Much of our current work focuses on engaging state and local public health departments regarding planning for meaningful use.  In the last two weeks alone, we’ve had excellent conversations with five state health departments.  A recurring theme: What to do about the state HIE?

--KJH

Long term, there is no question that the right thing is to have a single source for electronic health information.  Public health would be well-served by this one “healthcare data pipeline” that carried syndromic data, infectious disease reports, lab results, immunization reports and registry data.

That’s the vision of a functional state HIE. And it is the right one.

State HIEs are looking for ways to do the right thing.  Short term, they have milestones to demonstrate their overall value—to the government, providers, and payers.

The HIEs are also concerned about establishing a long-term sustainable revenue model.  That’s the right thing to do as well.

Eligible hospitals and eligible professionals will be seeking credit for meaningful use via syndromic surveillance data exchange—definitely the right thing to do.

For State Epidemiologists, the list of rights is much longer. They need to add hospitals and professionals to their existing syndromic surveillance system (if they have one) and support the state HIE.

Here’s where it gets complicated. Because all of those rights could easily turn into a wrong.

The relationship between the state health department and the HIE is not likely to provide the core revenue model for sustaining the HIE going forward.  At best, it is a value add to the health department and an incremental revenue stream for the HIE.

But the HIE can demonstrate benefit from public supported funds by working with public health. In return, public health can quite sensibly provide a list of milestones for the HIE to accomplish.

A demonstration project can fit the bill for both parties.  Public health can continue to meet the needs of eligible hospitals and professionals while engaging the HIE.

What would that project look like?

It would involve cooperative demonstration of the HIE ability to securely connect healthcare providers to the system and monitor for real-time data flow and quality.  This type of task is different in nature than many other data exchange requirements that lack a real-time data requirement.  Billing and charges for health information exchange can be off by days or a week.  Patient medication history may not include prescriptions written in the last 24 to 48 hours.  But for syndromic surveillance, these are key requirements for compliance.

A demonstration project would show that the health department and the HIE can work together, in a limited scope, to provision data connections while managing them effectively.

Starting with a limited demonstration project lessens the risk of impacting the overall syndromic surveillance project. And it gives the HIE an opportunity to demonstrate its capabilities without undertaking a substantial new effort.

It’s a positive scenario for both public health and the HIE. And it’s definitely the right thing to do.

In the discussions we’ve had with our EpiCenter users, one topic is on everyone’s minds—the challenges of implementing Meaningful Use and Syndromic Surveillance. Some clients have moved further along in the process than others, but the common thread we’re hearing is that a collective effort of insight, ideas, and assistance would be of great benefit.

--KJH

To help our clients deal with these challenges, HMS is coordinating a conference call to bring together Public Health Professionals from across the country. We’ll frame each call with a topic, then ask for input—anything from questions to proposed solutions—to help all involved move through the issues and find a workable solution.

A number of our clients have told us that an impediment to implementation has been coordination with state Medicaid programs. And it’s no wonder. These state programs have faced a daunting task to get up and running in a hurry. The Public Health Professionals who have successfully coordinated with state Medicaid programs are finding that they’re now fielding many questions from hospitals and eligible professionals about Meaningful Use and Syndromic Surveillance.

It’s time to open up a discussion about what’s working and what is not. By sharing information and ideas, we can help to simplify the process of Meaningful Use and Syndromic Surveillance implementation.

All that we need is your assistance. We’re getting ready for the inaugural Public Health Professionals’ Meaningful Use conference call in May.  If you are not a current EpiCenter user and are interested in participating, please contact This e-mail address is being protected from spambots, you need JavaScript enabled to view it for more information.

Health Monitoring Systems is committed to providing Public Health professionals with resources that give insight into Meaningful Use, Health Information Exchange, and Syndromic Surveillance challenges.

On Tuesday, May 29, the Health Information and Technology Practice Group and the Public Sector Health Lawyers Task Force will hold a webinar to explore Stage 2 Meaningful Use criteria regarding electronic reporting. The webinar, "Public Health Reporting Through a Health Information Exchange," will cover techniques for streamlining or automating mandatory reporting for infectious disease surveillance and other public health reporting requirements. Panels will explore models for electronic reporting and address security safeguards.

Learn more and register for the webinar at The American Health Lawyers Association website.

We encourage you to continue an open dialogue about Meaningful use and Health Information Exchange by commenting on our blogs.

Penn Krause, HMS’ Vice President of Business Development, has previously served as a CEO, COO, and Division Vice President in non-profit and investor-owned healthcare systems. During his tenure as COO of the Pittsburgh Mercy Health System, the system was named one of Hospitals and Health Networks “Most Wired.”

In a recent HealthData Management article, Joseph Goedert writes, “sales of electronic health records (EHR) systems hit $17.9 billion in 2011, a 14.2 percent increase over the previous year, according to an annual study from Kalorama Information, a New York-based research firm.”

As the adoption of EHRs accelerates, more hospitals are working to understand the financial and technical requirements of Syndromic Surveillance Implementation.

Health Information Exchange (HIE) is a key component in the move toward meaningful use of electronic health records. Because working with an HIE is relatively new to many in Public Health, there are a number of questions surrounding it. One of the biggest involves how the state’s HIE will support public health needs for the collection and monitoring of healthcare data. This data can include syndromic surveillance data, notifiable condition data, immunization, health registries, or other unique projects.

That is a tough question. To answer it, we need to fill in the landscape a little bit.

Going back to 2006, Health Monitoring Systems (HMS) completed a study of existing functional health information exchanges. At the time, they were referred to as RHIOs – Regional Health Information Organizations. We undertook the study with the expectation that EpiCenter, our Syndromic Surveillance system, would need to work—from day one—in concert with the evolving RHIOs.

To our great surprise, we found that only two RHIOs nationally were viable and functional. Our research wasn’t exhaustive but it involved an active search for functional, self-sustaining RHIOs.

--KJH

So What Happened?

The big question then (and now) is why HIEs/RHIOs haven’t thrived. The benefits of exchanging healthcare data seem obvious. In our research, Dr. Andrew Walsh was able to demonstrate time savings, improved care, and financial savings associated with HIE use.

Despite these proven benefits, undefined costs remain—notably, who pays for the HIE?

The American Recovery and Reinvestment Act (ARRA) provided funding for HIE creation. Along with the standards supported through ONC, two substantial barriers have been lowered.

The jury is still out on whether the result will be a long-term, financially viable health information exchange.

In a previous HMS blog entry, Vice President of Business Development Penn Krause provided insights on the article Public Health Struggling to meet Meaningful Use Challenges.  As our friends in Public Health know, this isn’t new news. Last July, Barbara White (@frombarbara) tweeted the struggles of local public health officials (see Tech Target)

While it’s true that Public Health departments are wrestling with hard decisions on how to move forward—quickly—I don’t believe that should be defined as struggling.

We are in a unique position at HMS; we are working with a number of hospitals and health departments across the country, hearing their stories of what is working and what isn’t. Let’s consider some basic questions we hear from public health departments all across the country—these issues have arisen in just the past month:

• How do I fund this? Will the funds be available on an ongoing basis?
• Who is responsible for coordinating with Medicare and Medicaid to support self-attestation?
• The state hospital association wants to preview and approve the data requirements before we submit them to the hospitals, is that the right approach?
• My eligible professionals desperately want to connect, but they are lacking in funding and technical expertise. One hospital system won’t connect unless we’re able to work with all of their allied EPs concurrently.
• There is a lot of pressure to work with the state HIE but it isn’t even operable yet.  Syndromic, lab, and immunization data aren’t even on their radar.  The implementation plan would require us to write a query mechanism to pull, not just get the data.  What am I supposed to do?
• What technical resources will I need? I am not familiar with HL7 and data collection. I don’t have the background to understand and implement the ISDS recommendations for syndromic surveillance.
• What is a test message? I have a hospital that sent one message, but it was garbled and our system failed. Does this count as a success?

These inquiries prove that Public Health’s challenges are very real, and continually evolving. Most issues revolve around collaboration efforts with other branches of government, organizations, associations, and vendors—anyone who has worked in that environment knows it isn’t a struggle; it is an endurance event.

We’ll be following up with additional blog posts on recommendations and best practices based on what we’ve seen. If you have the chance, post comments with your thoughts, or drop us a line at This e-mail address is being protected from spambots, you need JavaScript enabled to view it .

--kjh

Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, challenged public health departments to take advantage of Meaningful Use reimbursement incentives. These incentives are available to providers who meet the Syndromic Surveillance requirements of Meaningful Use. Despite these enticing incentives, public health departments continue to face implementation challenges—one of the biggest being budget constraints. This article discusses how the ONC is modifying regulations in an attempt to address this issue.

--Penn

Three meaningful use objectives are focused on public health reporting: reporting to immunization registries, electronic lab reporting of reportable conditions, and syndromic surveillance.

Because of the difficulties public health agencies have had testing connections and onboarding a deluge of hospitals and eligible professionals, ONC made a significant change to ease the pressure: Hospitals and EPs that are in the testing queue with a state agency to exchange public health data can attest they have met that requirement, until such time they’re required to submit production data.

The reason for the change is that public health simply can’t keep up, Foldy told a packed room at the HIE symposium Monday, Feb. 20 at the HIMSS12 conference in Las Vegas. The agencies must replace their legacy systems to use national standards, as do most of their providers, while at the same time public health has been hit hard by state belt-tightening. More than 50,000 public health workers have been pink-slipped, along getting their budgets chopped, and information exchange initiatives such as the CDC’s BioSense project also faced funding shortfalls.

Read more here ...

The proposed rules for Stage 2 Syndromic Surveillance present both a challenge and an opportunity for public health professionals. Now that the Stage 2 requirements have been submitted for public comment, there are less than two years remaining before Syndromic Surveillance becomes mandatory. Non-compliance will result in ineligibility for Medicare and Medicaid reimbursements.

The greatest challenge ahead lies in connecting hospitals to the Syndromic Surveillance systems set up by state and local health departments. In addition to the monetary incentives for compliance, Syndromic Surveillance offers an opportunity for public health professionals to easily access timely, critical health information. Associated with this challenge is another opportunity—to work closely with hospital associations and medical societies. These organizations are engaged in communicating with their member hospitals to answer questions that arise as they face their own Meaningful Use challenges.

Now more than ever, building strong relationships with hospital associations is especially beneficial to public health. Hospital associations are actively seeking public health’s guidance through the Meaningful Use and Syndromic Surveillance implementation process.

A good deal of the work at HMS is focused on coordinating with hospital associations and public health to connect the remaining acute care facilities to the system. We’ve discovered that there is significant enthusiasm—and a willing audience ready to relay messages and coordinate webinars—for the overall process.The end result is a win-win-win situation for all: the hospital association, hospital, and public health.

-- kjh

The following is excerpted from the proposed rules, posted form comment at http://www.ofr.gov/OFRUpload/OFRData/2012-04443_PI.pdf.  For convenience, the rules related to public health and syndromic surveillance are reproduced below, with a quick link to the PDF document for the citation.

--kjh

from pages 35 ...

c.  State Flexibility for Stage 2 of Meaningful Use

We propose to offer States flexibility with the public health measures in Stage 2, similar to that of Stage 1, subject to the same conditions and standards as the Stage 1 flexibility policy.  This applies to the public health measures as well as the measure to generate lists of specific conditions to use for quality improvement, reduction of disparities, research or outreach.

In addition, whether moved to the core or left in the menu, States may also specify the means of transmission of the data or otherwise change the public health measure, as long as it does not require EHR functionality above and beyond that which is included in the ONC EHR certification criteria as finalized for Stage 2 of meaningful use.

We solicit comment on extending State flexibility as described for Stage 2 of meaningful use and whether this remains a useful tool for State Medicaid agencies.

d.  Stage 2 Criteria for Meaningful Use (Core Set and Menu Set)

We are proposing to continue the Stage 1 concept of a core set of objectives and a menu set of objectives for Stage 2.  In the Stage 1 final rule (75 FR 44322), we indicated that for Stage 2, we expected to include the Stage 1 menu set objectives in the core set.  We propose to follow that approach for our Stage 2 core set with two exceptions.  We are proposing to keep the objective of "capability to submit electronic syndromic surveillance data to public health agencies" in the menu set for EPs.  Our experience with Stage 1 is that very few public health agencies have the ability to accept ambulatory syndromic surveillance data electronically and those that do are less likely to support EPs than hospitals; therefore we do not believe that current infrastructure supports moving this objective to the core set for EPs.  We are also proposing  to keep the objective of "record advance directives" in the menu set for eligible hospitals and CAHs.  As we stated in our Stage 1 final rule (75 FR 44345), we have continuing concerns that there are potential conflicts between storing advance directives and existing State laws.

from page 84 ...

(b) Objectives and Measures Carried Over (Modified or Unmodified) from Stage 1

Menu Set to Stage 2 Core Set

We signaled our intent in the Stage 1 final rule to move the objectives from the Stage 1 menu set to the Stage 2 core set. The HIT Policy Committee also recommended that we move all of these objectives to the core set for Stage 2.  We propose to include in the Stage 2 core set all of the objectives and associated measures from the Stage 1 menu set, except for the objective "capability to submit electronic syndromic surveillance data to public health agencies" for EPs, which would remain in the menu set for Stage 2.  As discussed later, we also propose to modify and combine some of these objectives and associated measures for Stage 2.

from page 118 ...

(c)  Public Health Objectives

Due to similar considerations among the public health objectives, we are discussing them together.  Some Stage 2 public health objectives are in the core set while others are in the menu set.  Each objective is identified as either core or menu in the below discussion.

•  Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice.

•  Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.

•  Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice.

•  Capability to identify and report cancer cases to a State cancer registry where authorized, and in accordance with applicable law and practice.

•  Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.

We are proposing the following requirements, which would apply to all of the public health objectives and measures.  We propose that actual patient data is required for the meaningful use measures that include ongoing submission of patient data.

There are a growing number of public health agencies partnering with health information exchange (HIE) organizations to facilitate the submission of public health data electronically from EHRs.  As we stated in guidance for Stage 1, (see FAQ at: https://questions.cms.hhs.gov/app/answers/detail/a_id/10764/kw/immunizations) we clarify that such arrangements with HIE organizations, if serving on the behalf of the public health agency to simply transport the data, but not transforming content or message format (for example, HL7 format), are acceptable for the demonstration of meaningful use.  Alternatively, if the intermediary is serving as an extension of the EP, eligible hospital or CAH's Certified EHR Technology and performing capabilities for which certification is required (for example, transforming the data into the required standard), then that functionality must be certified in accordance with the certification program established by ONC.

•  An eligible provider is required to utilize the transport method or methods

supported by the public health agency in order to achieve meaningful use.

•  Unlike in Stage 1, a failed submission would not meet the objective.  An eligible provider must either have successful ongoing submission or meet exclusion criteria.

•  We expect that CMS,  CDC and public health agencies (PHA) will establish a process where PHAs will be able to provide letters affirming that the EP, eligible hospital or CAH was able to submit the relevant public health data to the PHA.  This affirmation letter could then be used by the EP, eligible hospital or CAH for the Medicare and Medicaid meaningful use attestation systems, as well as in the event of any audit.  We request comments on challenges to implementing this strategy. We will accept a yes/no attestation and information indicating to which public health agency the public health data were submitted to support each of the public health meaningful use measures.

Where a measure states "in accordance with applicable law and practice," this reflects that some public health jurisdictions may have unique requirements for reporting and that some may not currently accept electronic data reports.  In the former case, the proposed criteria for this objective would not preempt otherwise applicable State or local laws that govern reporting.  In the latter case, EPs, eligible hospitals and CAHs would be excluded from reporting.

from pages 124 ...

Proposed Objective:  Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice.

This objective is in the Stage 2 core set for eligible hospitals and CAHs and the Stage 2 menu set for EPs.  The Stage 1 objective and measure acknowledged that our nation's public health IT infrastructure is not universally capable of receiving syndromic surveillance data from Certified EHR Technology, either due to technical or resource readiness.  Given public health IT infrastructure improvements and new implementation guidance, for Stage 2, we are proposing that this objective and measure be in the core set for hospitals and in the menu set for EPs.  It is our understanding from hospitals and the CDC that many hospitals already send syndromic surveillance data.  The CDC has issued the PHIN Messaging Guide for Syndromic Surveillance: Emergency Department and Urgent Care Data [http://www.cdc.gov/ehrmeaningfuluse/Syndromic.html] as cited in the ONC proposed rule on EHR standards and certification.  However, per the CDC and a 2010 survey completed by the Association of State and Territorial Health Officials (ASTHO), very few public health agencies are currently accepting syndromic surveillance data from ambulatory providers, and there is no corresponding implementation guide at the time of this proposed rule.  CDC is working with the syndromic surveillance community to develop a new implementation guide for ambulatory reporting of syndromic surveillance information, which it expects will be available in the fall of 2012.  We anticipate that Stage 3 might include syndromic surveillance for EPs in the core set if the collection of ambulatory syndromic data becomes a more standard public health practice in the interim.

The HIT Policy Committee recommended making this a core objective for Stage 2 for EPs and hospitals.  However, we are not proposing to adopt their recommendation for EPs.  We specifically invite comment on the proposal to leave syndromic surveillance in the menu set for EPs, while requiring it in the core set for eligible hospitals and CAHs.

Proposed Measure:  Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period.

Exclusions:  Any EP, eligible hospital or CAH that meets one or more of the following criteria may be excluded from this objective: (1) the EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR reporting period (we expect that the CDC will be issuing (in Spring 2013) the CDC PHIN Messaging Guide for Ambulatory Syndromic Surveillance and we may relay on this guide to determine which categories of EPs would not collect such information); (2) the eligible hospital or CAH does not have an emergency or urgent care department; (3) the EP, eligible hospital, or CAH operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required by ONC for EHR certification for 2014 at the start of their EHR reporting period; or (4) the EP, eligible hospital, or CAH operates in a jurisdiction for which no public health agency is capable of accepting the specific standards required for Certified EHR Technology at the start of their EHR reporting period.  As was described under the immunization registry measure, the third and fourth exclusions do not apply if the public health agency has designated an HIE to collect this information on its behalf and that HIE can do so in the specific Stage 2 standards and/or the same standard as the provider's Certified EHR Technology.  An urgent care department delivers ambulatory care, usually on an unscheduled, walk-in basis, in a facility dedicated to the delivery of medical care, but not classified as a hospital emergency department.

Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency department.  Often urgent care centers are not open on a continuous basis, unlike a hospital emergency department which would be open at all times.

HMS has reworked its blog to feature timely stories and insights that impact our partners in Public Health. Check back often for entries on the challenges and benefits of Meaningful Use regulations—including commentary on Syndromic Surveillance implementation. We'll provide a mix of our opinions, guest commentary, and links to articles that we hope you'll find to be useful as you move forward with Meaningful Use Compliance.

This week, we're sharing an article about the core use objectives of Stage 2 Meaningful Use. Stay tuned next week for our thoughts on the article and its implications for Public Health.

-- kjh

From  Penn ...

Proposed Stage 2 requirements raise the bar for providers

By Christine LaFave Grace

Posted: February 23, 2012 - 5:15 pm ET

The proposed Stage 2 meaningful-use requirements raise the bar for hospitals and eligible professionals on the use of computerized physician order entry, electronic prescribing and electronic recording of several patient-health measures, according to CMS officials.

Four health information technology and policy officials with the CMS previewed the Stage 2 measures in a presentation at the Healthcare Information and Management Systems Society's 2012 Conference and Exhibition in Las Vegas on Thursday morning. On Thursday afternoon, the proposed requirements were published on the Office of the Federal Register's website (PDF). They are slated to be published in the Federal Register on March 7.

You can also find the copy of the proposed rules for comment here ...

Farzad Mostashari spoke this morning about the opportunity presented by Meaningful Use for ambulatory care surveillance. This resonated with our staff. Meaningful use has presented an opportunity for public health to improve surveillance with a willing partner.

Not-so-coincidentally, Health Monitoring Systems has been working on understanding the value behind ambulatory care surveillance.  We are in the process of conducting a demonstration project on over 100 offices.

And here is our first insight -- we don't think public health needs anymore anomalies, alerts, alarms, notifications, or passenger pigeons of doom.   Ambulatory care presents an excellent additional layer to electronic surveillance, adding more depth and richness to the information available.

So, what should be done with it?  Let me hear your thoughts below and we will be updating the blog with ours moving forward.

This article from the HealthCare Economist is about a year old but nicely introduces the topic of Accountable Care Organizations (ACOs).   Whether ACOs develop into a long term solution in improving the efficiency of delivering medicine or are added to the scrap pile of dead acronyms remains to be seen.

--kjh

What are Accountable Care Organizations?

Accountable Care Organizations (ACOs) are the latest rage in the health policy world.  The question is, what are ACOs.  The Urban Institute’s Kelly Devers and Robert Berenson try to answer the following question: “Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries?”

The goal of ACOs is to pay providers in a way that encourages them to work together, to pay providers in a way that does not encourage supplier induced demand, and to create an organization that is rewarded for providing high quality care.  What kind of organizations are currently poised to evolve into ACOs. This chart evaluates the prospects.

One question is why doesn’t Medicare just use their current Medicare Advantage program to accomplish these goals.  In the Medicare  Advantage program, Medicare pays a lump sum to private insurers and holds them accountable for all the medical care the beneficiary needs.  However, there are three main differences between ACOs and HMOs.

1. The “accountability” rests with the providers.  Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
2. Direct contracting with provider organizations without the reliance on a health plan intermediary.
3. The ACOs allow for flexibility in the type of organization.  Some regions may prefer independent practice associations (IPAs) while others  may prefer a physician-hospital organization (PHO).

The physician-centered organization makes much sense to many policymakers because “the resources that flow from the decisions physicians make with patients account for a major portion of overall health care costs, regardless of where the care actually takes place.”

Read more here ...

It Doesn't Make Sense

When we formed Health Monitoring Systems in 2006, Regional Health Information Organizations (RHIOs) were a big deal.  As a young company, we plotted an aggressive course and developed an internal White Paper on the topic.

For two months we researched, emailed and made calls -- that was a significant investment for fresh, barely hatched company.  The result of our white paper was clear.

RHIOs didn't make sense.  CHINs/HINs didn't make sense.  Even dressed-up tricked out, new-fangled language HIEs don't make sense.  They would just never become self-sustaining organizations.  They couldn't.

The benefit from the exchange of data was always tomorrow.  Always over the river through the woods and 1/2 of the way to grandma's house.

Since that time, we have done a lot of work exchanging healthdata.  EpiCenter collects data from over 400 hospitals and submits it to public health for analysis.  That's health information being exchanged right there. MediCenter builds on that, reverses the data flow and provides medication history in an acute care setting.

So why does EpiCenter work?

EpiCenter is a purpose-driven example of health information being exchanged.  Between previous experience and work here at Health Monitoring Systems, our staff has worked with about 600 hospitals, pushing and pulling syndromic data getting better and better results.

More importantly, it works because public health receives benefit and public health is willing to pay.

And that is the key point -- it works because someone who is willing to pay receives a specific benefit and takes a real interest in it.

The current model being advanced for health information exchange doesn't do that.  So, it is hard for me to believe that it is somehow going to work.

What would work?

That is a big question.  It might even be a loaded one.  To answer it we need to peel back a couple of layers and determine what information needs to be shared and who benefits from the sharing.

Take the two together and if the benefit outweighs the cost, then you have a formula that works.

I'll put some thoughts together in another entry here.  Until then email me ( This e-mail address is being protected from spambots, you need JavaScript enabled to view it ) or add your comment with your thoughts on what will make HIE work.

EpiCenter successfully detected the New Year.  As clearly shown by the system's "Alcohol Related" classification, the U.S had a merry holiday.

Syndromic surveillance isn't just for detecting bio-terrorism, apparently.  Previous festive events detected by syndromic surveillance systems include Super Bowl XL, when merry sports fans checked into Ohio hospitals on their way back to Pittsburgh from Detroit.

Tongue-in-cheek comments aside, Happy New Year to everyone.  May it be a safe and healthy one.

--kjh

Andrew Walsh, PhD is Health Monitoring Systems resident expert is public health.  A Johns Hopkins graduate, he attended this years annual International Society of Disease Surveillance conference and has this tongue-in-cheek report.  -- kjh

Who doesn't love a good tag cloud these days? If there had been a tag cloud for 2010 ISDS conference, the largest words would certainly be "meaningful use", "social network", and "stakeholder" in some order. So because no one demanded it, here are my musings on these topics, plus a few more that I thought should have been given higher billing.

Meaningful use - Maybe it's just the timing of the conference, but these conversations reminded me a little of my kids when the toy catalogs come at Christmastime. There was a sense of "You mean we get to ask for stuff and someone will actually give it to us?!?"-level excitement, a belief that they'd get everything on their list, and very little discussion of whether they'd be better off if they actually did.

Out of all the discussion, I thought the most interesting comment was that many providers and facilities are being encouraged to go after public health reporting options with the expectation that public health won't be able to receive the data, an outcome that lets the senders off the hook. That seems like an important issue, but it was essentially a throwaway comment; there was no discussion on how to be ready to receive the data. Now maybe that's because the various health departments are confident that they are ready, but I still thought it would have come up more.

Also, after two talks from the ISDS Meaningful Use Workgroup, I'm still confused about what the purpose of their document is. As I understand things, it can't become part of the federal requirements, at least for Stage I. So is it meant to be a guideline for states when they are deciding what they will actually accept? Or is it just to give providers and facilities a notion of what syndromic surveillance is all about so they know what will be done with the data and what data actually needs to be sent? I would love to be enlightened.

Social Network - It turns out that this meant different things to different people, which led to an amusing panel discussion on "Harnassing social networks for public health surveillance" that wound up being something of a non-sequitor since not all the panelists had the same interpretation. There's the original notion of a social network as a set of people and the physical contacts that exist between them, which can be used to understand the spread of certain diseases (generally less contagious diseases which require significant contact that can actually be quantified). This overlaps somewhat with the second notion of a social network like Facebook where the connections now exist in a virtual realm, but might also give some information about who interacts with whom in physical space. But then some people are interested in Facebook and Twitter because they are a place where people talk about being sick, which might be another indicator of disease prevalence. And finally, there were social networking platforms like Facebook but specifically set up for people to post data on their own health and talk to other people about specific health-related issues. Talk about overloaded terminology; maybe next year there will be a panel discussion about vectors.

Stakeholder - This word was used constantly, and yet not one presenter made the obvious Buffy the Vampire Slayer joke; I'm not sure if I'm pleased or disappointed.

And now, EpiSanta, I've been a good boy, so here is my list of things I'd like to hear more about next year.

Validation - A lot of people were building quantitative, predictive models from data, and many of them paid lip service to validation as a good thing to do and something they hoped to get around to, but very few actually did anything about it. When everyone works in their own corner on their own dataset, overfitting is a major concern. There was even a prime example of it at last year's conference - someone from Google Flu gave a plenary talk in which they revealed that their trend line showed no signal from H1N1 flu in the Spring of '09. Why? They didn't say in exactly these terms, but basically they had overfit to keywords related to "normal" flu patterns. If we're going to be in the business of making predictions, we need to pay more than just lip service to seeing if those predictions bear any resemblence to reality.

Standard data sets - Ostensibly, much of the research in syndrome surveillance is on detection algorithms. Algorithms are the domain of computer science, and in computer science they compare algorithms on the same data so that they actually have some basis for making comparisons and judgements. If we're going to focus on algorithms, perhaps we should borrow more ideas from the folks who lead that field. I heard several pleas from public health practitioners for help in assessing the value of using one algorithm over another; such assessments will never be possible until we start making apples-to-apples comparisons.

Something other than the flu! - Everywhere I looked, someone was doing something with the flu - modeling it, detecting it, predicting it, DiSTRIBuTing it. And all of that is perfectly understandable since it is a major public health concern. But it seems like any time a new data stream is created/found/summoned from the ether, we see if it predicts the flu, and when it does we declare victory and move on. And that just makes me wonder - Why do we need yet another data source that shows the same trends? And if everything predicts the flu, what does that tell us about the bar we've set?

Case in point - everyone was agog over a research talk about using Twitter to track the flu season (Zut alors, surely such a thing cannot be done!). Given the response, you would have thought we had seen lead turned to gold before our very eyes, and yet all they had was one year of data that was so heavily smoothed that it could have been approximated quite nicely with a second order polyomial. Then they showed their fitted curve, which was clearly a higher-order polynomial that had more structure than their data (overfitting, anyone?) and declared victory without quantifying the fit in anyway or doing any serious validation.

(And no, I'm not bitter at all that everyone thought Mr. Twitter was both brilliant and hilarious, while my abstract was summarily rejected for lack of rigor.)

We were discussing meaningful use in the office today and hit upon the perfect description for what hospitals want to hear from public health.  "Easy Check Off"  They want a quick win, a clear victory, a slam dunk.  How can we make that happen?

Here are some initial thoughts on what can be done.

First, they need to cut through any confusion.  Public health should work with the hospital association and let healthcare providers know what their strategy is for syndromic surveillance, laboratory reporting, and immunization registries.  This can be a little tricky since some data collection programs are run by state health departments and others by county health departments.  Outlining how this works clearly, in a letter to each healthcare organization can go a long way.

The next obvious issue they will need to address is, "What work do I have to do on my part?"  I can't answer for other systems, but for the EpiCenter system this is pretty straightforward.  They need to contact Health Monitoring Systems, implement a standard HL7 feed (or file transfer) over a secure connection (VPN most likely) and the process is done.  Anecdotally, this can take as little as four hours.

We like to cite the time we visited a facility in northwest Ohio.  The morning meeting went very well.  By the time we were back in our Pittsburgh office the facility's IT staff had contacted us and were ready to test.

Finally, the last question is going to be, "How do I know I will get credit for this?"  That applies to current organizations providing data as well as ones looking at the possibility.  I recommend that either public health (or the vendor) supply a letter to the facility indicating that they are "in compliance" or "actively sending data" or "successfully sent a test message".  This provides the hospital documentation that show they are in compliance.

Hospitals are evaluating their strategies on how to achieve meaningful use criteria.  Part of this evaluation is the three optional criteria geared toward public health.  The question for public health to answer is how to get hospitals and other eligible providers to select these criteria.

The introduction of meaningful use, the impact of HITECH, and the push for health information exchange have made a healthcare IT a dynamic, challenging environment.  IT leaders are looking at strategies to comply with these initiatives, understand the impact on clinical care, and ensure full reimbursement.  No small feat.  In talking to healthcare IT personnel over the last few months, there were a few points of insight gained that benefit public health.

1. Communication. IT personnel have a lot going on.  Don't assume that they understand the optional criteria for public health.  Don't assume that hospitals already participating in an established system realize that theyalready meet some of the optional criteria.   Health departments need to communicate with healthcare providers to ensure they understand the approach being taken in their region to meet the public health criteria.
2. Clarity. Healthcare IT personnel need to make plans on how to achieve the meaningful use criteria.  They need clear explanations of how the process will work to contribute to the public health system and demonstrate compliance.
3. Simplicity. IT personnel are looking for an easy win.  The want  a step-by-step guide for participating in the public system, that can be assigned directly to a member of the IT team.  Straightforward processes and answers will go a long way to influencing IT decision makers to select the optional criteria.

The single biggest challenge is bridging the communication gap.  For most of the meaningful use criteria, healthcare has to demonstrate that their system complies.  This means using a certified software system or implementing functionality that can be certified and approved.  Working with a public health data system doesn't follow the same process.   What process is to be used needs to be made clear to healthcare IT if they are to select the optional criteria.

--kjh

As reported by Modern Healthcare, RWJF has issued its 2010 update on emergency health preparedness.  In contrast to the Modern Healthcare piece, RWJF reports the highest ever scores, but progress is threatened by budget cuts.   Judge for yourself.  --kjh

"Ready or Not? 2010" Finds States Achieve Highest Ever Scores for Health Emergency Preparedness, But Progress Threatened by Budget Cuts

In the eighth annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 14 states scored nine or higher on 10 key indicators of public health preparedness. Three states (Arkansas, North Dakota, and Washington State) scored 10 out of 10. Another 25 states and Washington, D.C. scored in the 7 to 8 range. No state scored lower than a five.

The scores reflect nearly 10 years of progress to improve how the nation prevents, identifies, and contains new disease outbreaks and bioterrorism threats and responds to the aftermath of natural disasters in the wake of the September 11th and anthrax tragedies. In addition, the real-world experience responding to the H1N1 flu pandemic—supported by emergency supplemental funding—also helped bring preparedness to the next level.

However, the Ready or Not? report, released today by the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation, notes that the almost decade of gains is in real jeopardy due to severe budget cuts by federal, state, and local governments. The economic recession has led to cuts in public health staffing and eroded the basic capabilities of state and local health departments, which are needed to successfully respond to crises. Thirty-three states and Washington, D.C., cut public health funding from fiscal years (FY) 2008-09 to 2009-10, with 18 of these states cutting funding for the second year in a row. The report also notes that just eight states raised funding for two or more consecutive years. The Center on Budget and Policy Priorities has found that states have experienced overall budgetary shortfalls of $425 billion since FY 2009.

In addition to state cuts, federal support for public health preparedness has been cut by 27 percent since FY 2005 (adjusted for inflation). Local public health departments report losing 23,000 jobs—totaling 15 percent of the local public health workforce—since January 2008. The impact of the recession was not as drastically felt by the public health workforce until more recently because supplemental funds received to support the H1N1 pandemic flu response and from the American Recovery and Reinvestment Act have almost entirely been used.

Continue reading here...

Get the full text of the report here...

A recently published report by the Robert Woods Johnson Foundation finds what public health has to contend with everyday -- limited budgets and resources has slowed the adoption of public health data exchange.  -- kjh

Report finds health data exchange lags

by Paul Barr

The electronic exchange of health information is targeted as needing improvement in a new public health preparedness report from Trust for America's Health and funded by the Robert Wood Johnson Foundation.

In a state-by-state analysis looking at 10 indicators of emergency preparedness, seven states' health departments were identified as not being able to send and receive health information electronically to providers and community health centers. The 52-page report, "Ready or Not? Protecting the Public's Health from Diseases, Disasters and Bioterrorism," notes that as seen during the H1N1 influenza outbreak, "this type of communication is crucial to ensure public health departments have an accurate picture of the on-ground events and that healthcare practitioners are given the most up-to-date, accurate information.” 

In addition, 10 states do not have a health department that has an electronic syndromic surveillance system—which uses data that precede diagnosis—that can report and exchange information. Better public health data collection and management also was the subject of a recent report from the Institute of Medicine.

The report notes that budget cuts at federal, state and local levels are threatening the country's ability to respond to public health emergencies.

Read original here...

"What impact will meaningful use have on the EpiCenter application?  Has there been exploration to determine if the system will meet the criteria for meaningful use?"

-- Julie, Kane County Illinois

EpiCenter is a syndromic surveillance system used by state and local public health departments.  The optional meaningful use criteria leaves it to public health to determine if and how syndromic surveillance is conducted in their region.

Certification applies to electronic health records (EHR).  There is a lot of discussion about this topic, as well as the process and meaning of certification.  There are multiple stages of certification that apply to EHRs and those stages align with the implementation of Meaningful Use criteria.

Since EpiCenter is not an EHR, the Certification Commission for Health Information Technology (CCHIT) certification process does not apply to it.