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ORIGINAL ARTICLE
An informatics framework for public healthinformation systems: a case studyon how an informatics structure for integratedinformation systems provides benefit in supportinga statewide response to a public health emergency
Ivan J. Gotham • Linh H. Le • Debra L. Sottolano •
Kathryn J. SchmitReceived: 17 April 2013 / Revised: 8 October 2013 / Accepted: 23 January 2014 /
Published online: 8 February 2014
� Springer-Verlag Berlin Heidelberg 2014
Abstract This chapter illustrates how a well-established public health informatics
framework provides an integrated information system infrastructure that assures and
enhances the efficacy of public health emergency preparedness (PHEP) actions
throughout the phases of the health emergency event life cycle. Key PHEP activities
involved in supporting this cycle include planning; surveillance; alerting; resource
assessment and management; data-driven decision support; and intervention for
prevention and control of disease or injury in populations. Information systems
supporting these activities are most effective in assuring optimal response to an
emergent health event when they are integrated within an informatics framework
that supports routine (day to day) information exchange within the health infor-
mation exchange community. In late April 2009, New York State (NYS) initiated a
statewide PHEP response to the emergence of Novel Influenza A (H1N1), culmi-
nating in a statewide vaccination campaign during the last quarter of 2009. The
I. J. Gotham (&)
School of Public Health, Department of Health Policy Management University at Albany,
State University of New York , 1 University Place, Rensselaer, NY 12144, USA
e-mail: igotham@albany.edu
L. H. Le � K. J. Schmit
New York State Department of Health, Office of Information Technology Service,
Empire State Plaza, Room 148, Albany, NY 12237, USA
e-mail: lhl02@health.state.ny.us
K. J. Schmit
e-mail: kjs05@health.state.ny.us
L. H. Le
Department of Nursing, Sage College, Albany, NY 12180, USA
D. L. Sottolano
Center for Health Care Quality & Surveillance, New York State Department of Health,
875 Central Avenue, Albany, NY 12206, USA
e-mail: dls20@health.state.ny.us
123
Inf Syst E-Bus Manage (2015) 13:713–749
DOI 10.1007/s10257-014-0240-9
established informatics framework of integrated information systems within NYS
conveyed significant advantages and flexibility in supporting the range of PHEP
activities required for an effective response to this health event. This chapter
describes, and provides, performance metrics to illustrate how a public health
informatics framework can enhance the efficacy of all phases of a public health
emergency response. It also provides informatics lessons learned from the event.
Keywords Public health informatics � Information systems �Public health emergency preparedness and response
1 Introduction
1.1 Public health informatics and information systems
While there are many definitions of ‘‘Information System’’ in the literature, one
could distill the authors’ thoughts into the following description:
An Information System is the arrangement of data, processes, people, and
information technology that interact to collect, store and communicate
information as needed to facilitate planning, control, coordination and
decision making for a subject matter domain across an enterprise. (See
Businessdictionary 2013; Whatis.techtarget 2013; Whitten and Bentley 2007)
The practice of informatics is essential to assuring that information systems are
successful and provide value (e.g. see Massoudi et al. 2012; Chen et al. 2007). At
the most abstract level, Public Health Informatics (PHI) is defined as ‘‘the
systematic application of information and computer science and technology to
public health practice, research, and learning’’ (O’Carroll et al. 2003). The ultimate
goals of PHI, then, are to:
• assure development and governance of information systems that can be
effectively used within the health enterprise to support routine (day to day)
information exchange
• assure that those information systems provide value to both Public Health
practitioners and their information trading partners (e.g. see Massoudi et al.
2012).
PHI is therefore focused on implementing information systems which support public
health activities that are integrated with, and supportive of, the programmatic goals
of prevention and control of disease and injury in populations (see Yasnoff et al.
2000; O’Carroll et al. 2003; Lombardo and Buckeridge 2007). To be successful and
provide value, public health related information systems must exist within an
operational informatics framework that embodies Health as an enterprise and
supports the broader community of health information exchange (e.g. see O’Carroll
et al. 2003; Kukafka and Yasnoff 2007; Gotham et al. 2010; Massoudi et al. 2012).
Figure 1 depicts a paradigm for such a public health informatics framework and,
as described below, public health emergency preparedness (PHEP) provides an ideal
714 I. J. Gotham et al.
123
use case and means to evaluate its value proposition. The framework, while
supported by technology, has as its focal point the health information exchange
community sustained by value-added information trading synergies (Fig. 1). This
information exchange community embodies the subject domains, organizations and
jurisdictions of health as an enterprise. The synergy, or value proposition, occurs
when information providers and recipients within that community each derive
benefit through bi-directional ‘trading’, or exchange, of health information. It is this
focus that drives the implementation of integrated information systems governed by
the information needs, business rules, policies, regulations, and data-sharing
agreements of the health enterprise.
Implementation of information systems is actualized by a governance process
and based on measurable value and benefit as defined by the enterprise (Fig. 1).
This process informs an agile informatics environment that is able to respond
rapidly to both planned and emergent health information system needs. This
environment is led by informaticians and health domain subject matter experts and
supported by a team of technical experts, rapid development tools, reusable services
and data (Fig. 1).
Within the context of a public health informatics framework, these information
systems support public health activities such as disease surveillance (see Chen et al.
2010; Lombardo and Buckeridge 2007) and outbreak management, laboratory
reporting, health alerting, health care quality assurance, health care resource
availability and capacity assessment, registry reporting and situational awareness. A
model for assessing the value proposition of public health information systems has
been developed by the Public Health Informatics Institute (PHII 2005). A detailed
business process and benefit analysis for interoperable immunization registry data
exchange within a health information exchange community has also been described
by Grannis, Dixon and Brand (2010). The Joint Public Health Informatics Taskforce
has proposed a ‘‘consensus framework’’ to guide collaborations across the public
health enterprise (JPHIT 2011).
The information systems within our model framework are in turn supported by
enabling services (Fig. 1) that assure an arrangement and interaction of data,
processes, people, and technology that effectively collects, stores and communicates
heath information. These enabling services provide foundational support for:
business rules and processes; effective use of information systems; derivation of
information from data; reusable core functions and processes that support multiple
information systems; as well as standardization and interoperability of data and
information.
Services supporting business rules and processes would include provision of user
account privileges and data access control management that assures confidentiality
of data while at the same time providing seamless and appropriate access to data
across information systems based on user role and need to know. Services
underwriting effective use of information and underlying systems include project
management, user training/support, common user interface and single sign-on
across all information systems. Services supporting derivation of information from
data include data analytics and visualization capabilities such as GIS, dashboards,
integrated data reporting and query services, modeling and statistical analysis
An informatics framework for public health information systems 715
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packages. Services supporting standardization and interoperability of data and
information include those standards that assure technical, semantic and process
interoperability of health information exchange (see Benson 2012; IHE 2013).
Core functions and processes assure integration across information systems and
sustainability through reuse of common services by those systems. Examples
include:
• A common data layer service that assures all information systems have the same
integrated view of health data and use the same authoritative version of the
‘truth’.
• Common Directory services. These services include: a communications
directory service that provides role and contact information for organizations,
health providers and users; and a provider and health facility directory service
which provides attribute information on health facilities (e.g. geo-location,
staffed beds by specialty, isolation rooms, fixed equipment assets) and providers
(e.g. certifications, practice status, populations served). Both services provide a
common source of information to systems and users that is consistent, reliable
and up to date.
• Common messaging, alerting and notification services that allow the system and
its processes and users to transmit and confirm notifications to organizations,
Fig. 1 Model Public Health Informatics Framework
716 I. J. Gotham et al.
123
users or other processes by multiple interoperable communication venues (e.g.
voice, text, e-mail, XML).
• Common visualization and analysis services that allow users a single interface to
information for a common operational picture of health information or health
event status. The services allow information system processes to automate
updating of those common operational pictures.
• A common permissions and access control interface provides the authoritative
source for information systems to support workflow processes and access rights
by user role.
The technical infrastructure layer of this framework assures that information
systems and supportive enabling services are interoperable, based on a Service
Oriented Architecture (SOA), secure, resilient and recoverable from disasters,
highly available and able to accommodate surge in usage.
1.2 Benefit of an informatics framework and information systems to public
health emergency preparedness
The US Federal Emergency Management Agency (FEMA 2011) has established a
National Preparedness Goal (or NPG) for preventing and responding to natural
disasters and terrorist attacks. The five components of the NPG include: Prevention,
Protection, Mitigation, Response, and Recovery. These components are cyclic in
nature, with lessons learned from response and recovery actions from previous
emergency events feeding into improving the first three components. The first three
components deal with actions to be taken in advance as preparation for the potential
events through planning, drills/exercises, risk mitigation, infrastructure develop-
ment and protection. In our discussion we will consolidate these three components
into a single category: Preparedness.
Thus public health emergency preparedness (PHEP) is the capability of public
health and healthcare systems, communities, and individuals to prevent, protect
against, mitigate, quickly respond to, and recover from health emergencies,
particularly those whose scale, timing, or unpredictability threatens to overwhelm
routine capabilities. It is a state of sustainable ‘‘readiness to act,’’ for all sectors and
stakeholders, that is achieved over time as part of the essential public health
activities that health departments practice daily (see Gotham et al. 2010).
This key point is an essential component of our model informatics framework
(Fig. 1). PHEP activities/functions, if instantiated within such an extensible or ‘dual
use’ framework, can be a value proposition of information systems that are in daily
use for routine health information exchange by various health organizations,
including Public Health. Indeed, as shown in preparedness drills and exercises
(Gotham et al. 2007, 2010) and actual health events (Gotham et al. 2001, 2007,
2008), the efficacy of information systems supporting PHEP is optimized when
embedded within an established informatics framework supporting a broad-based
community of health information trading partners engaged in routine (day to day)
information exchange activities (Gotham et al. 2001, 2007, 2008, 2010).
An informatics framework for public health information systems 717
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National Frameworks and Emergency Support Functions (ESF) evolved as an
outcome of the NPG (see FEMA 2013). These define an extensive list of core
capabilities and functions required to support the activities involved in prepared-
ness, response and recovery. Among these are operational coordination and
communication, threat and risk assessment, active and passive surveillance,
detection, intelligence and information sharing, situational awareness and decision
support, intervention campaigns, public information, resource assessment for
response and recovery. These functions are singularly dependent on bi-directional
exchange of information among response partners that is authoritative, timely,
accurate, trusted, appropriate and up to date.
Effective information systems by our very definition are absolutely critical in
assuring the efficacy of these activities and functions. Thus effective public health
emergency preparedness requires rapid and agile leverage of integrated information
systems that are readily adoptable in supporting novel emergent situations as well as
core public health activities, such as planning and policy; surveillance; alerting;
health resource assessment and management; situational awareness, data-driven
decision support; and implementation, coordination and management of public
health response and recovery interventions. Thus we can see that our definition of
information system and our informatics framework are well suited to encompassing
the needs of emergency preparedness.
In late April 2009, NY State (NYS) initiated a statewide PHEP response to an
international health emergency: the emergence of Novel Influenza A (H1N1). The
NYS response culminated in a statewide vaccination campaign during last quarter of
2009. The established informatics framework of integrated information systems
within NYS conveyed significant advantages and provided a single point of input
and dissemination of critical information that supported the range of PHEP activities
required for an effective response to this health event. This chapter describes, and
provides, performance metrics that illustrate how a public health informatics
framework and its information systems can enhance the efficacy of all phases of a
Public Health emergency response. The chapter also provides Informatics lessons
learned from the event.
2 A well established informatics framework and dual-use information systeminfrastructure plays an important role in preparedness for an emergencyevent
2.1 Established infrastructure needs to be in place prior to an event
An element that is essential to the value proposition of our informatics framework
paradigm (Fig. 1) is the ‘dual use’ nature of information systems. That is, systems
that are familiar and in daily use by response partners for routine health information
exchange are best suited for, and constitute a key aspect of the ‘‘preparedness’’
phases (prevent, protect, mitigate) that are necessary for effective response and
recovery of an emergency event.
718 I. J. Gotham et al.
123
The NYSDOH informatics framework and its infrastructure have evolved over
the past 17 years to support the state department of health’s strategic approach to
information exchange within the community of its health information trading
partners. The infrastructure, or Health Commerce System (HCS), is a closed, web-
enabled portal, supporting secure information exchange activities with all regulated
health entities in NY State (Gotham et al. 2001, 2007, 2008, 2010); see Table 1. The
flow of data and information within the HCS architecture and its foundation
informatics framework (Fig. 1) are shown in Fig. 2
The information systems within the HCS support all health-related, day-to-day
information exchange activities, from vital records and health care quality assurance
and finance to disease registry and condition reporting, statewide communicable
disease and laboratory reporting, arbovirus surveillance, child health insurance
reporting, managed care, even prescription pad orders. Given this mission, the HCS
architecture is multi-tiered, highly available, and with full off-site disaster recovery
capabilities. That architecture, therefore, is a platform well suited for responding to
public health emergencies, given its architecture and routine use by partner
organizations who would be involved in the response. Thus, based on our paradigm
(Fig. 1), an array of information systems has been implemented within the HCS to
support both PHEP and routine core public health activities.
The PHEP functions and the HCS information systems used to support them are
listed in Table 2 and their data flow within the HCS system is shown in Fig. 2.
These systems support both routine and PHEP activities for health alerting;
electronic laboratory and disease reporting; syndromic surveillance; targeted health
facility patient surveillance; monitoring of health facility status [e.g., Emergency
Department (ED) traffic]; health facility resource inventories and antiviral inventory
tracking; general situational awareness; executive decision support; school-based
surveillance and medical countermeasure administration (Table 2).
Of particular note is the Health Emergency Response Data System, HERDS, an
information system that supports dynamic, real-time deployment of ongoing
surveillance reporting and ad hoc surveys (see Gotham et al. 2007, 2010; Table 2).
HERDS is used for routine electronic reporting and surveys as well as for
information exchange during emergency events. State, regional, and local health
offices all have access to HERDS data as soon as it is reported by health facilities.
Statewide data is typically available and integrated into decision support systems
within 24 h of deployment of a HERDS survey (Table 2).
2.2 Routine, ongoing use of information systems leads to an advance
preparedness advantage
The HCS PHEP information systems relevant to PHEP had been in use for years
prior to the H1N1 Pandemic event and already had been used to support statewide
responses to emergent infectious disease events, emergency disaster declarations,
health resource shortages, elevated national threat levels and high-profile national
security events (Gotham et al. 2001, 2007, 2008, 2010).
The HERDS system had been used to monitor statewide hospital bed availability
and ED patient traffic reporting since June 2003, and provides statewide, facility-
An informatics framework for public health information systems 719
123
specific surveillance on bed availability by specialty type (e.g., adult and pediatric
medical/surgical, ICU, burn). The system has been used to monitor ED patient
registrations, and had also been used to compile and maintain an ongoing statewide
inventory of hospital assets since August 2004. The critical asset survey, deployed
via HERDS, is an exhaustive inventory of current staffed and surge capacity of beds
by specialty; special treatment capacities (e.g., trauma and burn center, hyperbaric,
decontamination); transportation capacities; durable and fixed equipment (e.g., adult
and pediatric ventilators, cardiac monitors); airborne infection isolation room
capacity; staff capacities by specialty; communication and generator capacities.
Reporting of laboratory-confirmed influenza cases, by age group, among hospital
patients, has also been maintained on HERDS since December 2004. Along with
HCS dashboard analytics on the HCS (Table 2), HERDS was instrumental in
supporting the NY State response to the national influenza vaccine shortage in 2004
(Gotham et al. 2008).
Prior to the emergence of the H1N1 event, use of HERDS had been expanded to
support routine surveillance and resource reporting by all Local Health Departments
(LHDs), nursing homes, adult and home care entities, and schools statewide.
Nursing home reporting of bed availability, critical assets, and vaccination rates for
Table 1 NYS health commerce system (HCS) demographics and usage as of July, 2009
Organization or user group Number Users
H1N1 vaccine providers 6,113 5,955
Clinical or environmental labs (Labs) 1,481 3,388
Clinics and treatment centers (Clinics) 1,498 7,369
Home and adult care facilities (adult care) 1,701 15,785
Hospitals 230
Local health departments (LHDs) 58 6,823
Medical professionals – 43,984
NYSDOH central health office 1 4,428
NYSDOH regional health offices 4 1,107
Nursing homes 663 12,287
School districts 1,311 4,259
Pharmacies 2,259 3,388
Other organizations 1,902 10,107
Usage statistics
250 applications
14,500 user logins per day
800,000 access hits per day
30 Gbytes in transactions per day
LHDs include NY City Department of Health and Mental Hygiene
Other organizations include schools, fire and EMS, federal and state agencies, tribal nations, managed
care organizations, etc. Organization counts are by physical facility. Medical Professionals include MDs
and practices, dentists, veterinarians, physician assistants, nurse practitioners
720 I. J. Gotham et al.
123
influenza and pneumococcal infection and other health care surveillance is captured
in HERDS, as are reports, by all types of schools, of vaccination rates and other
public health concerns. Given the established history of the framework, information
systems and the technical infrastructure, the HCS infrastructure had become an
integral component of NYS Health Department incident management processes as
well as of NY State’s all-hazards and pandemic influenza plans (see Gotham et al.
2007, 2010).
Emergency response plans and their underlying components must be tested
periodically to assess their efficacy and revised according to lessons learned. Thus
HCS and its information systems had been used as integral functions in both routine
drills and full-scale exercises (Gotham et al. 2007). In spring of 2006, NY State
Department of Health (NYSDOH) conducted a full-scale exercise simulating the
emergence of a novel influenza strain in the western region of the state (Gotham
et al. 2010). The scenario was entirely data driven, lasted a month in duration, and,
as part of NY’s pandemic influenza plan, leveraged its existing informatics
infrastructure to support the ongoing ‘‘response.’’ The information systems used by
the exercise participants to respond to the scenario included health alerting,
epidemiological surveillance, health care resource and medical countermeasure
management, and data-driven decision support through integrated dashboard
visualization. Situational awareness was provided to all of the organizational
Fig. 2 Health Commerce System (HCS) Technical Information Architecture
An informatics framework for public health information systems 721
123
Table
2Pre-H
1N1HealthEmergency
Preparedness(PHEP)FunctionsandInform
ationSystem
susedontheNYStateHealthCommerce
System
(HCS)to
SupportThem
Generic
publichealthem
ergency
preparednessfunction
ActivitiessupportingNYSPHEPpreparedness,
response
andrecovery
Statewideinform
ationsystem
onHCSsupportingPHEPactivities
‘Health’Facilitysurveillance,
dynam
icresourcereportingand
response
Dynam
icDatareportingfrom
hospitals,nursing
homes,adultcare
facilities
andschools
for
surveillance
andem
ergency
response
Healthem
ergency
response
data
system
(HERDS—
hospital,nursinghome
andadultcare
facility
instances)
Dynam
ic,multitaskingsystem
supportinglivedatafeedsforelectronic
surveillance,surveys,resourceandassettracking,surge,
bed
availability,
patienttracking.andem
ergency
response
inhospitals
HERDS(schoolinstance)
Dynam
ic,multitaskingsystem
supportinglivedatafeedsforstate-wide
electronic
reportingofdatafrom
both
publicandprivateschools
Emergency
Department(ED)Surveillance
System
(EDSURV)
Automated
reportingofchiefcomplaintdataforem
ergency
departm
ent
admissionsforsyndromic
surveillance
NosocomialOutbreakReportingApplication(NORA)
Reporting,follow-upandcloseoutofnosocomially-acquired
infectionsfor
individual
casesoroutbreaksofcommunicable
diseaseswithin
the
hospital
andnursinghomesettings
Disease
reportingand
epidem
iological
surveillance
Reportingofcommunicable
disease
cases
communicable
disease
electronic
surveillance
system
(CDESS)
Statewidesystem
forreportingofdisease
casesforstatemandated
disease
conditionsbylocalhealthdepartm
ents
(LHD)s;includes
contact
tracing
andintegrationwithElectronic
Laboratory
Reporting
HERDS(county
instance)
Dynam
ic,multitaskingsystem
supportinglivedatafeedsforsurveillance
andsurvey
distributionandreturn
forLHDs
AlertingandCommunication
Provides
general
andtargeted
healthalertingand
notificationusingautomated
phone,
cell,fax,
e-mailandsecure
web
postings
CommunicationsDirectory
(ComDir)
Central
directory
ofrole
andcontact
inform
ationforallHCSparticipants;
maintained
bycoordinators
atparticipantHCSorganizations
Integratedhealthalertingandnotificationsystem
(IHANS)
Provides
healthalertingandnotificationusingautomated
phone,
cell,fax,
e-mail,andweb
postings;
integratedwithComDir
722 I. J. Gotham et al.
123
Table
2continued
Generic
publichealthem
ergency
preparednessfunction
ActivitiessupportingNYSPHEPpreparedness,
response
andrecovery
Statewideinform
ationsystem
onHCSsupportingPHEPactivities
Laboratory
reporting
Electronic
reportingofclinical
test
resultsfrom
clinical,publicandnational
commercial
labs
Electronic
clinicallaboratory
reportingsystem
(ECLRS)
Supportsautomated
andmanual
electronic
reportingofpositivetestresults
forreportable
disease
conditionsto
CDESS,includinginfluenza
Decisionsupport,datavisualization
andsituational
awareness,incident
managem
entandoperational
support
Providedecisionsupport,situational
awareness
andacommonoperationalpicture
forexecutive
decisionmakersat
local,regional
andstate
levels
Providerich
andinteractivevisualizationof
event-relateddatafrom
across
datasources
toallprogramsandorganizationsinvolved
inthe
response
effort
Providegeneral
situational
awarenessto
the
communityofHCSorganizations
Executive
dashboard
anddata
visualizer
Access-controlled
system
providinghigh-level
situational
awarenessto
key
decisionmaker
rolesacross
response
partner
organizations;integratesand
summarizes
multiple
datastream
s(H
ERDS,CDESS)into
graphical
displays
Event-specificwebsite
Aweb
site
within
theHCSprovidinginform
ationpostingsandupdates
toentire
HCScommunityduringan
event
Secure
file
view
er
Supportssecure
‘push’ofstatic
contentto
targeted
rolesandorganizations
VirtualHealthOperationsCenter(VHOC)
Access-controlled
system
usedto
supportplanning,incidentmanagem
ent
process
anddiscussionforumsbetweenorganizationsandincident
commandinvolved
intheevent
Medical
countermeasure
response
administrationandinventory
Reportingandmanagem
entofpatientdataand
medical
countermeasuresandinfluenza
vaccinations
Clinic
data
managem
entsystem
(CDMS)
Dynam
ic,form
s-based
system
forreportingandmanagem
entofanymedical
counterm
easure
orprophylacticadministeredfrom
county
clinicsorPoints
ofDistribution(PODs).Alsousedin
annual
LHD-based
seasonal
influenza
clinics
NYState
Immunizationinform
ationsystem
(NYSIIS)
Immunizationregistry,supportingmandated
reportingofvaccinationsby
medical
professionalsto
childrenages
under
19)
An informatics framework for public health information systems 723
123
entities that might directly participate in the response or contribute resources to
facilitate the response. Exercise participants included multiple state agencies, state
and local health departments, and health care facilities.
The exercise provided the opportunity to measure the response rates and
utilization metrics for the information systems supporting PHEP activities. It
demonstrated that the presence of an established, integrated informatics framework
for health information exchange conveys significant advantages in advancing
preparedness in terms of rapid and accurate execution of requested actions and
responses within a simulated emergency event (Gotham et al. 2010). Lessons
learned from the exercise were used to improve the information system’s
capabilities for response to emergent events. The exercises and drills were of
fortuitous benefit: in early spring 2009, nearly 3 years to the day of the 2006
exercise, NYS activated its Incident Management System (IMS) in response to the
emergence of Novel Influenza A (H1N1) within the state. All of the HCS PHEP-
related information systems and informatics infrastructure was called upon to
respond to the event.
3 Background and history of events surrounding NY state response to a publichealth emergency: Novel Influenza A (H1N1)
In mid-March, 2009, the Mexican government identified 3 separate events of
increased influenza-like illness (ILI) and pneumonia along with rising death tolls
that caused it to close schools, cancel public events, and isolate ill individuals at
places of work (WHO 2009). On April 24, 2009, NYSDOH activated its Incident
Management System (IMS) in collaboration with NY City Department of Health
and Mental Hygiene as a preparatory measure in anticipation of positive test results
for what was then called Swine Origin Influenza A (H1N1) among a cluster of
respiratory illnesses within a student cohort at a NY City school (US CDC 2009a).
On Saturday, April 25, NYSDOH initiated a health alerting process, providing
initial guidance to local health and health care entities in NY. By April 26 several of
the NY City specimens had tested positive (US CDC 2009a) and by April 28, 2009,
there were 45 confirmed cases in NY (US CDC 2009b), NYSDOH IMS was in full
response mode, and all PHEP information systems were actively engaged in
supporting the response.
The rapidly advancing geographic spread of the Novel Influenza strain led the US
Government to declare the situation a public health emergency on April 26 (US
CDC 2010a). On June 11, the World Health Organization (WHO) raised the
pandemic alert level to Phase 6, signaling that a global pandemic was under way
(US CDC 2010a). As of June 11, NYSDOH’s website reported over a thousand
confirmed cases of H1N1 distributed across 40 NY counties and NY City. By late
June 2009, the disease was becoming better understood (CDC 2009c, 2010a) and
early estimates by the CDC put the total US cases at between 1.8 and 5.7 million by
late July (Reed et al. 2009). Atypically, the H1N1 influenza activity peaked in late
spring, decreased in midsummer, and increased again in fourth quarter 2009 (see
CDC 2010b). The picture was complicated by the fact that (the usual) ‘‘seasonal’’
724 I. J. Gotham et al.
123
influenza activity remained high throughout the summer and displayed the same
multimodal pattern of activity (see CDC 2010b). The experience reinforced the
importance of information systems and procedures for timely communication, data
collection and analysis to support science-based public health decisions in
responding to this event.
Absent a vaccine for H1N1 when the national public health emergency was
declared, the Centers for Disease Control (CDC) Strategic National Stockpile (SNS)
program began releasing inventories of antiviral medications and respiratory and
personal protective equipment to the States, including NY (US CDC 2010a). These
assets, in combination with NY State’s medical reserve cache, were forward-
deployed to supplement potential shortages in medications and infection control. In
June 2009, plans were under way to implement a national H1N1 vaccination
campaign to control the anticipated re-emergence of the disease in fall of 2009 (see
CDC 2010a). The expected availability date of the H1N1 vaccine was October 2009.
Given the short time frame and competition for resources needed for the seasonal
flu vaccine, however, it was anticipated that the supplies would be limited. In late
July 2009, the CDC’s Advisory Committee on Immunization Practices (ACIP)
released guidance on H1N1 vaccination administration based on the disease
characteristics, concern over the potential for increased severity upon re-emergence,
and limited availability of vaccine at the start. The guidance assigned priority to
specific groups of individuals to receive the vaccine, including health care workers
(see CDC 2010a). As in the 2004 vaccine shortage (Gotham et al. 2008), States were
given local autonomy to sub-allocate CDC allocations. States would identify
vaccination providers by priority group, determine the provider sub-allocation, and
electronically place orders for specific products with the CDC; the CDC would ship
the product to the designated provider through an independent agent.
4 PHEP activities and information systems supporting response to the event
The general pattern of PHEP activities and information system use during the
response phase of the event lifecycle related to the emergence of H1N1 was similar
to that which occurred during the emergence of West Nile Virus in NY State in
1999 (see Gotham et al. 2001). The overall PHEP response to the novel influenza
event occurred in three phases spread out over a period of 9 months. In analogy with
a foot race: Phase 1 was a sprint, immediately followed by a long distance marathon
(Phases 2 and 3).
The initial response phase occurred from late April through mid-June 2009.
During that time, NY State had to rely on the Pandemic flu plan, HCS information
systems and informatics infrastructure that existed at the time. In the second phase
(June to mid-September 2009), more was known about the disease, its activity
ebbed and Federal vaccine response plans were in process.
In Phase 2 (June to mid-September 2009), PHEP activities involved continued
monitoring and surveillance of disease activity for any changes in status in the
community and health care settings. This phase also involved intensive planning
and information system development/modification activities to prepare for the re-
An informatics framework for public health information systems 725
123
emergence of the disease in fall 2009 and for a statewide vaccination campaign to
start in October when that countermeasure would become available. The planning
and information system development activities were based on lessons learned from
Phase 1, NY State health executive governance policies and needs (Fig. 1) and
federal vaccine response plans and policies.
The third phase involved implementation of the response plan, which included
the H1N1 vaccine campaign as a public health intervention to control the spread of
the disease (September 2009 to January 2010). Table 3 lists the public health
activities, the HCS information systems supporting them, and how they were used
throughout the phases of response.
4.1 Phase 1: established information systems supported the initial response
to the emergency health event
The initial response required intensive health alerting and communication of
situational awareness to, and among, response partners in the health community;
rapid gathering and distribution of data related to surveillance and assessment of
disease severity, geographic spread, and antiviral resistance; assessment of the
impact on health care resources; control and mitigation of infection in the health
care and community settings; management and distribution of antiviral counter-
measures and respiratory and personal protective equipment.
There was an immediate imperative for situational awareness and guidance from
a single authoritative source that could provide rapid distribution of guidance,
advisories and updates and related communiques statewide to the global HCS
community (Figs. 1, 2; Table 1), including all Local Health Departments (LHDs),
acute care and long-term care facilities, clinical laboratories, and health providers.
The Integrated Health Alerting and Notification System (IHANS) and event-specific
website within the HCS system provided the methodology for distribution of these
materials (Table 3) and the HCS health information exchange community provided
the venue (Figs. 1, 2; Table 1).
Access to event-specific information was also important: laboratory and case
reporting of suspect and confirmed cases were supported by existing HCS systems
(Tables 2, 3, see ECLRS and CDESS). Syndromic Surveillance was maintained
through the HCS Emergency Department Surveillance System (Tables 2, 3, see
EDSURV). Healthcare-based outbreaks were monitored via the Nosocomial
Outbreak Reporting Applications (see NORA, Tables 2, 3). The HERDS system
(Tables 2, 3) was leveraged to provide heightened surveillance on increases in
patients presenting with febrile or Influenza-Like Illness (ILI) at hospitals;
assessment of impact on health care status (e.g., ED traffic); assessment of critical
healthcare resource inventories (e.g., Personal Protective Equipment and antiviral
medications); tracking of antiviral medications distributed to the state through the
Strategic National Stockpile (SNS); and assessment of vendor-managed inventories
of antiviral medications available through pharmacy chains.
Additional baseline information was also required, including seasonal influenza
surveillance data from acute health care facilities; inventories of fixed health care
assets from acute and long-term care facilities (e.g., ventilators, airborne isolation
726 I. J. Gotham et al.
123
infection rooms); and bed availability. As the demographics of the viral infections
became better understood, guidances regarding school closings and absenteeism
were distributed via the health alert system and event website (Table 3). School
absenteeism surveillance, required to make decisions regarding school closings, was
implemented through the HERDS system (Table 3), allowing all schools across NY
State to report this data and receive event information in exchange. The dynamic
nature of the HERDS information system allowed for real time creation of reports
for each of these needs, with information provided on appropriate levels to the
decision makers across the HCS domain of response partners (see Tables 2, 3;
Gotham et al. 2007)
Situational awareness and decision support were paramount for the executive
policy and decision makers across the domains of the health information enterprise
of the HCS community. Data feeds from surveillance, health care resource
monitoring, and health care facility status were integrated into the HCS executive
dashboard and data visualization system as well as a Virtual Health Operations
Center (Tables 2, 3) to provide situational awareness and decision support for
executives within the Incident Management System (IMS) (Table 3, see also
Gotham et al. 2010).
Thus the existing HCS information systems supported the response to the initial
phase of the emergency response. However, the marathon phase of the response was
about to begin.
5 Phase 2: an established informatics framework enabled agile developmentof new or modified information systems to support recovery, planningand preparedness for disease re-emergence and countermeasure intervention
The second phase of the H1N1 event encompasses both the ‘‘recovery’’ phase of the
event lifecyle, that is, recovery from Phase 1 and re-initiation of the cycle into
‘‘preparedness’’ for what, at the time, was envisioned as Phase 3: re-emergence of
the disease and medical countermeasures against it. One component of Phase 2
involved ongoing monitoring and surveillance of disease activity for any changes in
status in the community and health care settings as well as alerting and situational
awareness reporting. These activities were supported by the existing HCS
information systems (Tables 2, 3). A second component of Phase 2 involved
engaging in intensive planning activities to prepare for the re-emergence of the
disease and a vaccine countermeasure campaign in fall 2009.
Federal policies, distribution plans, reporting mandates, as well as lessons
learned locally from Phase 1 by NY State dictated that completely new intervention
and surveillance plans had to be developed to support a federally-brokered, state
fiduciary-based vaccination campaign. The campaign was slated to start that
October when federal entities would make the vaccine available to providers and
states. The existing PHEP systems, such as HERDS, were well tuned to the
information needs of an emergent event of short duration. The existing Immuni-
zation Registry and clinic data management system were well suited to monitoring
administration of vaccines by providers and mass vaccination clinics (Tables 2, 3).
An informatics framework for public health information systems 727
123
Table
3Publichealthem
ergency
preparedness(PHEP)activitiesandNYState
healthcommerce
system
(HCS)inform
ationsystem
ssupportingtheem
ergency
response
toH1N1
PHEPfunctionanddata/inform
ation
sources
ActivitiessupportingPHEPresponse
HCSinform
ationsystem
Planningandincidentmanagem
ent
State,regional
andlocalhealth
officials
Supportelectronic
collaborationfordevelopment,
distributionandcommentonresponse
plansas
they
evolved
betweenJuneandAugust2009
SupporttheNYSHealthIncidentCommandSystem
(ICS),throughelectronic
collaboration,mission
assignments
andsituationreports
Virtual
healthoperationscenter(V
HOC)
Epidem
iologic
surveillance
Hospitalsstatew
ide
Monitorhospital
admissions/deathswithlaboratory
confirm
edseasonal
influenza
byagegroup
Monitorhospital
admissions/deathsdueto
acute
febrile
respiratory
illnessbyage
MonitorInfluenza-likeillness(ILI)symptomsfor
emergency
departm
ent(ED)admissions(N
YCity)
HERDS—
hospital
instance
Conduct
ED
syndromic
surveillance
based
onchief
complaintdataonED
admission
Emergency
departm
entsurveillance
(EDSURV)
Schools
andschooldistricts
statew
ide
Collectstudentandfacultyabsenteeism
from
schools
andschooldistrictsin
supportofnovel
andseasonal
influenza
surveillance
HERDS—
schoolinstance
LocalHealthdepartm
ents
(LHDs)
statew
ide
Statewideelectronic
communicable
disease
case
reportingbyLHDs—
novel
influenza
case
reporting
from
sentinel
facilities
Communicable
disease
electronic
surveillance
system
(CDESS)
Clinical
laboratories
(National,
Privatein
State
andHospital)
Automated
reportingofpositivetest
resultsforre-
portabledisease
conditions,integratedwithCDESS—
PositiveInfluenza
testresultsbytype,includingnovel
influenza
Electronic
clinical
laboratory
reportingsystem
(ECLRS)
728 I. J. Gotham et al.
123
Table
3continued
PHEPfunctionanddata/inform
ation
sources
ActivitiessupportingPHEPresponse
HCSinform
ationsystem
Nursinghomes
andhospitals
Reportingofnosocomiallyacquired
infections;areasof
thefacility
involved,number
anddispositionof
affected
patients,andinfectioncontrolmeasurestaken
tocontain
andmanagetheoutbreak
Nosocomialoutbreak
reportingapplications(N
ORA)
Monitorandtrack
healthcare
facility
status,resourceutilizationandavailability,
surgecapacity
Hospitals
Inventory
statew
idehospital
assets
andequipment
deemed
essential
toem
ergency
response
(e.g.
pharmacyinventory,diagnostic
equipment,life
supportequipment,supplies,personal
protective
equipment(PPE),airborneinfectionisolationrooms
(AIIR))
Monitorhospitalbed
availabilitybystaffedservice(e.g.
adult/pediatric:medical
surgical,ED,IntensiveCare
Unit(ICU))
Monitorevent-relatedhospital
resourceutilization(e.g.
ventilators)andfacility
stress
status(facility
emergency
planactivated,diversionstatus,surge
strategiesactivated)
HERDS—
hospital
instance
Longterm
care
facilities
Inventory
statew
idenursinghomeassetsandequipment
deemed
essential
toem
ergency
response
(e.g.
pharmacyinventory,diagnostic
equipment,life
supportequipment,supplies,PPE)
Monitornursinghomebed
availabilitybystaffed
service
HERDS—
nursinghomeinstance
AlertingandCommunication
An informatics framework for public health information systems 729
123
Table
3continued
PHEPfunctionanddata/inform
ation
sources
ActivitiessupportingPHEPresponse
HCSinform
ationsystem
Global
HCScommunity(see
Table
1)
Distribute
general
notificationsandalerts
regarding
novel
influenza
disease
status,vaccineavailability,
infectioncontrol,stateandfederal
guidance
toHCS
community
Integratedhealthalertingandnotificationsystem
(IHANS)and
communicationsdirectory
(ComDir)
Targeted
healthresponse
partners
(LHDs,hospitals,longterm
care
facilities,medical
professionals)
Customized
organization—androle-specificdistribution
ofevent-relatedalerts,advisories
andupdates:e.g.
response
andinfectioncontrolandexposure
protocols;case
definitions;vaccinationpriority
groups;vaccineefficacy
inform
ation;em
ergency
waiver
inform
ation
H1N1vaccinationproviders
(medical
professionals,LHDs,
healthfacilities
andother
organizationsadministeringH1N1
vaccineto
targeted
priority
populations)
Targeted
individual
andmasscommunicationof
inform
ation,updates
andadvisories
relatedto
the
novel
infuenza
vaccineadministrationcampaign:e.g.
ordering,order
status,reportingofadministered
doses,priority
groupadministration,andallocation
protocols
Publichealthintervention:statewidevaccinecampaign:medicalcounterm
easure
managem
ent,vaccineordering,managem
ent,distribution,administrationandreporting
H1N1vaccinationprovidersordering
vaccine
Registerto
order
vaccine,place
vaccineorders,receive
vaccineallocationinform
ation,checkorder
status
Vaccineorderingandmanagem
entsystem
(VOMS)
Medical
practitioner
orpracticeor
healthfacility
aggregate
administereddosesreporting
Weekly
reportingofaggregatevaccinedoses
administeredvia
phoneorweb
applicationby
practitionersandhealthfacilities
forreportingpriority
populationgroupvaccinations
Medical
practitioner
orpractice
patient-level
administereddoses
reporting
Reportnumbersofpatient-level
vaccinationsfrom
provider
office
based
settings
New
York
State
ImmunizationInform
ationSystem
(NYSIIS)
LHD
Clinics/PointsofDispensing
(PODs)
Reportnumbersofpatient-level
vaccinationeventsand
inform
ationat
county-based
massvaccinationclinics
Clinic
DataManagem
entSystem
(CDMS)
730 I. J. Gotham et al.
123
Table
3continued
PHEPfunctionanddata/inform
ation
sources
ActivitiessupportingPHEPresponse
HCSinform
ationsystem
Hospital,nursinghomeandadult
care
healthcare
workers
Assessvaccinationratesforseasonal
andnovel
influenza
amonghealthcare
workersat
health
facilities
HERDS—
hospital,nursinghomeandadultcare
facility
instances
State
executivedecisionmakersand
incidentmanagem
entstaff
Allocatelimited
supplies
ofevent-relatedvaccineto
fill,
orpartially
fill,provider
ordersbased
ongeographic
location,coverageofpriority
populationsserved
by
providers,order
history
andmultiple
other
eventand
disease-related
factors
VOMS
State
incidentmanagem
entstaffand
LHDs
Tracking,reportingandinventory
ofmedical
counterm
easures,equipmentandsupplies
deployed
duringhealthem
ergency
from
stateandfederal
stockpiles
Medicalem
ergency
response
inventory
trackingsystem
(MERITS)
Situationalawarenessanddecisionsupport
Global
HCScommunity(see
Table
1)
Providehighlevel
situational
awarenessregardingthe
eventto
healthresponse
partnersandusersoftheHCS
system
,includingdisease
severity,extent,prevalence;
vaccinecampaignstatus,stateguidance
onexposure
precautions,overviewsofresponse
plans,federal
guidance
onpriority
groupvaccinationpriorities
H1N1event-specificweb
site
Executivedecisionmakersand
incidentmanagem
entstaffingat
stateandregional
healthoffices
andLHDs
Supportvaccineallocationprocess
andsituational
awareness,providingorganizationandrole
appropriateaccess
tointegratedviewsofnovel
influenza
surveillance
data(hospital
admissions,
syndromic
surveillance,schoolabsenteeism
,lab
reports);event-relatedhealthfacility
resourcedata
(bed
availability,ventilatorutilization,facility
PPE
supplies,etc.);vaccinecampaigndata(e.g.summary
inform
ationonprovider
registrations,vaccineorders,
vaccineshipments,vaccinationadministrationsby
priority
group,geographic
extent,populationdensity)
Executivedashboardanddatavisualizer
system
An informatics framework for public health information systems 731
123
However, no system existed to support transactional placement of vaccine orders,
order and inventory tracking, and reporting for orders placed to the CDC. Further,
there was no integrated allocation system to implement the state’s requirements for
distribution and reporting. The situational awareness and decision support
capabilities of the HCS also had to be attuned to this information flow in order to
allow decision makers to assess need based on federally mandated priority
populations, place orders for vaccine supply, and report the number of vaccines
administered.
As described in our definition of information systems and our informatics
framework (Fig. 1), people and processes form an important infrastructure
component of each paradigm. Our model informatics framework includes a
governance process which informs an agile informatics team of the needs of the
enterprise, the team being tasked with the responsibility of developing and
implementing the information system to meet them.
Thus, NY State maintains a staffing infrastructure of subject matter experts in
technology, project management, informatics and health knowledge domains who
make up an informatics team (see Fig. 1 for roles on that team). That team was
tasked with the responsibility for design, development, and implementation, by
October 1, 2009, of the systems required to order, manage, track inventory, and
report the status of vaccination campaigns. Additionally, all data feeds from these
new systems and existing information systems had to be integrated into the
executive dashboard (Tables 2, 3) to enable a common operational picture to
provide situational awareness as well as decision support in ordering, prioritizing
and distributing vaccine among the NYS population.
The governance structure was centered around a series of Health Knowledge
domain executive workgroups created to cover all programmatic information
system needs for the response. The Informatics team participated as an integral
component on all of these programmatic workgroups and was tasked with the
responsibility of developing the informatics component of the plan: a compre-
hensive approach to support (1) incident management; (2) vaccination campaign;
(3) epidemiologic surveillance; (4) monitoring health care facility status,
resource utilization and availability, surge capacity; (5) community mitigation;
(6) alerting and communication; (7) situational awareness and decision support
(see Tables 2, 3).
Executive workgroup products–objectives, response triggers, guidance, policy,
protocols, and operational documents–were created and posted within a Virtual
Health Operations Center (VHOC) within the HCS system (Table 3). The VHOC
information system provided a vehicle to share and collaborate on plan development
with external response partners within the information exchange community of the
HCS. The VHOC also supported the IMS process through electronic tracking of
assignments and collaborative production of daily reports (Situation Reports) for
executive consumption.
A key deliverable of the Informatics team was to formulate a cohesive and
comprehensive Master Data Management Plan (MDMP). An MDMP was essential
to establishing a single integrated and authoritative source of information to the data
layer services that would support the Information Systems to be used in the response
732 I. J. Gotham et al.
123
(e.g. see Figs. 1, 2). This effort was largely focused on identifying the data elements
that were well defined and reliable; used a standard vocabulary; could be obtained
without overburdening the data providers; were needed to support state and local
executive decision making and situational awareness and to present a common
operational picture to the IMS staff; and would lead to information products that
offered value back to the data provider. Defining data sharing and access rules and
other key metadata elements was also included in the plan. A data dictionary was
developed and linked to electronic data collection templates for deployment in the
HERDS systems. Each template was tailored to the needs of agreed-upon scenarios
of disease severity.
The informatics forum for developing the MDMP included participants from
organizations that cross-cut the information exchange community on the HCS:
NYSDOH health care and public health subject matter experts (SMEs), New York
City Department of Health and Mental Hygiene (NYCDOHMH) local public health
agency programs, LHDs, hospital associations, and long-term care facilities. The
result of this effort was a well-defined and realistic MDMP that was supported by
the health care and local health response partners. The MDMP also addressed the
need for school closure and absenteeism surveillance. The informatics workgroup
used a similar approach working with NYSDOH epidemiologists, the NYS
Education Department, LHDs, and representatives from schools and school districts
to design a plan for schools to report absenteeism via the HERDS information
system. The data collected from these reporting streams would, as part of the plan,
be integrated into the HCS executive dashboard visualization system to provide a
common operational picture and situational awareness to executive staff and the
IMS.
The informatics team engaged an agile project management approach to
developing and implementing a Vaccine Ordering and Management System
(VOMS). The process started with a ‘‘top-to-bottom’’ business analysis of existing
vaccine ordering and distribution protocols and procedures to gather requirements
and assess how technology could improve workflow and streamline the process and,
further, allow the flexibility needed for rapid responses to changes in vaccine supply
and demand at the national, state, or local level. The ability to react to, and
accommodate, changes in the VOMS system was essential as the vaccination
campaign itself presented complex and rapidly evolving state and federal
requirements. An overview of the information and process flow of the vaccine
campaign is shown in Fig. 3. VOMS requirements dictated that the system must:
• Allow vaccination provider organizations to register electronically and to
acknowledge their agreement to federally mandated conditions, place orders,
receive order status updates, and make changes in orders online
• Allow local health departments to assess provider rankings in priorities
• Support a data-driven allocation process
• Place orders with the Centers for Disease Control
• Accept reports from providers of vaccine doses administered to priority
populations as identified in federal guidance
An informatics framework for public health information systems 733
123
• Be operational before October 19, 2009, when supplies of the vaccine would be
available to fill state orders
The third phase involved implementation of the response plan, which included the
vaccine campaign as a public health intervention to control the spread of the disease
(September 2009 to January 2010). A common operational picture of disease
surveillance data, health care facility status and resources, vaccine ordering and
administration status, and infection control actions had to be made rapidly available
to policy makers and response partners. The influenza vaccine countermeasure
would be made available to vaccination providers according to the federal
government’s prioritization recommendations. State allocation decisions would be
informed by multiple data sources, including: surveillance, healthcare status, and
reports of administered doses from mass clinics, school-based clinics, hospitals,
community health centers, and private providers.
5.1 Phase 3: implementation of information systems supporting the revised
response plan and vaccine countermeasure campaign
The third phase involved implementation of the revised Phase 2 response plan. The
goal was to establish and sustain a ‘long-term’ public health intervention campaign
designed to control the spread of the disease (September 2009 to January 2010). The
plan dictated the absolute need for decision makers and response partners across the
HCS community to have real-time access to a common operational picture of
disease surveillance data, health care facility status and resources, vaccine ordering
and administration status, and infection control actions. The influenza vaccine
orders placed with the CDC by the States would be made available to vaccination
providers according to the federal government’s prioritization recommendations and
the States’ allocation plans. Therefore, NY State orders to the CDC for vaccine and
its allocation supplies must be informed by multiple data sources, including:
surveillance, healthcare status, and reports of administered doses from mass clinics,
school-based clinics, hospitals, community health centers, and private providers.
5.1.1 Epidemiologic surveillance information systems
Using the MDMP, NYS implemented enhanced influenza surveillance activities by
leveraging its existing information systems tracking both severity and extent of both
novel influenza and seasonal influenza (see Tables 2, 3). These systems included:
Electronic lab reporting system, HERDS, communicable disease case reporting, and
syndromic surveillance. Thus, given the the long history of HCS’s information
systems, surveillance data collected in previous years could be used as baselines for
comparison against any changes in seasonal trends in activity or patient attributes in
the data collected during Phase 3 (see Fig. 4).
The HERDS school surveillance information system was activated to provide a
tool for schools and LHDs to collect and track absenteeism data in a consistent way
across the state, to facilitate monitoring of potential increases in illness, and to
provide objective data to support local decision making regarding possible
734 I. J. Gotham et al.
123
community mitigation actions, such as school closures. All related data feeds from
these surveillance activities were integrated into the executive dashboard decision
support system, informing the vaccination campaign as well as assisting in
providing a common operational picture of disease extent across the state (see
Figs. 4, 5).
5.1.2 Information systems monitoring and tracking health care facility status,
resource utilization and availability, surge capacity
The MDMP called for a staged approach to monitoring health facility status and
resource utilization or shortfalls across the continuum of acute and long-term care
facilities, based on severity of the disease (Tables 2, 3). The intent was to monitor
status, assess the level of ‘‘stress’’ the facilities were experiencing due to hospital or
ED admissions, and activate IMS intervention processes to allocate physical or
staffing resources if needed to help maintain the ability of facilities to provide
routine care or respond to even greater demands. The HERDS system was used to:
• Track bed availability and utilization, by service category (e.g., adult/pediatric
ICU, medical/surgical, monitored, isolation), in comparison to the total staffed
beds at health care facilities
Fig. 3 Interrelation and Information Flow between Information Systems Supporting the VaccinationCampaign
An informatics framework for public health information systems 735
123
• Track supplies of personal and respiratory protective equipment
• Track critical life support equipment (e.g., ventilators)
• Track pharmacy supplies
• Assess facility stress levels as indicated by activation of surge plans, emergency
operations centers, diversion status, cancellation of elective procedures, etc.
• Assess health care worker shortages
The data feeds from both acute care and long-term care facilities were also
integrated into the executive dashboard (see Fig. 5) to inform the IMS leads and
also the vaccination campaign.
5.1.3 Information systems supporting the vaccination campaign
The complex data and workflow needed to support the VOMS system as well as
other supportive information systems (Fig. 3) were integrated using the SOA and
reusable core services within NY’s framework (Figs. 2, 3). This allowed NY State
to effectively take orders for vaccine from providers, allocate them according to
ACIP priority groupings, place orders with the CDC and track all portions of the
transaction. Using the executive dashboard decision support system (Fig. 5) with
information integrated in real time from the provider registrations and orders from
allocated H1N1 vaccine doses and types from the CDC, NYSDOH was able to
allocate the available doses of vaccine to appropriate providers and target the groups
recommended by ACIP to receive vaccine.
Once allocated, vaccine orders were transmitted electronically to CDC for
distribution to providers either directly from CDC or via state or local health
departments. NYSDOH also automatically tracked each vaccine shipment and
Fig. 4 Hospital patients testing positive for influenza virus, New York State, October 2007–May 2010
736 I. J. Gotham et al.
123
provided information to state and local health officials for distribution planning and
tracking and to providers via the Order History Report for immunization scheduling
and coordination with patients. After vaccine was administered, providers were
required to report the number of administered doses via one of three mechanisms:
H1N1 Vaccine Administered Doses Reporting System, which utilized a dual phone
and web data entry interface, Clinical Data Management System for mass
Fig. 5 Example of NYSDOH Executive Situational Awareness Dashboard and Data Visualizer System
An informatics framework for public health information systems 737
123
vaccination clinics hosted by local health departments, and NYS Immunization
Information System (Tables 2, 3). If providers needed to redistribute vaccine to
others, they could also report through a web interface so the data could be used for
both allocation and tracking purposes. Based on the MDMP, all information from
these systems were integrated into a centralized data layer so they could be analyzed
and visualized for operational decision support and situational awareness via the
executive dashboard and other visualization tools (Fig. 5).
5.1.4 Situational awareness and decision support
The MDMP developed by the Informatics team provided the framework for assuring
the effectiveness of data-driven decisions throughout the Phase 3 response. The
Executive Dashboard and Data Visualizer tool (Tables 2, 3) provided a single,
seamless, and highly visual interactive interface for executive decision makers and
IMS managers to have access to a common operational picture based on
standardized and agreed-upon data elements and visual objects (Fig. 5). The
dashboard provided summary information as well as interactive drill-down into
aggregated and time-series data views from HERDS, laboratory surveillance
systems, syndromic data, hospital resource availability, bed utilization, school
absenteeism, and vaccine ordering and administration for state and local health
officials.
Access to these data informed the vaccine allocation process, providing all
information necessary to formulate, execute, and communicate executive and
operational decisions in vaccine management, allocation, and distribution across
providers, jurisdictions, and DOH programs. Of key importance was that all
decision makers and supporting analysts used a common operational picture and
standard data sets on which to base their decisions and actions. Resulting data-
driven executive policies, vaccine administration and reporting procedures, and
other patient care–related information regarding the vaccination campaign were
flash-transmitted to a cohort of some 5,500 vaccination provider organizations via
the IHANS system (Tables 2, 3). Information about the response and vaccination
campaign was regularly made available to the HCS health information exchange
community via the event-specific website (Tables 2, 3). Information on the website
included daily vaccine campaign status reports of doses ordered, allocated, shipped,
and administered for all local health departments.
6 Value of an informatics framework and information systems in supportingemergency preparedness and response
We have discussed the role of a model Informatics Framework and the information
systems it encompasses in providing value throughout the cycle of Public Health
Emergencies: Preparedness, Response and Recovery (Figs. 1, 2). The final stage,
recovery, is considered in Sect. 4. In this section we review some of the beneficial
outcomes of this Framework.
738 I. J. Gotham et al.
123
6.1 Preparedness benefit: well established and routinely used informatics
framework
NY State’s existing informatics framework conveyed the following advantages in
responding to the novel influenza event:
• The dual use nature of the HCS and its information systems entrained and
cultured a community of electronic heath information exchange partners that
cross-cut health organizations across the state. Thus all needed response partners
were already using the HCS systems and their role and contact information was
captured in the communications directory at the time of the event (Tables 1, 2, 3).
• Lessons learned from a history of responding to health events such as West Nile
Virus, 9/11, natural disasters, and health care resource shortages allowed
systems to evolve to support routine and emergency use (e.g. Gotham et al.
2001, 2007, 2008). Thus NY State had the information systems in place to
respond immediately to the health event.
• existing information systems not only allowed for rapid response to the event but
also provided a history of baseline data for monitoring changes in trends during
the event.
• Ongoing exercises and drills that use and test the informatics framework and its
information systems resulted in both user and information system preparedness
to respond to the health event (see Gotham et al. 2010).
• A governance process and an existing and experienced team of experts in
informatics, health domain subjects, project management and information
technology enabled NY State to rapidly develop and modify information
systems and MDMP to meet the information and planning needs of the longer
term response to the health event. The existence of the HCS information
exchange community provided a source of health organizations able to
contribute to the MDMP as well as provide input into the development of
new information systems based on their knowledge and use of the existing HCS
systems.
6.2 Response benefit: health alerting and notification: rapid communication
of critical event-related information across response partners
The Integrated Health Alerting and Notification System provides general and
targeted health alerting and notification, using multiple communications modalities:
automated phone, cell, e-mail notifications with acknowledgements (Tables 2, 3;
Fig. 2) (see Le et al. 2010). Routine health alerting drills are conducted with local
health departments and health facilities assure proficiency in its use (see Gotham
et al. 2007, 2010; Le et al. 2010). The IHANS serves multiple purposes during an
emergency response: (1) notifying targeted organizations as to new health alert
postings or materials posted on the event website within the HCS (see below); (2)
direct distribution of documents and information to targeted HCS organizations; (3)
notifying targeted organizations of surveys activated within the HERDS systems. In
the initial weeks of the novel influenza response (April 24–June 1, 2009) the IHANS
An informatics framework for public health information systems 739
123
was used to transmit 309 separate event-related notifications to an aggregate total of
396,014 users. The targeted organizations included LHDs, hospitals, nursing homes,
adult and home care organizations. Table 4 presents representative examples of
average time to alert pickup by key HCS organizations during the initial phases of
the PHEP response.
6.3 Response and recovery benefit: decision support, situational awareness:
informing decision-makers, response partners and the health information
exchange community in general
Situational awareness for the HCS community was provided via two mechanisms:
(1) health alert postings within the HCS Health Alert Network (HAN) Viewer
system; and (2) an event-specific website within the HCS portal itself. IHANS is
used to notify targeted HCS groups that new postings are available. As described
earlier and indicated in Table 1, the HCS portal is a diverse information exchange
platform. The NYSDOH response protocol for a health event is to establish an
event-specific website within the HCS portal system (Tables 2, 3; Gotham et al.
2010). This site is the focal point for access to all event-related postings,
applications, information, and data. This includes links to the HCS Health Alert
Viewer as well as to collections of electronic documents. The documents posted in
the HAN Viewer and the website included case definitions, infection control
protocols, clinical and treatment guidance, specimen handling and biosafety
procedures, laboratory testing protocols; school closing and surveillance recom-
mendations; guidance for EMS workers and facility-specific guidance for long-term
care, educational, child care, and correctional facilities and summer camps.
Between April 24 and June 1, 2009, some 482,681 event-related documents were
downloaded by 32,185 distinct HCS users from the Alert Viewer and event website.
Table 5 presents the document access distribution among key organizations from
April 24 through December 31, 2009. Over this period of time, over 45,000 users
downloaded approximately 1.3 million documents from HCS. On average, 70 % of
these users were repeat users, defined as having downloaded materials on 3 or more
separate days. LHDs were the highest user group in terms of both volume of
documents downloaded and percent of repeat users. Medical practitioners as a group
constituted the greatest number of users accessing event-related materials.
6.4 Preparedness, response and recovery benefit: flexible and dynamic
surveillance, visualization and reporting systems deployed and in routine
use across the organizations within the health information exchange
community: immediate responsiveness to information needs for any event
or routine health program initiative
The HERDS system is completely dynamic and does not require programing to
develop and deploy information gathering and reporting applications (see Gotham
et al. 2007). This information system was used throughout the response to support a
wide array of ongoing and customized information and data collection needs
dictated by the event and the phase of the response to the event. It supported event-
740 I. J. Gotham et al.
123
related data reporting required for epidemiologic surveillance, reporting of resource
and bed availability, assessment of facility stress level due to patient influx, and
oversight of vaccination rates in the healthcare setting (Tables 2, 3). The system was
used for data exchange by facilities ranging from acute care hospitals to long-term
care facilities and schools, and it simultaneously supported customized surveillance
needs of the NYCDOHMH. As HERDS has been in use since 2003–2004 for
periodic reporting of bed availability, critical assets, and seasonal influenza testing
by hospitals, the NYSDOH had historical trend data to provide baseline information
for comparison against the evolving seasonal and H1N1 influenza patterns. For
example, hospital reporting of patient admissions with laboratory-confirmed
influenza (any type) showed a dramatic shift in pattern during the spring and fall
of 2009 over previous years (Fig. 4). The integrated information architecture of the
HCS system (Figs. 1, 2) assures that the diverse data streams flow into a central data
repository and are available for visualization and provision of a common operational
picture via a single dashboard system (Fig. 5; see also Gotham et al. 2010). Table 6
presents the composite access transactions against HERDS instances for hospitals,
nursing homes, and schools from April 24 through December 31, 2009. Over this
period of time, there were over 6.6 million access transactions (submitting data or
retrieving reports) by over 14,000 users. On average, across all organizations 43 %
of these users were repeat users, accessing the system on 3 or more days.
6.5 Preparedness and response benefit: existing informatics framework assures
rapid, effective response to new information systems needs: case study-
vaccine ordering and administration system
The Vaccine Ordering and Management System (VOMS) was required to manage
the ordering and distribution of vaccine, short in supply, and to assure that the
majority of organizations providing vaccinations to the federally designated priority
groups met certain requirements. The information system required linkage of a
complex information and process workflow (Fig. 3). Physicians were required to
register to order the H1N1 vaccine, to report the number of patients they serve in the
priority population groups, and to attest their agreement (electronically) to a
federally required vaccine receipt agreement. It was critical that the majority be
registered and able to place orders in advance of the availability of vaccine (October
19, 2009) to allow NYSDOH executive decision makers the ability to execute the
allocations according to provider attributes (e.g. priority populations served) and
other critical information available from the common operational picture presented
in the dashboard system (Figs. 2, 4, 5).
A shortage of vaccine and delays in production at the onset of the campaign
created unanticipated demand and increased pressure to distribute limited supplies
of vaccines. These events had a significant impact on planning assumptions. Rapid
and frequent changes in business rules were required during the development of the
Vaccine Ordering and Management System (VOMS). Nevertheless, given the rapid
development environment within NYS informatics framework, combined with the
adoption of agile methodology, the process—requirement gathering, business rule
definition, and technical development of VOMS—was completed in only 1 month.
An informatics framework for public health information systems 741
123
Table
4Exam
ple
healthalertresponse
ratesfornovel
influenza
(H1N1)events
Exam
ple
one
Exam
ple
two
Exam
ple
three
Exam
ple
four
Exam
ple
five
Exam
ple
six
Target
organization
LHDs
Hospitals
LHDs
NursingHomes
LHDs
HomeHealth
Agencies
Date/time
initiated
April28,2009
10:10a.m.
May
1,2009
15:32p.m
.
May
2,2009
15:10p.m
.
May
1,2009
8:21a.m.
April26,2009
18:59p.m
.
April30,2009
20:28p.m
.
Purpose:
Initiate
LHD/NYSDOH
epidem
iolog-icalbriefings
ActivateHERDSSurvey
Baseline
PPEandSupplies
AlertLHDsto
SNSasset
distribution
Guidance:
Patientand
Staff
Carein
LongTerm
CareSetting
for‘‘Swine
Influenza’’
Initial‘‘Swine
Flu’’briefing
withLHD
Officialsand
hospitals
NYSDOH
Swine
Influenza
A
(H1N1)
inform
ationand
Q/A
sessions
forLTC
providers
Urgency
level:
Alert;highesturgency
Alert;highesturgency
Alert;highest
urgency
Advisory
HighAdvisory
Advisory
Contact
Mode:
Phone,
Phone,
Phone,
Phone;
Confirm
ation
rate:
100%;LHDs(59);
NYCDOHMH;NYSDOH
regions(6);
96%;NYShospitals(256/267)
100%;LHDs
(59);
NYCDOHMH;
NYSDOH
regions(6)
92%
Nursing
Homes
(597/
652)
100%
LHDs
(59);
NYCDOHMH;
NYSDOH
regions(6);
91%
hospitals
(200/219)
81%
Home
Health
Agencies
(230/
283)
Confirm
ation
stats:
Mean;min;
max;mode
10;4;50;6(m
inutes)
62;13;291;19(m
inutes)
9;4;25;4
(minutes)
70;10;589;13
(minutes)
247;10;1048;
166(m
inutes)
604;15;1000;
N/A
(minutes)
742 I. J. Gotham et al.
123
Tab
le4continued Exam
ple
one
Exam
ple
two
Exam
ple
three
Exam
ple
four
Exam
ple
five
Exam
ple
six
Rolesalerted:
LHD:Commissioner/PH
Dir;
PHEPEpidem
iologyContact;
PHEPPrimaryContact;
Communicable
Disease
InvestigationStaff;LeadEpi;
Dir.Disease
Control;Dir
PatientServices;
NYSDOH
Region:Im
munization
Coord;LeadEpi;Regional
Epi;
Dir.,Disease
Control
Hospital:ChiefExecutive
Officer;Bioterrorism
Coordinator;Designated
Pharmacist;Emergency
Response
Coord;HERDSData
Manager;HERDSData
Reporter;HERDSSurvey
Reporter
LHD:
Commissioner/
PH
Dir;SNS,
Coord;On-
Duty
PH
Officer;
NYSDOH
Region:Dir,
Regional
Office
NursingHome
Administrator;
Director,
Nursing;
Emergency
Response
Coordinator;
HPN
Coord;
NursingHome
DataReporter;
PlantManager
LHD:
Commissioner/
PublicHealth
(PH)Director
(Dir);
Incident
Command-
LHD;Public
Inform
ation
Officer
NYSDOH:PHEP
Education/
TrainingCoord;
PHEPCoord;
State
HAN
Coord
HHA:
Administrator;
Emergency
Preparedness
Coord;HPN
Coord
LHD
LocalHealthDepartm
ent,NYSDOH
New
York
State
Departm
entofHealth,NYCDOHMH
New
York
CityDepartm
entofHealthandMentalHygiene,
HERDS
HealthEmergency
Response
DataSystem
,PPEPersonalProtectiveEquipment,SNSStrategicNationalStockpile,NYSNew
York
State,PHPublicHealth,Dir.Director,
PHEPPublicHealthEmergency
Preparedness,EpiEpidem
iologist,Coord
Coordinator,HANHealthAlertNetwork,HPNHealthProvider
Network,HHAHomeHealth
Agency
An informatics framework for public health information systems 743
123
The process of registration and order placing for vaccine was expedited by the fact
that 95 % of the vaccination provider organizations were existing members of the
HCS system and had used it for other applications. Owing to the existing HCS
infrastructure, its experienced user community, and the agility of VOMS, approx-
imately 80 % of vaccine providers were registered in VOMS and placing orders by
October 20, when H1N1 vaccine was available at the federal level for distribution. As
shown in Fig. 6, a total of 5,509 provider organizations registered over the course of
the event. Eighty percent of the providers had registered prior to the deadline and had
placed orders with the state for some 750,000 doses. By the end of the year the
providers had placed orders for nearly 13 million doses of vaccine (Fig. 6).
7 Conclusions and lessons learned
The presence of an established integrated informatics framework for health
information exchange and PHEP in NY State conveyed significant advantages in
Table 5 H1N1 Influenza-related Documents Downloaded from Event Website and Integrated Health
Alerting and Notification System (IHANS) by NYSDOH Health Commerce System (HCS) Organizations
(April 24 through December 31, 2009)
Organization
type
Organizations
downloading
Documents downloaded
(total = 1,321,580)
Users downloading documents
(total = 45,172 repeat
users = 31,797)
Percent registered
with HCS
Percent total downloads Percent total
downloading
Percent
repeat users
Laboratories 73 2.7 5.9 72
Clinics 41 2.3 2.6 75
Adult care 82 14.9 9.5 85
Hospitals 100 14.0 12.0 80
LHDs 100 20.2 6.7 87
Medical
professionals
42 16.9 36.0 55
NYSDOH
central
100 5 3.0 81
NYSDOH
regional
100 3.4 2.1 80
Nursing
homes
98 13.8 9.2 85
School
districts
75 4.5 8.8 68
Pharmacies 50 1.5 2.8 81
Other na 0.9 0.4 69
Documents include guidance, alerts, updates, advisories, infection control protocols and other com-
muniques related to the event. Percent repeat users: percent of users who accessed documents on 3 or
more separate days
LHD Local Health Departments including NY City Department of Health and Mental Hygiene, NYSDOH
NY State Department of Health
744 I. J. Gotham et al.
123
preparedness and response to H1N1. The final stage of managing an emergency
event is Recovery, which includes ‘‘evaluation of the incident to identify lessons
learned’’. The data collected and reported through the HCS has made this analysis
possible.
The key preparedness objectives achieved during the emergency event include:
(1) rapid alerting, communication and distribution of guidance and other materials
to a broad community of response partners; (2) rapid and flexible deployment of
customized surveillance and resource assessment activities across a wide array of
organization types; (3) establishment and maintenance of situational awareness
across response partners; (4) integration of data from various sources to support
executive decision makers; (5) support of the PHEP planning and implementation
process for response; (6) support for a statewide public health intervention, the 2009
H1N1 vaccination campaign.
Lessons learned from the event response include:
• Existing informatics infrastructure is essential to preparedness for emergency
events. NY State’s PHEP readiness to leverage its informatics infrastructure to
respond to the emergence of this novel influenza virus was enhanced by (1)
incorporating its use as part of the agency’s pandemic flu plan and (2) having
used it as an integral component of exercises and drills. During the full-scale
novel influenza exercise of Spring 2006 (Gotham et al. 2010), NY State used its
information infrastructure to meet most of the information and alerting needs
that ultimately were required in the real-life event 3 years later. Lessons learned
from the exercise were used to enhance capacities and procedures needed to
improve the effectiveness of the infrastructure.
• Adopt a model informatics framework that is based on dual use and value chain
synergies accrued from an information exchange community as its focus. PHEP
readiness is optimized when supportive information systems are embedded
within an established, dual-use, informatics framework, such as the NYSDOH
HCS system, which supports a broad-based community of health information
trading partners engaged in routine information exchange, as the information
trading partners become response partners in PHEP events. For example, 95 %
of the vaccine provider organizations that served the ACIP-defined priority
populations and that needed to access VOMS to register for and order H1N1
vaccine were existing HCS users, familiar with the system and with prior
experience accessing event-related information on the HCS.
• Consider ways in which current information systems may be adapted to
emergency needs. The dual-use concept also extends to application systems
within such a framework. Systems, such as HERDS (Gotham et al. 2007), that
support rapid, integrated, and flexible deployment of ongoing surveillance or
surveys across the universe of health care facilities and other partners are ideally
suited to respond to emergent PHEP events. Deploying dynamic, multiuse
systems (i.e., HERDS)—as opposed to single-purpose, monolithic systems—for
reporting of routine public health ‘‘survey’’ data allows those multiuse systems
to incorporate PHEP reporting rapidly, when needed, because the reporting
organizations are already familiar with the user interface and operational needs
An informatics framework for public health information systems 745
123
Table 6 HERDS Usage by NYSDOH Health Commerce System (HCS) Organizations Across All
Facility Instances for Hospital, Nursing Homes and Schools (April 24 through December 31, 2009)
Organization type Access transaction hits
(total = 6,655,304)
Users accessing HERDS (total = 14,110
repeat users = 6,067)
Percent total transactions Percent total
accessing
Percent repeat
users
Hospitals 9.5 17.9 48
LHDs 3.8 6.4 40
Medical
professionals
2.3 7.8 15
NYSDOH central 2.4 3.2 31
NYSDOH regional 2.0 2.9 40
Nursing homes 41.0 33.6 60
School districts 39.0 28.2 55
NYSDOH and LHDs access HERDS solely to gain access to data reported by reporting entities (Hos-
pitals, Nursing Homes, Schools). Reporting entities access HERDS for both data reporting and access to
data. Percent repeat users: percent of users who accessed documents on 3 or more separate days
LHD Local Health Departments including NY City Department of Health and Mental Hygiene, NYSDOH
NY State Department of Health, HERDS Health Emergency Response Data System
Fig. 6 H1N1 vaccine providers registered and orders submitted, vaccine order management system,New York State, 9/25–12/31, 2009
746 I. J. Gotham et al.
123
of the system. Thus NY State was able to deploy specialized reporting across a
wide variety of PHEP response partner organizations at short notice.
• Reach across institutional and organizational boundaries. Ubiquitous deploy-
ment of dual-use applications is also critical. In PHEP events in the past
(Gotham et al. 2008), NY State had not yet completed deployment of these
systems across the universe of HCS organizations, resulting in data management
barriers. The lessons learned from past PHEP events energized NY’s efforts to
deploy HERDS across key HCS organizations, providing the platform that
allowed NY rapidly to implement surveillance and resource assessment across
all needed PHEP partners. Dynamic, multiuse data reporting systems are ideal
for rapid extension of influenza surveillance beyond the traditional healthcare
settings; an example is NYSDOH’s use of HERDS for school absentee
surveillance.
• People and processes are critical assets for rapid and effective information
systems; develop an enterprise culture that invests in, nurtures and sustains this
infrastructure. Subject matter experts that can work as part of an organized team
and cross-cut the agile informatics environment as depicted in Fig. 1 are critical
assets to the enterprise and an essential component of our model informatics
framework. As shown in the Phase 2 response period of H1N1, the governance
process and the informatics team infrastructure of subject matter experts (Fig. 1)
were informed of, and acted on, the value-based information systems needs of
the enterprise and assured that the emergent needs of the response were met in a
timely and effective manner.
• Be ready to expand the existing information systems on short notice. The success
of the H1N1 vaccination campaign can be attributed to the flexibility of the
informatics framework implemented at NY State (Figs. 1, 2). Dynamic
applications such as HERDS allow real-time development and deployment of
information reporting applications for emergent health program needs as well as
emergency events (see Gotham et al. 2001). Architecting core reusable services
and data layers (Figs. 1, 2) facilitates rapid implementation of new information
systems that are easily integrated into process and data flows or other
information systems and use the same authoritative source of data.
• Invest the effort in Master Data Management Plans and data-sharing
agreements BEFORE the emergency event. Finally, and most important, is the
Master Data Management Plan (MDMP), including at its core well-defined and
accepted data sharing and access agreements. NY has been involved in many
first-time PHEP events: emergence of West Nile, the 9/11 attacks, the Northeast
power outage, and others. Repeatedly and predictably, absent an MDMP, the
initial ‘‘heat’’ of the emergency drives executive leadership to sequester
information vitally needed to promote situational awareness. There are many
facets to an MDMP, but one key component defines, in advance and in
collaboration with ALL partners in the information exchange community, the
agreed-upon information to be provided to persons in appropriate roles, at the
appropriate time, at the appropriate levels of data quality required for an
effective response. The least optimal time for discussing, negotiating, and
implementing these agreements is just after an emergency has occurred. An
An informatics framework for public health information systems 747
123
operational MDMP is essential for launching an effective response to public
health emergencies. The MDMP is part and parcel of the enterprise governance
process which assures that the enterprise (the health information exchange
community) prioritizes information system needs and investments based on
value or benefit to be received from that investment.
Acknowledgments We are indebted to Robert L. Burhans, Former Director of Health Preparedness,
and Dr. Dale Morse, MD, Former Director Office of Science, at NYSDOH for their leadership and
support. We also acknowledge the New York State Association of County Health Officials and the
hospitals and local health departments of NY State for their contributions to the successful response of
New York State to public health events. This publication was supported by Cooperative Agreement
Numbers U50/CCU223671 and U90/CCU216988 from the U.S. Centers for Disease Control and
Prevention (CDC) and by Cooperative Agreement Number 6U3RHS05934 from the U.S. Health
Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors
and do not necessarily represent the official views of CDC or HRSA.
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