The fervor over health insurance reform and electronic medical records in the HITECH Act seems to have sucked all the oxygen away from health information technology that is not about direct patient care.
Public health, health research and other parts of the broader health system have less healthcare IT influence than ever in the face of market forces geared toward healthcare delivery and the push to demonstrate the accomplishments of health insurance reform accomplishments.
Even less prominent now are the distinct IT needs of these vital other health areas.
The irony is that much of the actual “meaningful use” of health IT comes from areas that are not exclusively about direct patient care. Many of the outcomes that can actually improve health depend on supporting broader public health requirements than those of just electronic medical records (EMRs).
Yes, there are some public health meaningful use (MU) criteria. And, yes, there were some funds in the stimulus for public and population health. But consider their relative priorities: A back of the envelope calculation shows that only about 0.1 percent of HITECH funding is oriented to supporting public health IT.
The Centers for Disease Control and Prevention has closed the National Center for Public Health Informatics and the Public Health Information Network (PHIN) initiative may be headed toward a similar fate. Even the actual text of the MU rule says that public health needs are being deferred until later years. For all who once worried that “secondary use” was too derogatory a term for public and population health IT activities, being only “secondary” must seem awfully attractive now.
A narrow focus on healthcare delivery IT and the low priority given to public health IT is doubly difficult. Not only are public health needs not being engineered into the nascent healthcare IT infrastructure, government is not assuming its critical role of advancing complementary public health IT functions.
In healthcare, much of the IT challenge relates to market forces that don’t always drive the best implementations and outcomes. In public health, there are no major market forces driving IT at all. If government does not drive a public health IT agenda, does not set public health priorities for healthcare, and does not support a connected infrastructure between healthcare and public health, it simply will not get done.
Some public health needs that do not seem to be even on the horizon include:
Case reporting. There exists a fundamental, legally required (in every state) need for physicians to report to public health agencies on the occurrence of certain communicable diseases and conditions. Although inconvenient in discussions of patient confidentiality, this reporting is about specific cases and not aggregate data (as so-called syndromic surveillance is). Nowhere is there expressed a driver for EMR vendors to include public health case reporting in their products – despite its legal status.
Disease investigation. Many of the most useful surveillance activities and “shoe leather” epidemiologic investigations require retrieving data types and data relationships that will not be routinely pushed-out or reported.
Like many other population health needs, the investigation need is not supported by point-to-point data exchange and requires data look-up and query functions. Cross-organizational query capabilities, while useful for many other purposes like post market drug surveillance and medical errors determination, seem to be now largely defeated by ongoing data ownership issues and the reconsideration of health information exchange that has occurred at the federal level.
Vital statistics. Demonstrating regional variations in health and healthcare is among the most compelling way of improving the quality of public health and healthcare. But it is highly dependent on getting consistent and clearly defined vital statistics data. Most behavioral risk data, for example, are manually collected and tend to be incomplete and relatively untimely. The advancement of an alternative electronic system will not be accomplished through a measure by measure application of MU criteria, but must be based on broader data aggregation and analysis.
Prevention. Schedules and reminders for preventative services would seem to be very well aligned with decreasing healthcare costs, but specifications for the delivery of these materials into EMRs are not now a requirement. Nor is there any clear path to a consensus on developing these specifications, now that the Healthcare Information Technology Standards (HITSP) panel has been terminated by ONC.
Integration with drug and immunization delivery. MU does include “testing the ability to report” routine immunizations, but broader supply chain management and delivery data are necessary for apportioning response countermeasures in emergency situations. There are also needs for tight coupling of drug and immunization delivery with surveillance systems to support “active” surveillance of side effects.
Well standardized data exchange. Public health is inherently multi-organizational. While the HHS Standards Committee should be complimented for beginning to identify high level terminology standards for recording clinical data, the proposed standards do not go near the level of specification of the messages and unambiguous data sets necessary to reduce the costs of hooking-up multiple organizations for information exchange.
Public health personnel will tell you that neglect of public health needs is a common phenomenon. It seems that it is only during health emergencies that attention is paid to the public health infrastructure. Then, in the emergency, there are inevitable questions asked about why the public health infrastructure is not more robust. Finally, after the emergency, sustained attention and funding is usually lost before there is time to implement lasting solutions.
The H1N1 flu was the latest public health emergency, but it garnered little attention for public health IT infrastructure. Some have said that H1N1 actually showed the strength of the public health system to respond. In fact, H1N1 was so contagious it rapidly exceeded the ability of public health to contain it and led to fall back “controls” of encouraging hand washing and better sneezing etiquette rather than tracking and isolating active cases of the disease.
What if SARS, Anthrax, drug resistant tuberculosis, or other diseases with greater morbidity were contained to the degree of H1N1? Health IT has been shown to be important in all modern health emergencies even with a very limited infrastructure. It would be ironic to perpetuate its problems because the latest emergency got out of hand too fast.
Health insurance reform may have, or have the ability to deliver funds that can be used to help the public health IT infrastructure. To do so, there needs to be a broader recognition of the importance of the non-direct care aspects of health and a renewed focus on the importance of these areas in delivering broad meaningful use.
-- Dr. John W. Loonsk is chief medical officer for CGI, an IT services firm. Previously, he was director interoperability and standards in the Office of the National Coordinator for Health Information Technology (ONC) and was associate director for informatics at the Centers for Disease Control and Prevention.
