In July 2004, the Department of Health and Human Services released a Strategic Framework report entitled The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care.1 The framework outlines four major goals to be pursued by public and private health sectors in order to shape a vision to utilize information technology in health. Simply, these four goals are to (1) inform clinical practice, (2) interconnect clinicians, (3) personalize care, and (4) improve population health. All of these goals fall within the realm of public health practice.
Within the framework is the call to create the Regional Health Information Organizations (RHIOs) to foster regional collaborations around clinical care records and a Nationwide Health Information Network (NHIN) to support communication and ensure secure, interoperable information exchange among these organizations. The formation of the RHIOs creates local and regional health collaborations that enable patient information to be securely stored, yet electronically accessible to care providers and other authorized users. The RHIOs are instrumental in providing "local leadership, oversight, fiduciary responsibility and governance" in developing, implementing, and applying the exchange of secure health information.1
In order to facilitate communication and interoperability among the RHIOs, a communication infrastructure or Nationwide Health Information Network is needed. An NHIN provides authorized users such as patients, healthcare providers, and public health entities the ability to access and share health information in real time.2 The Office of the National Coordinator for Health Information Technology (ONC) has asked for assistance to begin to realize the vision of an NHIN in the form of a viable network, and as of June 2005, over 500 organizations and individuals have responded to its request for information.3 Furthermore, the ONC has awarded four contracts to create prototype NHIN architectures.4 Initial mandates and funding are in place for an NHIN; nevertheless, it is still in the formative stages, and as such will require capable oversight to realize the vision in a timely manner.
Public health, with a proven track record of maintaining the privacy and confidentiality of health information and a long history of using data for decision making and taking action, is in a strong position to be a primary driver of the NHIN vision. This is particularly evidenced by the fourth goal of the strategic framework which focuses on improving "Population Health," including unifying public health surveillance architectures, streamlining quality and health status monitoring, and accelerating the dissemination of evidence. This goal highlights the significant contribution that public health adds to Health Information Technology (HIT) and Health Information Exchange (HIE).
Health Information Technology is "The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making."1 Health Information Exchange is the "mobilization of health information electronically across organizations within a region or community."5 The electronic health record (EHR) is a central component of HIT/HIE, and EHR systems support and often simplify activities of healthcare, such as ordering, messaging, documenting, care management, and analysis and reporting.6 Currently, there is no universal EHR model in use and many vendors offer EHR software with varying functions. However, efforts to standardize EHR functionality are currently in progress.
Experts have identified HIT/HIE as a key tool in addressing the major challenges that healthcare faces today in efficiency, safety, and quality. In November 2001, the National Committee on Vital and Health Statistics (NCVHS) acknowledged the need for HIT/HIE by calling for the creation of a National Health Information Infrastructure (NHII). In addition, Institute of Medicine (IOM)6-9 reports have stimulated efforts that utilize HIT/HIE to improve the quality of healthcare and health in the United States.
A recent survey of state, regional and community-based HIT/HIE initiatives and organizations5 identified 109 HIT/HIE efforts in 48 states. Of the 109 HIT/HIE efforts, 65 have implementations that are advanced and well underway, including 25 efforts that are fully operational. Almost a third of these advanced efforts are driven by "public health surveillance needs." Of these advanced stage efforts,
* 32% are providing disease or chronic care management, with an additional 21% anticipating such services within 6 months,
* 27% are currently supporting quality-performance-reporting efforts, with an additional 18% to support such effort within the next 6 months, and
* 25% currently providing public health-related case management services, 20% providing public health surveillance services, and 14% providing electronic laboratory reporting services for public health.
As these HIT/HIE efforts mature, it is expected that they will evolve into the RHIOs paradigm put forth by the framework.
How Can an NHIN and the RHIOs Improve Public Health?
To the public health practitioner, the use of the term population health in the strategic framework appears to be a misnomer; however, within the context of the report, the term population health is used to mean public health. Public health focuses on the multiple factors-biological, behavioral, environmental, and social-that influence the health of groups of people.10 A public health approach develops and implements interventions to improve the health of the entire population, not just individuals. Such interventions can also be technologic in nature. In order to achieve public health goals, an infrastructure must be in place to help health professionals carry out the 10 essential services and core functions of public health.
The framework builds on widespread adoption of an NHIN with interoperable EHR systems directed toward streamlining public health surveillance, performance measurement, and health research. In a strong show of leadership support for public health's role in achieving the NHIN vision, the US government chartered the American Health Information Community ("Community" hereafter) to advance the president's call for an EHR within 10 years. The Community identified several HIT/HIE applications that could produce a specific and tangible value benefiting public health. Known as "breakthroughs" by the Community, examples of these applications include chronic disease management, biosurveillance and pandemic surveillance, and quality monitoring and reporting.11 In another show of support, the ONC has awarded over $18 million toward the creation of prototype NHIN architectures.4 To promote the use of health information exchanges for planning, implementing, and value demonstration, the Agency for Healthcare Research and Quality (AHRQ) awarded $139 million in contracts and grants, including 100 grants totaling $96 million in 38 states. In addition, the Robert Wood Johnson Foundation (RWJF) has established a new program, Connecting Public Health with Health Information Exchanges, which funds grants to support the participation of state and local public health agencies in health information exchanges.
An NHIN and the RHIOs are critical to the future integration of clinical healthcare with public health data systems, and they have the potential to positively impact public health data generation and reporting processes (Table 1). If appropriately developed, an NHIN and the RHIOs could fundamentally change many existing health intervention models and paradigms. It could be possible to detect disease outbreaks early enough to prevent primary and secondary transmission, to empower people to make more informed health decisions, to enable communities to monitor and address local health and environmental issues before they become significant hazards, and to cost-effectively screen entire at-risk populations for many diseases.
Public Health's Role in an NHIN and the RHIOs
Public health can play a significant role in local, regional, and national efforts related to the establishment of an NHIN and the RHIOs, including the standardization of interoperable electronic health record systems, the adoption of HIT/HIE, and the development of regional health information organizations. From an information systems perspective, public health professionals and agencies have much to contribute to the development of an NHIN and the RHIOs (Table 2).
Utilizing its collective public health expertise, the Centers for Disease Control and Prevention (CDC) has formulated the Public Health Information Network (PHIN) to advance the use of interoperable information systems for public health.12 The CDC and other public health agencies are a trusted neutral party experienced with maintaining confidential health information that could substantially aid health information exchange governance and architecture.14 Public health agencies, in their policy-making role, can develop and implement legislative initiatives that foster the establishment of an NHIN and the RHIOs and encourage (or even require) the adoption and use of national standards for interoperable EHR systems by playing a critical role in regional health information exchanges.
One challenge that public health and clinical care face today is the slow delivery of vital statistics and certain disease information. Doyle et al suggested that the reporting rate for notifiable diseases is currently 49% at best.15 Public health may benefit from participation in HIT/HIE through increased speed of surveillance and reduced cost while delivering useful public health information more rapidly to the point of clinical service, and assessing better health data quality. Fiscal benefits to public health may result from an NHIN and the RHIOs. The Center for Information Technology Leadership (CITL)16 estimated that interoperability will result in annual cost savings to public health departments of about $195 million. In addition, efficiencies and savings in annual healthcare spending (7.5-30%)13 realized through health information exchanges will help bring the uninsured and other underserved populations into the mainstream of healthcare with better disease monitoring and management of chronic diseases.
In summary, public health agencies can derive many benefits from participating in regional health information exchanges:
* improved quality, completeness, and timeliness of public health data reporting from clinical care settings;
* improved ability to monitor and act upon public health threats in a timely manner and with better-quality information through timely disease reporting, improved case management and care coordination, communicable disease patient management, improved analysis of patterns of care, and gaps in delivery of preventive services;
* improved ability for planning and resource allocation for preventive services;
* ability to move from a traditional paper-based, retrospective data collection and review mode of operation, to a real-time, interactive electronic data exchange and action response practice.
There is no sharp line of demarcation between healthcare and public health. Healthcare and public health are part of the same continuum and it is erroneous to split them. Likewise, patient (individual) health and public health are part of the same continuum and they are interdependent. In reality, health information flows in a continuous loop between healthcare providers and public health agencies, and is returned to healthcare providers in the form of surveillance data, public health research, risk assessment, clinical research, survey methods, registries, services, education, regulations, guidelines, innovations, strategies, and furthermore within the overall goals of public health. Thus, public health plays a key role in the inception and continued growth of an NHIN and the RHIOs.
Conclusion
Public health is a critical player in forming the building blocks for health information sharing and community (or regional) HIT/HIE-essential to the long-term viability of an NHIN. Public health closes the loop with an NHIN and the RHIOs by contributing to visions, policies, processes, standards, and needs/requirements.
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