processes, and technology used in a given enterprise, and the relations between them. n It includes databases, applications, standards, procedures, hardware, software, networks, etc.

25. 25 An information architecture … n Returns locus of control and decision making to the executive level, away from the IT community. An information architecture provides the basis of business control over the distributed development of information systems.

26. 26 2. Avoiding IT Disasters n I.T. project failure rates high l 1/6 succeed, ½ partial success, 1/3 total failure n Sources of risk in I.T. projects l High level of abstraction l Unrealistic expectations l Management often non-intuitive n Keys to success l Interdisciplinary teams l Clear requirements definition (e.g. iterative prototyping) n I.T. project failure rates high l 1/6 succeed, ½ partial success, 1/3 total failure n Sources of risk in I.T. projects l High level of abstraction l Unrealistic expectations l Management often non-intuitive n Keys to success l Interdisciplinary teams l Clear requirements definition (e.g. iterative prototyping)

27. 27 Paradigm for I.T. Project Success n Behavior Modification l management l users n Minimize increments of change n Use intermittent positive reinforcement l provide real benefits to users l what they want, NOT what you want n Behavior Modification l management l users n Minimize increments of change n Use intermittent positive reinforcement l provide real benefits to users l what they want, NOT what you want

28. 28 Informatics: Key to Healthy Communities n National Health Information Infrastructure l Health care information always available when and where needed l Latest guidelines and research applied immediately to patient care n Closer integration of medical care and public health using IT l Protection from disease through – Earlier detection of outbreaks – More effective monitoring of disease patterns n National Health Information Infrastructure l Health care information always available when and where needed l Latest guidelines and research applied immediately to patient care n Closer integration of medical care and public health using IT l Protection from disease through – Earlier detection of outbreaks – More effective monitoring of disease patterns

29. 29 PHI Textbook l Springer-Verlag l October, 2002 l 824 pages, $79.95 [note: royalties of CDC authors go to CDC Foundation] l Springer-Verlag l October, 2002 l 824 pages, $79.95 [note: royalties of CDC authors go to CDC Foundation]

30. 30 THANK YOU! n Questions? n Additional References l Yasnoff et al. Public Health Informatics: Improving and Transforming Public Health in the Information Age. J Pub Health Management Practice 2000; 6(6):67-75. l Yasnoff et al. A National Agenda for Public Health Informatics. J Am Med Informatics Assn 2001; 8:535-545. n Contact information: William A. Yasnoff, MD, PhD Department of Health and Human Services William.Yasnoff@hhs.gov 202/690-7100 n Questions? n Additional References l Yasnoff et al. Public Health Informatics: Improving and Transforming Public Health in the Information Age. J Pub Health Management Practice 2000; 6(6):67-75. l Yasnoff et al. A National Agenda for Public Health Informatics. J Am Med Informatics Assn 2001; 8:535-545. n Contact information: William A. Yasnoff, MD, PhD Department of Health and Human Services William.Yasnoff@hhs.gov 202/690-7100