Over the last 30 years, health information exchanges (HIEs), previously called community health information networks and regional health information organizations, have tried to share an individual's health data to clinicians across multiple settings. The advent of the Internet made data sharing more feasible, but none of these efforts have fully succeeded. Public health was rarely involved, and in any case, public health care professionals perceived little benefit from participation.
This commentary reviews why public health must be involved in HIEs and roles that public health can play. It will first review why public health essential services1 can be fully realized only through participation in HIEs and then address public health's natural interests in HIEs, identify obstacles to participation, and, finally, identify ways for public health to engage with HIEs. Because HIE is the current acronym, it will be used in this commentary, but it is meant to describe any health information network that spans providers, health care organizations, supporting services (such as laboratories), geography, and government agencies.
Public Health Monitors the Health Status of the Community and Identifies Health Problems
Appropriate access to comprehensive health data would finally allow public health to effectively and efficiently perform surveillance, to identify health problems and hazards, and to assess interventions.2 Analysis of health outcomes will allow public health to evaluate the effectiveness, accessibility, and quality of person- and population-based health services and formulate policies and plans for protecting and improving health. Access to comprehensive health data is the only route to truly evidence-based public health.
Public Health Ensures the Provision of Health care
Public health has the responsibility to ensure that everyone in a community receives health services. Health information exchange data can be used to identify the gaps between needs and resources and link people to needed services. Exchange of clinical data between private and public providers will enhance public health's ability to provide care not offered by private providers, including communicable disease control and case management.
Public Health Enforces Laws and Regulations
No other entity has the legal and regulatory right to view personal health information solely because of its public health importance. Health care providers, in general, do a poor job of fulfilling legally mandated reporting laws; direct access to the data will improve public health's ability to protect health.
Public Health Evaluates the Quality of Health Services
New quality-of-care mandates are hard to enforce without access to data. Questions have been raised about the validity of data provided by health care enterprises to fulfill "report card" requirements.3 If public health can data mine HIE databases using identical system rules, the data will be comparable, even if flawed.
Public Health Has an Economic Stake in HIEs' Success
Health and human services government agencies are as much economic stakeholders in health care as any large business purchaser or private health care entity. Local, state, and federal governments are by far the largest health care purchasers, as safety net providers, Medicare purchasers, Medicaid subsidizers, and employers. Public health must be able to assess the value of its health care dollar.
Disparities in health information technology funding may exacerbate disparities in health outcomes. Public health, as a government entity and an HIE participant, can help underwrite information technology infrastructure, pool funding to maximize resources, and level some of the financial imbalances.
Public Health Has Made More Progress Than Health care Organizations in HIE Standards
Public health, its partners, and stakeholders have long exchanged public health data across traditional economic and geographic boundaries to facilitate the exchange of data of public health importance. Public health can assist clinical medicine in defining data exchange standards and, if necessary, impose standards.
Public Health Can Be Perceived as a Neutral Convener and Partnership Builder
Public health is not viewed as a rival by competing health care organizations; is not tied to any single for-profit or nominally not-for-profit healthcare organization; and is platform, vendor, and business organization agnostic.
Similarly, public health has a long track record of bringing together community stakeholders to identify and solve health problems. Advances in technology, such as the Internet and electronic health information data, have facilitated the HIE concept. Technology, however, is not the limiting factor in a health information network, building and maintaining a partnership is.
Public Health Is a Natural Long-term Guardian of Health Information
An information network must be sustainable. Business entities may come and go, but government will always be with us. Public health has a natural role-and obligation-as a long-term guardian of health data. Public health per se may not be the daily custodian of an individual's health record, but it must be part of the organization that is the ultimate guardian of the community health record. Each HIE needs a business model, a realistic plan to be financially self-sustaining while meeting customers' needs, but an HIE also needs a strong public service model, something at which public health excels.
Obstacles
Public health's role, not only as the protector of a community's health but also of its health data, is a natural evolution, not an automatic one. The same barriers that slow progress toward individual electronic health records-privacy concerns, data ownership and control issues, and the disconnect between cost of technology ownership and the return on investment-are barriers in the implementation of health information networks and to public health involvement.
Individuals perceive the government as an untrustworthy ally in protecting data privacy despite public health's long history of handling reportable disease data confidentially. Health data continue to have financial value, and few of its current owners want to relinquish ownership to a partnership, especially a public or semipublic entity. Finally, the cost of building and maintaining an HIE is high and public health entities have limited fiscal resources.
Access to massive amounts of health data will have complex implications for how public health manages information. Public health has a history of isolating data by program or disease, of putting it in "siloes." Data in the HIE data warehouse need to have versatile metadata labels so that it can be extracted and analyzed by a variety of public health interests.
How Can Public Health Have a Role?
There are obstacles to HIEs, but public health can have a role in overcoming many of them and, in the process, secure a role.
1. Public health must take a lead in organizing HIEs. Simply put, it is easier to guide the process when you have convened the meeting than when you are merely an observer.
2. Public health can share its standards expertise. Information standards and vocabularies are fundamental to HIE interoperability. Public health has long brokered standards for information exchange on the subject of public health interest.
3. Public health must make its interest in the data clear. Public health has no financial or competitive interest in the data but does have a significant interest in health data for a myriad of public health and economic policy purposes, ranging from named reporting of communicable disease cases to population-based cancer incidence.
4. HIE data warehouses must be designed with public health-as well as clinical-purposes in mind. The data logic model needs to be optimized for multiple purposes, and public health needs to participate in the design of the system architecture.
5. Public health must take concerns about privacy and competition seriously. As part of its HIPAA self-evaluation, public health has been forced to recognize the importance of health data security.
6. Public health must contribute resources, including money, to be a full partner in an HIE.
7. As a corollary, state and local public health must control some of the HIE implementation dollars. The vast majority of HIE funding currently comes from the federal government. Some of this money must be contingent on public health involvement or be funneled to public health to fund its involvement. In addition, the state must use its purchasing power (both as an employer and as a Medicaid administrator) to foster HIE development and to ensure public health's place at the table.
8. Public health has the legal right and the obligation to regulate HIEs. In its regulatory role, public health can create an administrative role for itself.
Conclusion
The purpose of HIEs is praiseworthy, but it would be naive to think that because HIEs invoke the needs of cost, safety, and quality, they will succeed where previous health data-sharing efforts have failed. Public health can provide neutral, noncompetitive ground on which to structure information-sharing organizations.
Health information exchanges will probably have their time in the sun, to be replaced by other acronyms and other organizations and steps in an evolutionary process. One constant factor in this evolution must be public health. Public health is not solely responsible for the success of HIEs, but without public health's involvement, neither public health nor HIEs can fully succeed.
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