Bridging the Digital Divide
The Public Health Informatics Institute helps broker unprecedented agreement on a standard for exchanging critical health information in the United States.
It’s a cold January morning, but the conversation is heating up in a conference room at The Task Force for Global Health where the Digital Bridge governance body has gathered. To reaffirm their commitment to the project’s mission, members stand in a semicircle facing a bare whiteboard and answer a single question: The Digital Bridge will enable me to…? Slowly, each member writes on sticky notes and places their feedback on the wall according to their areas of expertise.
Part policy think tank, part start-up incubator, Digital Bridge is a working collaborative among U.S. public health as well as the healthcare and health information technology (IT) sectors. Since 2016, The Task Force’s Public Health Informatics Institute (PHII) and Deloitte Consulting LLP have led the project management office of the initiative to develop a standardized approach for exchanging information about cases of infectious diseases and potentially other health conditions. The initiative is funded by the Centers for Disease Control and Prevention and the Robert Wood Johnson and de Beaumont Foundations.
There are dozens of infectious diseases that are classified as reportable because of their threat to the public’s health. Public health departments rely on healthcare providers to submit case reports of these diseases for surveillance and determining actions that are needed to stop outbreaks. Yet, for most diseases, it is estimated that only 20-30 percent of these cases are actually reported due to barriers in the flow of information. Many of these barriers are technical, while others stem from complex variations across states’ reporting requirements and antiquated manual reporting requirements that are too burdensome for healthcare providers to meet.
In many parts of the country, providers still fax or mail in forms to public health departments when they diagnose someone with a reportable infectious disease. While laboratories often transmit their findings electronically to health departments, these case reports typically lack patient care information, which prevents public health from having a comprehensive understanding of a potential outbreak.
The Digital Bridge Approach
U.S. healthcare has undergone a digital revolution since 2009 when the American Recovery and Reinvestment Act incentivized the transition to electronic health records (EHRs). The shift from paper-based records has dramatically improved the ability of health systems to manage patient care information. However, most EHR systems have limited functionality to exchange data with the information systems used by public health agencies.
Prior to becoming president and CEO of The Task Force for Global Health, Dave Ross, ScD, served as PHII director and helped launch Digital Bridge. “Digital Bridge at its core is about governance,” he explained. “These information systems talking to one another require sophisticated levels of agreements among multiple parties.”
Digital Bridge tackles the complex issue of “interoperability” among the information systems used by the nation’s largest healthcare systems and U.S. public health agencies. As the project management office and neutral conveners, PHII and Deloitte have provided a forum for the partners to reach consensus on a standard for connecting these disparate systems.
The Michigan Experience
In 2017, Digital Bridge selected pilot sites across the country to test a standard for exchanging electronic case information. Each site involves a state or local public health agency, a healthcare system, and its EHR vendor.
For the Michigan pilot site, a local health department clinic serves as the healthcare partner. District Health Department #10 is about 90 miles north of Grand Rapids and provides clinical services, including vaccinations, screening and treatment for sexually transmitted infections, primarily to low-income residents.
When District #10 providers diagnose a patient with a reportable infectious disease, they are required to report the case to the state health department. The process involves manually entering the information into a separate system used by the state health department. The approach is time-consuming, redundant, and introduces the possibility of data-entry errors. In addition, if state officials want more information about specific cases, they have to reach back out to District #10 providers and wait for responses to their inquiries.
The proposed Digital Bridge approach would allow District #10’s EHR system to use so-called trigger codes to flag potential reportable disease cases and automatically send an electronic initial case report (eCR) to the system used by the state health department. This automated eCR approach is expected to significantly improve public health’s ability to monitor for disease outbreaks, while giving providers more time to focus on patient care.
“With this approach, we don’t have to reach back to the provider to get more information about case reports and the information arrives to us in a more timely way,” said Jim Collins, MPH, director of the Communicable Disease Division of the Michigan Department of Health and Human Services. “That really is, to me, the promise of electronic case reporting.”
The Digital Bridge eCR approach also provides a mechanism for the bi-directional exchange of information between the state health department and District #10, which should allow for quicker responses to disease outbreaks. For example, if the state health department receives multiple case reports of hepatitis A diagnoses in the area, they can alert District #10 of these findings and recommend the department take actions to address a potential outbreak in their community.
The Potential for Digital Bridge to Transform U.S. Public Health Digital
Bridge governance body members see enormous potential benefit to U.S. public health if the Digital Bridge eCR approach is widely adopted. “I think Digital Bridge is critical to the health and safety of our nation,” explained John Lumpkin, MD, chair of the Digital Bridge governance body and a senior vice president for the Robert Wood Johnson Foundation. “The flow of important information from health care about diseases that occur in the population needs to go to public health so they can implement the appropriate intervention.” The lack of reliable surveillance data undermines public health’s ability not only to respond to disease outbreaks, but also to accurately understand the health profile of communities. If Digital Bridge is successful, Ross anticipates that electronic case reports will help usher in an era of Big Data for public health. “When we have a better handle on the data, we’ll have a granular, real-time view of the health of the population,” he said. “I think we’re going to see, for example, a much higher level of enteric illness than is currently being detected.”
Ross believes a better understanding of the health status of the population will have significant implications for policy and funding. “Good, actionable data is meaningful to lawmakers,” he said, “and can help drive more resources to improve public health.” Although Digital Bridge is currently focused on infectious diseases, the governance body’s vision is to evolve the eCR approach to noncommunicable diseases, including heart disease, cancer, and stroke, which represent the biggest health burdens in the United States.
“Having better reporting and tracking of these kinds of conditions will be the future – especially for underserved and high-risk groups, which is the traditional role of public health,” says Bob Harmon, MD, Cerner senior physician executive and Digital Bridge governance body member. “By continuing Digital Bridge’s work, we have an opportunity to drive real change in how health care and public health preparedness are coordinated throughout the United States.”