Introduction to Public Health and HIE
A health department administrator may ask if it is critical to join a health information exchange organization (HIO) today, and whether HIE will be important for the health department’s future. Even if the answer to the first question is “No,” the answer to the second is a definite “YES!”
This toolkit seeks to help public health departments to do the following:
- understand health information exchange (HIE) services and the types of organizations providing them;
- understand how a health department might use or support such services; and
- assess if the value of participating in HIE will be worthwhile.
The toolkit also seeks to orient HIOs to the functions of health departments, and their value as customers and partners in HIE.
A. What is Public Health?
An orientation for HIE leaders
“Public health” is a complex concept, defined broadly as “what society does collectively to assure the conditions for people to be healthy.”[i] Health care providers, businesses, schools, non-profit organizations and other government agencies all contribute to the public health of a community.
In the United States a “health department” is a government agency that oversees public health in a state or local jurisdiction (including U.S. territories). Health department functions now go beyond enforcing sanitary codes and delivering direct services, to encouraging and coordinating various public and private activities that promote and protect health in their jurisdictions.
Although health departments once provided much healthcare for the indigent, publicly-funded insurance (such as Medicaid, Medicare and the Affordable Care Act insurance exchange subsidies) and community health centers have largely replaced this role in many communities.
Local, State and National Public Health
Because the U.S. Constitution reserved ‘police powers’ (including public health) for states rather than the federal government, there is considerable variation in what services are offered and how they are organized. In some states, public health authority and budgets are centralized at the state level; in others, these are subject to “home rule” by counties, villages and cities.
While the federal government has direct control over public health in limited domains like inter-state commerce, much of its influence on state and local public health departments is based on funding, research and consensus building. One consequence of this is that most ‘national’ public health information systems are actually built from somewhat independent state-level systems. This partly decentralized approach led to the creation of national public health information exchange (PHIN) standards, some of which were incorporated into the EHR Incentive Program (Meaningful Use) specifications.[ii] [iii]
Many public health information systems are operated at the state level, such as communicable disease reporting, immunization information systems, syndromic surveillance systems and cancer registries. However, like HIOs, some of these also developed and remain active at local or regional sub-state levels.
Public Health Core Functions, Essential Services and Accreditation
Three core functions and services are common for any public health jurisdiction:
(1) assessment of population health and risks,
(2) assurance of necessary services, and
(3) policy-making for a healthier environment and population.
Essential public health services include:
- Monitoring health status to identify and solve community health problems.
- Diagnosing and investigating health problems and health hazards in the community.
- Informing, educating, and empowering people about health issues.
- Mobilizing community partnerships and action to identify and solve health problems.
- Developing policies and plans that support individual and community health efforts.
- Enforcing laws and regulations that protect health and ensure safety.
- Linking people to needed personal health services and assure the provision of health care when otherwise unavailable.
- Assuring competent public and personal health care workforce.
- Evaluating effectiveness, accessibility and quality of personal and population-based health services.
- Researching for new insights and innovative solutions to health problems.
A national system for voluntary accreditation of local and state health departments, based on these functions and services, was recently implemented by the Public Health Accreditation Board.[iv]
Health Departments and HIE
There are many areas of potential overlap between health departments and most HIOs. Health departments have been an important voice in the evolution of early HIE organizations, and continue to play several key roles in the development of HIE services and use cases.
Given their roles in monitoring community health, mobilizing partnerships, and improving health services, local and state health departments are often important facilitators of HIE organizations. They bring two key advantages to the process:
1) They can play the role of neutral convener among health care providers who are in competition with one another.
2) Public health grants sometimes provide implementation funding for certain exchange use cases.
Information Users / Contributors
Health departments are important information users. Examples of the types of information used include the standardized reports listed among the “Population” and “Public Health” Meaningful Use objectives of the EHR Incentive Program, such as:
- laboratory results for reportable illnesses;
- syndromic surveillance of healthcare utilization for various symptom complexes;
- immunization events to populate immunization information systems; and
- reports of cancer incidence and treatment through cancer registries.
In some jurisdictions HIE organizations are critical suppliers of this reporting (see Appendix A: Public Health Use of HIE – Case Study #1on page 48).
Health departments consume other information as well. They may have information needs similar to primary care providers, such as receiving laboratory and imaging results, or viewing a patient’s medical summary for the case management of a contagious or chronic disease.
Health departments also benefit from population statistics on health risks (like the prevalence and distribution of obesity or chronic disease), and on the utilization of preventive services. Some health departments are creating community-level registries to support coordinated clinical and community management of health risks like obesity or asthma (see Appendix B: Public Health Use of HIE – Case Study #2 on page 51). Some are participating in efforts to leverage HIE to support public health nurse support for diabetes care, school nurse participation in asthma care plans, and to enhance information availability for EMS professionals, all in in non-medical settings (see Appendix C: Public Health Use of HIE – Case Study #3 on page 54).
Health departments are important information contributors. Some health departments offer laboratory and diagnostic services, and many still provide clinical services ranging from immunizations and comprehensive primary care to home health services, without which a community health record would be incomplete.
Various public health registries aggregate information from many providers, like immunization information systems and chronic disease registries. By providing a historical patient record from multiple providers, these can provide critical information for accurate clinical quality measurement and clinical decision support.
Health departments may also provide timely alerts important to clinical decision-making, such as advice about disease outbreaks or environmental emergencies. Some have begun to support Clinical Decision Support using standards like InfoButton.[v]
In some communities, health departments provide small-area information about the prevalence of health risk factors and community assets that help healthcare providers recognize and combat disparities in the context of an individual’s health care.
Transformers of Healthcare
Many health departments play a critical role in the transformation of healthcare in communities. In this role, they may work with HIOs to develop use cases for better multi-disciplinary or multi-organizational team care; for better health care access, navigation and coordination; or to link patients with community-based services.
Unfortunately, it is difficult to generalize about health departments given the variability in their programs, authority, leadership and informatics competency. An HIO needs to get to know the unique constellation of assets and needs of the state and local health departments within its service area. The State HIT Coordinator may help introduce HIO leaders to state public health leaders. The state association of local health departments may also be a very useful partner in obtaining information about local health departments.[vi]
In some states it may be tricky to ascertain if HIE initiatives should route information transactions through statewide public health systems or more local systems. For example, some states have multiple (local or regional) immunization information systems or cancer registries. Joint conversations with state and local public health leaders may be important to resolving such questions to the greatest satisfaction of all concerned.
In virtually all cases, however, local and state health departments will be important partners in the planning, governance and execution of health information exchange.
[i] Institute of Medicine. The Future of Public Health. Washington, DC: National Academies Press; 1988.
[iii] Foldy S. National Public Health Informatics – United States. In Public Health Informatics and Information Systems, 2nd ed. JA Magnuson and Paul Fu, Jr., editors. London: Springer Verlag, 2014.