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Public Health Informatics and Information Systems

J.A. Magnuson Paul C. Fu, Jr. Editors

2nd Edition

Health Informatics

Health Informatics

J.A. Magnuson • Paul C. Fu, Jr. Editors

Public Health Informatics and Information Systems

Second Edition

ISBN 978-1-4471-4236-2 ISBN 978-1-4471-4237-9 (eBook) DOI 10.1007/978-1-4471-4237-9 Springer London Heidelberg New York Dordrecht

Library of Congress Control Number: 2013954973

© Springer-Verlag London 2014

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Editors J.A. Magnuson, PhD Department of Medical Informatics and Clinical Epidemiology Oregon Health and Science University Portland, OR USA

Paul C. Fu, Jr., MD, MPH Pediatrics Department Health and Policy and Management Los Angeles County Harbor-UCLA Medical Center David Geffen School of Medicine at UCLA UCLA Fielding School of Public Health Torrance , CA USA

www.springer.com
As a medical student in the early 1980s, I was rather scandalized to discover that my required textbook of medicine did not provide standard treatment protocols for even the most common of medical conditions. What good is a textbook, I asked myself, if it does not provide even this most basic treatment information? The textbook in question was the (then) current edition of the Principles and Practices of Medicine , originally published by William Osler in 1892 and continually updated by Johns Hopkins University School of Medicine faculty in many editions to this day. In suc- ceeding years, of course, I came to realize that fi eld-encompassing textbooks cannot and should not be concerned with the specifi c treatments and protocols of the day, but rather – as Osler understood – the principles and practices that perennially defi ne the fi eld from generation to generation. This is similarly the essence and focus of this, the second edition of this public health informatics textbook: the principles and practices that defi ne and shape this growing and exciting discipline.

Having said that, there is a reason why Osler’s venerable textbook has been updated through dozens of editions and an ever-changing cast of editors: the chal- lenges and context for a discipline, whether medicine or public health informatics, are ever-changing, and textbooks that seek to guide, inform, and inspire new stu- dents of a given discipline must change likewise.

The fi rst edition of Public Health Informatics and Information Systems [1] was begun as a straightforward compendium of key public health–relevant information systems: mortality and natality data systems, survey-based systems (like the Behavioral Risk Factor Surveillance System), and so forth. But the editors quickly came to feel that a more comprehensive focus on informatics was needed, for two primary reasons: (1) the burgeoning information age presented the fi eld of public health with extraordi- nary and unprecedented opportunities to improve its effi ciency and effectiveness, and even to revolutionize the ways in which public health itself was practiced; and (2) an absence of familiarity with the basic tenets of informatics had led, and would inevita- bly lead in the future, to costly (and sadly predictable) failures to develop effective, integrated, and sustainable new information system applications for public health.

With this in mind, the project evolved into what would become the fi rst American public health informatics textbook, and its fi rst edition was expanded to include a broad presentation of the principals and practices, as well as the context and basic science, of

Foreword

vi

public health informatics. To be sure, the major information systems in general use by public health professionals were described and explained. But two concluding parts of the book were included, to describe then-emerging information systems and chal- lenges; and to illustrate through a diverse series of case studies the kinds of value that were being accrued through public health information system development, as well as the special challenges that the development of these systems often entailed. Through these case studies, undergirded by the material that preceded them, the essential prin- ciples and practices of public health informatics were illustrated in real-world terms.

This second edition, developed by JA Magnuson and Paul Fu, Jr., continues this focus and tradition. The basic sections of the original textbook have been preserved, providing the student with the context and science of public health informatics; descriptions of key public health information systems; overviews of new challenges and emerging systems; and a series of illustrative case studies. The material in every section has been enormously updated, however, to refl ect astonishingly rapid advances in information technology as well as profound changes in the societal and legislative context for both healthcare and public health.

By way of illustration, consider that when the fi rst edition was published in 2003, social media and social networking applications were essentially unknown. Facebook © , for example, was not launched until 2004. Yet as of September 2012, Facebook © had over one billion active users—roughly one-seventh of the entire global population (and a much higher proportion in developed countries). Consider also that the US Patient Protection and Affordable Care Act was only signed into law in March 2010 (roughly 3 years ago at this writing), and will not take full effect until 2014. Yet this game-changing legislation is already altering the landscape for healthcare in ways that powerfully promote truly health- oriented (as opposed to procedure-oriented) healthcare. By highlighting the importance of prevention—in fi nancial as well as ethical terms—the Act also promotes closer con- nections and collaboration between the healthcare and public health sectors.

These and many other rapid technological and societal developments present today’s informatics professionals with enormous, unprecedented opportunities to apply information science and technology in innovative ways to promote the pub- lic’s health. There has never been a better time to exert passionate and creative lead- ership to improve existing systems of prevention and public health, and to invent new and yet-undreamt-of approaches to promote human health and well-being.

With that, let me invite the student of public health informatics to take full advan- tage of the information and guidance in this textbook to ignite your passion and develop your creative informatics leadership; and let me congratulate the editors on this much-improved second edition.

Seattle, WA, USA Patrick W. O’Carroll, MD, MPH, FACPM, FACMI

Reference

1. O’Carroll PW, Yasnoff WA, Ward ME, Ripp LH, Martin EL, editors. Public health informatics and information systems. New York: Springer; 2003.

Foreword

When the fi rst edition of Public Health Informatics and Information Systems was published in 2002, Public Health Informatics was a relatively young fi eld. That fi rst edition was invaluable in helping to establish the fi eld of study and provide structure for the emerging discipline. A decade later, great progress has been made, but Public Health Informatics is still an emerging fi eld that needs continued focus in order to grow into its full potential.

This edition builds upon the foundation established by the fi rst edition. We have expanded into new areas that have become important due to changing technologies and needs, as well as updating and augmenting many of the original core tenets. The breadth of material included in this work makes it suitable for both undergraduate and graduate coursework in Public Health Informatics, enabling instructors to select chapters that best fi t their students’ needs.

Structure and Objective of This Book

The template for the chapters in this book contains learning objectives, an abstract or overview, the chapter content, review questions, and references. The book itself is organized into fi ve parts: • Part I. Context for Public Health Informatics provides a background for the text-

book. This part begins with an introduction to the subject of Public Health Informatics and a review of the history and signifi cance of information systems and public health. The context of biomedical informatics is discussed and the governmental and legislative context of informatics is reviewed.

• Part II. The Science of Public Health Informatics reviews the technology and science behind the fi eld of informatics. Informatics infrastructure and informa- tion architecture are discussed. This part examines data sources and tools, and the critical issue of information standards. The topics of privacy, confi dentiality, security, and ethics are explored. Electronic health records are examined, as well as project management and system evaluation.

Pref ace

viii

• Part III. Key Public Health Information Systems are studied in this part. The areas of disease prevention and epidemiology, and environmental health, are reviewed. Specifi c systems and instances for public health laboratories, risk factor informa- tion systems, the National Vital Statistics System, and immunization information systems are discussed.

• Part IV. New Challenges and Emerging Solutions addresses some of the newest challenges facing Public Health Informatics, as well as emerging solutions. Included are new means of data collection and accessibility, geographic informa- tion systems, health information exchange, decision support and expert systems, delivery of preventive medicine, and case-based learning.

• Part V. Case Studies: Information Systems and the Strata of Public Health high- lights informatics case studies from the different strata of public health. The case studies begin with local and regional public health, progressing to state examples for both high population and low population states. Then, national perspectives are represented by examples from the USA, Canada, and a collaborative chapter illustrating informatics experiences in Malawi and Rwanda.

Portland, OR, USA J.A. Magnuson, PhD Torrance, CA, USA Paul Fu, Jr., MD, MPH

Preface

This book refl ects the hard work and dedication of many people. As editors, we want to acknowledge the contributions of our chapter authors,

who generously managed to fi nd the time to share their wealth of knowledge and experience. Their contribution was absolutely critical to this effort, and we are grateful that so many leaders in the fi eld of Public Health Informatics were willing to participate in this project.

We are also grateful to the editors of the previous edition, whose hard work and inspiration pioneered a path for Public Health Informatics. The enthusiasm and encouragement given to us by that edition’s senior editor, Patrick O’Carroll, is espe- cially appreciated.

Finally, we would like to acknowledge the skill and support of our editor at Springer, Grant Weston, and our developmental editor Connie Walsh. Their encour- agement, guidance, and skills were invaluable.

J.A. Magnuson, PhD Paul Fu, Jr., MD, MPH

Acknowledgements

Part I Context for Public Health Informatics

1 Introduction to Public Health Informatics . . . . . . . . . . . . . . . . . . . . . 3 J.A. Magnuson and Patrick W. O’Carroll

2 History and Signifi cance of Information Systems and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 John R. Lumpkin and J.A. Magnuson

3 Context and Value of Biomedical and Health Informatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 William R. Hersh

4 Governmental and Legislative Context of Informatics . . . . . . . . . . . 47 Margo Edmunds

Part II The Science of Public Health Informatics

5 Public Health Informatics Infrastructure . . . . . . . . . . . . . . . . . . . . . . 69 Brian E. Dixon and Shaun J. Grannis

6 Information Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Dina Dickerson and Patricia Yao

7 Data Sources and Data Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Edward Mensah and Johanna L. Goderre

8 Public Health Information Standards . . . . . . . . . . . . . . . . . . . . . . . . . 133 J.A. Magnuson, Riki Merrick, and James T. Case

9 Privacy, Confi dentiality, and Security of Public Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 William A. Yasnoff

Contents

xii

10 Electronic Health Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Stephen P. Julien

11 Ethics, Information Technology, and Public Health: Duties and Challenges in Computational Epidemiology . . . . . . . . . . . . . . . . 191 Kenneth W. Goodman and Eric M. Meslin

12 Project Management and Public Health Informatics . . . . . . . . . . . . . 211 James Aspevig

13 Evaluation for Public Health Informatics . . . . . . . . . . . . . . . . . . . . . . 233 Paul C. Fu, Jr., Herman Tolentino, and Laura H. Franzke

Part III Key Public Health Information Systems

14 Informatics in Disease Prevention and Epidemiology . . . . . . . . . . . . 257 Richard S. Hopkins and J.A. Magnuson

15 Informatics in Toxicology and Environmental Public Health . . . . . . 277 Edwin M. Kilbourne

16 Public Health Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Riki Merrick, Steven H. Hinrichs, and Michelle Meigs

17 The National Vital Statistics System. . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Charles J. Rothwell, Mary Anne Freedman, and James A. Weed

18 Risk Factor Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Alan Tomines

19 Setting National Policies and Standards for Immunization Information Systems. . . . . . . . . . . . . . . . . . . . . . . . 355 Nedra Y. Garrett

Part IV New Challenges and Emerging Solutions

20 New Means of Data Collection and Accessibility . . . . . . . . . . . . . . . . 375 I. Charie Faught, James Aspevig, and Rita Spear

21 Geographic Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 Carol L. Hanchette

22 Public Health Informatics and Health Information Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 J.A. Magnuson and Paul C. Fu, Jr.

23 Decision Support and Expert Systems in Public Health . . . . . . . . . . 449 William A. Yasnoff and Perry L. Miller

Contents

xiii

24 Delivery of Preventive Medicine in Primary Care . . . . . . . . . . . . . . . 469 Paul C. Fu, Jr., Alan Tomines, and Larry L. Dickey

25 Case-Based Learning in Public Health Informatics . . . . . . . . . . . . . . 489 Herman Tolentino, Sridhar R. Papagari Sangareddy, Catherine Pepper, and J.A. Magnuson

Part V Case Studies: Information Systems and the Strata of Public Health

26 Local and Regional Public Health Informatics . . . . . . . . . . . . . . . . . . 513 Jeffrey M. Kriseman and Brian J. Labus

27 Public Health Informatics in High Population States: New York and Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531 Geraldine S. Johnson, Guthrie S. Birkhead, Rachel Block, Shannon Kelley, James Coates, Bob Campbell, and Brian Fowler

28 State Public Health Informatics: Perspective from a Low Population State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 James Aspevig

29 National Public Health Informatics, United States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573 Seth Foldy

30 Public Health Informatics in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . 603 Lawrence E. Frisch, Elizabeth M. Borycki, Alyse Capron, Abla Mawudeku, and Ronald St. John

31 Perspectives on Global Public Health Informatics . . . . . . . . . . . . . . . 619 Janise Richards, Gerry Douglas, and Hamish S.F. Fraser

Part VI Epilogue

32 Public Health Informatics: The Path Forward . . . . . . . . . . . . . . . . . . 647 J.A. Magnuson

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Contents

Contributors

James Aspevig , MS, MPH Health Care Informatics , Montana Tech of the University of Montana , Butte , MT , USA

Guthrie S. Birkhead , MD, MPH New York State Department of Health , Public Health Informatics and Project Management Offi ce , Albany , NY , USA

Rachel Block New York State Department of Health , Offi ce of Health Information Technology Transformation , Albany , NY , USA

Elizabeth M. Borycki , RN, PhD School of Health Information Science, University of Victoria , Victoria , BC , Canada

Robert J. Campbell, PhD Ohio Department of Health

Alyse Capron , Masters of Nursing Clinical Strategy Unit, HealthLink BC , Victoria , BC , Canada

James T. Case , MS, DVM, PhD California Animal Health and Food Safety Laboratory , University of Calafornia, Davis , Davis , CA , USA

James Coates , MS, DVM, PhD Informatics Division , Explorys, Inc. , Cleveland , OH , USA

Dina Dickerson , MPH Maternal and Child Health Assessment, Evaluation and Informatics , Oregon Health Authority Center for Prevention and Health Promotion , Portland , OR , USA

Larry L. Dickey , MD, MPH California Department of Health Care Services , Health Information Technology , Sacramento , CA , USA

Brian E. Dixon , MPA, PhD Department of BioHealth Informatics, School of Informatics and Computing, Indiana University , Indianapolis , IN , USA

Center for Biomedical Informatics, Regenstrief Institute, Inc. , Indianapolis , IN , USA

Center of Excellence on Implementing Evidence-Based Practice, Health Services Research and Development Service, Department of Veterans Affairs, Veterans Health Administration , Indianapolis , IN , USA

xvi

Gerry Douglas , PhD Department of Biomedical Informatics , Center for Health Informatics for the Underserved, University of Pittsburgh , Pittsburgh , PA , USA

Margo Edmunds , PhD Evidence Generation and Translation, Academy Health , Washington , DC , USA

I. Charie Faught , PhD, MHA Health Care Informatics , Montana Tech of the University of Montana , Butte , MT , USA

Seth Foldy , MD, MPH, FAAFP Department of Family and Community Medicine , Medical College of Wisconsin , Milwaukee , WI , USA

Brian Fowler , MPH Division of Prevention and Health Promotion, Ohio Department of Health , Public Health Informatics and Vaccine-Preventable Disease Epidemiology , Columbus , OH , USA

Laura H. Franzke , PhD, MPH Scientifi c Education and Professional Development Program Offi ce , Centers for Disease Control and Prevention (CDC) , Atlanta , GA , USA

Hamish S. F. Fraser , MBChB, MRCP, MSc, FACMI Division of Global Health Equity, Department of Medicine , Brigham and Womens Hospital , Boston , MA , USA

Mary Anne Freedman , MA Poinciana Consulting, LLC , Venice , FL , USA

Lawrence E. Frisch , MD, MPH School of Population and Public Health, University of British Columbia; Vancouver Coastal Health Research Institute , Vancouver , BC , Canada

Paul C. Fu, Jr., MD, MPH David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health , Los Angeles County Harbor-UCLA Medical Center , Torrance , CA , USA

Nedra Y. Garrett , MS Division of Informatics Practice, Policy and Coordination , Centers for Disease Control and Prevention , Atlanta , GA , USA

Johanna L. Goderre , MPH Health Policy and Administration Division , School of Public Health, University of Illinois at Chicago , Chicago , IL , USA

Kenneth W. Goodman , PhD University of Miami Bioethics Program , Miami , FL , USA

Shaun J. Grannis , MD, MS Department of Family Medicine , Indiana University School of Medicine , Indianapolis , IN , USA

Center for Biomedical Informatics, Regenstrief Institute, Inc. , Indianapolis , IN , USA

Carol L. Hanchette , PhD Department of Geography , University of Louisville , Louisville , KY , USA

Contributors

xvii

William R. Hersh , MD Department of Medical Informatics and Clinical Epidemiology , Oregon Health & Science University , Portland , OR , USA

Steven H. Hinrichs , MD Department of Pathology and Microbiology , University of Nebraska Medical Center , Omaha , NE , USA

Richard S. Hopkins , MD, MSPH Department of Epidemiology , University of Florida College of Public Health and Health Professions and College of Medicine , Gainesville , FL , USA

Geraldine S. Johnson , MS New York State Department of Health , Public Health Informatics and Project Management Offi ce , Albany , NY , USA

Stephen P. Julien Department of Laboratory Medicine and Pathology , Mayo Clinic , Rochester , MN , USA

Shannon Kelley , MPH New York State Department of Health , Offi ce of Health Information Technology Transformation , Albany , NY , USA

Jeffrey M. Kriseman , PhD, MS Department of Informatics , Southern Nevada Health District , Las Vegas , NV , USA

Edwin M. Kilbourne , MD Health Solutions Group , Science Applications International Corporation (SAIC) , Atlanta , GA , USA

Brian J. Labus , MPH Health Solutions Group , Southern Nevada Health District , Las Vegas , NV , USA

John R. Lumpkin , MD, MPH Robert Wood Johnson Foundation , Princeton , NJ , USA

Abla Mawudeku , MPH Health Security and Infrastructure Branch , Public Health Agency of Canada , Ottawa , ON , Canada

J. A. Magnuson , PhD Department of Medical Informatics and Clinical Epidemiology , Oregon Health & Science University , Portland , OR , USA

Michelle Meigs Informatics Program , Association of Public Health Laboratories Silver Spring , MD , USA

Edward Mensah , PhD Health Policy and Administration Division , School of Public Health, University of Illinois at Chicago , Chicago , IL , USA

Riki Merrick , MPH Consultant, Public Health Informatics , Carmichael , CA , USA

Eric M. Meslin , PhD Indiana University Center for Bioethics, Indiana University School of Medicine , Indianapolis , IN , USA

Perry L. Miller , MD, PhD VA Connecticut Healthcare System , West Haven , CT , USA

Center for Medical Informatics, Yale University, School of Medicine , New Haven , CT , USA

Contributors

xviii

Patrick W. O’Carroll , MD, MPH, FACPM, FACMI Offi ce of the Assistant Secretary for Health, US Department of Health and Human Services , Seattle , WA , USA

Sridhar R. Papagari Sangareddy , MS (EECS), MS (MIS) Public Health Informatics Fellowship Program , Centers for Disease Control and Prevention , Atlanta , GA , USA

Catherine Pepper , MLIS, MPH Medical Sciences Library , Texas A&M University , Round Rock , TX , USA

Janise Richards , PhD, MPH, MS Division of Global HIV/AIDS , Center for Global Health, Centers for Disease Control and Prevention , Atlanta , GA , USA

Charles J. Rothwell , MS, MBA National Center for Health Statistics, CDC, HHS , Hyattsville , MD , USA

Rita Spear , MS Health Care Informatics , Montana Tech of the University of Montana , Butte , MT , USA

Ronald St. John , MD, MPH St. John Public Health Consulting International , Manotick , ON , Canada

Herman Tolentino , MD Scientifi c Education and Professional Development Program Offi ce , Centers for Disease Control and Prevention (CDC) , Atlanta , GA , USA

Alan Tomines , MD Department of Pediatrics , Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA , Torrance , CA , USA

James A. Weed , PhD, National Center for Health Statistics, CDC, HHS (Retired) , Hyattsville , MD , USA

Patricia Yao , MSc (Medical Informatics) Department of Medical Informatics and Clinical Epidemiology , Oregon Health & Science University , Portland , OR , USA

William A. Yasnoff , MD, PhD NHII Advisors , Arlington , VA , USA

Contributors

Part I Context for Public Health Informatics

3J.A. Magnuson, P.C. Fu, Jr. (eds.), Public Health Informatics and Information Systems, Health Informatics, DOI 10.1007/978-1-4471-4237-9_1, © Springer-Verlag London 2014

Abstract The transformation of public health by informatics is still in the nascent stages. Thus far, informatics in public health generally has been relegated to “pushing the broom” at the end of the parade: public health has tended to bring in informaticists to help resolve systemic issues such as non-interoperability, rather than realizing the full potential benefi ts that would accrue from their involvement at the outset.

To facilitate the understanding of Public Health Informatics, this chapter includes a brief review of public health, discussing the purpose, history, structural organization, and challenges of public health. Once the context of public health has been reviewed, the principles of Public Health Informatics are described, including some history and background, and the challenges encountered, as well as the drivers for change.

Although the discipline of public health informatics has much in common with other informatics specialty areas, it differs from them in several ways. These include (a) a focus on applications of information science and technology that promote the health of populations, rather than of individuals, (b) a focus on disease prevention, rather than treatment, (c) a focus on preventive intervention at all vulnerable points in the causal chains leading to disease, injury, or disability, and (d) operation within a governmental, rather than a private, context.

Drivers of change forcing public health professionals to be conversant with the development, use, and strategic importance of computerized health information

Chapter 1 Introduction to Public Health Informatics

J. A. Magnuson and Patrick W. O’Carroll

J. A. Magnuson , PhD (*) Department of Medical Informatics and Clinical Epidemiology , Oregon Health & Science University , 5th Floor Biomedical Information Communication Center (BICC) , 3181 S.W. Sam Jackson Park Rd., Portland , OR 97239 , USA e-mail: jamagnuson@gmail.com

P. W. O’Carroll , MD, MPH, FACPM, FACMI Offi ce of the Assistant Secretary for Health, US Department of Health and Human Services , 2201 Sixth Avenue , Seattle , WA 98105 , USA e-mail: patrick.ocarroll@hhs.gov

4

systems include health reform, advances in information technology, the advent of Big Data, and continuation of disruptive innovation.

Keywords Big Data • Disruptive innovation • Electronic Health Record • Gene patenting • Healthy People • Informatician • Informaticist • Informatik • Informatique • Infrastructure • Meaningful use • Mobile technology • Open access • Personal health record • Personalized medicine • Prevalence • Preventability • Severity • Software as a Service • SaaS • Telehealth • Value • Variety • Velocity • Volume

Introducing Public Health Informatics

Karl Steinbuch (1917–2005) is often credited with creating the term informatik [ 1 ], for automatic information processing, a term which came to denote computer sci- ence in German. In 1962, Philippe Dreyfus [ 2 ] devised the French term informa- tique , and in 1966 Alexander Mikhailov et al. [ 3 ] promoted the Russian term informatika for the theory of scientifi c information. In the US, a public health infor- maticist or informatician (both are correct) is a professional in the “systematic application of information and computer science and technology to public health practice, research, and learning” [ 4 ], illustrating the relation but clear distinction between computer science and informatics in this usage.

The scope of public health informatics includes the conceptualization, design, development, deployment, refi nement, maintenance, and evaluation of communi- cation, surveillance, information, and learning systems relevant to public health. Public health informatics requires the application of knowledge from numerous disciplines, particularly information science, computer science, management, organizational theory, psychology, communications, political science, and law. Its practice must also incorporate knowledge from the other fi elds that contribute to public health, including epidemiology, microbiology, toxicology, and statistics.

Learning Objectives 1. Defi ne the concept of public health informatics and explain the aspects that

it has in common with medical informatics. 2. Understand the four principles that defi ne, guide, and provide the context

for the types of activities and challenges that comprise public health infor- matics and differentiate it from medical informatics.

3. Describe the history, organization, purpose, and challenges of public health in the US.

4. Explain how the four main drivers of change are affecting the future of public health informatics.

5. Discuss the major developments that have increased the importance and immediate relevance of informatics to public health.

J.A. Magnuson and P.W. O’Carroll

5

Although public health informatics draws from multiple scientifi c and practical domains, computer science and informatics science are its primary underlying dis- ciplines. Computer science, the theory and application of automatic data processing machines, includes hardware and software design, algorithm development, compu- tational complexity, networking and telecommunications, pattern recognition, and artifi cial intelligence. Informatics science encompasses the analysis of the structure, properties, and organization of information, information storage and retrieval, information system and database architecture and design, library science, project management, and organizational issues such as change management and business process reengineering.

An important distinction between medical and public health informatics is illu- minated by the difference between medicine and public health. Public health is concerned with the health of populations, whereas clinical medicine involves the health of the individual. The World Health Organization perspective of health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infi rmity” [ 5 ] can be extrapolated to population health as well. Public health includes not only the often-spotlighted communicable disease pro- grams, but also chronic disease control, health and wellness promotion, environ- mental health, mental health, and other program areas.

Public health informatics differs from other informatics specialties in that it involves:

1. A focus on applications of information science and technology that promote the health of populations, rather than of individuals;

2. A focus on disease prevention, rather than treatment; 3. A focus on preventive intervention at all vulnerable points in the causal chains

leading to disease, injury, or disability; and 4. Operation typically within a governmental, rather than a private, context.

Principles of Public Health

In order to understand public health informatics, it is necessary to have a good intro- duction to public health. As referenced earlier in this chapter, public health is con- cerned with the health of populations. The key characteristics of public health as contrasted with medicine are presented in Table 1.1 .

History of Public Health

Data forms the foundation of public health, and has very early roots in that area. Some of the earliest known examples of public health data involve the pneumonic plague surveillance conducted by the Venetian Republic in the fourteenth century, and the recording of vital events in the sixteenth century in the London Bills of

1 Introduction to Public Health Informatics

6

Mortality [ 6 ]. As time passed, these rich sources of data came to be increasingly analyzed and studied for public health reasons. In the US, Massachusetts developed a postcard-based reporting system in 1874, which marks the beginning of US infec- tious disease reporting [ 7 ].

The Communicable Disease Center, precursor of the Centers for Disease Control and Prevention (CDC), was established in 1946 [ 8 ]. The new center was an exten- sion of the wartime agency MCWA (Malaria Control in War Areas), developed to combat malaria through mosquito control. From those DDT-drenched roots grew today’s CDC, with its emphases on working with states and other partners to moni- tor and prevent outbreaks; maintain national health statistics; and, as included in its very name (Disease Control and Prevention), to prevent and control infectious and chronic diseases, injuries, and environmental health hazards.

Public Health Strata in the United States

Public health in the US is a composite of agencies/responsibilities. Although some regions differ in their public health composition or have entirely different structures such as tribal health agencies, in general , public health agencies in the US are arranged into three strata – federal, state, and local.

• Federal level – There are numerous so-called “operating divisions” within the US Department of Health and Human Services (HHS) that comprise the federal public health family: CDC, US Food and Drug Administration (FDA), National Institutes of Health (NIH), Indian Health Service (IHS), Substance Abuse and Mental Health Services Administration (SAMHSA), and Health Resources and Services Administration (HRSA) foremost among them. However, as regards the day-to-day practice of public health, the CDC [ 9 ] may be considered HHS’s

Table 1.1 Some critical differences between public health and medicine

Attribute Medicine Public health

Source Clinicians, health practitioners Agencies and organizations Primary

focus Persons with disease, injuries,

other health problems Populations (in communities, states,

the nation) Primary

strategy Treatment of persons with disease,

injury, or disability; secondary emphasis on prevention

Prevention of disease, injury, and disability

Timing of action

Usually taken after illness/injury occurs

Both before illness/injury (e.g., prevention) and after (e.g., surveillance)

Intervention context

Clinical and surgical encounters and treatment

Any vulnerable points in the causal chain. Modes include education, policy, research, monitoring, assurance

Operational context

Private practices, clinics, hospitals Governmental context, requiring responsiveness to legislative, regulatory, policy directives, and political context

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primary federal public health agency. It has many important responsibilities, including but not limited to:

– Development and dissemination of prevention guidelines and policies. – Distribution of federal funds to states (and, to a lesser degree, directly to local

health departments) for specifi c public health programs (e.g., immunization, HIV-AIDS, preparedness). Many state initiatives and program areas rely almost exclusively on federal funding.

– Collaboration, representation, and leadership in the public health arena – Assistance to other public health organizations, at their request. In 2011, for

example, CDC sent Epi-Aid assistance (Epi-Aids are requests to the CDC for epidemiological assistance) to US states (Wisconsin, Arkansas, Louisiana, and Georgia), and Ethiopia [ 10 ].

• State and Territory level – State health departments coordinate public health at the state level. Responsibilities include:

– Assisting local health departments (LHDs) with investigations such as out- break investigations

– Coordinating statewide initiatives and programs, such as statewide electronic laboratory reporting, vital statistics, immunization registries, etc.

– Setting state policy and legislation, such as state notifi able conditions. The Council of State and Territorial Epidemiologists (CSTE) maintains a State Reportable Conditions Assessment (SRCA) that represents an annual assess- ment of reporting requirements by state and territory [ 11 ].

– Distributing funds (often federal funds) to LHDs.

• Local level – The local level includes county health departments, metropolitan area health organizations, tribal public health, and regional collaboration organizations.

– LHDs often have the primary responsibility for investigating cases and outbreaks.

– Not all states have LHDs; some may perform all investigations at a state level. – Many large metropolitan areas have health organizations that function at the

level of an LHD. For example, the New York City Department of Health and Mental Hygiene gathers data and provides information on residents of New York City [ 12 ].

– The National Indian Health Board (NIHB) works with a variety of partners, including the Indian Health Service (IHS) and CDC, on public health projects such as the recent Traditional Foods Project and the Methamphetamine and Suicide Prevention Initiative (MSPI) [ 13 ].

– Regional public health initiatives may adhere to the ten HHS-designated regions of the US [ 14 ] or may constitute a response to local needs, such as Alaska’s public health centers [ 15 ].

In addition to governmental structure, public health is arranged into program areas based on activity and purpose. The Public Health Accreditation Board (PHAB) offers public health department accreditation options to tribal, state, local, and

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territorial public health departments in the US. The core public health programs and activities covered under PHAB [ 16 ] include:

• Access to clinical services • Chronic disease prevention and control • Communicable disease • Community health • Environmental public health • Governance • Health education • Health promotion • Injury prevention • Management/administration of public health programs and activities • Maternal and child health • Public health emergency preparedness • Public health laboratory services