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Population Health Informatics in Health Care and Public Health

Topic Areas:• Long Term Objectives for Working Population Issues• Best Practices for Health Registries• Information Exchange (IEx) for Detection and Monitoring:

Clinical Care to Health Departments• IEx for Clinical Communication and Coordination:

Health Department to Clinical Care• Health Departments and HITECH / ACA• Balancing Personal and Population Privacy Needs• Social and Mobile Media and Prevention• Open Source and Cloud for Public and Population Health:

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IEx for Clinical Communication and Coordination: Health Department to Clinical Care

Joe Gibson, MPH, PhDDirector of Epidemiology, Indianapolis (Marion County)

Catherine Schenck-Yglesias, MHSProject Director, Johns Hopkins International

Development Program

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PERSONALLY IDENTIFIABLE AND NON-IDENTIFIABLE PUBLIC HEALTH DATA FOR CLINICAL BENEFIT

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Identified PH Data for Clinicians

• What vaccines does this patient need now?– Pt’s immunization history, compared to recommended

schedule• Newborn genetic disorder testing results

– Routing heel-stick blood test results to pediatricians & parents

• Results of special lab tests– Some tests are usually done at public health laboratories

• Home visit information from public health nurses• Rx monitoring program (identify excessive narcotic

use)

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Unidentified PH Data for Clinicians

• Setting the Index of suspicion– What unusual diseases are around today?– What is prevalent today, and with whom?– Examples: TB, syphilis (diseases familiar to MDs)

• Unusual Outbreaks– What symptoms?– Where the treatment & follow-up recommendations?– What are the prevention recommendations?– Examples: Monkey pox, pH1N1, contaminated

injectable steroids

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HEALTH AND HUMAN SERVICES DATA FOR CLINICAL BENEFIT

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Health and Human Services Information of Use to Clinicians

• Risk– Data on social service issues of the community

and specific individuals that represent risk factors, comorbidities or challenges to preventive health and treatment plans

• Resolution– Programs at local health and human/social

services departments that may be able to assist patients in addressing current and preventing future clinical issues

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Preventive Health Examples

• Environmental Hazards– Agency for Toxic Substances and Disease Registry (ATSDR) Pu

blic Health Assessments• when people have been or are likely to be exposed to a toxic substance

and, usually, how and when they were exposed• whether the exposures are likely to lead to illness• recommends ways to protect public health

• Obese patients– What is his most convenient opportunity for exercise? What

programs are near his home?– Are fresh fruits and vegetables available at a nearby store?– Are walking or biking trails near his home?– What parks are nearest his home? Do they have free or low-cost

physical activity programs?– Does his neighborhood have sidewalks?

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Potential HHS / Social Service Data Sharing

Source: Shank, Nancy C., "Understanding Human Services Utilization: Opportunities for Data Sharing between Federally Funded Programs” (2009). Nancy Shank Publications. University of Nebraska Public Policy Center. Paper 6.

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Appropriate Referral to Local Health and Social Services

• Adult Mental Health Services• Adult Protective Services• Aging Services• Catholic Charities• Child Care Services• Child Welfare Services• Domestic Violence Service via Abused Persons

Program• Early Learning and Child Care• Education through Public School System• Emergency Assistance• Environmental Hazard Elimination• Federally Qualified Health Centers• Fitness/Wellness Programs• Foster Care• Goodwill Services• Head Start Providers• Homeless Program• Housing Stabilization Services• In-home Aide Services• Income Support Services

• Jewish Community Center• Limited English Proficiency (LEP) Services• Maternity Services• Medical and Primary Care Services• Medicaid Enrollment• Protective Adoption• Public Health TB Clinic• Public or Medicaid Provider Mental Health

Treatment• Senior Centers• Smoking Cessation Programs• Supplemental Nutrition Assistance Program

(SNAP), formerly known as Food Stamps• Special Needs Housing Services• Substance Abuse Treatment• Temporary Assistance for Needy Families (TANF)• Vocational Rehabilitation• Workforce Investment Act (WIA) Services (training

and employment)• Women, Infants and Children (WIC) Services• Workforce Services

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INFORMATICS INTERVENTIONS

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PH data to clinicians:Current Usual Practice

• Push to providers: via letters, email, faxes– For both identified & broadcast information

• Pull by providers: web sites, media• Providers log-in to immunization

databases• Lab results often delivered by mail

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Nascent Electronic Exchange

• Secure email• Electronic alerts delivered via HIE

– same route as lab. results• Conditional alerts in EHRs

– During a TB outbreak among homeless, system prompts for TB tests when homeless appear at ED

– During syphilis outbreak, patients meeting the outbreak profile were flagged for testing

• Immunization histories pushed to EHR

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The Future: Knowing a pt’s context

Regarding an obese patient:• What programs are near his home?• Are fresh vegetables available nearby?• Has sidewalks in his neighborhood?• What support networks are available?

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• What data gets pushed from PH?• What data gets pulled by EHR?• Are other modes more effective?• What data requires provider

authentication?

The Future

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ABC Residential

& Group Care

Health & Disability

Caseworker Team

Planning & Resource Allocation

Financial Management

Program Management

Information Technology

Child Welfare

Aging Voc. Rehab

Mental Retardation

Seniors Centers

Medicaid Contractor

No Child Left

Behind

GoodwillServices

DevelopmentalDisabilities

Community Health

CommunityMental Health

Workforce Develop

Medicaid

Income(TANF, Emerg.

AidMedicaid

Jewish Community

CenterCatholic

Chairities

Child Care

CourtsCriminalCivilJuvenile JusticeFamily CourtDivorce

Head Start

Team-basedIntegrated

Intake

Head Start Providers

Federal Dept.of HHS

Federal Dept. of Education

Criminal Justice Ecosystem

Health & Human Services Ecosystem

State Health & Human Services

Local Social Service Agencies

Information Technology

State DepartmentOf Education

Multi-Discipline

Client Plan & Review

WIA

PortalClient dataProvider dataReferral dataPerformance

Workflow &Scheduling

TANF

EBT

Data Warehouse

BI ToolsEAI Tools

State Tax

Suppliers

One Stop CentersMultiple LocationsInterdisciplinaryPre-eligibility AssessmentEmergency AssistanceChild careService Delivery (e.g. Empl.)Facilitate Self-service

Secured Internet

Police

Banks ClientsUnited WayHospitals

Network of Community Service

Providers

SACWIS

Child Support

Integrated Case Management

Food Stamps

Child Welfare Caseworker

Team

Child SupportCollections

Income Sec.Caseworker

Team

K-12 Education Ecosystem

Workforce Inv.Child Welfare

Foster CareProtectiveAdoption

Public HealthMental Health

SubstanceAbuse

Treatment

ERP

Schools

RevMax

MedicaidTANF

Regional State & Local Client Plan & Assessment Teams

Productivity &Collaboration

IntegrationTechnologies

Provider Management

Compliance Management

Human Resource Management

IT Management

DepartmentManagement

Microsoft A

rchitectural Vision

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Public Health

Addictions & Mental Health

Medical Assistance Programs

Children, Adults & Families

SAMHSA

ACF

IHS

RSA

State View: Silo’d Architectures, Funding, Services

Rich Howard – CIO Oregon DHS

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Informatics Linking Health with Human/Social Services

• Build a common client index or master client index to track overlapping and unduplicated client load – better anticipate need and improve service delivery

• Integrate eligibility for all health and social programs federal, state and local with eligibility requirements

• Ensure compliance with all federal, state and local confidentiality and privacy protocols

• Digitize all records and move to a paperless environment• Integrated case management system that allows for public and private

sector users access and use of the system• Routine data sharing/integration options:

– Real time, two-way integration– Periodic, two-way integration– Periodic, one-way integration and – Periodic, one-way analysis integration

Source: Stewards of Change; Montgomery County Dept of Health and Human Services; Homeless Management Information System (HMIS) Integration Strategies and Solutions

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POLICY ENVIRONMENT NEEDED TO SUPPORT THESE INFORMATICS INTERVENTIONS

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Data Sharing Plans

• Intent and scope• Risks & benefits of sharing, of not sharing, and monitoring

plan• Data sharing methods• Staff roles and responsibilities• Minimum data elements needed• Method to ensure confidentiality and security• How data will be used, published, and retained/destroyed• Confidentiality agreements• Knowledge and training requirements

– Annual training for staff accessing identifiable dataSource: Centers for Disease Control and Prevention. Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Programs: Standards to Facilitate Sharing and Use of Surveillance Data for Public Health Action. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011

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Supportive Policy and Practice Environment

• Information sharing is clearly defined, meets confidentiality and privacy requirements, and is integrated in training and practice.

• Integrated case management is clearly articulated by leadership and embedded in operations, procedures, training and practice.

Sources: Stewards of Change Human Services 2.0™: A Framework for Interoperability

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Supportive Policy and Practice Environment

Goal: • A nationally recognized confidentiality policy that enables data

sharing

Current status:• Different laws and rules apply to different data sources and

diseases– Communicable diseasas– Birth & death data– HIV– Mental health– HIPAA, FERPA

Sources: Stewards of Change Human Services 2.0™: A Framework for Interoperability and Alliance of States with Prescription Monitoring Programs

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TOWARD A CONSENSUS STATEMENT ON THE POTENTIAL CLINICAL BENEFITS OF PUBLIC HEALTH INFORMATICS

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Data Sharing Summary

Health Department Non-identifiable Data

Social Services Non-identifiable Data

Health and Social Services Identifiable Data

Data Shared Local community and relevant subpopulation statistics (e.g., by race and ethnicity, SES, risk factors) in the community (health statistics)

Available local, state, and federal programs for health and human services to respond to health problemsfor populations of varying means

Information on the individual from health information exchanges, health department registries and social service records

Via E-mail, website? E-mail, website? InfoAlert – e.g., same system that lab results come through. Letter/fax.

Clinician Action

More effectively target screening of patients for specific health problems

Refer patients to the relevant services

Continuity of care

Informatics Intervention

Extract/send relevant population data

Extract/send relevant population data

Extract/send relevant individual data or integrate systems

Policies and Plans

Data Sharing Plans, Confidentiality and Security Policies

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Discussion Questions

• How do we ensure that the right patients get the right benefits from public health and human services data sources at the right time?

• Prioritizing the data and information to communicate– What content is available?– What is valued by clinicians and patients?– When is it needed?

• How do we effectively deliver the information?– Push by PH to EHR (or other interface)?– Pull by EHR from PH?– MD authentication & pt matching for identified data

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Session Title

• Discussion Synopsis: