Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
APPENDIX C DATA AND INFORMATION SUBCOMMITTEE REPORT
Data and information are essential aspects of the public health infrastructure. The Data and Information Subcommittee defined data and information as "… knowledge about health status, health resources and threats to health, specific to the jurisdiction or community of interest, e.g. health statistics and reportable diseases, environmental monitoring, health services statistics, community resources inventories."52 They also agreed on the following Healthy People 2010 principles:
"Public health data must be accessible, accurate, timely and clearly stated; information systems must be linked with other data systems, and must be linked with and integrated at the Federal, State and Local levels."53
- Andrew Doniger, M.D., Chair, Commissioner of Health, Monroe County Department of Health
- Steven Jennings, Health Planner, Jefferson County Department of Health, and member of the New York State Public Health Council
- Edward Reinfurt, Vice President, New York State Business Council
- Michael Medvesky, MPH, Director Public Health Information Group, NYSDOH
The goal of the subcommittee was to assess the capability of data and information systems utilized to meet the public health core functions of assurance, assessment and policy development. Further, the committee sought to identify gaps and to recommend opportunities to strengthen the system. They were guided by a primary vision: Each state and local health department and partner organization will be able to electronically access, analyze and distribute up-to-date public health information and emergency health alerts, monitor the health of communities, and assist in the detection of public health problems.
The Data and Information Subcommittee reviewed existing materials relevant to data availability, access, and the information system infrastructure. They also convened a Focus Group of local health department leaders to learn their views first hand on how to improve the data and information infrastructure. Certain published reports were reviewed including:
- The CDC National Public Health System Performance Standards Program/New York, Versions 5b and 5c referencing data submitted May-November 2001;
- The Department of Justice/CDC Public Health Performance Assessment of Emergency Preparedness State-wide Preliminary Results from December 14, 2001;
- The New York State Department of Health (NYSDOH) and New York State Association of County Health Officers (NYSACHO) Spring 2002 County Connectivity Survey; and
- Results from a local health department Focus Group session held in February 2003.
Three recent assessments conducted to evaluate performance and conformance with essential public health services, emergency preparedness, access to IT hardware and software as well as overall IT capability had been carried out over the past two years. The Subcommittee was informed by the results of each assessment as presented on the following pages.
1. The CDC National Public Health Performance Standards Program (NPHPSP) Versions 5b and 5c, May-November 2001.
The NPHPSP was established in 1998 to improve the practice of public health, the performance of public health systems, and the infrastructure supporting public health activities. The NPHPSP developed a series of performance standards based on the ten essential public health services as delineated in Public Health in America, 1994. New York State local health departments participated and utilized Local Public Health System Performance Instruments Version 5b (county answers alone; N= 49) and 5c (county answers with community partners; N= 8). The Data and Information Subcommittee reviewed county responses for Essential Services #1 and #2 reviewed below.
Essential Public Health Service #1: Monitor Health Statistics to Identify Community Health Problems
- 1.1 Population-based community health profile;
- 1.2 Access to and utilization of current technology;
- 1.3 Maintenance of population health registries.
As seen in Figure 1 above, counties have generally low scores for EPHS# 1, Monitor Health Status, as compared to the overall state average for all ten essential services of 64. The overall mean score for 5b counties was 48 with a standard deviation (SD) of ±17. For the 5c counties, their mean score was 52 with a SD of ±25. The range of scores for all counties was 0 to 93. Counties scored higher on developing community health profiles (Version 5b: 49±23; Version 5c: 62±29) and maintaining health registries (Version 5b: 69±23; Version 5c: 65±30), but lower on using current technology (Version 5b: 27±22; Version 5c: 29±31).
Essential Public Health Service # 2 - Diagnose and Investigate Health Problems and Health Hazards
- 2.1. Identification and surveillance of health threats; and
- 2.2. Plan for and respond to public health emergencies.
County responses for Essential Public Health Service #2: Diagnose and Investigate Health Problems and Health Hazards are presented above in Figure 2.
The mean scores for identification and surveillance of health threats was 86±15 for Version 5b counties and 72±14 for Version 5c counties. The range of scores for all counties was 34 to 100. Regarding planning for and responding to public health emergencies, Version 5b counties had a mean score of 84 with a SD of ±21, and Version 5c counties with a score of 86 and a SD of ±24. The range was 0 (one county) to 100 (21 counties).
Results from this study present generally lower scores for local health departments for Essential Public Health Service #1: Monitor Health Statistics to Identify Community Health Problems compared to the State average for all essential services. On the other hand, counties felt more confident in meeting Essential Public Health Service #2: Diagnose and Investigate Health Problems and Health Hazards. Compared to EPHS #1, the mean scores were higher for both the identification and surveillance of health threats and the planning for, and responding to, public health emergencies.
The Subcommittee discussed survey limitations with the CDC National Public Health Performance Standards Program. The Version 5b counties "self assessed" their public health performance, and some engaged community members in completing the surveys, i.e. some Version 5b counties followed Version 5c process. Therefore it is difficult to make cross-county comparisons. Some Version 5c counties stated that the survey scores might have changed had different community members been able to participate. This would affect the comparability of the scores among counties.
2. The Department of Justice/CDC Public Health System Performance Assessment of Emergency Preparedness, New York State, December 2001.
A summary report from DOJ/CDC assessing the emergency preparedness of New York State counties as of December 2001 was shared with the Subcommittee. The information collected was modified from the ten essential public health services. The Subcommittee had access only to summary data; neither the actual data collection methodology nor a copy of the survey instrument was available.
Results from the DOJ Survey on Emergency Preparedness regarding questions on the modified Essential Public Health Services # 1 and Essential Public Health Services # 2 are presented in Figure 3 on a separate page.
In summary, local health departments (LHDs) responded favorably to the following questions:
- Emergency coordinators access to computers (mean= 87)
- LHDs receiving health alerts from the State Department of Health (DOH) (mean= 81)
- LHDs having written computer security policies (mean= 63)
- LHDs safeguarding data (mean= 81)
- LHDs having access to epidemiologist (mean= 63)
Conversely, the report identified areas needing immediate attention, as defined by the authors as having scores presenting a mean of <60. These included the following essential service deficits:
- Health outcome monitoring (mean= 46)
- Hazard assessment (mean= 50)
- LHD broadcast alerts to community (mean= 22)
- LHD or school health departments (SHD) transmit disease info to community (mean= 48)
- LHD uses statistical tools (mean= 31)
- Sample epidemiology protocols (biological/chemical/radiological) available (mean= 33)
- Sample epidemiology protocols integrating human and veterinary (mean= 16)
- Develop roster of technical experts (mean= 50)
Rural counties were more limited in their ability to use statistical tools, epidemiology protocols or to access technical expertise although these services are often provided to rural counties by the New York State Department of Health. Interpretation of the data from this study was influenced by the realization that substantial progress had been made in emergency preparedness in the intervening months since December 2001. The February 2003 Focus Group validated this progress with their own experiences and commentary.
3. NYSDOH/New York State Association of County Health Officials Spring 2002 "County Connectivity" Survey.
The Survey revealed that for the reporting LHDs (43 of 57 surveyed) all had e-mail access and all but one had Internet access. However only 18.6% of the reporting counties indicated that they had backup or redundant Internet access, and a small percentage (12%) indicated that they did not have a firewall protecting their local area computer network (LAN) from the Internet. Twenty two percent of the counties commented that their Internet access was either sluggish or unreliable. The vast majority (92%) of counties had no problem with access to the HIN/HAN. This survey was conducted prior to the distribution of resources from the CDC Bioterrorism Grant, and many counties have improved their connectivity using these funds. Recent follow-up information collected by DOH during early 2003 indicates improvement in county connectivity. Backup on redundant Internet access improved from 18.6% to 60% and all but 3 counties now have "dedicated" Internet access. In addition, the follow-up survey indicated 77% (44 of 57) of the counties have cellular devices capable of receiving text alerts and 58% (33 of 57) now have video conferencing capability. The DOH/local health department goal is that by August 31, 2003 all counties will have:
- a) "dedicated" Internet access;
- b) backup or redundant Internet access;
- c) a non-Internet method of connectivity to the HIN/HPN;
- d) cellular devices that can receive text alerts; and
- e) video conferencing units.
4. Local Health Department Focus Group
The Data and Information System Subcommittee convened a Focus Group on February 5, 2003. Its purpose was to solicit views on the strengths and weaknesses of the data and information infrastructure in use to support local public health service delivery. Representatives from 5 counties and one member of the Subcommittee participated in the four hour-long session (2 rural, 1 suburban, 1 urban county); two New York State DOH representatives were present as observers. The Focus Group was facilitator led. One county was unable to attend and provided subsequent, written responses to the questions. The local health department representatives provided qualitative feedback and offered specific examples of gaps in the data and information infrastructure. Each participant made recommendations for system improvement. Their observations were similar to the findings published in the surveys and assessments conducted earlier.
Six questions drove the discussion.
- How do you rate the integrity of your data (accuracy, timeliness, completeness, utility and importance)?
- How would you characterize the quality of information obtained from your systems (speak to access, interpretation and analysis of data)?
- Are your data and information systems fully robust (i.e. firewalls, security protocols, redundancy, user expertise)?
- How do you engage your community health partners in sharing/using data and information systems? Cite examples of success/failure where data/information systems were central to decision/action (e.g. disease outbreaks, emergency health alerts, system networking, etc).
- Is there resource balance with your systems between manpower and machine power such as personnel, training, hardware, software, and linkages?
- Name three initiatives or recommendations to improve data and information system infrastructure at the county and/or state level.
The Focus Group findings underscore some of the same issues that the Subcommittee identified earlier through their review of other published assessments. For example:
- Present networks such as the Health Information Network (HIN), Health Provider Network (HPN), and the Health Alert Network (HAN) are excellent sources of information but are not utilized to their fullest potential. More training on these systems, particularly on the HPN for local hospitals and other medical providers, is needed;
- Bioterrorism (BT) related activities have strengthened the local IT infrastructure. They have also raised the visibility of public health and provided opportunities to improve community partner linkage. The emerging BT process requiring a coordinated approach to data and information activities can serve as a model for system wide improvements;
- Competing priorities for analytic staff remain a constant problem. Most counties "make do" with existing staff. Key expertise is acknowledged to be lacking; suggestions for making expertise available through regional multi-county alliances, such as those alliances currently pilot testing the sharing of epidemiology resources across counties, was suggested. In addition, personnel competency with computer technology can be improved through more training.
- Guidance from State DOH should be made available to define a set of core or common public health program/service indicators for use with local assessment activities; Data are often not timely and key information is not always available at the sub-county level;
- Information technology (IT) and Local Public Health (LHD) relationships vary across the counties. Some LHDs have integrated information technology staff. Others have to rely on a separate county IT department. The degree of support provided by IT varies. When the county has IT strength, the LHD benefits; when the county does not have IT strength, the LHD may suffer;
- There are too many data systems and/or data collection points. There needs to be a standard set of definitions and entry points developed with federal, state and local input. Information system linkages among public health programs as well as between community health partners at the county and state level are not integrated.
Based on county responses to the CDC National Public Health Performance Standards Program survey (e.g. below average scores for the ability to develop community health profiles, the use of current information technology and using information obtained from the local health department), the Focus Group cited the need for technical and epidemiological assistance. They also requested a consolidation of information systems wherever possible. As a result of this feedback and other reviews, the Data and Information Subcommittee developed a set of priority and long-term recommendations.
Comprehensive Data and Information System Plan
1. The NYS DOH and local health departments should develop a Comprehensive New York State Data and Information System Plan. Such a plan would inventory and identify the various systems currently in place, describe their functions, quantify the resulting data and information gaps, and identify a set of system and user needs in order of priority. The objective of this assessment and plan would be to present a comprehensive design and execution strategy for a system architecture capable of meeting today's public health infrastructure requirements for the State of New York. This plan, replete with specifications and standards for performance, would be developed in consultation with federal and local agencies.
2. The federal, state and local governments should standardize public health program indicators so that effectiveness can be measured, benefits communicated, and shifts in policy direction or service delivery appropriately made. 3. The NYS DOH and its academic partners should collaborate to develop methods to teach public health evaluation methodologies and to strengthen the capacity at the State and LHD to undertake such evaluations with consistency.
Long Term Recommendations
1. The NYS DOH should fund a "best practices" pilot in one county to demonstrate an ideal data and information operation. It should specify and demonstrate integrated data collection using common intake, common database, common definitions, common data fields and standardized outcome indicators. Key health partners should have authorized access to the system through a secured user password network. This Pilot should be undertaken in concert with a comprehensive strategic plan referenced above.
2. The NYS DOH should institute periodic and ongoing review of existing data systems and information technology resources (platforms, software, databases, networks and users) at the state and local level to determine gaps and redundancies.
3. The NYS DOH and the federal government, in cooperation with local health departments, should establish standardized public health program outcome indicators.
4. An alliance should be formalized at the state level between organizations such as the NY State Office for Technology, the New York State Association of County Health Officials (NYSACHO) and the State Association of Information Technology Directors.
5. The NYS DOH, in collaboration with appropriate provider organizations, should work towards the integration and linkage of public health information systems across all appropriate public and private partner networks, where appropriate and feasible.
6. The NYS DOH should develop information technology "best practice" standards for individuals and contractors working with new or existing public health information systems.
7. NYS DOH should continue its commitment to improve and provide continuous technical assistance and training on specific Information Technology (IT) networks such as the Health Provider Network (HPN), the Health Information Network (HIN) and the Health Alert Network (HAN). This applies to local health department personnel and their community partners (hospitals) for whom the HPN would deliver particular benefit.
8. Effective and efficient training and technical assistance must be scheduled and carried out periodically to assure that state and LHD staff is competent in the use of current technology, and in data analysis.
52 Adapted from "Concepts and Definitions" developed by the Work Group by Kristine Gebbie, Dr. PH, RN and Healthy People 2010
53 Healthy People 2010