Public Health Informatics
One of the most pressing issues for public health departments is keeping accurate, detailed, accessible records, reducing record duplication among human service agencies and making better use of computerized databases for financial management, benefit eligibility, developing patient data, tracking clients across clinics and within human service systems, and for epidemiologic studies of their communities. No health department activity is too small to benefit from Informatics, use and training. Data systems can be used to make patient appointments, keep patient histories, link eligibility data in the health department with the social service, Medicaid, and mental health systems, and to send bills. Data on clients can be aggregated to build activity summaries, or to plot maps showing the distribution of services within the community. An ideal public health informatics system will start with the first citizen contact.
The electronic examination room.
In a "state-of-the-art" clinic examining room, you walk in to see a patient and carrying a wireless linked laptop to review the patient's current clinical record. All examination and interview rooms are connected wirelessly so that all patient and family information is at your fingertips. A list of the patient's current problems will appear on the screen in SOAP format. When you ask to review the first problem, a summary of the patient's problem history to date, and results of recent laboratory tests or x-rays will appear (all this currently occurs in my family doctor’s Health Information System (HIS, but only about 60% of primary care physicians currently have such information systems)). Before you examine the patient the computer can display an outline of the patient's body on the screen. A touch of the light pen to the appropriate part of the body image on the terminal will provide an enlarged view of the area to be examined. While examining the patient you will enter data on the electronic chart communicating with the computer using a touch stylus, or microphone and Dragon Software, which converts speech to text. As the information is entered, it will appear on the laptop screen. The information system will be programmed to compare the data entered with a database to abstract expected clinical patterns for comparison. The system will suggest additional physical examinations, laboratory tests, or request more history. It also will suggest options for diagnosis and treatment. After the appropriate diagnosis is entered into the system, you will select a course of treatment, or consider one suggested. If you need to order drugs, the computer will check your order against a pharmacopeia to ensure the dose is correct for age, weight, sex, and concurrent conditions (such as pregnancy), at which time it will forward the prescription to the pharmacy to be filled (available at my pharmacy in 2014). The system will scan the clinic appointment subsystem to make the next appointment and will also arrange the patient's transportation if necessary (while a potential, because my doctor is part of a residency site with residents coming and going the appointments are still set at the front desk). A message could be sent to the district public health nurse (case manager) responsible for the patient's care to request a home visit. The medication will be waiting for the patient at the pharmacy. A few clinics, hospitals in the U.S. (about 15% at the last survey) and many in Japan and Europe can do all this today. Public health departments can be expected to show that funds provided for clinical services are in fact used for those services and peers can review clinical services. State of the art electronics makes all this possible today. State government and many medical institutions in 2015 are still several years behind the state of the art in use of health informatics. See Chapter 3 (page 131 [toward the bottom of the page] and following pages through page 136) of the Future of Public Health in the 21st Century. The Federal Government expects all medical care providers to have automated system in place by 2014 but failed to provide funds within the reimbursement system accomplished this, a common problem when congressional initiatives enacted without any capability of execution due to lack of funding. See the HHS Health Information Technology web site which provides guidelines on the recommended development and standards through 2020.
The medical record will provide an audit trail of a patient's attendance and the service provided. The patient records are stored on a network server. For security purposes, copies of the medical records should be stored for at least ten years after a patient becomes inactive. All records systems should have multiple backups performed daily. One copy of records should always be stored at a site remote from the active network while a second copy should be stored on a separate storage site within the active network. The medical network should provide record access for staff in the clinic or doctor's office, a hospital nursing station, and the patient's bedside, as well as the laboratory, pharmacy, admissions office, radiology center and other related sites. The hospital/clinic nursing staff should be allowed access to the department's database after the department has closed. Then, when a patient appears in a hospital emergency room their records are available to the physician treating the patient. The next major step in use of data systems will require extensive education of health personnel as well as the public at large. There is great concern about security. Most of the security issues that concern the public, as well as doctors and nurses, are the results of misperception and the visibility given to hackers. As security improves and the health care users, both patients and professionals, understand and believe that records are secure and cannot be viewed without a patient's agreement, we can move forward. The ability to produce a flash card, to be used until a truly integrated national system has been developed, that contains a patient's history, carried by the patient, would be invaluable in emergencies. Such cards could improve access to, and improve the quality of emergency care, especially when the patient is unable to respond to questions. Such information is in its infancy with the Medic-alert bracelets worn by some with chronic diseases. The ability to develop a lifetime medical history starting at birth is possible today, but will never be universal until security issues are resolved. This becomes even more important with the rapid increase in genetic evaluation of an individual's disease and personalizing it with medication shown as specific for that genetic scan. Such a historical record could remind parents when to obtain periodic check-ups for children and when to return for immunizations. Such a record could interact with home computer systems and health institutions to ensure that individuals are reminded of appropriate preventive interventions and need for checkups for conditions such as PKU, or diabetes. While conceptually and practically simple the concerns about 'big brother' and invasion of privacy are delaying institutionalization of systems that can save life, promote health, reduce disability, delay premature death, and minimize costs of care. Microsoft and Google are starting to provide repositories for electronic health records which patients can have medical personnel access. Federal law required that all health records systems were to be converted to electronic systems by 2014, but failed to occur due to failure to adopt a national electronic health system approach while numerous vendors offered practices and hospitals different IT platforms that failed to exchange data with each other.
Little discussed is the ability of a practice electronic information system to provide periodic updates of the problems seen in a practice, the outcomes achieved and the associated procedures. While such data is seen in the NAMCS databases this is a national database and tells physicians nothing about the patients and processes in their practice which need tweaking to minimize adverse outcomes and improve efficiency and effectiveness.
An issue with use of electronic records is a fear by many individuals that someone will hack into their records and blackmail them, or distribute information about them on the Internet. Another concern is that employers will use such data to deny them jobs or to remove them from a current job as posing an unacceptable hazard/expense to the company. There are also concerns that insurance companies will gain access to medical information and deny them insurance. While these fears are real there is little evidence to show that such actions have taken place. There has been increased action by federal and state legislators to restrict access to personal records and disallow exchange of information without permission of the individual whose information is requested.
There is increasing evidence that the best historical data results in the best diagnoses and best treatments. There is enhanced software available today that allows a doctor or pharmacist to improve medication use, to avoid adverse effects between medications when more than one medication is used. Pharmacy programs will match the best and least expensive medication to the history and results of laboratory tests found in electronic records.
As more diagnosis and treatment becomes 'evidence based', accurate patient records will ensure more rapid diagnosis and treatment, particularly for chronic diseases.
Another problem remaining is the agreement on language for health related databases. While a human knows that male and man are similar, computer systems do not, Just as we have an ICD(A) code for diagnoses we must have common terminology for health and human services. This is lacking today and may cause as much difficulty as security.
Local health departments need to exchange information with regional, state and federal health agencies. The Public Health Foundation (PHF), a non-profit arm of the Association of State and Territorial Health Officers (ASTHO), has developed an electronic bulletin board and proposed improved linkages between Public Health & Primary Care. The PHF gives a health department that applies an identification code that allows it to receive and return messages from other local and state health departments and ASTHO. This bulletin board can act as a gateway to the CDC, EPA, FDA and other health related agencies in the federal government. All you need is a modem, and communications software and a local Internet Service Provider. The CDC has developed multiple data systems linking the agency to state & local health agencies for tracking data from local to state to federal centers:
Public Health Surveillance and Informatics Program Office (PHSIPO)
Mission: advance the science and practice of public health surveillance and informatics.
Strategic goals (page 3) were designed to help sustain and improve public health surveillance and informatics. The goals are outlined below, with supporting detail provided in the following pages.
Local health departments can obtain the CDC's MMWR weekly by email rather than waiting for paper copies. They can also have access the JAMA, BMJ and other medical periodicals over the internet through local hospital and university libraries. Increasingly the articles in these journals have hyperlinks to references on the Internet saving the reader time searching for references. There are also CME programs available using streaming video and Power Point from schools of public health such as UNC at Chapel Hill, GWU and UCLA, as well as from the CDC. These programs are particularly useful to rural health departments that do not have access to satellite TV services.
Local Health Department Computerization
In Loudon County, Virginia for over 10 years, the environmental staff have been tracking septic tank locations and problems electronically. Each lot can be located on a county or city-planning department plat map. After the septic tank and drain field site has been approved, the environmentalist uses a network connection to obtain a picture of the lot from the planning department's computer, and then draws the location of the drainfield with a light pen. The planning department uses this data to decide when to provide central sewer or water services, rather than installing additional septic tanks. Such systems are now being developed by cities and counties as part of their Geographic Information System (GIS) infrastructure.
In Henrico County, Virginia the county manager bought portable PCs and printers for all the environmentalists. Each one records the results of a restaurant inspection on the portable PC and prints out a copy for the restaurant. At the end of the day the portable unit's data is downloaded to the office PC and from there to the state’s restaurant inspection database. The department's software programs provide monthly reports of environmental activities by environmental district and census tract.
The individual inspections are recorded by name of place and type of food service. The food service program, using the standard federal food inspection point system, automatically calculates the inspection score. This stimulates competition among the environmentalists, and embarrasses business places that do not want to see their name show up on a public list with a low score. A similar program in Corpus Christi, Texas also enables the department to bill more than 1400 food service places each December and to send permits automatically, once the fee has been received and entered into the database. An activity that used to take two people three weeks now takes one person an hour. In return for the fee, the department agreed to inspect each food service place at least four times a year and report results quarterly to the restaurant association. About eight years ago the Virginia Department of Health developed the first statewide consolidated food service reporting system that is open to the public. This has been replicated by a number of other states and communities.
In Richmond, VA immunization records were ideal for computerized databases. This freed up floor space previously used for filing cabinets. Record retrieval is simpler and faster. When personal information is entered and validated, the program calculates when patients should return, and can print out messages when appointments are missed. The program was linked to interactive mapping software and could follow annual cohorts of infants to determine how well they were immunized prior to two years of age. The program can print reminder cards for patients and messages for immunization aides to make a home visit, when a patient misses an appointment. It prints a new immunization certificate after a visit, and provides monthly summaries of activities, fees collected, and clinic costs. Also, it can be programmed to track the vaccine inventory and print an order for a new supply of vaccine each month. This program was developed as part of the Robert Wood Johnson Foundation’s All Kids Count immunization tracking grant. Now all states are developing or have developed immunization registries (IIS) in cooperation with the CDC. Nurses can use laptop computers when making home visits. Now with the advent of cellular phone systems and wireless cards nurses. When visiting homes with children can link to the local or state registry, and determine if an immunization is necessary. There are many ways to use new technology to improve efficiency and effectiveness. Software is improving rapidly. The cost of hardware, particularly memory, is dropping rapidly.
Some staff need to be able to use programs such as Power Point to develop a training and information programs for other staff and the public. One or two should also be trained in the use of Geographic Information Systems (GIS) for epidemiologic analysis and enhancing community information. Today each department should have a set of Web-pages for community information. The most used graphic (mapping) information systems (GIS) are marketed by ESRI of California. ATLAS, which can manage all the needs of 98% of public health departments (local and state.) is the simplest effective GIS systems and is the system of choice by the WHO and many European countries. The most complex, with the highest learning cure is 'ARCVIEW' by ESRI and is now in use by many cities and counties that need the ability of overlay photographic maps with geographic information, and integrate the pictures with large databases.
Data Exchange between programs
As the health and medical systems move to comply with the DHHS regulations so they can continue to receive payments from Medicare and Medicaid the exchange of data from clinical, epidemiologic, quality assurance and payment subsystems becomes critical. Further, there is great concern about maintenance or privacy of health records. There is not agreement yet on the terminology that will be used by various systems so that data can be transferred between doctor’s offices, hospitals, laboratories, health agencies, and third party payers. At present the thousands of involved health systems, both multi-institutional and single are each developing their own systems while their representatives sit on national committees trying to make sense of the data structures necessary. Other countries have solved many of these problems but we seem destined to repeat all their errors rather than learning from them.
Despite everyone's best efforts Murphy's Law is still with us. Things still go wrong. Back up everything you do often. Always attach backup power supplies that allow the computers to shut down without losing data, if there is a power failure. When you want permanent storage of data consider using tape backups. There is nothing more infuriating than losing all your data to a power failure or surge during a thunderstorm, let alone the time and effort needed to recreate it.