Meaningful Change Coming to Public Health

EXECUTIVE SUMMARY: Hospital CIOs and CMIOs across the country, as well as their counterparts in public health departments, are preparing to submit and accept health records electronically. While experts say that the transition from paper will provide an unprecedented opportunity to engage the health community on population health in a more meaningful and coordinated way, some observers, including public health officials, say public health agencies are not prepared to make the switch.

Hennepin County Medical Center, a 469-bed hospital in Minneapolis, has been working with the Minnesota Department of Health (MDOH) on using computer systems to submit immunization data for almost 15 years. But only recently has that process been truly automated.

“Historically we would send an Excel file that would be processed through the immunization registry software, but there was a lot of manual work on both ends to get that data cleaned up and validated,” recalls Kevin Larsen, M.D., Hennepin's chief medical information officer.

But now Hennepin is involved in one of the first pilots of the Direct Project sponsored by the Office of the National Coordinator for Health IT (ONC). It has begun sending HL7 immunization data directly from its clinical systems to MDOH using secure, encrypted messaging. “We also now have a button in our [Verona, Wis.-based] Epic EMR that lets users look up data in the state immunization registry,” Larsen says. “We want the state database to be the one source of truth and build it into our decision support logic. They are going to be more adept at following any changes in immunization guidelines.”

WE WANT THE STATE DATABASE TO BE THE ONE SOURCE OF TRUTH AND BUILD IT INTO OUR DECISION SUPPORT LOGIC. THEY ARE GOING TO BE MORE ADEPT AT FOLLOWING ANY CHANGES IN IMMUNIZATION GUIDELINES.-KEVIN LARSEN, M.D.

Across the country, hospital CIOs and CMIOs, as well as IT officials at public health departments, are doing assessments of their capabilities to exchange data. Stage 1 of the meaningful use guidelines requires eligible hospitals to choose one of three menu options related to public health:

Submitting electronic data to immunization registries;
Electronic lab reporting for a predefined set of monitored conditions; or
The capability to submit electronic syndromic surveillance data. (Syndromic surveillance is defined as the systematic collection and analysis of data for the purposes of detecting and characterizing outbreaks of disease.)

Executives who work in public health informatics are excited that these capabilities are part of the meaningful use guidelines. “Public health has been seeking to engage the larger health community on population health for decades,” says Bill Brand, director of programs for the Public Health Informatics Institute in Decatur, Ga. “This is a tremendous opportunity to engage in a more coordinated way.”

Kevin Larsen, M.D., CMIO, Hennepin County Medical Center

Of the three use cases, public health agencies have made the most progress on creating immunization registries and the least progress on syndromic surveillance, but lab reporting is what hospital CIOs should be focusing on most, stresses Jim Daniel, CIO at the Massachusetts Department of Public Health who has taken a one-year leave to work as public health coordinator for the ONC. “If we can get that data flowing, public health departments can do so much more than they currently are just by avoiding a lot of the manual data entry they are doing now. They can focus on disease surveillance. They could catch a hepatitis A outbreak and zero in on the cases before more people are exposed.”

Electronic lab reporting is a challenge for both hospitals and public health agencies, explains Daniel. “A lot of labs are sending data with HL7 2.3.1 and they have to upgrade their message format to 2.5.1 and start sending LOINC [Logical Observation Identifiers Names and Codes] and SNOMED [Systematized Nomenclature of Medicine] codes,” he adds.

Also, the large number of hospitals that have been submitting on paper and are going to start sending electronically in the next few years is a huge capacity issue for public health agencies, he says. “There is a lot of hand holding and several steps that require epidemiologists and infection control people to make sure you are filtering data for the appropriate results. That takes a lot of time. It is important not to turn off the paper-based reporting until you are sure the electronic submission is working properly. In Massachusetts, we required that they send both for six weeks.”

In order to meet meaningful use requirements, the lab result must be sent to the public health organization from a certified electronic health record (EHR). But most hospitals use separate LIS (laboratory information system) software that sends data directly to public health. “If the LIS is not a certified module, then it would appear not to meet meaningful use,” says Noam Arzt, president of the San Diego-based HLN Consulting LLC, which advises public health agencies on IT issues. “I don't think people have worked through that issue yet.”

Arzt notes that some states have achieved interoperability on immunization, while others are still working on it. “Of the three meaningful use goals, this is probably the easiest to understand and least controversial because the states have been working on it for some time,” he says. “Many agencies just haven't had the funding to embellish their immunization information systems. And on the provider side, some aren't electronic yet or can't extract that data in a usable format yet.”

WILL PUBLIC HEALTH BE READY?

Noam Arzt

There is some concern about the level of preparedness of state agencies to receive data. The first Medicare providers that adopt EHRs were hoping to test data transmission with public health agencies by April 2011 to receive their incentive payments. Last November the Association of State and Territorial Health Officials (ASTHO) asked its members if they would be ready to receive data by April. Seventy-nine percent said they planned to have their electronic lab reporting system ready; 85 percent planned to have their immunization information system ready; but only 52 percent plan to have their syndromic surveillance system ready.

Respondents to ASTHO's survey cited lack of funding, lack of flexibility with current funding, and a lack of technical expertise as the top three barriers to readiness. A few respondents mentioned that they may have the technical capability to receive messages, but are concerned about the capacity to deal with an influx of providers who plan to send data, according to ASTHO.

TRADITIONALLY THE STATE SYSTEMS ARE SOMEWHAT SILOED AND PROGRAM-SPECIFIC AND THE CROSSOVER IS NOT AS IDEAL AS IT SHOULD BE. WE WANT TO LOOK AT OUR INFRASTRUCTURE FROM AN ENTERPRISE PERSPECTIVE RATHER THAN AS A SET OF INDIVIDUAL SYSTEMS. -AMY ZIMMERMAN

The Rhode Island Department of Health has undertaken an effort to assess its readiness to exchange electronic data with the hospitals and eligible providers in the Ocean State. Leading that project is Amy Zimmerman, MPH, chief of health information technology for the department.

The department is trying to discern how it can maximize electronic health information without creating point-to-point interfaces for each program with every provider, Zimmerman says. “Traditionally the state systems are somewhat siloed and program-specific and the crossover is not as ideal as it should be,” she adds. “We want to look at our infrastructure from an enterprise perspective rather than as a set of individual systems.”

Having started many years ago, the state has made more progress on health information exchange (HIE) than most, and ideally it could be a central source of data for public health. But Zimmerman explains that because its privacy and consent provisions require voluntary opt-in by patients, it may limit the value to public health, which needs information on the entire population. “If the enrollment is high enough, there may be things public health can do with it, but we are working to get information directly from providers.”

Like most states, Rhode Island has made the most progress on immunizations. Many years ago, the state built what is referred to as an “HIE for kids” called KidsNet and it includes the state immunization registry, but it is not yet a lifetime system, and when reporting to immunization registries becomes a core measure for Medicare providers, the state will need to support that. “We were moving in that direction already, so this will just push us faster,” Zimmerman says. “We will develop an interim step so that providers can send that data as we build out our registry.”

The department is not yet receiving lab reports electronically from the 11 hospitals in Rhode Island but has started the work of identifying the people and processes that will be involved.

The most challenging use case for Rhode Island is syndromic surveillance. In the past it has mainly involved recording chief complaints from hospital emergency rooms. Under meaningful use, it is an option for eligible providers in the ambulatory setting. “We want to be cognizant and respectful of the available time and resources in provider offices. We need to set clear, concise parameters for what data we ask providers send to us. We do not want to collect data purely for the sake of collecting it.”

The department is holding workgroup meetings with representatives from each program to look at both the short-term and long-term impacts of electronic health data on the work they do. “Meaningful use is the short-term goal in the next several months,” said Zimmerman, “and we need to continue to engage and educate our team about the impact that policy decision will have on day-to-day operations.” Over the long term, she adds, it will transform the work public health does in every area. “One of our long-term goals is to have nursing home inspectors and medical disciplinary boards able to utilize electronic records as part of investigations.”

Public health agencies may be overwhelmed by the number of hospitals wanting to work through electronic lab reporting agreements in the next year or two. “We have heard conservative estimates that this will triple the number of reports coming in to public health,” says the Public Health Informatics Institute's Brand. Complicating matters is the fact that agencies are facing severe budget cuts at a time they are also expecting this huge influx of data, he adds. Public health agencies also have serious workforce development issues. They need staffers more knowledgeable about HL7, for instance, Brand says.

At this year's HIMSS conference in Orlando, Fla., Doug Hamaker, the National Electronic Disease Surveillance System Coordinator for the Texas Department of State Health Services, noted that the 542 acute-care hospitals in the state will soon be knocking on his door saying they want to work on electronic lab reporting to meet meaningful use goals. “When we do get them all in the system, it will mean a tsunami of data, with tens of thousands of live reports that we will have to be prepared for,” Hamaker says.

WHEN WE DO GET THEM ALL IN THE SYSTEM, IT WILL MEAN A TSUNAMI OF DATA, WITH TENS OF THOUSANDS OF LIVE REPORTS THAT WE WILL HAVE TO BE PREPARED FOR. -DOUG HAMAKER

To help providers transmit lab data to public health agencies, the Centers for Disease Control and Prevention recently awarded a grant to Surescripts (Arlington, Va.), the American Hospital Association (AHA) and the College of American Pathologists (CAP). During the two-year grant period, the AHA, CAP, and Surescripts will recruit, educate, and connect at least 500 hospital labs to public health agencies.

POTENTIAL ROLE FOR HIEs

One potential solution to the time-consuming process of setting up point-to-point interfaces between hospital lab systems and public health databases is to involve the state HIE as an intermediary. Involving an HIE could cut down on the number of interfaces a provider organization has to maintain.

The New Mexico Department of Health has turned over the electronic lab reporting and syndromic surveillance IT tasks to the New Mexico Health Information Collaborative (NMHIC). “Public health has really outsourced the data gathering, filtering, and hosting of the data to NMHIC,” says Dave Perry, CIO for NMHIC, which is operated by LCF Research in Albuquerque.

“We now handle the electronic lab reporting for 10 hospitals, including eight hospitals in the Presbyterian Health System, on 107 reportable conditions, as well as emergency encounter information for syndromic surveillance,” Perry says, “and our goal is to include most of the 59 hospitals in the state by 2014.”

NMHIC did have to work out e-reporting agreements with hospital partners. “It took so much time to get hospitals to sign those agreements,” Perry notes. “The legal and compliance issues took months to work through, but we got it done.”

If a statewide HIE develops in Minnesota, Hennepin would be glad to send public health data through it. “A hub-and-spoke system would be most valuable to us in dealing with cross-state data transfers,” says CMIO Kevin Larsen, “because we could not ourselves keep up with laws and regulations regarding privacy and other issues on interstate transmission.”

Larsen says government agencies, providers, EHR vendors, and software developers of immunization registries are finally starting to come out of their silos and prioritize interoperability.

“It has taken something as big as this HITECH Act to get us to start developing standards,” he adds. “Now it's like we are all starting to program in HTML for the day they turn the Internet on, instead of building with whatever we had, as we used to do.”

Finding More Information

One common complaint from healthcare providers is that state health departments and ONC haven't made it clear enough whom to work with on meeting meaningful use goals. ONC is revising its website to make that information easier to find and each state is designating someone in its public health department as a meaningful use point of contact.