View source for Interoperability of Public Health and Clinical Information Systems

== Introduction ==

Exchange of data between clinical information systems (CIS) and public health information systems (PHIS) is critical to public health. The ability to promote disease prevention at a population level and to respond to public health emergencies, such as disease outbreaks, is dependent on the flow of patient and population-level data, which has been highlighted in the COVID-19 pandemic.<ref name="covid collaboration">Lenert LA, Ding W, Jacobs J. Informatics for public health and health system collaboration: Applications for the control of the current COVID-19 pandemic and the next one. Journal of the American Medical Informatics Association, 28(8), 2021, 1807-1811. http://doi.org/10.1093/jamia/ocab066</ref>
* The most common use case is reporting of electronic lab data from CIS to PHIS to support disease surveillance and contact tracing, but bidirectional information exchange related to key public health interventions such as immunizations is also necessary.
* As of 2014, 67% of lab reports for notifiable conditions were transmitted electronically, but adoption was inconsistent (much higher for large laboratory companies than hospital laboratories).<ref name="MMWR">Lamb W, Satre J, Pon S, et al. Update on Progress in Electronic Reporting of Laboratory Results to Public Health Agencies - United States, 2014. Morbidity and Mortality Weekly Report, 64(12), 2015, 328-30. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6412a5.htm</ref> Additionally, electronic transmission of the data alone may not be a sufficient metric if the PHIS cannot interpret the meaning of that data. This can occur if the CIS data is not coded to a vocabulary standard and/or if it uses a local standard that requires translation by the PHIS.<ref name="semantic">Dixon BE, Vreeman DJ, Grannis SJ. The long road to semantic interoperability in support of public health: Experiences from two states. Journal of Biomedical Informatics, 49, 2014, 3-8. http://dx.doi.org/10.1016/j.jbi.2014.03.011</ref>
*Recent trends have helped to push CIS-PHIS integration to the forefront, including increased financial incentives and policies by governmental and private insurance providers to promote population health.<ref name="Bridging Big Data">Gamache R, Kharrazi H, Weiner J. Public and Population Health Informatics: The Bridging of Big Data to Benefit Communities. IMIA Yearbook of Medical Informatics, 2018, 199-206. http://dx.doi.org/10.1055/s-0038-1667081</ref>

== Barriers to CIS/PHIS Interoperability ==

'''Lack of consistent use of vocabulary standards within CIS'''
* Meaningful use provision within HITECH act incentivized use of vocabulary standards but those still have not been universally adopted. An analysis of Indiana and Wisconsin public health systems from 2010-11 revealed less than 20% of incoming transmitted electronic laboratory reporting messages were in standard SNOMED/LOINC vocabularies and while use of standardized vocabularies has likely improved since then, it likely remains below 100%. <ref name="EHI Quality">Dixon BE, Siegel JA, Oemig, TV, Grannis SJ. Electronic Health Information Quality Challenges and Interventions to Improve Public Health Surveillance Data and Practice. Public Health Reports, 2013, 546-53. http://dx.doi.org/10.1177%2F003335491312800614</ref><br>
'''Mapping codes is resource-intensive'''
* Mapping local codes to standardized vocabulary is complex and costly and Public health systems are chronically underfunded so these resources are either unavailable or need to be diverted from other projects.<ref name="semantic"></ref> 

'''Patient identification is not straightforward'''
* Lack of national patient identifier makes patient identification challenging which can impede a rapid response to a public health emergency.<ref name="covid collaboration"></ref>
'''Need to protect patient privacy'''
* Volume of data that needs to be transmitted should be sufficient to properly identify and track the case of concern, but be the minimum required to respect patient privacy. <ref name="mishra">Mishra NK, Duke J, Lenert L, Karki S. Public health reporting and outbreak response: synergies with evolving clinical standards for interoperability. Journal of the American Medical Informatics Association, 27(7), 2020, 1136-38. http://dx.doi.org/10.1093/jamia/ocaa059</ref>

'''Siloed data systems'''
* There are not only silos between information systems (e.g. CIS vs PHIS) but also intra-information system with multiple disjointed databases within PHIS systems. For example, there are at least 60 distinct state and regional immunization information systems that transmit data nationally to CDC, but they are not directly linked, impeding the ability for health systems to query a single repository <ref name="covid collaboration"></ref>

== Solutions to improve CIS/PHIS Interoperability ==

There are numerous opportunities and approaches to improve interoperability between clinical and public health information systems. Increasing use of data vocabulary standards to improve semantic interoperability is one key step, and HITECH has incentivized institutions to adopt these standards as part of "meaningful use". For clinical systems to devote resources toward improving semantic interoperability to PHIS, there also needs to be a benefit to the clinical system, however, beyond the governmental incentives that do not fully meet the costs required for a CIS to achieve true meaningful interoperability. <ref name="semantic"></ref> 

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One key incentive to encourage a clinical system to devote resources towards use of data standards and tools to promote interoperability would be for the CIS to be able to access information from the PHIS in a bidirectional manner. Immunization information systems (IIS) are one example of how collaborative data exchange can promote operational adoption and investment by healthcare providers. <ref name="covid collaboration"></ref> Currently, regional and state IIS are disjointed and the ability for healthcare providers to broadly query those databases is limited. Lenert et al discussed the development of a centralized data repository architecture using flat FHIR interoperability (e.g. a standard that permits push button population health queries of patient-level data across a population).<ref name="covid collaboration"></ref><ref name="smarthealth">SMART/HL7 Bulk Data Access (Flat FHIR). https://smarthealthit.org/smart-hl7-bulk-data-access-flat-fhir/</ref> Their VacTrac data architecture would wrap IIS data into a flat FHIR clinical data repository that would improve clinical health system providers' access to data across immunization registries. 

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Another requirement for efficient and rapid data exchange between PHIS and CIS is a mechanism to disambiguate patient identity. This would limit the complex data mapping that must be done to ensure the right data is linked to the right patient, which is necessary to permit targeted outreach efforts by public health systems. A national patient identifier is one solution to this problem, but has been hampered by concerns about privacy. <ref name="covid collaboration"></ref>. Further research and advocacy will be needed to determine if a national patient identifier or another solution to this problem is achievable.

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Along with disambiguation of patient identity, there will also be a need to ensure that PHIS access the minimum required information to fulfill their public health missions. Clinical health systems may hesitate to open their data warehouses to PHIS without assurance that other irrelevant patient data will not be accessed. Mishra et al reported one potential solution to this challenge with an example for infectious disease surveillance - the Public Health Automated Case Event Reporting (PACER) architecture. The PACER system is maintained on the clinical providers' network and, as such, the clinical system retains control and the public health system can only submit pre-approved queries. This could help to provide assurance to the clinical system that protection of patient data will be maintained in the process of data sharing with the PHIS.<ref name="mishra"></ref>

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Ultimately, though, any of these solutions requires resources and improved funding for public health systems will be a necessity to achieving semantic interoperability between CIS and PHIS.

== References ==
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Submitted by Anne Fallon, MD
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