Tutorial Module 8: Viewing Public Health Data and Data Standards in a larger context - Public Health Informatics

Public health’s effectiveness depends on accurate, timely, complete, and reliable information from a wide variety of sources to support analysis, communication and informed decision making.(1, 2, 3, 4) While public health professionals historically have designed useful information systems to meet the needs of individual public health programs or applications, public health has not yet taken advantage of the extraordinary advances in information sciences and technology to improve overall public health practice as well as to transform present-day capacity.(5, 6) Understanding public health information through the discipline of public health informatics allows public health to reach this potential.

This module includes a definition of public health informatics, compares public health informatics to other health informatics disciplines, and discusses the importance of public health informatics to significantly improve public health practice. In addition, challenges to promoting the field are identified as well as entities involved.

Definition

Public health informatics is "…the systematic application of information and computer science and technology to public health practices, research and learning."(7) It is the efficient and effective organization and management of data, information and knowledge generated and used by public health professionals to fulfill the core functions of public health: assessment, policy and assurance.(8) (See Module 1 for more information about the core functions of public health.)

Exhibit 1: Disciplines and Fields Upon Which Public Health Informatics Is Based                     Source: O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.

In an article introducing public health informatics as a needed discipline, Friede, et. al. emphasized public health informatics as going beyond the application of "computer science" and adding the synthesis of knowledge from public health and information technology disciplines to improve public health.(9) Recent articles support the applied as well as multi-disciplinary nature of public health informatics. While rooted in computer and information sciences, informatics draws from a host of other scientific disciplines (e.g., management, organizational theory, psychology, communications, political science, and law) as well as fields that contribute to the practice of public health (e.g., epidemiology, microbiology, toxicology and statistics).(10) (See Exhibit 1.)

"The scope of public health informatics includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, information and learning systems relevant to public health."(11) According to some, it is primarily an engineering discipline, in that it is a practical activity, based in computer and information sciences, for the purpose of accomplishing tasks.(12) Areas of computer science include:

• hardware and software design;

• networking and telecommunications; and

• artificial intelligence (expert systems, decision support, and other functions that show how intelligent systems work together and can be utilized in health care settings);

Areas of information science include:

• information system and database architecture design;

• data and security standards;

• design and manipulation as well as effective use of data, information and knowledge tools to build, manage, merge, retrieve, and analyze health data; and

• project management and organizational issues such as change management and business process reengineering.(13)

Specific public health tasks made possible or enhanced through the application of computer and information sciences go well beyond automation of existing activities. They include communicating synthesized, time-sensitive knowledge to the public through voice or video (in addition to television and radio); electronic data at data entry and real-time monitoring, if needed, of clinical data to identify anomalous patterns of illness and injury; adopting data standards to support data integration across the public health and health care systems; and adding public health relevant key words to the MeSH (Medical Subject Headings) system to improve public health’s ability to access complex textual data.(14, 15, 16, 17)

The preview for this module is an example of an innovative way to promote public health using informatics.

Public Health Informatics vs. Medical Informatics

Public health follows several other health-related, specialty areas to which the general discipline of informatics has been applied, (e.g., medicine, nursing, dentistry, etc.). The field of medical informatics, in particular, emerged in the 1970s and 1980s as a scientific field that "…concerns itself with the cognitive, information processing and communication tasks of medical practice, education and research, including the information science and technology to support these tasks."(18) Examples of the systems on which medical informatics focuses include "…hospital and clinical information systems (automating medical charts, linking laboratory data to clinical data, etc.), computerized diagnostics systems, biomedical engineering, patient and student education, and medical library automation."(19)

As was discussed in Module 1, "What is Public Health?" there is overlap between medical informatics and public health informatics. Similarities include:

• Both disciplines use information science and technology to improve health;

• Both disciplines are concerned with data standards including message standards and content standards;

• Informatics applications that include systems for accessing and using public health data from clinical encounters (e.g., vaccinations) can be both public health and medical informatics applications; and

• Lessons learned in medical informatics, in terms of training and research activities, for example, often apply to public health informatics.(20)

However, public health informatics encompasses much more than medical informatics, guided by four distinguishing principles:

• Public health informatics applications promote the health of populations as opposed to health of specific individuals (although monitoring systems integrated with public health informatics applications may identify specific individuals in need of medical attention);

• Public health informatics applications have an epidemiological and prevention rather than a treatment focus to prevent disease and injury by altering the conditions or the environment that put populations of individuals at risk;

• Public health informatics applications explore the potential for a variety of preventive interventions at all vulnerable points in the causal chains leading to disease, injury or disability, not just clinical or surgical interventions; and

• Public health informatics applications reflect the governmental context in which public health is practiced; for example, applications may need to enable rapid response to public health threats and to inform and change legislative policy.(21)

Exhibit 2: Key Differences Between the Attributes of Medicine and Public Health

Another distinct characteristic of public health informatics is that it relies on the manipulation and synthesis of multiple disparate data sources to assess a population’s health and risk, e.g., hospital discharge data, social services data, housing data, population-based survey data, etc. Data must be integrated and aggregated in useable forms, presented clearly and convincingly to various decision makers, while at the same time insuring that privacy of health information about individuals is maintained.(22) (See Modules 3 and 4 for more information on public health data and how they are used. See Module 6 for more information on the rationale for adopting data standards in public health.)

Importance of Public Health Informatics to Improve Public Health Practice

Several factors have contributed to the importance and timeliness of public health informatics as a knowledge base to improve public health data collection and analysis, communication, and decision support:

• The Institute of Medicine, in its 1988 report on the future of public health, emphasized the importance of information for public health to have the capacity to perform its core functions: assessment, policy development and assurance.(23)

• Two recent Institute of Medicine reports, on the future of public health and educating public health professionals, point out the continuing problems with public health’s ability to handle situations for which rapid, clear communication and information transfer are essential.

• Both more powerful computer systems as well as the proliferation of the Internet have dramatically increased the potential for the development of computerized health information systems.(24) "Public health needs to be at the front of the evolutionary wave."(25)

• Collaboration between managed care companies and public health around prevention has created an increased need and opportunity for application of efficient information technology in partnership with health care.(26)

• Recent events, such as September 11, 2001, the anthrax tragedies and bioterrorist threats have called even more attention to the need for the public health system to have a strong information infrastructure to accomplish its increasingly complex mission.

Challenges to Promoting the Field of Informatics

To better promote the field of public health informatics, it is important to identify the potential challenges and define ways to meet them successfully. Several authors have written about challenges to promoting public health informatics or the public health information infrastructure, which include:

• Ability to achieve consensus on a defined set of standards and business processes and requirements to develop coherent, integrated national public health information systems.

• Slow adoption of uniform data standards, specifically, that meet the needs of diverse groups who record and use health information.

• Proliferation of stand alone systems and lack of coordination between city, state and federal as well as public and private systems.

• Time delays in public health reporting.

• Addressing concerns about the impact of information technology on privacy and confidentiality without hindering the ability to access and use important health data.

• Organizational and financing issues that make it difficult to integrate information systems or bring potential partners together.

• Developing closer integration between public health and clinical care. For example, manual data entry on the clinical side can result in underreporting of many reportable diseases and conditions.

• A public health and clinical workforce that lacks essential information technology skills.(27, 28, 29)

Entities Playing a Role in Promoting the Field of Public Health Informatics to Improve Public Health

Several federal government agencies, universities, associations and states, among other entities, are interested in promoting the field of public health informatics to improve public health practice. The membership of the Public Health Data Standards Consortium includes many of these organizations because data standards are a fundamental part of informatics. Examples of specific federal or national efforts are provided in Exhibit 3:

Exhibit 3: Federal or National Public Health Informatics Efforts

Internet References

The following are links to other sources of information regarding public health informatics.

• American Medical Informatics Association

• A National Agenda for Public Health Informatics

• CDC Information Council

• CDC WONDER

• Current Bibliographies in Medicine: Public Health Informatics

• Guide to the Implementation of the National Electronic Disease Surveillance System in State Public Health Agencies

• Health Alert Network

• Health Resources and Services Administration (HRSA)

• HHS Health Informatics Initiative

• Information Network for Public Health Officials

• NACCHO - National Electronic Disease Surveillance System (NEDSS)

• National Committee on Vital and Health Statistics - The National Health Information Infrastructure

• National Electronic Disease Surveillance System (NEDSS)

• National Information Center on Health Services Research and Health Care Technology

• National Library of Medicine’s Partners in Information Access for Public Health Professionals

• NEDSS Presentation by Denise Koo for the June 27, 2001 NCVHS Full Committee Hearings

• Oregon Public Health Services NEDSS Resources

• Public Health Information Network facilitated by the CDC

• Public Health Infrastructure Resource Center (PHF)

• Public Health Practice Program Office - Centers for Disease Control and Prevention

• Rollins School of Public Health of Emory University

• The ASTHO Public Health Informatics Project

• The Public Health Informatics Institute. A Program of the Robert Wood Johnson Foundation.

• University of Illinois at Chicago School of Public Health - Online MPH in Public Health Informatics

• University of Washington matrix and Core Curriculum

Endnotes

(1) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(2) Yasnoff, William A. O’Carroll, Patrick W. Koo, Denise. Linkins, Robert W. Kilbourne, Edwin M. (November 2000). Public Health Informatics: Improving and Transforming Public Health in the Information Age. Journal of Public Health Management and Practice. Vol. 6 No. 6, pp. 67-75.
(3) Friede, Andrew. Blum, Henrik L. McDonald, Mike. (1995). Public Health Informatics: How Information-Age Technology Can Strengthen Public Health. Annual Review of Public Health. Vol. 16, pp. 239-52.
(4) Lasker, Roz D. Humphreys, Betsy L. Braithwaite, William R. U. S. Public Health Service. Public Health Data Policy Coordinating Committee. (July 6, 1995). Making a Powerful Connection: The Health of the Public and the National Information Infrastructure.
(5) Yasnoff, William A. O’Carroll, Patrick W. Koo, Denise. Linkins, Robert W. Kilbourne, Edwin M. (November 2000). Public Health Informatics: Improving and Transforming Public Health in the Information Age. Journal of Public Health Management and Practice. Vol. 6 No. 6, pp. 67-75.
(6) Gebbie, Kristine, Linda Rosenstock, Lyla M. Hernandez, eds. The Institute of Medicine Committee on Educating Public Health Professionals for the 21st Century. Board on Health Promotion and Disease Prevention. (2002). Who Will Keep the Public Health?: Educating Public Health Professionals for the 21st Century. National Academies Press. Washington, DC.
(7) Yasnoff, William A. O’Carroll, Patrick W. Koo, Denise. Linkins, Robert W. Kilbourne, Edwin M. (November 2000). Public Health Informatics: Improving and Transforming Public Health in the Information Age. Journal of Public Health Management and Practice. Vol. 6 No. 6, pp. 67-75.
(8) Kambic, Bob. Public Health Informatics Lecture.
(9) Friede, Andrew. Blum, Henrik L. McDonald, Mike. (1995). Public Health Informatics: How Information-Age Technology Can Strengthen Public Health. Annual Review of Public Health. Vol. 16, pp. 239-52.
(10) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(11) Ibid.
(12) Ibid.
(13) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(14) Friede, Andrew. Blum, Henrik L. McDonald, Mike. (1995). Public Health Informatics: How Information-Age Technology Can Strengthen Public Health. Annual Review of Public Health. Vol. 16, pp. 239-52.
(15) Yasnoff, William A. O’Carroll, Patrick W. Koo, Denise. Linkins, Robert W. Kilbourne, Edwin M. (November 2000). Public Health Informatics: Improving and Transforming Public Health in the Information Age. Journal of Public Health Management and Practice. Vol. 6 No. 6, pp. 67-75.
(16) Gebbie, Kristine, Linda Rosenstock, Lyla M. Hernandez, eds. The Institute of Medicine Committee on Educating Public Health Professionals for the 21st Century. Board on Health Promotion and Disease Prevention. (2002). Who Will Keep the Public Health?: Educating Public Health Professionals for the 21st Century. National Academies Press. Washington, DC.
(17) Friede, Andrew. Blum, Henrik L. McDonald, Mike. (1995). Public Health Informatics: How Information-Age Technology Can Strengthen Public Health. Annual Review of Public Health. Vol. 16, pp. 239-52.
(18) Greenes, R.A. Shortliffe, E.H. (1990). Medical informatics, an emerging academic discipline and institutional priority. Journal of the American Medical Association. Vol. 263, pp.1114-20.
(19) Friede, Andrew. Blum, Henrik L. McDonald, Mike. (1995). Public Health Informatics: How Information-Age Technology Can Strengthen Public Health. Annual Review of Public Health. Vol. 16, pp. 239-52.
(20) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(21) Ibid.
(22) Ibid.
(23) Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. Board on Health Promotion and Disease Prevention. (2003). The Future of the Public’s Health in the 21st Century. National Academies Press. Washington, DC 2003.
(24) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(25) Fleming, MD. David. Deputy Director for Science and Public Health. Centers for Disease Control and Prevention. (December 2, 2002). Presentation at the National Association of Health Data Organizations Conference.
(26) O’Carroll, Patrick W., William Yasnoff, M. Elizabeth Ward, Laura H. Ripp, Ernest L. Martin, eds. (2003). Public Health Informatics and Information Systems. Springer-Verlag. New York, NY.
(27) Lasker, Roz D. Humphreys, Betsy L. Braithwaite, William R. U. S. Public Health Service. Public Health Data Policy Coordinating Committee. (July 6, 1995). Making a Powerful Connection: The Health of the Public and the National Information Infrastructure.
(28) Lumpkin, John R. Richards, Margaret S. (2002). Transforming The Public Health Information Infrastructure. Health Affairs. Vol. 21, No. 6.
(29) Koo, Denise. O’Carroll, Patrick. LaVenture, Martin. (November/December 2001). Public Health 101 for Informaticians. Journal of the American Medical Informatics Association. Vol. 8, No. 6.
(30) National Committee on Vital and Health Statistics. (November 15, 2001). Information for Health: A Strategy for Building the National Health Information Infrastructure. Report and Recommendations from the National Committee on Vital and Health Statistics. Washington, DC.
(31) Christopherson, Gary A. Deputy CIO for Health, Department of Veterans Affairs. (August 29, 2002). Consolidated Health Informatics: Health Information Interoperability Standards in Federal Healthcare. Presentation to the National Committee on Vital and Health Statistics
(32) The Public Health Data Standards Consortium supports the concept of the Public Health Information Network.
(33) Centers for Disease Control and Prevention. (September 5, 2003). PHIN Brochures-Public Health Information Network Messaging System (PHIN MS). National Electronic Disease Surveillance System (NEDSS) Base System (NBS) and Health Alert Network (HAN). [On-line], Available: http://www.cdc.gov/phin/components/index.htm.