For COVID-19 resources for health IT developers and other stakeholders, click here.

By Kedar Ganta, Co-Chair, EHRA Standards & Interoperability Workgroup

For centuries, public health has been a story of the quest to find effective means of preventing diseases, containing outbreaks and analyzing health trends in the population. 

The “old” public health ecosystem focused on the environment, while the “new” public health focus is on the individual within a given population. Shifting the focus from finding sources of epidemic and endemic infectious diseases in our surroundings to finding them in the individual necessitated an evolution from trial and error to scientific inquiry that revolves around defining diseases, measuring their frequency and seeking effective interventions.

During the 20th century, science and technology reshaped our shared understanding of diseases and helped restructure public health and medicine. This “new” era will be guided by the rapidly growing availability of health data to detect, observe and understand health patterns at a population level using advanced computing and analytics.

Electronic health records (EHRs) continue to play an important role in influencing and improving population health outcomes by efficiently collecting standardized individual data that can be shared among different healthcare organizations and public health agencies.

The Progress

Traditionally, healthcare providers reported certain conditions and individual data using paper or special point-to-point connections to certain registries or health systems. Individual public health data such as immunizations, birth defects, cancer, syndromic surveillance, diabetes, etc. is sourced at the local and state levels from healthcare providers for disease surveillance. 

In the last several years, public health reporting has evolved alongside the increase in EHR technology adoption and meaningful use participation, allowing healthcare providers to earn benefits from the Centers for Medicare and Medicaid services (CMS) and states by electronically submitting public health data. The EHR incentive programs were developed to facilitate the growth of public health infrastructure to enable health IT to send reportable data from EHRs.

As of 2017, nearly nine out of 10 office-based physicians had
adopted EHRs and were able to electronically submit
immunization information, syndromic surveillance reports
and electronic lab results to public health agencies.

As of 2017, nearly nine out of 10 office-based physicians had adopted EHRs^[4] and were able to electronically submit immunization information, syndromic surveillance reports and electronic lab results (ELR) to public health agencies. Today, more than 90% of hospitals are sending Immunization reports, 88% are submitting electronically reportable lab results, and 76% are providing syndromic surveillance data to public health agencies as part of the Medicare and Medicaid incentive program^[6].

The Problem

Certified EHR technology is adhering to nationally recognized standards and associated implementation guidelines to perform public health reporting. To that end, the health data community has made tremendous progress in developing systems that reduce variability and improve the quality of data collected.

The Office of the National Coordinator for Health Information Technology (ONC) established technical requirements for EHRs that enable additional reporting, including:

1. Transmission to immunization registries for safe and effective provision of child healthcare 
2. Transmission to public health agencies for reportable lab tests and values / results, syndromic surveillance, electronic case reporting (eCR), antimicrobial use and resistance reporting, and healthcare surveys
3. Transmission to cancer registries to reduce morbidity and mortality

Public health systems still need to address challenges such as:

• Variation in local vocabulary codes used across public health repositories
• Variation in the granularity of reportable data and issues with data robustness, timeliness and quality
• Variation in technical infrastructure and specifications across different agencies, including redundant connections to individual public health systems
• Lack of harmonization of messaging and data transportation standards across domains that enable the use of public health data
• Variation in requirements of local, state and federal laws

The Opportunity

There is an opportunity for public health to develop infrastructure and systems that reduce variability, eliminate redundant connections, and effectively achieve full interoperability. Public health infrastructure can evolve to:

• Develop a nationwide network to harmonize data gathering and transport protocols
• Build community tools such as the one created by American Public Health Laboratories (APHL) that allows for receiving immunization, syndromic surveillance, reportable lab results, electronic case reporting, cancer registry, and specialized registry data
• Increase real time bi-directional data exchange between EHRs and registries that allows for complete and up-to-date information
• Enable consensus-based implementation guides (IGs) for electronic transmission of reportable data such as immunization, syndromic surveillance, lab reports, and cancer registry data 
• Improve collaboration between public health agencies and networks, data aggregators and HIEs
• Provide technical and administrative assistance for designing and implementing interoperable systems to reduce local variability that inhibits data exchange

Case in Point: Electronic Case Reporting (eCR) and Electronic Lab Reporting (ELR)

In recent times, the healthcare community has witnessed novel disease mutations, from the 2009 H1N1 Swine Flu to today’s SARS-CoV-2. Given this situation, eCR and ELR have been given top priority in health reporting, with public health agencies collecting information on communicable diseases to aid in comprehensive reporting for detection and rate of recovery. 

ELR and eCR allow automated electronic transmission of
lab results and reportable conditions to public health
agencies, which results in better timeliness, a reduction
in manual data entry errors and more holistic reports. 

ELR and eCR allow automated electronic transmission of lab results and reportable conditions — with supporting information from EHRs and other labs — to public health agencies, which results in better timeliness, a reduction in manual data entry errors and more holistic reports. State regulations require that healthcare providers and labs report certain diseases to their local health office, and meaningful use objectives for public health agencies promote ELR adoption, but these requirements do not fully address agencies’ challenges in receiving the data, nor whether all providers and labs are including all data of interest.  

As additional data is asked for to gain new insights, further stress has been put on the documentation, reporting, and submission process. It is critical that all data requirements are, as much as possible, based on what is already made available. Where additional data is required it should be included via the most efficient and appropriate method. For example, adding further data requirements to ELR rather than eCR increases requirements on data collection, transmission, and reporting that could be more efficiently addressed by eCR. Close collaboration between public health agencies, providers, laboratories and their health IT suppliers is essential to optimize this flow.

Developing an ecosystem of robust ELRs and eCRs can mean better preventive healthcare for familial conditions and those related to social determinants of health; early-detection systems for future outbreaks; and tracking of non-communicable diseases/vitamin-deficiencies detected during routine or specific lab tests. The care workflow includes:

1. EHRs reducing provider burden by transmitting public and population health data to public health officials using data already obtained through existing documentation
2. Public health organizations applying advanced analytics to better monitor, prevent, and manage disease at a population level
3. Alerts and reminders proactively reminding providers when patients need immunizations
4. Decision support enabling providers to send updates to patients for preventive/follow up care

Conclusion

As the evolution of public health continues and as pathogens continue to evolve along with our environment, the public health ecosystem will be better prepared to face the challenges ahead — aided by a clear understanding of the past, and guided by health IT technology and insights.

These electronic reporting efforts will help public health agencies receive data from clinicians through EHRs to measure the prevalence of diseases, investigate and manage outbreaks, conduct continual and timely monitoring, and respond to public health emergencies while eliminating duplicate reporting of the same data to multiple agencies/jurisdictions.

For COVID-19 resources for health IT developers and other stakeholders, click here.

---

References

1. Lurio J, Morrison FP, Pichardo M, Berg R, Buck MD, Wu W, Kitson K, Mostashari F, Calman N. “Using electronic health record alerts to provide public health situational awareness to cliniciansWeb Site Disclaimers.” J Am Med Inform Assoc. 2010
2. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2009.163956
3. https://www.healthit.gov/sites/default/files/2019-08/onc_public_health_surveillance_infographic-11042014.pdf
4. https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php  https://www.healthit.gov/sites/default/files/page/2019-04/AHAEHRUseDataBrief.pdf
5. https://dashboard.healthit.gov/quickstats/pages/FIG-Hospital-Progress-to-Meaningful-Use-by-size-practice-setting-area-type.php
6. https://dashboard.healthit.gov/quickstats/pages/FIG-MU-Hospitals-Public-Health-Measure-Attestations.php
7. https://clinfowiki.org/wiki/index.php/Electronic_Laboratory_Reporting
8. https://www.healthit.gov/playbook/population-public-health/#section-10-3