Description
Managing the quality and cost of co-morbid populations is one of the most challenging aspects of health leadership. In this Discussion, you are challenged with selecting those data which will be most helpful in the management of Medicare populations. As health information exchanges (HIEs) progress at the state, federal, and nation level, health leaders are tasked to participate in the development of analytics tools that can be used to pull data and inform policy practice.
Scenario: Review the high volume Medicare Data Scenario located in the Learning Resources. In this scenario you are asked to work with a complex dataset of co-morbidity data of patients that have three concurrent co-morbid conditions (Chronic Condition Triads: Prevalence and Medicare Spending). How can data from HIT systems be used to formulate useful information to facilitate in the management of this population?
To prepare:
- Using the health care information systems standards for clinical and financial data discussed in Week 6 (Chapter 11 of Health Care Information Systems: A Practical Approach for Health Care Management), identify specific types of data (data sets, standards, examples of those data) that can be redeveloped into Big Data tools and used to address the management of population health initiatives.
- Define a “Big Data” analysis dataset to include in a data warehouse by identifying two specific types of clinical and financial data from the Chronic Condition Triads: Prevalence and Medicare Spending dataset in your Learning Resources that you feel could be used to drive behavior change in the patient and provider populations. This Big Data dataset will become the focus of your Discussion.
Post:
Explain why the two specific types of clinical and financial data you selected as your Big Data dataset would best affect behavior change in the type of co-morbid Medicare populations served in the scenario. Explain and assess how this Big Data dataset can change the behaviors of health care providers in the scenario. Assuming that your Big Data dataset is going to be shared in a regional health information exchange, explain how the Centers for Medicare and Medicaid Services and private payers might use these regional data sets to increase value in delivering services to co-morbid Medicare patient populations in the region.
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
F u tu re N e e d s o f H e a lth D e p a r tm e n ts
A R id e in t h e l i m e M a c h in e : In f o r m a t io n M a n a g e m e n t
C a p a b ilitie s H e a lth D e p a r t m e n t s W ill N e e d
Seth Foldy, MD, MPH, Shaun Grannis, MD, MS, David Ross, PhD, and Torney Smith, MSHE
W e have proposed needed
information m anagem ent ca
pabilities for future US health
dep artm en ts predicated on
trends in health care reform and
health information technology.
Regardless of whether health
departments provide direct clin
ical services (and many will),
they will manage unprece
dented quantities of sensitive
information for the public health
core functions of assurance and
assessment, including populationlevel health surveillance and
metrics. Absent improved ca
pabilities, health departments
risk vestigial status, with conse
quences for vulnerable popula
tions. Developments in electronic
health records, interoperability
and information exchange, pub
lic information sharing, decision
support, and cloud technologies
can support information man
agement if health departments
have appropriate capabilities.
The need for national en
gagement in and consensus
on these capabilities and their
importance to health depart
ment sustainability make them
appropriate for consideration
in the context of accreditation.
(Am J Public Health. 2014;104:
1592-1600. doi:10.2105/AJPH.
2014.301956)
WHAT INFORMATION MANAGE-
ment capabilities will be needed
by tomorrow’s US health depart
ments? The Public Health Ac
creditation Board establishes
standards and provides accredita
tion to US local, tribal, and state
health departments. Because we
are experienced in local, state, and
federal public health informatics
(the systematic application of in
formation and computer science
and technology to improve public
health practice, research, or edu
cation),1 a Public Health Accredi
tation Board think tank asked us to
predict the effects of emerging
trends on requirements for future
accreditation standards.
The Patient Protection and
Affordable Care Act (ACA) may
radically change the functions of
US health departments. New de
velopments in health information
technology (technology standards,
applications, and hardware for
health data) will profoundly
change how information is man
aged and exchanged. Different
predictions about these changes
may produce markedly different
predictions of required health de
partment capabilities.
Some have asserted that ACA
reforms (more people insured,
preventive services covered, and
1 5 9 2 | Government, Law, and Public Health Practice | Peer Reviewed | Foldy et al.
provider incentives) may lead
health departments to stop deliv
ering individual services, such as
immunizations.2 Meanwhile, some
predict that digitization and the
exchange of health care data will
produce “distributed access to in
formation without exposing the
details of the underlying data . . .
collect[ing] only summarized data…
or key results.”3 Taken together,
these trends suggest that health
departments may eliminate direct
services and consume rather than
create health information products,
thus minimizing their management
of sensitive health information.
We predict, rather, that health
departments will struggle with
managing more information to
improve service cost efficiency,
collaborate on prevention with
a leaner health care system, and
meet demands for unbiased pop
ulation health statistics. Competi
tive pressures will emerge rapidly
over the next 5 years. Health
departments that cannot manage
information appropriately may
become vestigial—to the detriment
of their communities (and espe
cially to vulnerable underserved
populations). The pace of change
will challenge many health de
partments. Emerging advances in
health information technology can
help meet these challenges, but
only if health departments de
velop needed capabilities.
HEALTH DEPARTMENT
ROLES AND INFORMATION
MANAGEMENT
Aspects of the ACA encourage
private health care providers to
perform preventive care. Reduc
tions in the number of uninsured
individuals, improved financial in
centives for preventive services,
and business models such as ac
countable care organizations and
primary care medical homes,
could reduce the need for health
departments to provide personal
services, such as immunizations
and tuberculosis management.
However, this reduction may
be offset by a continuing obliga
tion to ensure prevention for those
remaining unprotected and an in
creased demand for communitybased services. Assumptions that
ACA reforms will optimize popu
lation deliveiy of preventive
services rest on continuous care
access and accountability. Millions
will still lack health insurance
(especially in states declining
Medicaid expansion),4 move fre
quently,5 and experience provider
turnover because patients and
American Journal of Public Health | September 2 0 1 4 , Vol 104, No. 9
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
insurers will shop for value. The
ACA reduces hospital reimburse
ment, which may disrupt uncom
pensated care, although new
nonprofit requirements may offset
this. Thus, discontinuities in insur
ance, care, and information (pend
ing improved health information
exchange) will perpetuate preven
tive service gaps. The ACA follows
earlier reforms (e.g., health main
tenance organizations, managed
competition) that, despite great
promises, yielded mixed and modest
changes in preventive care.6
Despite recommendations to shift
from service delivery to assurance,
from 1997 to 2008 22% of local
health departments maintained or
increased the types of dinical ser
vices they offered.7 In 2013 more
than 90% offered immunizations,
more than 80% offered some in
fectious disease screening or treat
ment, and more than 60% offered
some chronic disease screening.8
Under Massachusetts’s ACA-like re
form, public health programs expe
rienced varying changes in demand,
and an incapacity to analyze client
data impeded planning.9 Many
departments will continue serving
uninsured and hard-to-reach
individuals,10 and expectations that
they bill insurers, when possible,
will compound information man
agement needs.11
Beyond clinical services, depart
ments may be invited to partner in
case management and communitybased services (foreshadowed in
ACA initiatives, e.g., community
health teams and home visit pro
grams).12 Success in such partner
ships cannot be assumed because
there is cost competition in the
resource-constrained accountable
care organization environment.
Health departments will need to
accept electronic referrals as other
• Which prenatal care factors
providers do. W hether serving in
tality disparities?
• Which infants lack follow-up
for abnorm al new born
screens?
whole-community health informa
tion, ensuring public access to un
biased information about the
health of the community and
• W here do concentrations of
sometimes providing impartial
assessment of the performance
of health care providers and net
works. This accountability will re
quire health departments to use
sured or uninsured patients, in
partnerships or separately, health
departments will be expected to
deliver and document services
more efficiently than before.
Thus, departments will need to
assess and satisfy patients’ needs
in a timely, coordinated way, not
at the convenience of fragmented
programs. Patients’ longitudinal
and cross-program information
will be needed at the point of
service and for performance im
provement. This requires chang
ing the program-based culture of
many health departments with
silos of disconnected informa
tion.13 Cross-program business in
telligence is becoming business as
usual in the private sector and is
becoming critical to creating
“learning health systems” that
contribute to local infant mor
people live with chronic disease
risk factors who are not receiv
ing preventive services?
Such information is required for
effective public health assessment
and assurance and is supported by
unique reporting mandates and
Health Insurance Portability and
Accountability Act consider
ations.15 Although accountable
care organizations may perform
within-network measurement and
may report similar metrics, this
will not assess people and prob
lems falling between networks.
Private providers are also reluc
tant to share information that
might affect competition for
continuously improve services.14
Health departments that do not
deliver direct services will continue
patients or payers. This conflict
between competition and trans
to receive and manage sensitive
health information for disease and
health departments to create im
injury surveillance, outbreak and
emergency management (e.g., vac
cine or drug countermeasure ad
ministration), and maternal, child,
and environmental health. The
capability to match identifiable
records over time and across all
health care providers is needed to
track important community-level
questions, such as,
• W hat proportion of persons with
HTV lacks antiviral treatment or
screening for tuberculosis and
syphilis?
• W ho received a first but not
second immunization for a new
pandemic influenza strain?
Septem ber 20 1 4 , Vol 10 4, No. 9 | American Journal of Public Health
parency may create demand for
partial metrics of quality and
safety, as they do for vital events,
diseases, and injuries.16 Legally
authorized, neutral public health
registries (e.g., immunization reg
istries and disease registries) often
have established community-wide
information sharing even as other
health information exchange ar
rangements fall prey to competi
tive pressures.17
Therefore, provider-controlled
aggregate reports may augment,
but cannot replace, the mandated
universal reporting of identifiable
individual reports to health de
partments. W e believe health de
partments will continue to be held
accountable for the completeness,
accuracy, and transparency of
and steward individuals’ health
information.
The demand for person-linked
information across diverse sources
and systems will also grow be
cause of the recognition of “syndemics,” for example, interactions
between HIV, tuberculosis, and
syphilis and other sexually trans
mitted infections; relationships
between obesity, diabetes, and
hypertension and other cardio
vascular diseases; relationships
between social factors, infant
mortality, adverse childhood ex
periences, and chronic disease
morbidity; and the relationships
of these syndemics to health dis
parities, whose elimination are
a national priority.18 Segregated
information silos are inadequate
for studying and managing such
syndemics, which require a syner
gistic (personcentric and needs
based, not program based) para
digm for public health services
and the information systems that
serve them.
Thus, future health depart
ments must maintain and improve
their capability to receive, secure,
manage, link, analyze, and use
individuals’ personal health infor
mation for many purposes. Pri
vacy and security will remain
critical concerns, requiring ongo
ing capability building to stay
Foldy et at. | Peer Reviewed | Government, Law, and Public Health Practice | 1 5 9 3
G O VER N M EN T, LAW , AND P U B LIC HEALTH PR AC TICE
ahead of emerging security
threats.19 In many jurisdictions,
privacy concerns have led to pro
hibitions against sharing informa
tion across public health programs.
Unfortunately, such barriers limit
departments’ ability to meet clients’
needs, improve programs, and
protect the public health, when,
ironically, private companies now
routinely link identified data for
marketing and other goals of lesser
public importance.
Fortunately, technical advances
can facilitate the management,
security, and use of tomorrow’s
growing information challenges
and may obviate the need for
every health department, state and
local, large and small, to maintain
all needed systems locally.
ELECTRONIC HEALTH
RECORDS
The federal Electronic Health
Record (EHR) Incentive Program
(often called “Meaningful Use”),
which began in 2010, is acceler
ating health professionals’ and
hospitals’ adoption of EHR sys
tems.20 The requirement for EHR
systems to be certified to new
interoperability standards (which
enable machines to exchange and
use information with minimal hu
man intervention), combined with
incentives to achieve meaningful
use objectives of public health
reporting, is creating more stan
dardized information exchange
between health care providers and
health departments.
The rules of meaningful use
stages 1 and 2 specify message
formats and vocabularies for
reporting immunizations, syn
dromic surveillance, electronic
laboratory results, and cancer
diagnoses and care. In stage 3
(beginning 2015), EHRs may be
required to display patient vacci
nation histories and incomplete
immunization alerts from public
health immunization information
systems.21 Previously, information
exchange relationships between
health care providers and health
departments were established idiosyncratically using a variety of
standards and methods, and they
often failed to scale up to include
large proportions of the popula
tion or to achieve operational
efficiency. For example, many im
munization information and elec
tronic laboratory results systems
receive reports from only a mod
est proportion of providers despite
supporting multiple information
exchange formats.22 The new
combination of national standards
and provider incentives creates
a compelling opportunity (if not
requirement) for health depart
ments to migrate toward more
universal, rapid, and automated
electronic communication with
providers’ EHR systems.23 This
could increase the ascertainment,
speed, and efficiency of reporting
but requires health department
capability to do the following:
• Update public health systems to
new interoperability standards
for secure transmission (e.g.,
the Direct project protocol),
formatting (e.g., HL7 version
2.5.1), and vocabulary (e.g.,
SNOMED-CT).
• Interpret and improve the
quality of information derived
from EFIRs. Public health
systems increasingly rely on
information recorded for
1 5 9 4 | Government, Law, and Public Health Practice | Peer Reviewed | Foldy et al.
clinical—not public health—use,
risking misreporting or misinter
pretation. Data elements and vo
cabularies used in EHRs for pub
lic health reporting must be
thoughtfully defined (nationally)
and consistently used.
• Manage larger information vol
umes. For example, electronic
laboratory results have in
creased report volumes over
manual methods.24 Process
automation can help staff man
age the increase.
• Respond in real time to urgent
information. Health depart
ments should leverage elec
tronic reporting for faster
data-driven suppression of
emergencies, such as hepatitis
A and meningococcal out
breaks.25
• Protect privacy and security.
Electronic information must
be protected during transmis
sion, storage, and use to
avoid loss, corruption, and
diversion.
New organizations and tech
nologies may facilitate public
health access to EHR information.
Health information exchange or
ganizations can facilitate report
deliveiy and record access.26
Distributed data-mining protocols
increasingly allow health depart
ments to actively query EHRs to
augment or replace passive sur
veillance of provider-initiated re
ports (while concealing sensitive
personal identifiers, if desired)27
Because health departments re
main accountable for surveillance
data quality and completeness,
they must decide whether such
arrangements are to be used and,
if so, how.28
DECISION SUPPORT
Health care professionals rely
on timely public health informa
tion, but delivering actionable in
formation in the context of care
to improve medical decisions is
a challenge. EHR clinical decision
support systems can monitor care
and trigger alerts to improve di
agnosis, treatment, and disease
prevention at the point of service.
The EHR incentive program is
accelerating the adoption of stan
dardized clinical decision support
systems. In addition to helping
clinicians adhere to static
evidence-based practice rules,
clinical decision support systems
have been used by health depart
ments to signal when a patient is
at particular risk from a local out
break or a recent drug recall (situ
ational clinical decision support).29
For example, a provider caring for
a preschool patient with diarrhea
can be alerted to a current local
daycare-associated dysentery out
break, potentially improving diag
nostic and therapeutic decisions.30
EHR systems can solicit infor
mation from public health immu
nization registries to alert providers
to immunization deficiencies and
from prescription drug-monitoring
databases for evidence of sub
stance abuse.31 Clinicians can also
be alerted to opportunities to ad
dress health disparities on the basis
of elevated risks in a patient’s geo
graphic and demographic cohort.32
Health departments are
uniquely able to provide local,
timely, and population-based
information; thus, they have
a unique obligation to support
such situational clinical decision
support in clinical EHRs as the
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G O VERN M EN T, LAW , A ND P U B LIC HEALTH PR AC TICE
technical capability grows. As fa
miliarity increases, health depart
ments should also deploy decision
support in their own systems to
manage caseloads more efficiently
and effectively.
ENGAGING THE PUBLIC
AND THE DIGITAL DIVIDE
Members of the public are in
creasingly using personal health
records (PHRs), EHR patient por
tals, social media, and mobile
health tools. These support patient
engagement in health care but can
also facilitate information ex
change for public health surveil
lance, health promotion, research,
and other purposes. Patient ac
ceptance of sharing PHR informa
tion for public health purposes
(with appropriate privacy protec
tions) is high and increasing.33
Social media (eg., http://www.
patientslikeme.com) offer sharing
and networking about health is
sues beyond one’s medical team.
The capability and inclination of
individuals to send or broadcast
information over the Internet
(sometimes called Web 2.0, con
tributed data, or crowdsourcing) is
growing rapidly and becomes
more potent with ubiquitous smart
phones and mobile tablets, which
can add photos, video, and geo
graphic position.34 Standards fa
cilitating patient downloading and
sharing of their EHR informa
tion,33 combined with the ubiq
uity of smart mobile devices, may
enable powerful platforms for
public health surveillance, tailored
alerting (eg., notifying asthmatics
of air quality problems), and per
sona] health decision support (eg,
when to seek care).36
Crowdsourcing has already
assisted disaster and outbreak
management37 and many people
value opportunities to communi
cate about potential hazards and
events.38 Online information from
outbreak “cases” may replace
much future public health inter
viewing (as it has replaced voice
interactions for many purchases,
travel reservations, and appoint
ments). Information collected
electronically from affected indi
viduals is sometimes more useful
than is that obtained face-to-face
and filtered by health care pro
viders.39
Internet polls and surveys are
becoming more important as
landline and cell phone surveys
lose representativeness.40 Constit
uents and policymakers will also
likely expect health departments,
like other successful businesses, to
use Internet feedback to improve
services and products.41 Method
ological issues abound to ensure
that the noise of high volumes of
lay information can be appropri
ately filtered and structured to
reveal meaningful signals for
health departments, but as in other
businesses, rising quantities of
contributed and social media in
formation are coming whether
departments are prepared or not.
The public also expects un
precedented information access in
return. “Data liberation” is a fed
eral policy to make information
that public agencies hold accessi
ble to both individuals and appli
cation developers.42 Health de
partment data stewards should
expect to wrestle with increased
public data sharing while manag
ing privacy hazards (eg., mosaic
effect reidentification hazards
Septem ber 2 0 1 4 , Vol 10 4, No. 9 | American Journal o f Public Health
from the increasing availability of
multiple overlapping granular
data sets).
Technical inequalities, for ex
ample in computer skills or high
speed Internet access, are some
times called “the digital divide.” As
the use of electronic tools for
health become more widespread,
such inequalities must be identi
fied and managed to avoid rein
forcing health disparities. Trends
sometimes confound expectations.
For example, among cell phone
users today, African Americans
and Hispanics are more likely to
look up health information using
mobile devices than are White
non-Hispanics.43 Uneven diffu
sion of technology in the commu
nity also affects health department
costs. For example, persistence of
parallel paper systems may frus
trate anticipated savings from
electronic reporting.
INFORMATION AND
KNOWLEDGE OVERLOAD
These developments, together
with increased use of genomic and
phenomic data and the network
ing of sensors (Internet of things)
in home, work, and the environ
ment, will rapidly increase the
volume of information that health
departments manage.44 Health
departments will need to sort the
data flood into actionable infor
mation for various users’ needs
through 3 critical capabilities.
The first is to leverage interop
erability for automation: to use the
increasingly standardized formats
and vocabularies of high-volume
data streams to automate tasks of
receipt, validation, sorting, distri
bution, storage, filtering, and
display with minimal human in
tervention. Natural language pro
cessing and sophisticated algo
rithms might reduce the need to
standardize data tomorrow, but
meaningful use standards can
substantially advance automation
today.45
The second is to enable infor
mation, currently separated into
program-oriented silos, to be
linked on the basis of person,
specimen, location (e.g., address),
licensee, and event (e.g., outbreak),
thus allowing users to more easily
explore and understand informa
tion in context. An early example
is the “child health record” linking
information from multiple sources,
such as birth records, newborn
screening, lead screening, and im
munization records.46
Similar efforts are needed for
systems such as those to manage
foodbome outbreaks in which
complex information on patients,
laboratory specimens, food prod
ucts, and food-handling licensees
must be interpreted in concert
with speed and efficiency. Infor
mation can continue to be stored
separately (for security or other
considerations) but must be ac
cessible to integration applications
that can assemble it meaningfully
for use in different ways (e.g.,
caring for an individual, under
standing an outbreak, protecting
vulnerable populations in
a disaster).
Finally, this automation and in
tegration must be designed to
support the specific workflows of
different types of public health
workers: to help them perform
tasks efficiently, effectively, and
safely (i.e., a user-centered design).
For example, EHR systems
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GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
designed to support episodic
health care delivery may frustrate
longitudinal case management or
outbreak investigation, and sys
tems focused on collecting data for
state or national use may neglect
the workflow needs of local case
investigation. Analyzing and im
proving business processes and
their subsidiary workflows is
a critical first step in user-based
design. Because many of the most
urgent and complex information
tasks related to case and outbreak
management occur at the local
level, redesign should build from
local workflows upward to ensure
and improve the information sup
ply chain (even when statewide or
national information systems sup
port these functions)47
All 3 capabilities (automation,
information linkage, and usercentered design) are required to
manage overload and convert in
formation into better outcomes.
They require an enterprise-wide
information architecture (the ca
pability to access and use infor
mation across silo systems to meet
business needs). This is increas
ingly considered a core capability
of modem organizations both for
routine business processes (e.g.,
services) and for performance im
provement. National standards are
necessary but not sufficient. Pri
oritization, planning, and execu
tion of information architecture
(inside and between health de
partments and programs, sup
ported by national standards and
aligned program funding) are still
required to ensure that timely
actionable information reaches
those who need it.
The challenge of managing
public health knowledge (truth or
1596
principles gained from accumu
lated information and inference,
e.g., evidence-based practices, ex
perience) is growing alongside the
explosion in data and information.
This is driven by 3 factors: an
aging public health workforce
whose turnover requires transfer
of experiential knowledge; grow
ing volumes of public health and
prevention research; and the ev
ermore interdisciplinary nature
of public health work.48 These
require access to and sharing of
knowledge and expertise, includ
ing policies, procedures, and prac
tices; bibliographic and training
resources; and subject matter
experts who often as not work
outside a particular health depart
ment. Technologies to share
knowledge synchronously (live,
including webcasts and telecon
sulting) or asynchronously (storing
useful knowledge for searching
and retrieving on demand) are
developing rapidly. Using such
technologies effectively is an
emerging core capability for
future health departments.49
CLOUD COMPUTING
Improvements in Internet ac
cess, speed, and distributed com
puting now enable practical access
to massive computing power, ap
plications, and data sets “in the
cloud” (i.e., on the Internet) instead
of on local servers. This allows the
purchase of infrastructure as a ser
vice (i.e., online computing power),
software as a service, or entire
platform as a service (i.e., an online
environment combining access to
computing, software, and data
sets) from an expanding collection
of public and private providers.
| Government, Law, and Public Health Practice
| Peer Reviewed | FoMy et a t
Assuming ongoing progress in
cloud reliability, speed, security,
and cost, cloud technology will
likely allow health departments to
lease technology online less ex
pensively than by locally purchas
ing and maintaining servers and
software. Such doud-based ar
rangements can also facilitate se
cure information sharing between
organizations, programs, and ju
risdictions when appropriate. For
example, BioSense 2.0 leverages
cloud capabilities for syndromic
surveillance, facilitating data sub
mission from EHRs nationwide
and permitting the voluntary shar
ing of data, software, and analysis
products horizontally across juris
dictions and vertically from local
through federal levels.50
The power and cost-efficacy of
such shared platforms may prove
suffidently enticing to overcome
health department commitments
to separate jurisdictional and pro
grammatic data and hardware
silos. Programs and departments
will have to accede to standards
for defining and coding data ele
ments and greater uniformity of
workflows before they can enjoy
convenient, scalable cloud solu
tions. For example, information in
puts and outputs to manage a case
of tuberculosis must become more
uniform before cloud-based solu
tions become practical nationwide.
Health departments will need
greater focus on information
management (the competencies
associated with public health in
formatics) than on technology
management (server and network
administration) during and after
this transition. Fortunately, these
are the same competencies that will
remain in demand long after health
departments have converted
server closets to other functions.
TOMORROW’S CAPABLE
HEALTH DEPARTMENT
Health department roles will
change with health care finance
reform, but their need to use and
protect personal health informa
tion will still increase. Higher vol
umes of more timely information
will need to be integrated and
used more rapidly to improve
outcomes. Capabilities such as
those in Table 1 will be needed
to manage information to the
greatest advantage.
Stand-alone local solutions will
become obstacles to necessary in
teroperability and information
sharing (with health care pro
viders, the public, and between
local, state, and federal levels).
Cloud-based solutions offer econ
omies of scale and simplified in
formation sharing, but private
solutions will not emerge sponta
neously. Public health is a niche
market complicated by conflicting
jurisdictional and program re
quirements. Successful platforms
will require agreement on infor
mation governance, data stan
dardization, and, critically, health
department requirements and
capabilities such as those pro
posed in Table 1.
These capabilities (whether
managed locally or supported by
state or national cloud services)
have important, near-universal
implications for health department
sustainability, planning, budget
ing, workforce, and technology,
making them appropriate for dis
cussion in the context of accredi
tation. We hope there will be
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Foldy et al. | Peer Reviewed | Government, Law, and Public Health Practice | 1597
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
te s tin g and im proving clo ud a p p lic a tio n s
About th e Authors
o>
ensure m a in te n a n c e o f info rm atio n security and
services on th e basis o f w orkflow requirem ents;
P a rticip a te in design or selectio n o f c loud-based
SM Es and a ffe c te d w orkforce p a rtic ip a te in
both broad consideration and
timely consensus on such a set. ■
When this article was written, Seth Foldy
was with the Public Health Surveillance and
Informatics Program Office, Centers fo r
Disease Control and Prevention, Atlanta,
GA. Shaun Grannis was with the
Regenstrief Institute and Indiana
University School o f Medicine, Indian
apolis. David Ross was with the Public
Health Informatics Institute, Atlanta,
GA. Torney Sm ith was with the R e
gional Health Department, Spokane,
W A.
Correspondence should be sent to Seth
Foldy, 3 0 6 1 N. Marietta Avenue,
Milwaukee, W I 532 1 1 (e-mail: sfoldy@
sbcglobal.net). Reprints can be ordered at
http://unvw.ajph.org by clicking the
“Reprints” link.
This article was accepted February 16,
2014.
C ontributors
€53
S. Foldy authored each draft of the
article. All authors conceptualized,
reviewed, and edited the article.
(in clu d in g m obile In tern e t access)
The Public Health Accreditation Board
funded the think tank meetings where we
were tasked with forecasting longer-range
future informatics needs of health de
partments.
W e thank the members of the Public
Health Accreditation Board Informatics
Think Tank, Jim Jellison, MPH (Public
Health Informatics Institute), Joseph
Gibson, MPH, PhD (Marion County [IN]
Health and Hospital Corporation), and
Jeffrey Kriseman, PhD (Centers for
Disease Control and Prevention), for
helpful review and comments, and Jim
Jellison and Eliana Duncan (Public
Health Informatics Institute) for editorial
assistance.
Human P articip ant Protection
inform ation services
E valuate, n egotiate, and m anage c loud-based
Im p le m e n t and m a in ta in secure networks
Acknowledgm ents
No protocol approval was necessaiy be
cause this project did not involve research
participants.
Endnotes
1.
W.A. Yasnoff, P.W. O’Carroll, D. Koo,
R.W. Linkins, and E.M. Kilboume, “Public
Health Informatics: Improving and Trans
forming Public Health in the Information
1 5 9 8 | Government, Law, and Public Health Practice
| Peer Reviewed | Foldy et al.
Age,” Journal o f Public Health Management
& Practice 6, no. 6 (2000): 6 7 -7 5 .
2. G.C. Benjamin, ‘Transforming the Pub
lic Health System: W hat Are W e Learning?,”
http://iom.edu/Global/Perspectives/2012/
TransformingPublicHealth.aspx (accessed
February 9, 2014); Institute of Medicine,
For the Public’s Health: Investing in a
Healthier Future (Washington, DC,
2012), 6. Although this report and its
predecessors (The Future o f Public Health
[198
F u tu re N e e d s o f H e a lth D e p a r tm e n ts
A R id e in t h e l i m e M a c h in e : In f o r m a t io n M a n a g e m e n t
C a p a b ilitie s H e a lth D e p a r t m e n t s W ill N e e d
Seth Foldy, MD, MPH, Shaun Grannis, MD, MS, David Ross, PhD, and Torney Smith, MSHE
W e have proposed needed
information m anagem ent ca
pabilities for future US health
dep artm en ts predicated on
trends in health care reform and
health information technology.
Regardless of whether health
departments provide direct clin
ical services (and many will),
they will manage unprece
dented quantities of sensitive
information for the public health
core functions of assurance and
assessment, including populationlevel health surveillance and
metrics. Absent improved ca
pabilities, health departments
risk vestigial status, with conse
quences for vulnerable popula
tions. Developments in electronic
health records, interoperability
and information exchange, pub
lic information sharing, decision
support, and cloud technologies
can support information man
agement if health departments
have appropriate capabilities.
The need for national en
gagement in and consensus
on these capabilities and their
importance to health depart
ment sustainability make them
appropriate for consideration
in the context of accreditation.
(Am J Public Health. 2014;104:
1592-1600. doi:10.2105/AJPH.
2014.301956)
WHAT INFORMATION MANAGE-
ment capabilities will be needed
by tomorrow’s US health depart
ments? The Public Health Ac
creditation Board establishes
standards and provides accredita
tion to US local, tribal, and state
health departments. Because we
are experienced in local, state, and
federal public health informatics
(the systematic application of in
formation and computer science
and technology to improve public
health practice, research, or edu
cation),1 a Public Health Accredi
tation Board think tank asked us to
predict the effects of emerging
trends on requirements for future
accreditation standards.
The Patient Protection and
Affordable Care Act (ACA) may
radically change the functions of
US health departments. New de
velopments in health information
technology (technology standards,
applications, and hardware for
health data) will profoundly
change how information is man
aged and exchanged. Different
predictions about these changes
may produce markedly different
predictions of required health de
partment capabilities.
Some have asserted that ACA
reforms (more people insured,
preventive services covered, and
1 5 9 2 | Government, Law, and Public Health Practice | Peer Reviewed | Foldy et al.
provider incentives) may lead
health departments to stop deliv
ering individual services, such as
immunizations.2 Meanwhile, some
predict that digitization and the
exchange of health care data will
produce “distributed access to in
formation without exposing the
details of the underlying data . . .
collect[ing] only summarized data…
or key results.”3 Taken together,
these trends suggest that health
departments may eliminate direct
services and consume rather than
create health information products,
thus minimizing their management
of sensitive health information.
We predict, rather, that health
departments will struggle with
managing more information to
improve service cost efficiency,
collaborate on prevention with
a leaner health care system, and
meet demands for unbiased pop
ulation health statistics. Competi
tive pressures will emerge rapidly
over the next 5 years. Health
departments that cannot manage
information appropriately may
become vestigial—to the detriment
of their communities (and espe
cially to vulnerable underserved
populations). The pace of change
will challenge many health de
partments. Emerging advances in
health information technology can
help meet these challenges, but
only if health departments de
velop needed capabilities.
HEALTH DEPARTMENT
ROLES AND INFORMATION
MANAGEMENT
Aspects of the ACA encourage
private health care providers to
perform preventive care. Reduc
tions in the number of uninsured
individuals, improved financial in
centives for preventive services,
and business models such as ac
countable care organizations and
primary care medical homes,
could reduce the need for health
departments to provide personal
services, such as immunizations
and tuberculosis management.
However, this reduction may
be offset by a continuing obliga
tion to ensure prevention for those
remaining unprotected and an in
creased demand for communitybased services. Assumptions that
ACA reforms will optimize popu
lation deliveiy of preventive
services rest on continuous care
access and accountability. Millions
will still lack health insurance
(especially in states declining
Medicaid expansion),4 move fre
quently,5 and experience provider
turnover because patients and
American Journal of Public Health | September 2 0 1 4 , Vol 104, No. 9
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
insurers will shop for value. The
ACA reduces hospital reimburse
ment, which may disrupt uncom
pensated care, although new
nonprofit requirements may offset
this. Thus, discontinuities in insur
ance, care, and information (pend
ing improved health information
exchange) will perpetuate preven
tive service gaps. The ACA follows
earlier reforms (e.g., health main
tenance organizations, managed
competition) that, despite great
promises, yielded mixed and modest
changes in preventive care.6
Despite recommendations to shift
from service delivery to assurance,
from 1997 to 2008 22% of local
health departments maintained or
increased the types of dinical ser
vices they offered.7 In 2013 more
than 90% offered immunizations,
more than 80% offered some in
fectious disease screening or treat
ment, and more than 60% offered
some chronic disease screening.8
Under Massachusetts’s ACA-like re
form, public health programs expe
rienced varying changes in demand,
and an incapacity to analyze client
data impeded planning.9 Many
departments will continue serving
uninsured and hard-to-reach
individuals,10 and expectations that
they bill insurers, when possible,
will compound information man
agement needs.11
Beyond clinical services, depart
ments may be invited to partner in
case management and communitybased services (foreshadowed in
ACA initiatives, e.g., community
health teams and home visit pro
grams).12 Success in such partner
ships cannot be assumed because
there is cost competition in the
resource-constrained accountable
care organization environment.
Health departments will need to
accept electronic referrals as other
• Which prenatal care factors
providers do. W hether serving in
tality disparities?
• Which infants lack follow-up
for abnorm al new born
screens?
whole-community health informa
tion, ensuring public access to un
biased information about the
health of the community and
• W here do concentrations of
sometimes providing impartial
assessment of the performance
of health care providers and net
works. This accountability will re
quire health departments to use
sured or uninsured patients, in
partnerships or separately, health
departments will be expected to
deliver and document services
more efficiently than before.
Thus, departments will need to
assess and satisfy patients’ needs
in a timely, coordinated way, not
at the convenience of fragmented
programs. Patients’ longitudinal
and cross-program information
will be needed at the point of
service and for performance im
provement. This requires chang
ing the program-based culture of
many health departments with
silos of disconnected informa
tion.13 Cross-program business in
telligence is becoming business as
usual in the private sector and is
becoming critical to creating
“learning health systems” that
contribute to local infant mor
people live with chronic disease
risk factors who are not receiv
ing preventive services?
Such information is required for
effective public health assessment
and assurance and is supported by
unique reporting mandates and
Health Insurance Portability and
Accountability Act consider
ations.15 Although accountable
care organizations may perform
within-network measurement and
may report similar metrics, this
will not assess people and prob
lems falling between networks.
Private providers are also reluc
tant to share information that
might affect competition for
continuously improve services.14
Health departments that do not
deliver direct services will continue
patients or payers. This conflict
between competition and trans
to receive and manage sensitive
health information for disease and
health departments to create im
injury surveillance, outbreak and
emergency management (e.g., vac
cine or drug countermeasure ad
ministration), and maternal, child,
and environmental health. The
capability to match identifiable
records over time and across all
health care providers is needed to
track important community-level
questions, such as,
• W hat proportion of persons with
HTV lacks antiviral treatment or
screening for tuberculosis and
syphilis?
• W ho received a first but not
second immunization for a new
pandemic influenza strain?
Septem ber 20 1 4 , Vol 10 4, No. 9 | American Journal of Public Health
parency may create demand for
partial metrics of quality and
safety, as they do for vital events,
diseases, and injuries.16 Legally
authorized, neutral public health
registries (e.g., immunization reg
istries and disease registries) often
have established community-wide
information sharing even as other
health information exchange ar
rangements fall prey to competi
tive pressures.17
Therefore, provider-controlled
aggregate reports may augment,
but cannot replace, the mandated
universal reporting of identifiable
individual reports to health de
partments. W e believe health de
partments will continue to be held
accountable for the completeness,
accuracy, and transparency of
and steward individuals’ health
information.
The demand for person-linked
information across diverse sources
and systems will also grow be
cause of the recognition of “syndemics,” for example, interactions
between HIV, tuberculosis, and
syphilis and other sexually trans
mitted infections; relationships
between obesity, diabetes, and
hypertension and other cardio
vascular diseases; relationships
between social factors, infant
mortality, adverse childhood ex
periences, and chronic disease
morbidity; and the relationships
of these syndemics to health dis
parities, whose elimination are
a national priority.18 Segregated
information silos are inadequate
for studying and managing such
syndemics, which require a syner
gistic (personcentric and needs
based, not program based) para
digm for public health services
and the information systems that
serve them.
Thus, future health depart
ments must maintain and improve
their capability to receive, secure,
manage, link, analyze, and use
individuals’ personal health infor
mation for many purposes. Pri
vacy and security will remain
critical concerns, requiring ongo
ing capability building to stay
Foldy et at. | Peer Reviewed | Government, Law, and Public Health Practice | 1 5 9 3
G O VER N M EN T, LAW , AND P U B LIC HEALTH PR AC TICE
ahead of emerging security
threats.19 In many jurisdictions,
privacy concerns have led to pro
hibitions against sharing informa
tion across public health programs.
Unfortunately, such barriers limit
departments’ ability to meet clients’
needs, improve programs, and
protect the public health, when,
ironically, private companies now
routinely link identified data for
marketing and other goals of lesser
public importance.
Fortunately, technical advances
can facilitate the management,
security, and use of tomorrow’s
growing information challenges
and may obviate the need for
every health department, state and
local, large and small, to maintain
all needed systems locally.
ELECTRONIC HEALTH
RECORDS
The federal Electronic Health
Record (EHR) Incentive Program
(often called “Meaningful Use”),
which began in 2010, is acceler
ating health professionals’ and
hospitals’ adoption of EHR sys
tems.20 The requirement for EHR
systems to be certified to new
interoperability standards (which
enable machines to exchange and
use information with minimal hu
man intervention), combined with
incentives to achieve meaningful
use objectives of public health
reporting, is creating more stan
dardized information exchange
between health care providers and
health departments.
The rules of meaningful use
stages 1 and 2 specify message
formats and vocabularies for
reporting immunizations, syn
dromic surveillance, electronic
laboratory results, and cancer
diagnoses and care. In stage 3
(beginning 2015), EHRs may be
required to display patient vacci
nation histories and incomplete
immunization alerts from public
health immunization information
systems.21 Previously, information
exchange relationships between
health care providers and health
departments were established idiosyncratically using a variety of
standards and methods, and they
often failed to scale up to include
large proportions of the popula
tion or to achieve operational
efficiency. For example, many im
munization information and elec
tronic laboratory results systems
receive reports from only a mod
est proportion of providers despite
supporting multiple information
exchange formats.22 The new
combination of national standards
and provider incentives creates
a compelling opportunity (if not
requirement) for health depart
ments to migrate toward more
universal, rapid, and automated
electronic communication with
providers’ EHR systems.23 This
could increase the ascertainment,
speed, and efficiency of reporting
but requires health department
capability to do the following:
• Update public health systems to
new interoperability standards
for secure transmission (e.g.,
the Direct project protocol),
formatting (e.g., HL7 version
2.5.1), and vocabulary (e.g.,
SNOMED-CT).
• Interpret and improve the
quality of information derived
from EFIRs. Public health
systems increasingly rely on
information recorded for
1 5 9 4 | Government, Law, and Public Health Practice | Peer Reviewed | Foldy et al.
clinical—not public health—use,
risking misreporting or misinter
pretation. Data elements and vo
cabularies used in EHRs for pub
lic health reporting must be
thoughtfully defined (nationally)
and consistently used.
• Manage larger information vol
umes. For example, electronic
laboratory results have in
creased report volumes over
manual methods.24 Process
automation can help staff man
age the increase.
• Respond in real time to urgent
information. Health depart
ments should leverage elec
tronic reporting for faster
data-driven suppression of
emergencies, such as hepatitis
A and meningococcal out
breaks.25
• Protect privacy and security.
Electronic information must
be protected during transmis
sion, storage, and use to
avoid loss, corruption, and
diversion.
New organizations and tech
nologies may facilitate public
health access to EHR information.
Health information exchange or
ganizations can facilitate report
deliveiy and record access.26
Distributed data-mining protocols
increasingly allow health depart
ments to actively query EHRs to
augment or replace passive sur
veillance of provider-initiated re
ports (while concealing sensitive
personal identifiers, if desired)27
Because health departments re
main accountable for surveillance
data quality and completeness,
they must decide whether such
arrangements are to be used and,
if so, how.28
DECISION SUPPORT
Health care professionals rely
on timely public health informa
tion, but delivering actionable in
formation in the context of care
to improve medical decisions is
a challenge. EHR clinical decision
support systems can monitor care
and trigger alerts to improve di
agnosis, treatment, and disease
prevention at the point of service.
The EHR incentive program is
accelerating the adoption of stan
dardized clinical decision support
systems. In addition to helping
clinicians adhere to static
evidence-based practice rules,
clinical decision support systems
have been used by health depart
ments to signal when a patient is
at particular risk from a local out
break or a recent drug recall (situ
ational clinical decision support).29
For example, a provider caring for
a preschool patient with diarrhea
can be alerted to a current local
daycare-associated dysentery out
break, potentially improving diag
nostic and therapeutic decisions.30
EHR systems can solicit infor
mation from public health immu
nization registries to alert providers
to immunization deficiencies and
from prescription drug-monitoring
databases for evidence of sub
stance abuse.31 Clinicians can also
be alerted to opportunities to ad
dress health disparities on the basis
of elevated risks in a patient’s geo
graphic and demographic cohort.32
Health departments are
uniquely able to provide local,
timely, and population-based
information; thus, they have
a unique obligation to support
such situational clinical decision
support in clinical EHRs as the
American Journal o f Public Health | September 2 0 1 4 , Vol 10 4, No. 9
G O VERN M EN T, LAW , A ND P U B LIC HEALTH PR AC TICE
technical capability grows. As fa
miliarity increases, health depart
ments should also deploy decision
support in their own systems to
manage caseloads more efficiently
and effectively.
ENGAGING THE PUBLIC
AND THE DIGITAL DIVIDE
Members of the public are in
creasingly using personal health
records (PHRs), EHR patient por
tals, social media, and mobile
health tools. These support patient
engagement in health care but can
also facilitate information ex
change for public health surveil
lance, health promotion, research,
and other purposes. Patient ac
ceptance of sharing PHR informa
tion for public health purposes
(with appropriate privacy protec
tions) is high and increasing.33
Social media (eg., http://www.
patientslikeme.com) offer sharing
and networking about health is
sues beyond one’s medical team.
The capability and inclination of
individuals to send or broadcast
information over the Internet
(sometimes called Web 2.0, con
tributed data, or crowdsourcing) is
growing rapidly and becomes
more potent with ubiquitous smart
phones and mobile tablets, which
can add photos, video, and geo
graphic position.34 Standards fa
cilitating patient downloading and
sharing of their EHR informa
tion,33 combined with the ubiq
uity of smart mobile devices, may
enable powerful platforms for
public health surveillance, tailored
alerting (eg., notifying asthmatics
of air quality problems), and per
sona] health decision support (eg,
when to seek care).36
Crowdsourcing has already
assisted disaster and outbreak
management37 and many people
value opportunities to communi
cate about potential hazards and
events.38 Online information from
outbreak “cases” may replace
much future public health inter
viewing (as it has replaced voice
interactions for many purchases,
travel reservations, and appoint
ments). Information collected
electronically from affected indi
viduals is sometimes more useful
than is that obtained face-to-face
and filtered by health care pro
viders.39
Internet polls and surveys are
becoming more important as
landline and cell phone surveys
lose representativeness.40 Constit
uents and policymakers will also
likely expect health departments,
like other successful businesses, to
use Internet feedback to improve
services and products.41 Method
ological issues abound to ensure
that the noise of high volumes of
lay information can be appropri
ately filtered and structured to
reveal meaningful signals for
health departments, but as in other
businesses, rising quantities of
contributed and social media in
formation are coming whether
departments are prepared or not.
The public also expects un
precedented information access in
return. “Data liberation” is a fed
eral policy to make information
that public agencies hold accessi
ble to both individuals and appli
cation developers.42 Health de
partment data stewards should
expect to wrestle with increased
public data sharing while manag
ing privacy hazards (eg., mosaic
effect reidentification hazards
Septem ber 2 0 1 4 , Vol 10 4, No. 9 | American Journal o f Public Health
from the increasing availability of
multiple overlapping granular
data sets).
Technical inequalities, for ex
ample in computer skills or high
speed Internet access, are some
times called “the digital divide.” As
the use of electronic tools for
health become more widespread,
such inequalities must be identi
fied and managed to avoid rein
forcing health disparities. Trends
sometimes confound expectations.
For example, among cell phone
users today, African Americans
and Hispanics are more likely to
look up health information using
mobile devices than are White
non-Hispanics.43 Uneven diffu
sion of technology in the commu
nity also affects health department
costs. For example, persistence of
parallel paper systems may frus
trate anticipated savings from
electronic reporting.
INFORMATION AND
KNOWLEDGE OVERLOAD
These developments, together
with increased use of genomic and
phenomic data and the network
ing of sensors (Internet of things)
in home, work, and the environ
ment, will rapidly increase the
volume of information that health
departments manage.44 Health
departments will need to sort the
data flood into actionable infor
mation for various users’ needs
through 3 critical capabilities.
The first is to leverage interop
erability for automation: to use the
increasingly standardized formats
and vocabularies of high-volume
data streams to automate tasks of
receipt, validation, sorting, distri
bution, storage, filtering, and
display with minimal human in
tervention. Natural language pro
cessing and sophisticated algo
rithms might reduce the need to
standardize data tomorrow, but
meaningful use standards can
substantially advance automation
today.45
The second is to enable infor
mation, currently separated into
program-oriented silos, to be
linked on the basis of person,
specimen, location (e.g., address),
licensee, and event (e.g., outbreak),
thus allowing users to more easily
explore and understand informa
tion in context. An early example
is the “child health record” linking
information from multiple sources,
such as birth records, newborn
screening, lead screening, and im
munization records.46
Similar efforts are needed for
systems such as those to manage
foodbome outbreaks in which
complex information on patients,
laboratory specimens, food prod
ucts, and food-handling licensees
must be interpreted in concert
with speed and efficiency. Infor
mation can continue to be stored
separately (for security or other
considerations) but must be ac
cessible to integration applications
that can assemble it meaningfully
for use in different ways (e.g.,
caring for an individual, under
standing an outbreak, protecting
vulnerable populations in
a disaster).
Finally, this automation and in
tegration must be designed to
support the specific workflows of
different types of public health
workers: to help them perform
tasks efficiently, effectively, and
safely (i.e., a user-centered design).
For example, EHR systems
Foldy et al. | Peer Reviewed | Government, Law, and Public Health Practice | 15 95
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
designed to support episodic
health care delivery may frustrate
longitudinal case management or
outbreak investigation, and sys
tems focused on collecting data for
state or national use may neglect
the workflow needs of local case
investigation. Analyzing and im
proving business processes and
their subsidiary workflows is
a critical first step in user-based
design. Because many of the most
urgent and complex information
tasks related to case and outbreak
management occur at the local
level, redesign should build from
local workflows upward to ensure
and improve the information sup
ply chain (even when statewide or
national information systems sup
port these functions)47
All 3 capabilities (automation,
information linkage, and usercentered design) are required to
manage overload and convert in
formation into better outcomes.
They require an enterprise-wide
information architecture (the ca
pability to access and use infor
mation across silo systems to meet
business needs). This is increas
ingly considered a core capability
of modem organizations both for
routine business processes (e.g.,
services) and for performance im
provement. National standards are
necessary but not sufficient. Pri
oritization, planning, and execu
tion of information architecture
(inside and between health de
partments and programs, sup
ported by national standards and
aligned program funding) are still
required to ensure that timely
actionable information reaches
those who need it.
The challenge of managing
public health knowledge (truth or
1596
principles gained from accumu
lated information and inference,
e.g., evidence-based practices, ex
perience) is growing alongside the
explosion in data and information.
This is driven by 3 factors: an
aging public health workforce
whose turnover requires transfer
of experiential knowledge; grow
ing volumes of public health and
prevention research; and the ev
ermore interdisciplinary nature
of public health work.48 These
require access to and sharing of
knowledge and expertise, includ
ing policies, procedures, and prac
tices; bibliographic and training
resources; and subject matter
experts who often as not work
outside a particular health depart
ment. Technologies to share
knowledge synchronously (live,
including webcasts and telecon
sulting) or asynchronously (storing
useful knowledge for searching
and retrieving on demand) are
developing rapidly. Using such
technologies effectively is an
emerging core capability for
future health departments.49
CLOUD COMPUTING
Improvements in Internet ac
cess, speed, and distributed com
puting now enable practical access
to massive computing power, ap
plications, and data sets “in the
cloud” (i.e., on the Internet) instead
of on local servers. This allows the
purchase of infrastructure as a ser
vice (i.e., online computing power),
software as a service, or entire
platform as a service (i.e., an online
environment combining access to
computing, software, and data
sets) from an expanding collection
of public and private providers.
| Government, Law, and Public Health Practice
| Peer Reviewed | FoMy et a t
Assuming ongoing progress in
cloud reliability, speed, security,
and cost, cloud technology will
likely allow health departments to
lease technology online less ex
pensively than by locally purchas
ing and maintaining servers and
software. Such doud-based ar
rangements can also facilitate se
cure information sharing between
organizations, programs, and ju
risdictions when appropriate. For
example, BioSense 2.0 leverages
cloud capabilities for syndromic
surveillance, facilitating data sub
mission from EHRs nationwide
and permitting the voluntary shar
ing of data, software, and analysis
products horizontally across juris
dictions and vertically from local
through federal levels.50
The power and cost-efficacy of
such shared platforms may prove
suffidently enticing to overcome
health department commitments
to separate jurisdictional and pro
grammatic data and hardware
silos. Programs and departments
will have to accede to standards
for defining and coding data ele
ments and greater uniformity of
workflows before they can enjoy
convenient, scalable cloud solu
tions. For example, information in
puts and outputs to manage a case
of tuberculosis must become more
uniform before cloud-based solu
tions become practical nationwide.
Health departments will need
greater focus on information
management (the competencies
associated with public health in
formatics) than on technology
management (server and network
administration) during and after
this transition. Fortunately, these
are the same competencies that will
remain in demand long after health
departments have converted
server closets to other functions.
TOMORROW’S CAPABLE
HEALTH DEPARTMENT
Health department roles will
change with health care finance
reform, but their need to use and
protect personal health informa
tion will still increase. Higher vol
umes of more timely information
will need to be integrated and
used more rapidly to improve
outcomes. Capabilities such as
those in Table 1 will be needed
to manage information to the
greatest advantage.
Stand-alone local solutions will
become obstacles to necessary in
teroperability and information
sharing (with health care pro
viders, the public, and between
local, state, and federal levels).
Cloud-based solutions offer econ
omies of scale and simplified in
formation sharing, but private
solutions will not emerge sponta
neously. Public health is a niche
market complicated by conflicting
jurisdictional and program re
quirements. Successful platforms
will require agreement on infor
mation governance, data stan
dardization, and, critically, health
department requirements and
capabilities such as those pro
posed in Table 1.
These capabilities (whether
managed locally or supported by
state or national cloud services)
have important, near-universal
implications for health department
sustainability, planning, budget
ing, workforce, and technology,
making them appropriate for dis
cussion in the context of accredi
tation. We hope there will be
American Journal o f Public Health | September 2 0 1 4 , Vol 104, No. 9
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
September 2014, Vol 104, No. 9 | American Journal of Public Health
Foldy et al. | Peer Reviewed | Government, Law, and Public Health Practice | 1597
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
te s tin g and im proving clo ud a p p lic a tio n s
About th e Authors
o>
ensure m a in te n a n c e o f info rm atio n security and
services on th e basis o f w orkflow requirem ents;
P a rticip a te in design or selectio n o f c loud-based
SM Es and a ffe c te d w orkforce p a rtic ip a te in
both broad consideration and
timely consensus on such a set. ■
When this article was written, Seth Foldy
was with the Public Health Surveillance and
Informatics Program Office, Centers fo r
Disease Control and Prevention, Atlanta,
GA. Shaun Grannis was with the
Regenstrief Institute and Indiana
University School o f Medicine, Indian
apolis. David Ross was with the Public
Health Informatics Institute, Atlanta,
GA. Torney Sm ith was with the R e
gional Health Department, Spokane,
W A.
Correspondence should be sent to Seth
Foldy, 3 0 6 1 N. Marietta Avenue,
Milwaukee, W I 532 1 1 (e-mail: sfoldy@
sbcglobal.net). Reprints can be ordered at
http://unvw.ajph.org by clicking the
“Reprints” link.
This article was accepted February 16,
2014.
C ontributors
€53
S. Foldy authored each draft of the
article. All authors conceptualized,
reviewed, and edited the article.
(in clu d in g m obile In tern e t access)
The Public Health Accreditation Board
funded the think tank meetings where we
were tasked with forecasting longer-range
future informatics needs of health de
partments.
W e thank the members of the Public
Health Accreditation Board Informatics
Think Tank, Jim Jellison, MPH (Public
Health Informatics Institute), Joseph
Gibson, MPH, PhD (Marion County [IN]
Health and Hospital Corporation), and
Jeffrey Kriseman, PhD (Centers for
Disease Control and Prevention), for
helpful review and comments, and Jim
Jellison and Eliana Duncan (Public
Health Informatics Institute) for editorial
assistance.
Human P articip ant Protection
inform ation services
E valuate, n egotiate, and m anage c loud-based
Im p le m e n t and m a in ta in secure networks
Acknowledgm ents
No protocol approval was necessaiy be
cause this project did not involve research
participants.
Endnotes
1.
W.A. Yasnoff, P.W. O’Carroll, D. Koo,
R.W. Linkins, and E.M. Kilboume, “Public
Health Informatics: Improving and Trans
forming Public Health in the Information
1 5 9 8 | Government, Law, and Public Health Practice
| Peer Reviewed | Foldy et al.
Age,” Journal o f Public Health Management
& Practice 6, no. 6 (2000): 6 7 -7 5 .
2. G.C. Benjamin, ‘Transforming the Pub
lic Health System: W hat Are W e Learning?,”
http://iom.edu/Global/Perspectives/2012/
TransformingPublicHealth.aspx (accessed
February 9, 2014); Institute of Medicine,
For the Public’s Health: Investing in a
Healthier Future (Washington, DC,
2012), 6. Although this report and its
predecessors (The Future o f Public Health
[198
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