The Neolithic Revolution in Public Health

Public health faces radical change in the coming years. Recent federal policies that impact health care delivery will also affect the public health system. The Health Information Technology for Clinical and Economic Health (HITECH) provisions of the American Recovery and Reinvestment Act (ARRA) are stimulating the adoption of electronic health records and other health information technologies in hospitals, clinics, nursing homes, and other sites where care is delivered. Furthermore, HITECH’s signature initiative, administered by the Centers for Medicaid and Medicare Services (CMS) as “meaningful use,” incentivizes providers to electronically report data to public health agencies starting in 2014. These data pertain to a range of public health programs, including immunizations and disease surveillance. Meanwhile the Patient Protection and Affordable Care Act (PPACA) is shifting health care providers to be responsible not just for individual patient care but also the health of populations, which is traditionally the role of public health agencies. Together these policies are changing the nature of public health in the United States, ushering in a Neolithic revolution.

Increasingly available electronic data and information from health care providers transforms agencies from traditional roles as hunter-gatherers of data to agrarian cultivators of shared information farms. Historically, public health workers were dispatched into the field to collect data directly from a variety of sources including but not limited to patients, nurses, physicians, and allied health professionals. The rise of health information systems are resulting in more data and information being electronically reported from health care providers to public health agencies. For example, a 2010 report from the Council for State and Territorial Epidemiologists (CSTE) stated that just under half of states receive more than 50 percent of laboratory reports for infectious diseases via electronic systems.

Current trends suggest that, in the near future, public health agencies will spend less time gathering the data needed to monitor population health. Public health workers will instead focus their time and energy on analysis and application of data received. The exploding use of information technologies in health-related organizations has also increased the number of potential sources of data for use by public health agencies. For example, over-the-counter medication sales data from retailers are increasingly used for detecting outbreaks of gastrointestinal and other diseases. In addition, online surveying (e.g., SurveyMonkey) and crowdsourcing (e.g., Twitter) technologies are being explored by public health agencies as potential tools to capture electronic data on health behaviors directly from consumers.

The Neolithic revolution, however, challenges traditional approaches to the management of public health organizations and necessitates change. First, health officers and managers need to rethink agency roles in monitoring and improving population health. Second, the revolution requires health agencies to restructure their information infrastructures and workforce.

The unfolding revolution requires stronger partnerships between clinical and public health. In the recent past, public health agencies had a monopoly on population health management. Health agencies managed community-based prevention programs, providing vaccines and other preventive services to individuals without health insurance or were under-insured. The PPACA expands health coverage and requires preventive services to be covered at 100 percent, which may drive business away from health agencies. This is especially true for the Department of Veterans Affairs (VA) since Veterans will soon have a choice of receiving primary care at the VA or private physicians. Furthermore, the PPACA requires accountable care organizations (ACOs) to conduct community health assessments to ensure they are providing adequate population health. Community health assessments have long been the responsibility of public agencies, which spend considerable resources collecting, managing, and disseminating information about population health.

Loss of control and an attack on the existing business model can be viewed as either a threat or an opportunity. Either way, health agencies must change. As a convener, public health agencies can bring together ACOs and community-based organizations to ensure population health is addressed even if the agencies aren’t themselves delivering specific services. Furthermore, health agencies have an opportunity to offer their services as a strategic business partner to ACOs, strengthening the formal relationships between clinical and public health. A new kind of partnership offers health agencies an opportunity to diversify their sources of revenue while also providing input into how data are collected and reported to their various programs under existing state laws and regulations.

Responding to the Neolithic revolution will also require health agencies to update their information infrastructures and workforce. Existing information systems in health agencies typically focus on a single program function. For example, there are immunization registries, cancer registries, diabetes registries, systems for case reports of sexually transmitted infections, syndromic surveillance systems, etc. A recent survey of local health departments in Wisconsin documented the use of more than 80 distinct information systems and software packages, where only four were found to be common across nearly every health department. Thus data in health agencies tends to be siloed for specific uses, yet electronic data streams from clinical health organizations could be used for multiple purposes. For example, electronic laboratory data provide information necessary for sexually transmitted disease programs as well as seasonal disease surveillance (e.g., influenza testing) and communicable disease surveillance programs (e.g., meningitis). Therefore health agencies need to move towards common, flexible technology infrastructures that enable multiple programs to access shared systems and which accommodate a range of users’ information needs. An updated data management strategy will enable agencies to leverage increasingly electronic data sources to improve planning and policy processes across their entire spectrum of programs.

The public health workforce also requires some restructuring. Individuals who have traditionally focused on data gathering need to shift their focus to data analytics. New electronic sources of data require workers who can use advanced public health information systems as well as individuals who can design, implement, and train others on such systems – informaticians. Changing roles and responsibilities may require re-training individuals or acquiring talent with specialized skills sets. Such change will not be easy given that, according to National Association of City and County Health Officers (NACCHO), the majority of health departments have suffered workforce reductions over the last four years amounting to a total loss of 40,000 public health workers across the United States. Over the long term, the Neolithic revolution may enable health departments to do more with fewer people given higher levels of automation. Yet in the short term health agencies will need new resources to train and acquire talent with the right competencies to facilitate planning and execution of strategies to ensure a successful evolution in public health.

Change is never easy, but it is unavoidable given major shifts in health policy. There are organizations like NACCHO and the Public Health Informatics Institute available to support health agencies implement change in the coming years. However, the process will begin within individual agencies where health officials and managers acknowledge the need for change and initiate planning processes to facilitate a successful transformation from hunter-gathers to agrarian societies involving new partners, roles, and technologies to address the evolving needs in population health management.

_________________________________________________________________________________________________

Author: Brian Dixon is an assistant professor of health informatics at Indiana University, a research scientist at the Regenstrief Institute and a health research scientist with the Department of Veterans Affairs. Dr. Dixon’s teaching and research focus on the use of information technologies to improve population health outcomes, public health agency functions and exchange of data for clinical and public health decision-making processes. Dr. Dixon is also the current President of the Indiana Chapter of ASPA. He can be reached at [email protected].