Public Health Practice
Public Health Practice
For many years, public health practitioners believed that if nobody thought about public health, then public health must be doing its job. This perspective often stemmed from the fact that public health's successes were invisible.
Battles against infectious diseases (malaria, tuberculosis [TB], leprosy), chronic diseases, and environmental health hazards were often not highlighted in the media. These efforts were ongoing, but their preventative nature meant they didn't always capture public attention.
Public health issues often focus on preventing diseases before they occur, which can lack the urgency that attracts media and social attention compared to breaking news events or individual medical stories. Prevention is less sensational than reaction.
Recent outbreaks of SARS and Influenza A virus (H1N1), large-scale foodborne disease outbreaks, and the explosion of chronic illnesses linked to multiple vectors (e.g., obesity) have put public health in the media limelight. These events highlighted the importance of public health infrastructure.
Information delivery through mass media is instant and available around the clock. This accessibility is both an opportunity and a challenge for public health communication.
The proliferation of televisions, social media, and radio contributes to the wide spread of media in daily life. This omnipresence shapes public perception and awareness.
The more coverage a topic receives in the news, the more likely it becomes a concern of the public (e.g., COVID-19). Media attention drives public discourse and policy changes.
The need to be alert to emerging public health problems, responsive in emergencies, and accountable to the public has intensified health departments’ efforts to collect data and information from multiple sources. Data-driven decision-making is now essential.
Public health practitioners have tapped into information technology to manage overwhelming amounts of data and information. Technology enables efficient analysis and response.
Technology provides public health professionals with advanced tools to obtain accurate, detailed population data in real time. Granular data supports targeted interventions.
These data can help build more effective, actionable health strategies and coordinate a support system to address widespread disease outbreaks. Strategic planning relies on comprehensive data analysis.
2000-2010: Information systems have become widely adapted to fit the special needs of public health. This period saw significant advancements in public health informatics.
Recognizing the importance of linkages among clinical care, clinical care information systems, laboratory information systems, and other data sources has established data and information exchange standards to support system interoperability. Interoperability ensures seamless data flow between systems.
Public Health, Public Health Informatics, Public Health Nursing, and the Public Health Nurse Informatician
1920: C.E.A. Winslow defined public health as “the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public communities and individuals." This definition remains foundational to the field.
1798: The roots of public health were established in the US when the Public Health Service (PHS) was created by the Marine Hospital Service Act. This act marked the formal beginning of public health efforts in the US.
1944: With the passage of the Public Health Service Act, the PHS mission was broadened to protect and advance the nation’s physical and mental health. This expansion reflected a growing understanding of health determinants.
The Future of Public Health
A seminal study by the Institute of Medicine (IOM). This study shaped the modern understanding of public health functions.
The functions of public health were described as assessment, policy development, and assurance. These functions provide a framework for public health practice.
Assessment
Includes activities of surveillance, case finding, and monitoring trends; it is the basis for decision making and policy development by public agencies. Assessment informs effective interventions.
Examples: Tracking disease outbreaks, monitoring the prevalence of chronic disease. These activities provide critical insights into health trends.
Policy Development
Involves broad community involvement in formulating plans, setting priorities, mobilizing resources, convening constituents, and developing public health policies. Community engagement ensures relevant policies.
Examples: Policies developed by public health officials in relation to food handling and storage. These policies protect public safety.
Assurance
Covers activities that verify the implementation of mandates or policies and guarantees that the provision of necessary resources is provided to reach the public health goals. Assurance ensures policies are effectively implemented.
Examples: Public health officials ensure that all residents have access to essential services like vaccinations, prenatal care, and mental health services. Equitable access to services is a core goal.
Essential Services of Public health
To enhance further the core public health functions, a committee of public health agencies and organizations convened by the US public health described the 10 essential services of public health. These services guide public health activities.
Government’s Role in Public Health
The essential governmental role in public health is guided and implemented by a variety of federal, state/territorial, and local regulations and laws as well as federal, state/territorial, and local governmental public health agencies. Government provides the regulatory and legal framework.
This complex array of public health functions, services, responsibilities, and interactions is not a static environment, but one that is constantly changing. Public health must adapt to emerging challenges.
Public Health Information: Sources and Information
Information forms the basis of public health, and public health practitioners require timely, quality information. Accurate data is crucial for effective decision-making.
Due to a variety of sources, the existing sources lack standardization in data organization, nomenclature, and electronic transmission. Standardization improves data quality and comparability.
Innovative methods for storing, organizing, exchanging, and disseminating data gathered during public health activities provided the foundation for the field of public health informatics. Informatics enhances data management and analysis.
Public Health Informatics
The systematic application of information and computer science and technology to public health practice, research, and learning. Informatics transforms public health practice.
Main Focus: Use of information science and technology for promoting population health rather than individuals. Population health is the central concern of public health informatics.
Focuses on populations. Informatics addresses health at the community level.
Disease prevention rather than treatment focus: prevent change of events or disease spread. Prevention is more efficient than treatment.
Population-level data and information are collected, analyzed, and disseminated with the goal of supporting preventive interventions, NOT CURATIVE. Data supports targeted prevention strategies.
Privacy Rule
Provision in HIPAA (2004) that generally prohibits disclosure of an individual’s medical record and payment history without expressed authorization of the individual. HIPAA protects patient privacy.
Public Health Purposes: The Law provides disclosure of patient information to public health without authorization:
To prevent or control disease, injury, or disability. Disease control requires access to patient data.
For conducting public health surveillance, public health investigations, and public health interventions. Surveillance relies on data collection.
Public Health Nursing
Focuses on population health through continuous surveillance and assessment of the determinants of health with the intent to promote health and wellness; prevent disease, disability and premature death; and improve neighborhood quality of life (ANA). Public health nursing addresses broad health determinants.
These population health priorities are addressed via identification, implementation and evaluation of universal and targeted evidence-based programs that may provide primary, secondary, and tertiary preventive interventions. Evidence-based programs guide nursing practice.
Evidence based programs can be either:
Universal - which targets everyone or a specific group, or community. Universal programs reach a broad population.
Targeted Programs - focuses on groups or individuals that are High-Risk. Targeted programs address specific needs.
Emphasis: PRIMARY PREVENTION. Prevention is the cornerstone of public health nursing.
Goal: Achieving Health Equity. Equity ensures fair distribution of health resources.
Public Health Informatician (PHI)
A public health professional who works either in practice, research or academia and whose primary work function is to use informatics to improve population health. PHIs drive innovation in public health.
Requires more expertise than the multi-highly functional public health professional that assists with informatics-related challenges or supports personal productivity with information technology (U.S. Department of Health and Human Services, CDC). PHIs possess specialized skills.
Public Health Nurse Informatician (PHNI)
Combines the competencies of PHI and nursing informatics. PHNIs bridge nursing and informatics.
A PHNI who specialized in nursing informatics and has skills in supporting the establishment of systems to improve public health surveillance through access to clinical care information. PHNIs enhance surveillance capabilities.
The PHNI has advanced skills in using nursing taxonomies and nomenclature as a tool for nursing informatics in public health practice. Standardized terminology improves data analysis.
PHNI’s ensure that data needs are adequate to measure performance for multiple determinants of health
Determinants of health: are factors encompassing socioeconomic status, physical environment, and individual’s characteristics and behaviors. These factors influence health outcomes.
Example: income, education, occupation, access to safe drinking water. These examples illustrate health determinants.
The Public Health Surveillance Landscape
The public health mission is to promote the health of the population rather than to treat individuals. Population health is the overarching goal.
In support of the mission, public health workers collect data on the determinants of health and its risks from factors in the pre-exposure environment, the presence of hazardous agents, behaviors, and exposures. Data collection informs risk mitigation.
Public Health workers monitor the occurrence of health events, conditions, deaths, and the activities of the healthcare systems and their effects on health. Monitoring tracks health trends.
Public health professionals use these data to inform decisions about the most effective mechanisms for interventions. Data guides intervention strategies.
Information from multiple (sometimes incompatible) systems or sources must be combined for an accurate depiction of problems. Integration improves accuracy.
Data Collection and Sharing
Occurs at three levels: Local, State/Territorial, and federal- E.G., centers for Disease Control and prevention (Federal). Data flows through multiple levels.
Programs at each level have similar organization and management structures, most funding is based on programmatic need. Funding aligns with programmatic goals.
Many information systems have been built to support specific programs thereby creating “silo”-like systems.
Silo-like: Refers to fragmented approaches to healthcare where different departments or organizations operate independently thus hindering information sharing and collaboration. Fragmentation hinders data flow.
The program-oriented funding streams and information systems need to flow together to be more productive. Integration enhances productivity.
Overcoming Barriers to Data Collection and Sharing
Efforts to overcome barriers are seen in the implementation of regional, state/territorial, and local initiatives:-
Health information Exchanges (HIE’s)- Facilitates secure sharing of patient data. HIEs improve data accessibility.
National Electronic Disease Surveillance System (NEDSS)- Leverages patient data to enhance public health surveillance by enabling timely and accurate reporting of disease information across jurisdiction. NEDSS strengthens surveillance.
This comprehensive, rather than disease-specific, approach is the foundation of public health informatics and warrants further inspection. A holistic perspective is essential.
Infectious Disease Electronic Surveillance
Each year, the Council of State and Territorial Epidemiologists (CSTE) and the CDC jointly update a list of reportable diseases and conditions
Council of State and Territorial Epidemiologists (CSTE)- A professional organization that represents the interest of state epidemiologist from all 50 US states and territories working to improve public health. CSTE represents state epidemiologists.
CSTE supports the implementation epidemiologic activities such as disease surveillance, outbreak investigations, and public health research. CSTE supports critical activities.
Local (city or county) health department
Frontline of public health. Local departments are the first responders.
Interacts most closely with clinicians and agencies in the community. Local departments foster community partnerships.
Gathers reports of communicable diseases. Local departments collect disease reports.
Tracks and monitors cases. Local departments monitor disease cases.
Conducts investigation. Local departments investigate outbreaks.
Provides direct services (STD testing, vaccines, contact tracing, directly observed therapy (TB), case management). Local departments offer essential services.
State health department
Uses legislation, as well as regulations to require reporting by healthcare entities. State departments enforce reporting requirements.
To report certain illnesses. State departments track reportable illnesses.
To require vaccinations for school entry. State departments mandate vaccinations.
To coordinate statewide disease surveillance. State departments coordinate surveillance efforts.
To monitor incoming reports from counties. State departments monitor local reports.
And submit those reports, voluntarily and minus names, to the CDC. State departments contribute to national surveillance.
Research and Program Evaluations Published by the CDC
The CDC publishes national surveillance summaries and conducts research and program evaluations to produce public health recommendations. The CDC provides national guidance.
National Electronic Telecommunications System for Surveillance (NETSS)
1984: Epidemiologic Surveillance project
Began by the CDC, in cooperation with the CSTE and epidemiologists in 6 states
To describe and monitor health events.
Plan and implement interventions.
Evaluate public health programs.
Ultimately helping to prevent and control disease outbreaks.
Goal: To demonstrate the effectiveness of computer transmission of public health surveillance case-based data between state health departments and the CDC
1989: National Electronic Telecommunications System for Surveillance
All 50 states were participating in the reporting system.
The Epidemiologic Surveillance project was renamed the NETSS to reflect its national scope.
The NETSS system includes 22 core data elements for reportable disease conditions
Morbidity and mortality weekly Report (MMWR): Where the CDC disseminates analyzed data
The overwhelming volume of data to be managed by health departments led to the NEDSS initiative, which provides guidance for the technical architecture and standards for nationally reportable condition reporting
Difference between NETSS and NEDSS
NETSS
Case-based
Used proprietary Codes
Had limitations and restrictions that made it difficult to improve and adapt to changing needs
NEDSS
Person-based
Based on standards; it can capture data already in healthcare data streams
National Electronic Disease Surveillance System (NEDSS)
1999: The CDC, the CSTE, and state and local public health department staff began work on information system standards for the NEDSS initiative
The NEDSS Initiative
Uses standards to advance the development of efficient, integrated, and interoperable surveillance systems at the state and local levels.
Facilitates the electronic transfer of information from clinical information systems in healthcare
Reduces the provider’s burden of providing data, and enhances the timeliness and quality of information provided
Criteria of the NEDSS Initiative
States were funded to assess their current systems and develop plans to implement criteria compatible with the NEDSS initiative
THE CRITERIA INCLUDES:
Browser-Based System Data Entry
Electronic Laboratory Results (ELR) System- A system for laboratory staff to report results to health departments as authorized
Involves sending digital laboratory reports often from laboratories to local public health departments and healthcare partners
Instead of the traditional paper or manual method
Is important, since it provides a essential tool in a response to outbreaks
A single repository for integrated databases from multiple health information systems
NEDSS-Base SYSTEM (NBS)
A platform developed by the CDC for public health surveillance functions, processes, and data integration in a secure environment
This enables states to have the option to choose this platform or another NEDSS compatible system
Healthcare Providers Role and The NBS
Healthcare providers are responsible for providing clinical care and reporting state-designated reportable conditions to public health departments
As a registered user of the NBS, a healthcare provider can directly enter data from case and laboratory reports into the state’s electronic surveillance system at the point of care
Data that are collected for surveillance purposes are used at the local and state level to guide public health actions
The data are sent to the CDC to support surveillance at a national level.
Healthcare providers can send electronic case report using the Health level Seven Clinical Document Architecture (HL7 CDA) format when their electronic health record (EHR) is equipped to report in the standard format
HL7 CDA- A document mark-up standard, which is a set of rules that define how to embed instructions within a context document to control its structure and formatting
Specifies the structure of a clinical document, such as discharge summary, for the purpose of exchange
Clinical Laboratories and the NBS
Staff members in public and private laboratories are required by law to notify public health department of state reportable conditions
Registered laboratory users of the NBS system enter reports directly using the Web-based laboratory reporting function of the NBS
This report is then readily available to the public health NBS users to conduct the investigation
Public Health Practitioner Role and the NBS
Public health practitioners, who are registered users of the NBS, may review reports from laboratories and healthcare providers for patients residing within their jurisdictional boundaries
The public health practitioners may create an “alert” function for new data received in the NBS (such as for reports of meningococcal disease)
Upon receipt of a new report, the public health practitioner may order a public health field investigation
Clinical, Laboratory, Epidemiologic, and follow-up data are stored in the NBS.
The public health practitioner classifies the case, based on stored data and standard case definitions, and forwards the notification to CDC using the NEDSS messaging format, HL7, or NETSS (if no messaging guide exists)
A data transfer function in the NBS allow users to notify another jurisdiction when a patient moves and to transfer records for follow-up.
Federal (CDC) Role and the NBS
The capabilities of the NBS support public health investigations and interventions at the state level and allow reporting of nationally notifiable disease in a more complete and standardized manner and in near real time for analysis by CDC program areas
This supports effective policy formation at the national level when events of public health significance heappen.
The data are disseminated through the Morbidity and Mortality Weekly Report (MMWR) Series
Often called the voice of the CDC
The agency’s primary vehicle for scientific publication of timely, reliable, accurate, objective, and useful public health information and recommendation
Privacy Protection and the NBS
In order to protect personally identifiable information, the NBS requires user authentication, authorization, and auditing protocols
To verify the identity of the user, the NBS supports custom authentication. Once authenticated, the NPS application authorizes access to data based on user role, geographical area/s, disease/s, pubic health event/s, and action/s
The NBS creates an audit file containing a fingerprint trail with a timestamp of the user’s activities
Value of Information Solutions to Surveillance Practice
NEDSS-compatible infectious disease electronic surveillance systems change how public health departments at all levels communicate to perform their mission.
These systems enhance the capacity of local and state public health agencies to react quickly to disease occurrences.
Future Directions for Infectious Disease Surveillance
State public health programs face major funding and infrastructure challenges in adopting the standards-driven information systems for electronic disease surveillance.
The CDC encourages adequate and sustained funding by public health programs for the NEDSS initiative and encourages partners and clinical providers at the point of care to adopt standards and create a uniform, interoperable, and bi-directional process for electronic disease surveillance.
Using Informatics in an Immunization Information System
Public health has been an advocate for immunization to prevent disease for decades
The Philippine Setting, has 7 vaccine-preventable diseases: Measles, Mumps, Rubella, Polio, Whooping Cough/Pertussis, Tetanus, Diphtheria
Immunization Information System (IIS)
Newer immunization registries are based on electronic IIS
Electronic Immunization systems (IIS), also known as vaccine registries, are confidential, population-based, computerized databases that record, consolidate, and report vaccinations administered by participating providers to people within a specific area, supporting vaccination uptake and disease prevention
Benefits of Implementation
For the PUBLIC
Having a private and secure place to safeguard important immunization information from multiple providers that will be used throughout a person’s life
Receiving timely immunization reminders
Eliminating duplicate immunization
For the HEALTHCARE PROVIDERS
Consolidating immunization records from different sources
Automatically calculating the immunizations needed
Easily providing official copies of immunization records
Automating vaccine inventory and ordering procedures
Flagging high-risk patients for timely vaccination recalls
Assisting with vaccine safety and adverse event reporting
To accomplish these activities, the IIS must be able to exchange data and information. Data, Vocabulary, and transmission standards are critical to IIS success.
Using Informatics in a Tuberculosis Electronic Information System
Tuberculosis
Is a chronic bacterial infection caused by Mycobacterium tuberculosis
The common site of infection is the lungs, but other organs may be involved
Tuberculosis Electronic Information System
Is created to develop real time surveillance systems to monitor disease trends, identify outbreaks, and assess effectiveness of interventions
Confirmed TB Cases are reported by clinicians and laboratory staff Statewide Disease Surveillance programs connected to state health departments
Reporting is also recommended for patients who have suspected Respiratory TB prior to laboratory confirmation, to expedite contact tracing and TB transmission control.
Multiple Systems are involved in Electronic TB reporting. Data reporting systems include National TB Surveillance System, TB Genotyping Information Management System, Electronic Disease Notification System
CDC shares these reports electronically with health department programs receiving federal funding for TB prevention and control.
National TB Surveillance System
An electronic incidence system that collects 49 data items on newly diagnosed verified cases of TB in the United States.
The appropriate authority transmits the data from the state or designated health jurisdiction to CDC at three intervals
TB Genotyping Information Management System (TB GIMS)
A laboratory Based approach that is used to analyze the genetic material of mycobacterium tuberculosis
Builds upon the established infrastructure of the CDC’s National TB Surveillance System and incorporates genotype data to create a centralized database and reporting system
Electronic Disease Notification System
Is a centralized electronic reporting system that notifies the U.S. state and local health departments and screening clinics the arrival of immigrants requiring medical follow up
Alerts state and local health department program of refugees and immigrant arrivals to their jurisdictions and provides overseas medical screening results and treatment
The Public Health Informatician and the Emerging Roles for Public Health Nurse Informatician
The emerging role of the PHNI is illustrated in case studies to demonstrate the core public health functions of assessment and assurance performance by the PHNI and the PHI
First Case Study
The PHI ensured the retrieval of destroyed health records for displaced hurricane Katrina communities by linking people with their records through informatics
By retrieving health records, the PHI enforced rules regarding immunization record requirements while ensuring provision of needed immunizations
Second Case Study
The PHI while participating in assessment activities to monitor health status and health problems in displaced Hurricane Katrina communities, identified a norovirus outbreak
The PHI developed and used a simple data checklist of symptoms, and compiled daily information reports and environmental risk information to evaluate the ongoing effectiveness and quality of emergency public health services
Third Case Study
The PHNI designed an assessment activity for barriers to adherence behaviors with TB treatment
The PHNI describes a clinical nursing information system (CNIS) for a behavioral adherence model adapted to TB program literature
The resulting dataset can be used to manage data, monitor the performance plan, and evaluate the effectiveness and quality of personal health services.
Future Directions In Public Health Information Systems
Public health practitioners have not taken an active role in the development of health information systems
Public health practitioners must provide support and leadership to local health settings in the emerging concept of multi agency responsibility for health.
The use of data in innovative ways through the use of data visualization and decision support systems will increase