In the language of the seminal Institute of Medicine (IOM) report on The Future of Public Health, 1assessment refers to the regular and systematic collection, assembly, analysis, and dissemination of information on the health of the community, including statistics on community health status, community health needs, and studies of health problems. In the IOM report, states are referred to as "the central force in public health" with "primary public sector responsibility for health." State duties include "assessment of health needs in the state based on statewide data collection." 1(p8) The state-centered Assessment Initiative of the Centers for Disease Control and Prevention (CDC) was established in 1992 as a response to the federal responsibilities articulated in The Future of Public Health and the national health objectives in Healthy People 2000. 2,3

During the first 5-year funding period, the Assessment Initiative engaged eight states in the use of data to identify public health problems, set health objectives, and monitor progress toward achieving those objectives in a manner similar to the setting and monitoring of health objectives at the federal level. 2,3 Activities common to all states in the first funding period were the establishment of an advisory group to guide and facilitate assessment activities, development of an inventory of data systems relevant to public health, and systematic evaluation of these public health data systems. States also engaged in several activities to increase the use of data, including improving user interfaces for data systems, improving responsiveness to data requests from decision makers, establishing health indicators and health assessment tools, and improving data management and analysis skills of state and local health department personnel.

The focus of the second 5-year funding period has been the development of partnerships in the seven Assessment Initiative states (Kansas, Massachusetts, Minnesota, Missouri, New York, North Carolina, and Oregon) that expand public health data resources, applications, and the number of users. State projects have focused specifically on linking public health data (e.g., vital statistics and risk factor surveys) with clinical care data (e.g., Medicaid and managed care enrollment and claims data) to assess health care delivery. States have also focused on building local capacity for evidence-based community health assessment. Accomplishments of Assessment Initiative projects include the development of a Web-based health data-sharing system in Missouri, the Missouri Information for Community Assessment (MICA), which has attracted 11 states and organizations to request technical assistance to import the system. Massachusetts has identified and tested an algorithm to monitor prenatal health care from electronic claims data. This algorithm is under consideration to replace a similar Health Plan Employer Data and Information Set (HEDIS) measure that depends on medical record reviews. New York and North Carolina have published guidelines for community assessment by local health departments.

The articles in this issue of the Journal of Public Health Management and Practice (Vol. 8, No. 4) represent a progress report on the varied activities of current Assessment Initiative projects, as well as lessons that can be applied in other states. The article by researchers in Massachusetts describes the project experience working with health care organizations to share data and tools between public health and health care, thereby expanding the assessment capabilities of both. Experience-based ingredients to successful collaboration between public health and managed care organizations are shared for consideration at other sites. Investigators from Kansas, Missouri, and New York address their support of local health departments to conduct community health assessments. Insights are shared for developing and monitoring health assessments and for ensuring the availability of local data.

Authors from Oregon and Minnesota describe tools for using Medicaid data. These tools are perhaps the most readily exportable products of this issue. Moving from a medical claims database to a population-based surveillance system is a complex task. Inability to deal with such complexity has limited the public health use of Medicaid data, despite their availability in every state. Disease rosters represent an innovative method for establishing valid case subsets in Medicaid data and demonstrate the value of documenting the relationships between data sets to develop case criteria. The expense of longitudinal data collection and maintenance often puts such systems beyond the grasp of public health, yet the Oregon investigators offer an economical model for generating longitudinal data that link risk factors to subsequent health outcomes. In addition, the Oregon experience demonstrates methods for tracking patients, rather than health care events, in Medicaid claims data sets that allow states to study enrollment patterns and subsets of patients based on their access to health care. The Minnesota experience should facilitate the linkage of Medicaid data with other public health data sources when personal identifiers are not available or appropriate for direct linkage.

Investigators from Kansas and Missouri share examples of the power of data and public health methods to clarify common goals and leverage the interests of businesses to better the circumstances of their employees and communities. While elegant in its simplicity, the use of the Behavioral Risk Factor Surveillance System to describe the health needs of employees and their dependents as a catalyst to business investment in community health is quintessential public health. The technical assistance teams and tools deployed in Missouri helped leverage resources from the Missouri Hospital Association to support community prevention activities. Data, properly shared as information, are the currency of public health. The partnerships that the Assessment Initiative has fostered are expanding both the denominations of that currency and its valuation.

Many investments are being made to enhance the assessment capacity of public health in the United States. The Robert Wood Johnson and W.K. Kellogg Foundations have been investing in the Turning Point Initiative since 1996 to facilitate community-based collaborative strategies to strengthen public health systems at the state and local levels. That initiative has created "a network of public health partners across the country to broaden community participation in defining and assessing health, in prioritizing health issues, and in taking collective action to address priority health issues such as elimination of health disparities, access to quality care, aggressive prevention of infectious disease, promotion of healthier lifestyles, and protecting the population from hazards and toxins in the environment" (http://www.turningpointprogram.org/pages/about.html). Recent reports from the Pew Environmental Health Commission have recommended a Nationwide Health Tracking Network to identify and track chronic disease and monitor relevant environmental factors. The Pew Charitable Trusts sponsor two activities to build support for such a national public health surveillance system: Health-Track, a project that was established with a grant to Georgetown University (http://www.health-track.org), and The Trust for America's Health (http://healthyamericans.org). CDC is making major investments in the public health infrastructure for assessment through the National Electronic Disease Surveillance System (NEDSS, http://www.cdc.gov/od/hissb/docs.htm) and the Health Alert Network (HAN, http://www.phppo.cdc.gov/han/index.asp). Primarily through implementation of standards, NEDSS is facilitating the handling of public health data through collection, management, transmission, analysis, and sharing. Supporting data systems integration with principles of informatics positions public health to capitalize on electronic data from medical care and allied health fields. HAN uses the Internet as the backbone for a nationwide, integrated public health information and communications system. HAN is supporting high-speed, secure Internet connections for local health officials to access and share data, alerts, guidelines, and training. One immediate application of this enhanced electronic infrastructure is the Epidemic Information Exchange (Epi-X). Epi-X is the secure, Web-based system used by CDC and all state health departments to rapidly report and discuss disease outbreaks and other emerging health events, particularly those suggestive of bioterrorism.

The CDC investment in the Assessment Initiative is small, relative to the need for building assessment capacity in the United States. It is really an investment in innovation-seed projects to gain experience and tools for building efficient and effective public health assessment capacity at state and local levels. The sharing of lessons from Assessment Initiative projects in ways that enable others to use the tools and build on our collective experience is important. This issue of the Journal of Public Health Management and Practice is a fine vehicle for sharing such lessons.

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