Public Health Informatics Transformsthe Notifiable Condition System
Jac DaviesGreg Smith
Deb Gustafson
The science of informatics brings Washington public health practiceinto the 21st century.
Reviewing lab data oncommunicable disease,Seattle, c. 1953.
The notifiable condition surveillance system isthe foundation of disease control and preventionin the United States. This system was foundedmore than one hundred years ago, when statesfirst made tuberculosis reportable to public healthauthorities. Today, the practice of surveillance isnot much different than it was in the last century.Health care providers diagnose a patient with adisease of public health interest. The providerscontact local public health officials by telephoneor mail and relay specific information about thepatient and the case. Local health officials follow-up, contacting other individuals who may be atrisk and taking actions to protect the generalpublic. Local health agencies transmit relevantinformation about the case to the state healthagency, which aggregates all information from thelocal level and identifies inter-jurisdictionaltrends. Finally, state agencies send aggregatedinformation to the Centers for Disease Controland Prevention (CDC) to enable identification ofnational patterns and provide input into develop-ment of national disease prevention policies.
This system has proven to be generallyeffective, but is by no means perfect. It has grown
more complex, withmore conditionsbeing added tomandatory reportingregulations and morepublic health agenciesrequiring directreporting from bothhealth care providersand laboratories. Atthe same time, theclinical health caresystem, where themajority of diseasereports originate, hasalso gained complex-ity. Managed care haschanged the wayhealth care providers
see patients and diagnose disease. Increasinglyrestrictive payment systems have made it moredifficult for providers to find time to comply withdisease-reporting requirements. Health care hasalso become regionalized, with patients crossingjurisdictional boundaries to receive care.
A closer look at Washington’s notifiablecondition surveillance system illustrates thiscomplexity. Much of the information received bylocal health agencies comes from clinical laborato-ries. In Washington, a clinical laboratory mustunderstand the notifiable condition regulationsand know the appropriate state or local healthprogram for submitting a report. Laboratories maysend a disease report to the most convenient healthdepartment, such as the one for the county wherethe laboratory is located. Consequently, largecounty health departments often must sortincoming disease reports and forward them to theappropriate county. Reports can fall through thecracks or be significantly delayed in reaching theirdestination.
Once a local health agency or state programhas received a report, it must be entered into thatagency’s information system. If the report needs tobe forwarded to another program or agency, it mayneed to be reformatted to meet the requirementsof the new information system. Since differentprograms and agencies have different informationsystems, aggregating or comparing data acrossprograms or agencies takes time and effort.
Technology’s Role in NotifiableCondition Surveillance
Information technology offers hope for makingexisting systems function more effectively. Ideally,laboratories or physicians would automaticallygenerate disease reports directly from theirinformation system and send them securely andelectronically to the appropriate destination. Therecipient organization would incorporate theinformation directly into its information system.The information would be easily transmissible toother public health programs, including programs
Principles of Public Health InformaticsFour principles, flowing directly from the scope and nature of publichealth, distinguish it from other specialty areas.1. The primary focus of public health informatics should be applications of
information science and technology that promote the health of populationsas opposed to the health of specific individuals.
2. The primary focus of public health informatics should be applications ofinformation science and technology that prevent disease and injury byaltering the conditions or the environment that put populations of indi-viduals at risk.
3. Public health informatics should explore the potential for prevention at allvulnerable points in the causal chains leading to disease, injury, or disabil-ity; applications should not be restricted to particular social, behavioral, orenvironmental contexts.
4. As a discipline, public health informatics should reflect the governmentalcontext in which public health is practiced.
The nature of public health defines a special set of informatics challenges.For example, to assess a population’s health and risk status, data must beobtained from multiple sources, such as hospitals, social service agencies,police, departments of labor and industry, population surveys, and on-siteinspections. Data about particular individuals from these various sources mustbe accurately combined, and then individual-level data must be compiled intousable, aggregate forms at the population level. This information must bepresented in clear and compelling ways to legislators and other policy makers,scientists, advocacy groups, and the general public, while ensuring that theconfidentiality of the health information of specific individuals is not compro-mised.
From: Yasnoff WA, O’Carroll PW, Koo D, et al: Public health informatics: Improving andtransforming public health in the information age. J Pub Health Management Practice,in press.
outside categorical boundaries, and could beaggregated at the local, state, or national level. Butpublic health officials are faced with a difficultquestion. How can mutually compatible informa-tion technology be implemented across acomplex, interdependent yet functionallyautonomous heath care and public health system?
The answer lies in informatics, the scientificfield that deals with the storage, retrieval, sharing,and use of data, information, and knowledge.Over the last decade, informatics specialists havebegun shaping a unified framework for informa-tion technology through the development andadvocacy of standards.
Although standards offer the potential fororganizations to use common approaches toinformation technology, the complexity andproliferation of standards makes their applicationdifficult. As many informatics specialists say,“Standards are wonderful because there are somany to choose from.” Fortunately, public healthinformatics specialists are focusing on theapplication of informatics to the particular needsof public health (see sidebar on this page.)
Washington’s InformaticsApproach
For more than five years, Washington hasbeen developing an integrated notifiable condi-tion surveillance system, following the principlesof informatics. The effort began at the state levelwith a push at the state Department of Health(DOH) to map out all of the agency’s keybusiness functions and identify the informationflow associated with them. We recognized thatinformation systems in our agency should supportcommon business practices, such as diseasesurveillance or case management, using commoninformation technology design and data stan-dards. In this way, we could develop systems foruse by multiple agency programs. Further, werealized that these common business practices arenot unique to the state health agency. Local healthagencies have many similar processes andoperational needs. We concluded that we mustconsider the entire notifiable condition surveil-lance framework—the health care industry andlocal, state, and federal health agencies—as asystem, with a system-wide approach to planning.Consequently local health agencies and the CDChave joined forces with DOH to develop acomprehensive, holistic information technologyapproach to notifiable conditions.
This planning has led to the formation of theWashington Electronic Disease Surveillance
System (WEDSS) project. The WEDSS project ismodular; each of its projects (see table on p. 16and figure on p. 17) addresses a specific compo-nent of the notifiable condition surveillancesystem:
1. Reporting of data from the clinical healthcare system to the appropriate public healthagency and among public health agencies;
2. Management of case information;3. Management of aggregated surveillance
information4. Analysis and dissemination of information
WEDSS also includes a technology infrastruc-ture project to enable all of this informationexchange to take place in a secure electronicenvironment. The WEDSS work is funded in partthrough the CDC’s National Electronic DiseaseSurveillance System program and is consistentwith that national direction, which is beginning toestablish information technology standards forpublic health.
Secure electronic transfer of notifiablecondition data from laboratories, centralizedto simplify process. Automatic, rapid dissemi-nation of data to appropriate local healthagency.
Case management tool for local healthagencies, with standardized processes tosimplify receipt and distribution of electroniccase notifications, create a mechanism forworkload management, and improve qualityof case investigations.
Integrated data repository to replace existingcommunicable disease database andimprove ability to share and compare data.Based on national Public Health ConceptualData Model.
Browser-based interface for conductingstandard statistical analyses, geo-spatialanalyses, mapping, and report generation.
Creates an infrastructure using the backboneof the Washington IntergovernmentalNetwork to allow for secure transmission ofidentifiable disease information between localhealth agencies, DOH, and major partners.
Table 1. WEDSS Projects
WEDSS Component Projects
Web-Based PublicHealth Issue Manage-ment System (PHIMS)
Disease ConditionDatabase (DCD)
Epidemiologic Queryand Mapping System(EpiQMS)
Health Alert Network(HAN)/ Perimeter Secu-rity EnhancementProject
A modular, yet coordinated approach toinformation system planning has many advan-tages. Smaller projects have a better chance ofactually getting completed. Multiple fundingsources can be used, each directed at a singleproject or a combination of projects. If a singleproject fails or is delayed, the rest of the projectsare not jeopardized. Common technologysolutions, such as secure networks or databaseservers, can be identified and implemented tosupport multiple projects. As the long-termvision is refined, individual projects can bemodified to reflect the changed directionwithout adversely affecting the entire system.
A look at one of the WEDSS projects—theElectronic Laboratory Reporting system(ELR)—illustrates the application of publichealth informatics. In the new ELR systemclinical laboratories generate a data file fromtheir laboratory information management systemto send to DOH. The data file is in a health careindustry standard format, called HL7, usingnationally recognized codes for data elementssuch as patient demographics, analytical method,and test result. Because national standards arebeing used, the laboratory does not have toconstruct a data file unique to DOH. The samekinds of files can be sent to other data-trading
partners, such as insurance companies andhospitals. The files are sent via a secure Internetconnection to a single location, DOH. The use ofa common industry platform, the Internet, iscritical to this system’s success. Laboratories willnot have to develop custom connections fordifferent public health agencies, and so are morelikely to participate.
DOH is establishing a mechanism to auto-matically receive reports from laboratories,determine which local health agency or DOHprogram each report should go to, and forwardthe report appropriately. In an interim process, themechanism will also translate the file from HL7into the format appropriate for the end-recipient’sdatabase. As other WEDSS projects progress, sothat databases and software in public healthagencies around the state are using the samestandards, there will be less need forcustomization. Local health agencies participatingin a pilot of this system are receiving laboratoryreports more quickly than under the traditionalreporting system. Also, the reports are morecomplete, both in data content (more informationin each report) and quantity (more reports arebeing received).
What changes have to be made in publichealth agencies to implement a system such aselectronic laboratory reporting? Health depart-ments must be willing to adopt the national dataand information technology standards in use orbeing considered by the health care industry.National movement toward standardization hasbeen accelerated by regulations adopted under the1996 Health Insurance Portability and Account-ability Act (HIPAA) that require health careorganizations to use standards for any electronicdata transaction.
Another necessary change is in the area ofsecurity. Notifiable condition reporting requirestransmission of identifiable health information,sometimes of a very sensitive nature. We have tobe absolutely sure that any mechanism we use issecure. For this reason, we are implementingelectronic laboratory reporting in tandem with asecurity infrastructure enhancement project. Thesecurity project is using a variety of technologiesto enable safe transmission of information via theInternet. These include firewalls (electronicbarriers that prevent unauthorized access to anetwork) at each participating organization,authentication of users through the use of digitalcertificates, “tunneling” software to protect theinformation during transmission, and high-levelencryption. This work is being done as part of thestate’s implementation of the Health AlertNetwork, a component of the CDC’s bioterrorismpreparedness initiative.
Recommended ReadingYasnoff WA, O’Carroll PW, Koo D,et al: Public health informatics:Improving and transforming publichealth in the information age. J PubHealth Management Practice, in press.
HL7 information:www.hl7.org/
HIPAA information:aspe.os.dhhs.gov/admnsimp/
Health Alert Network information:www.phppo.cdc.gov/han/
NEDSS Information:www.cdc.gov/od/hissb/docs.htm
Fig. 1. Ideal data flow in thepublic health reporting sytem.
AuthorsJac Davies, M.S., M.P.H., isassistant secretary for Epidemiol-ogy, Health Statistics, and PublicHealth Laboratories in theWashington Department ofHealth.
Greg Smith is the WEDSSdevelopment director in theWashington Department ofHealth.
Deb Gustafson is the WEDSStechnical director in the Washing-ton Department of Health.
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A third significant change is in the area ofinformation flow. For the majority of notifiableconditions in Washington, the local health agencybears responsibility for collecting reports,conducting follow-up, and performing interven-tions. Historically the notifiable conditionregulations (WAC 246-101) have reflected thisresponsibility and required laboratories andclinicians to submit reports directly to theappropriate local health agency. In the interest ofefficiency, electronic laboratory reporting ischanging this information flow. Reports fromlaboratories will go to the state health agency, thenbe routed immediately to the appropriate localhealth agency. Local health agencies are willing toaccept this change in information flow, provided itdoes not affect their ability to receive reports in atimely manner. As part of the pilot testing of thenew ELR system, we are developing evaluationmethods for each laboratory that submits reports,so that local health agencies have an opportunityto verify that the new system is working as well asor better than the traditional reporting system.This process is needed not only to test theefficiency of the system but also to build trust inthe new information flow and in the technology.
Lessons LearnedOver the course of the last five years, we have
learned a number of lessons that may be helpful toother agencies looking to implement integratedinformation systems.
Cultural change is as important as techno-logical change. Although public health practitio-ners often focus on technology when implement-ing integrated information systems, the culturalchange that must come about in an organization isfar more difficult to accomplish. Organization orsystem-wide planning requires people to adoptnew behaviors—collaborating with others outsidetheir immediate program area, changing internalbusiness processes to align with external practices,and giving up short-term internal gains for long-term system-wide benefit. Change agents need tobe sensitive to these issues and be prepared toaddress them.
Communication is critical. Communicationwith all participants should begin early andcontinue throughout the planning and implemen-tation process. Individuals and groups who willnot immediately be affected but are likely to beinvolved in the future should also be included inthe communication loop. This can help reduceanxiety over potential changes and ensure thatspecific program needs are met.
Privacy and confidentiality issues must behandled aggressively, through strong security
practices. Electronic exchange of information andintegrated information systems raise the public’sand health officials’ concern over loss of privacyand confidentiality. To build and maintain trust inthe integration efforts, planners must activelypursue strong security measures and must testthose measures to ensure they are effective.
Training is essential. Not only do staff inpublic health agencies need training in how to usenew technology, background training in informat-ics is essential. This provides staff with a basicunderstanding of why integration is necessary andhow it works. That understanding helps promotethe necessary cultural change.
The scope of change envisioned for thenotifiable condition surveillance system can beintimidating, but there will never be a better timeto begin than now. In the public health systemand across the health care industry, the nationaldirection is toward standardization and organizedsystem planning. Funding opportunities areavailable now that may not be available in thefuture. Increasingly limited resources are forcingpublic agencies to be more thoughtful in how theyimplement information technology solutions.Public health officials understand the need tomake more effective use of surveillance informa-tion. With a comprehensive planning approachthat is well-grounded in public health informatics,we anticipate a transformation of the notifiablecondition surveillance system over the next fiveyears that will significantly improve Washington’sability to detect and prevent disease.
