Enhancing the nation's public health information infrastructure: a report from the ACMI symposium

Unbiased care, unequal outcomes: a nursing telehealth intervention reveals systematic inequities in COVID-19 care delivery

BACKGROUND

The Covid Connected Care Center (C4), a low-barrier telephone nurse hotline, was developed at an academic medical center to increase access to healthcare information and services across the state of Oregon, including to those without a usual source of care. Other studies have demonstrated that telephone triage services can positively influence health behaviors, but it is not known how this effect is maintained across racial/ethnic groups. The objective of this study was to show that the C4 reached throughout the state of Oregon, was valuable to callers, and that recommendations given affected callers' subsequent health-related behaviors.

METHODS

This mixed-methods study, informed by the RE-AIM (Reach, Effectiveness, Addoption, Implementation and Maintenance) framework, assessed caller demographics and clinical care from March 30 2020 until September 8, 2021. Descriptive statistics, multivariable risk models and Zou's modified Poisson modeling were applied to electronic health record and call system data; An inductive approach was used for patient and staff experience surveys and semi-structured interviews. Approval was obtained from the OHSU Institutional Review Board (Study 00021413).

RESULTS

145,537 telephone calls and 92,100 text-based contacts (61% and 39%, respectively) were included. Callers tended to not have a usual source of primary care and utilized recommended services. Emergency department utilization was minimal (1.5%). Racial or ethnic disparities were not detected in the recommendations, but Black (RR 0.92, CI 0.86-0.98) and Multiracial (RR 0.90 CI 0.81-0.99) callers were less likely than non-Hispanic white callers to receive a COVID-19 test. Participants in the post-call survey (n = 50) would recommend this service to friends or family. Interviews with callers (n = 9) revealed this was because they valued assistance translating general recommendations into a personalized care plan. C4 staff interviewed (n = 9) valued the opportunity to serve the public. The C4 was a trusted resource to the public and reached the intended audiences. However, disparities in access to COVID-19 testing persisted.

CONCLUSIONS

Nursing triage hotlines can guide caller behavior and be an effective part of a robust public health information infrastructure.

Training in Public Health Informatics and Technology Leveraging a Multi-institutional Partnership Model and Emphasizing Experiential Learning

BACKGROUND AND OBJECTIVE

 Though public health is an information-intense profession, there is a paucity of workforce with Public Health Informatics and Technology (PHIT) skills, which was evident during the coronavirus disease 2019 (COVID-19) pandemic. This need is addressed through the PHIT workforce program (2021-2025) by the Office of the National Coordinator for training and to increase racial and ethnic diversity in the PHIT workforce. The objective is to share details on the Training in Informatics for Underrepresented Minorities in Public Health (TRIUMPH) consortium, funded by the PHIT workforce program.

METHODS

 The TRIUMPH consortium is a collaboration between academic and practice partners with a commitment to training 879 students in PHIT. The Schools of Public Health and Nursing at the University of Minnesota, Jiann-Ping Hsu College of Public Health at Georgia Southern University, Morehouse School of Medicine, and Public Health Informatics Institute offer PHIT training through various programs. Academic institutions focus on student recruitment, developing courses/curriculum, and granting degrees/certificates, and the role of practice partners is to support experiential learning through internships/practicums.

RESULTS

 The TRIUMPH consortium is progressing toward its goals, with 692 students (79%) already trained in a PHIT modality as of December 2023. The learners comprise diverse race/ethnicity, including White (48%), Black/African American (32%), Asian (10%), White Hispanic (5%), American Indian/Alaska Native (2%), and Black Hispanic (1%). Numerous internships have been completed in settings ranging from state/local public health agencies to health care delivery systems. Diversity initiatives were supported by partnering with existing programs (e.g., the AMIA First Look program and the Nursing Knowledge Big Data Science conference).

CONCLUSION

 This consortium model is an excellent approach to informatics training and sharing expertise across partners. It provides scalability and broader geographic outreach while presenting opportunities to students from underrepresented backgrounds. Lessons learned have implications for overall informatics training (e.g., partnerships models, promoting racial/ethnic diversity).

MENDS-on-FHIR: leveraging the OMOP common data model and FHIR standards for national chronic disease surveillance

Objectives

The Multi-State EHR-Based Network for Disease Surveillance (MENDS) is a population-based chronic disease surveillance distributed data network that uses institution-specific extraction-transformation-load (ETL) routines. MENDS-on-FHIR examined using Health Language Seven's Fast Healthcare Interoperability Resources (HL7® FHIR®) and US Core Implementation Guide (US Core IG) compliant resources derived from the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) to create a standards-based ETL pipeline.

Materials and Methods

The input data source was a research data warehouse containing clinical and administrative data in OMOP CDM Version 5.3 format. OMOP-to-FHIR transformations, using a unique JavaScript Object Notation (JSON)-to-JSON transformation language called Whistle, created FHIR R4 V4.0.1/US Core IG V4.0.0 conformant resources that were stored in a local FHIR server. A REST-based Bulk FHIR $export request extracted FHIR resources to populate a local MENDS database.

Results

Eleven OMOP tables were used to create 10 FHIR/US Core compliant resource types. A total of 1.13 trillion resources were extracted and inserted into the MENDS repository. A very low rate of non-compliant resources was observed.

Discussion

OMOP-to-FHIR transformation results passed validation with less than a 1% non-compliance rate. These standards-compliant FHIR resources provided standardized data elements required by the MENDS surveillance use case. The Bulk FHIR application programming interface (API) enabled population-level data exchange using interoperable FHIR resources. The OMOP-to-FHIR transformation pipeline creates a FHIR interface for accessing OMOP data.

Conclusion

MENDS-on-FHIR successfully replaced custom ETL with standards-based interoperable FHIR resources using Bulk FHIR. The OMOP-to-FHIR transformations provide an alternative mechanism for sharing OMOP data.

Navigating the Landscape: Barriers and Facilitators in Electronic Case Reporting Implementation Across Public Health Agencies

OBJECTIVE

The objectives were to identify barriers and facilitators for electronic case reporting (eCR) implementation associated with "organizational" and "people"-based knowledge/processes and to identify patterns across implementation stages to guide best practices for eCR implementation at public health agencies.

DESIGN

This qualitative study uses semistructured interviews with key stakeholders across 6 public health agencies. This study leveraged 2 conceptual frameworks for the development of the interview guide and initial codebook and the organization of the findings of thematic analysis.

SETTING

Interviews were conducted virtually with informants from public health agencies at varying stages of eCR implementation.

PARTICIPANTS

Investigators aimed to enroll 3 participants from each participating public health agency, including an eCR lead, a technical lead, and a leadership informant.

MAIN OUTCOME MEASURES

Patterns associated with barriers and facilitators across the eCR implementation stage.

RESULTS

Twenty-eight themes were identified throughout interviews with 16 informants representing 6 public health agencies at varying stages of implementation. While there was variation across these levels, 3 distinct patterns were identified, including themes that were described (1) solely as a barrier or facilitator for eCR implementation regardless of implementation stages, (2) as a barrier for those in the early stages but evolved into a facilitator for those in later stages, and (3) as facilitators that were unique to the late-stage implementation.

CONCLUSION

This study elucidated critical national, organizational, and person-centric best practices for public health agencies. These included the importance of engagement with the national eCR team, integrated development teams, cross-pollination, and developing solutions with the broader public health mission in mind. While the implementation of eCR was the focus of this study, the findings are generalizable to the broader data modernization efforts within public health agencies.

MENDS-on-FHIR: Leveraging the OMOP common data model and FHIR standards for national chronic disease surveillance

Objective

The Multi-State EHR-Based Network for Disease Surveillance (MENDS) is a population-based chronic disease surveillance distributed data network that uses institution-specific extraction-transformation-load (ETL) routines. MENDS-on-FHIR examined using Health Language Seven's Fast Healthcare Interoperability Resources (HL7® FHIR®) and US Core Implementation Guide (US Core IG) compliant resources derived from the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) to create a standards-based ETL pipeline.

Materials and Methods

The input data source was a research data warehouse containing clinical and administrative data in OMOP CDM Version 5.3 format. OMOP-to-FHIR transformations, using a unique JavaScript Object Notation (JSON)-to-JSON transformation language called Whistle, created FHIR R4 V4.0.1/US Core IG V4.0.0 conformant resources that were stored in a local FHIR server. A REST-based Bulk FHIR $export request extracted FHIR resources to populate a local MENDS database.

Results

Eleven OMOP tables were used to create 10 FHIR/US Core compliant resource types. A total of 1.13 trillion resources were extracted and inserted into the MENDS repository. A very low rate of non-compliant resources was observed.

Discussion

OMOP-to-FHIR transformation results passed validation with less than a 1% non-compliance rate. These standards-compliant FHIR resources provided standardized data elements required by the MENDS surveillance use case. The Bulk FHIR application programming interface (API) enabled population-level data exchange using interoperable FHIR resources. The OMOP-to-FHIR transformation pipeline creates a FHIR interface for accessing OMOP data.

Conclusion

MENDS-on-FHIR successfully replaced custom ETL with standards-based interoperable FHIR resources using Bulk FHIR. The OMOP-to-FHIR transformations provide an alternative mechanism for sharing OMOP data.

Strengths, weaknesses, opportunities, and threats for the nation's public health information systems infrastructure: synthesis of discussions from the 2022 ACMI Symposium

OBJECTIVE

The annual American College of Medical Informatics (ACMI) symposium focused discussion on the national public health information systems (PHIS) infrastructure to support public health goals. The objective of this article is to present the strengths, weaknesses, threats, and opportunities (SWOT) identified by public health and informatics leaders in attendance.

MATERIALS AND METHODS

The Symposium provided a venue for experts in biomedical informatics and public health to brainstorm, identify, and discuss top PHIS challenges. Two conceptual frameworks, SWOT and the Informatics Stack, guided discussion and were used to organize factors and themes identified through a qualitative approach.

RESULTS

A total of 57 unique factors related to the current PHIS were identified, including 9 strengths, 22 weaknesses, 14 opportunities, and 14 threats, which were consolidated into 22 themes according to the Stack. Most themes (68%) clustered at the top of the Stack. Three overarching opportunities were especially prominent: (1) addressing the needs for sustainable funding, (2) leveraging existing infrastructure and processes for information exchange and system development that meets public health goals, and (3) preparing the public health workforce to benefit from available resources.

DISCUSSION

The PHIS is unarguably overdue for a strategically designed, technology-enabled, information infrastructure for delivering day-to-day essential public health services and to respond effectively to public health emergencies.

CONCLUSION

Most of the themes identified concerned context, people, and processes rather than technical elements. We recommend that public health leadership consider the possible actions and leverage informatics expertise as we collectively prepare for the future.