Comments on Public Health White Paper

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Building a Roadmap for Health Information Systems Interoperability for
Public Health

White Paper

Call for Public Review
(November 20 - January 19, 2007)

The Public Health Data Standards Consortium (PHDSC) and the Integrating the Healthcare Enterprise (IHE) invite public health, clinical and information technology experts to review the White Paper on Building a Roadmap for Health Information Systems Interoperability for Public Health.

The White Paper has been developed by the PHDSC-IHE Task Force participants to facilitate standardization of health information exchanges between clinical care and public health. The objective of the White Paper is to engage the public health community in a dialogue with health information technology (HIT) vendors to assure that the work processes and data needs of public health stakeholders in health information exchanges are 1) well understood and agreed upon by the stakeholders and then (2) communicated to the developers of the interoperable clinical Electronic Health Record (EHR) systems and Public Health information systems (EHR-PH Systems).

The White Paper consists of three sections. The first section describes public health and population health practices of public health agencies that require health information exchanges with clinical care. The second and third sections describe Immunization and Cancer Surveillance domains as examples of public health programs using the IHE Technical Tasks for Information Exchanges outline. The Appendix section contains the description of examples of other public health domains (research, chronic care, vital records, surveys, obesity, etc.).

We would like to invite the reviewers to join our Task Force to participate in the formation of a Public Health Domain at IHE and to facilitate collaboration between public health and HIT vendor communities in enabling electronic information exchange between clinical and public health settings. We believe that this White Paper may serve as a framing document for the creation of the Public Health Domain at IHE.

For more information about the PHDSC-IHE Public Health Task Force, please contact Dr. Anna Orlova, PHDSC Executive Director at < [email]aorlova@jhsph.edu[/email] >.

This is a test to assure submission of public comments to this thread.

We request that you provide your name, affiliation and e-mail address at the end of your comment, as shown below:

Megha Parikh
PHDSC
[email]mparikh@jhsph.edu[/email]

[mjenkins]

I am responding to the white paper from my perspective as an informatics professional, a researcher, and a primary care nurse practitioner. In my current position, I focus on consumer informatics, including PHR and EHR customization to promote self-management and quality of care. The paper is very comprehensive in terms of background public health functions that rely on accurate data. I was especially happy to learn about the existence of the national cancer registry, which could be a model for other registries; however, I wonder how complete and reliable the data are. I also applaud the efforts toward standardization and terminology mapping of data elements in national surveys (NHAMCS and NHANES).

Two suggestions I have for the document are:
1. The discussion on p. 42-43 on patient safety will benefit from the mention of bi-directional interoperability providing clinical decision support at the point of care. For example: an outbreak of an infectious disease could be noted in a region, and when other clinicians note similar symptoms or diagnoses, the public health agency could feedback information for its safe management.

2. The discussion on p. 44-46 on standards for national survey data elements will be enhanced by consideration of how identical data elements could eventually be included in EHRs through a mechanism such as CCHIT certification. Then the data would be accessible for HIE on a regional or national basis, decreasing the resources needed for a dedicated survey. I published a paper proposing this for NAMCS and suggesting the expansion of the NAMCS data set to include selected outcome measures (see Jenkins, M. (2003). Toward national comparable nurse practitioner data: proposed data elements, rationale, and methods. Journal of Biomedical Informatics 36(4-5), 342-350).

Melinda Jenkins, PhD, FNP
Coordinator of Consumer Informatics
Primary Care Information Project
New York City Department of Health and Mental Hygiene


Thank you for this solid white paper and for encouraging public comment.

[Ssalkowitz]

This reply represents the Data Exchange Standard Committee of the American Immunization Registry Association (AIRA)input to the paper to which it substantially contributed and was approved by the AIRA Board at its December 07 meeting. I am a Board member, ex officio, who was tasked with submitting this reply for AIRA

The statement "In the U.S., the American Immunization Registry
Association (AIRA) maintains the HL7 Implementation Guide for IIS, and associated code set standards."

should be reworded as

"In the U.S., the American Immunization Registry Association (AIRA) in collaboration with the CDC supports the HL7 Implementation Guide for IIS, and associated code set standards.

Note additions to:
2) Who are the Immunization Registry Stakeholders?
The following are the IIS stakeholders:

? Clinicians

Health plans and payers

? Consumers

? Public Health Agencies (local, state and federal)

? Professional Organizations, i.e., AIRA

? Schools and childcare

Editing for typos and inconsistency is required;
IIS is both singular and plural

The US effort on the development of the Immunization Registries and their information systems is sponsored by CDC27, state and local governments, and by private foundations throughout the country. The American Immunization Registry Association (AIRA) is the US professional non-profit organization that promotes IIS and standards for electronic data exchange among IIS including HL7 Implementation Guides.28 Because the goal of IIS is to maintain immunization records for an entire population, IIS programs seek to gain the participation of all public as well as private providers serving their population base. Decision support rules embodied in the VFM are derived from the Advisory Committee on Immunization practice (ACIP) recommendations.29 Often, state-specific local interpretations of the ACIP recommendations result in variations of decision support rules being implemented in different IIS.


Table 3 represents IIS Use Cases evolved from information supplied by the Canadian Infoway project that have been adopted by AIRA.

Should be reworded as:

The Canadian Infoway group contributed heavily to the development of HL7 Version 3 Immunization Domain message standards. These Use Cases have been mapped to the IHE Tasks for Information Exchanges.

Use Cases:
The Use Cases are meant to be broadly informative and not at the granularity needed to support development. It is also important to note that the use cases are not encompassing of all tasks, particularly with reference to those for HIEs.

Greater clarity could be provided by formatting the grid

IIS may focus upon childhood immunizations, and include only pediatric patients. Recently IIS are tending to include adolescent and adult immunizations as well, and can be used as tools for disaster preparedness, e.g., pandemic influenza prevention planning and/or in the eventuality that smallpox or other immunizations need to be given in mass to a population in response to a bioterrorism incident or risk of one.

1. Page 3 - Next to my name, Helen Chan, change to Association of Public Health Laboraties

2. Page 6 - Third paragraph, second sentence, change to "approximately 3,000 local health departments

3. Page 6 - Third paragraph, add in that there are approximately 2,000 public health laboratories

4. Page 12 - Third paragraph, change last sentence to "Lack of integration and interoperability across public health systems leads to the duplication of efforts, unnecessary costs, increased chances of failures and frustration among providers and consumers asked to provide the same information on multiple forms of varying formats to various programs. The extra costs associated with the silos of efforts are not reimbursed by health insurance."

5. Page 35 - Last paragraph...change to:
This effort will help promote communication and collaboration opportunities between the public and private sector on addressing standardization needs for interoperable clinical and public health EHR-PH systems.

Thank you for providing a platform for advancement of public health information exchange across the health care system. As a public health nurse I am aware of the many benefits that will accrue to individuals, public health systems, health care systems, and the health of the public when harmonization and information exchange have been achieved.
Edits:
p. 4 Washington Colorado to Washington County
p 15 Omaha to Omaha System
One of the hopes of public health data information exchange is that data will become available for research purposes (see Appendix 1 and several other mentions within the paper). Thus far in the evolution of the PHDSC-IHE discussion, the use of public health service delivery data for outcomes research has not been addressed. Research using public health data (e.g. birth data, mortality data, registry data) generally requires multiple data points over many years? time. Service delivery data offer a mechanism to bridge this gap by documenting intermediate outcomes of public health services. Service delivery data become available when client assessments and services are documented using standardized terminologies. Some public health departments have begun to compare outcomes using standardized classification data (Monsen et al., in review). There is potential for standardized language to serve as a meta-language to describe public health problems, interventions, and outcomes. There is potential to link public health service delivery data with population health outcomes, while controlling for population characteristics, in order to evaluate the effectiveness of public health programs in addressing major public health problems.
Karen A. Monsen, PhD, RN
Assistant Professor, University of Minnesota School of Nursing
[email]mons0122@umn.edu[/email]
Formerly of Washington County Minnesota Public Health and Environment


Monsen, K. A., Lytton, A. B., Taft, L. L., Schwichtenberg, L. D., & Martin, K. S. (In Review). Comparing public health nursing data across agencies.

[Jim Collins]

First I?d like to convey some general concern about the source of this document. There appears to be so many different groups involved in this process and so many new acronyms are being generated that it is honestly challenging to keep up with them all. Perhaps we need to create some type of centralized reference to the groups that are involved and describe their affiliations, aspirations and responsibilities.

I?d also note that this presents particular challenges from a public health perspective. In our community we speak of, and write to projects involving the Public Health Information Networks (PHIN). Perhaps more specifically, in communicable disease surveillance we address the needs of the National Electronic Disease Surveillance System (NEDSS). I?d say we were a bit taken to see no reference to PHIN in this document. Of course, we rarely see reference to some of the other projects in PHIN documents, so maybe this is another reference to my first paragraph.

Executive Summary

Perhaps public health needs more of a definition of ?domain?. I see the public health domain referenced, but also the immunization domain. Since immunizations are seen as a public health program, would we describe it as a program or a domain?

Page 12

Current practices:
I think this would be a good opportunity to reference some kind of minimal data set for reporting purposes. Beyond the broad spectrum of ?disease specific? reports, there seems to be a need to identify the data elements necessary to complete and appropriate public health referral (at least in the sense of communicable disease surveillance)

?Only 49% of the cases are getting reported????? I wish. That would be a gross over-estimate. The references cited don?t seem current or representative of an accurate environment.

Page 13

With so few truly functioning RHIOs, perhaps the issue of the lack of messaging capacity ect. for many public health systems is equally identified as a weakness of RHIOs (or HIEs).

Page 15

One of the places where I might have expected reference to PHIN, NCPHI, NEDSS ect.

[hayden123]

the role and responsibilities of the food and drink industry in tackling the obesity epidemic. It signals a reassuring shift in focus towards greater health promotion and protection by the health services.

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