Public Health Informatics: Sustainable and Strategic

State: NE Type: Model Practice Year: 2011

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Our primary goal for Public Health Information Technology and Management has been to develop and implement informatics resources that support and enhance our department's ability to accomplish its mission. Objectives include improving quality, cost effectiveness, efficiency, reporting and evaluation capacity. Through on-going analysis of need, evaluation of available resources (staff, funding and technology) as well as past successes and failures, we evolved a workable strategy.

The strategy includes overarching principles, basic design elements and a conceptual framework. These provide guidance for informatics staff and department decision-makers for all levels of resource investment and implementation. What may be most unique and innovative about our approach is the consistent, practical application of these basic principles and design elements over the past fifteen years. No one decision or application is entirely unique or even groundbreaking. However, the accumulated impact of a strategic approach to informatics resources has positioned our department well for the 21st century.

In 2001, the Health Director allocated $150,000 a year from state public health infrastructure funds (Tobacco Settlement) and issued the challenge to build a PHIT infrastructure for the Health Department. Over the next ten years, these funds paid for people and equipment. The Department also invested an additional $500,000 to $700,000 dollars from grants, savings and local funds to purchase specific software and associated hardware. During the same period, the department was able to coordinate with broad City and County infrastructure investments to improve our overall capacity. Our target population is the staff of the health department and by extension all the people served by the various department programs. 90% of the department programs are directly supported through specific applications, 100% of staff use information technology tools. 85% of direct services are supported by information technology at the point of service. The current status of our Public Health Information Technology Strategy is described below. It includes: --Four major point of service applications -EMR (direct nursing, medical and case management services) -Dental medical record systems (direct dental services) -Permits Plus (regulation and enforcement for Environmental Health) -Animal Control (regulation and enforcement --All point of service applications support in-house and remote work. Staff in the field use access the applications using tablets.

--Internal web server and web-site to deliver communication and reporting tools for staff. Enterprise version of Crystal reports is the department standard for all applications and allows easy access to reports for all staff. Other tools such as the Delivery database and staff directory are available on the internal web. As such tools are needed and designed, they can be deployed with minimal orientation using the website. We have started to work on easy ways for staff to access policies and accreditation activities using the website. Originally, the department's GIS mapping tools were located on this server. However, the City has improved and expanded their resources, so the Department is coordinating with that effort.

All published reports, maps, charts and graphs are accessible to staff on the website. --Key reporting tools were selected and implemented. They work with all the applications, databases and resources. Requirements for the original applications included the capacity to work with standard reporting tools such as Crystal Reports and GIS. The reporting tools help us integrate all the information and organize it to support decision-making. The following are our key tools: Crystal Reports enterprise; LogiXML Dashboard; GIS/ ESRI --A normalized database for assessment data was created in the last year. Our epidemiologist and programmer worked together with state staff to create scripts and protocols for each type

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Lincoln-Lancaster County Health Department
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Public Health Informatics: Sustainable and Strategic
Our primary goal for Public Health Information Technology and Management has been to develop and implement informatics resources that support and enhance our department's ability to accomplish its mission. Objectives include improving quality, cost effectiveness, efficiency, reporting and evaluation capacity. Through on-going analysis of need, evaluation of available resources (staff, funding and technology) as well as past successes and failures, we evolved a workable strategy. The strategy includes overarching principles, basic design elements and a conceptual framework. These provide guidance for informatics staff and department decision-makers for all levels of resource investment and implementation. What may be most unique and innovative about our approach is the consistent, practical application of these basic principles and design elements over the past fifteen years. No one decision or application is entirely unique or even groundbreaking. However, the accumulated impact of a strategic approach to informatics resources has positioned our department well for the 21st century. In 2001, the Health Director allocated $150,000 a year from state public health infrastructure funds (Tobacco Settlement) and issued the challenge to build a PHIT infrastructure for the Health Department. Over the next ten years, these funds paid for people and equipment. The Department also invested an additional $500,000 to $700,000 dollars from grants, savings and local funds to purchase specific software and associated hardware. During the same period, the department was able to coordinate with broad City and County infrastructure investments to improve our overall capacity. Our target population is the staff of the health department and by extension all the people served by the various department programs. 90% of the department programs are directly supported through specific applications, 100% of staff use information technology tools. 85% of direct services are supported by information technology at the point of service. The current status of our Public Health Information Technology Strategy is described below. It includes: --Four major point of service applications -EMR (direct nursing, medical and case management services) -Dental medical record systems (direct dental services) -Permits Plus (regulation and enforcement for Environmental Health) -Animal Control (regulation and enforcement --All point of service applications support in-house and remote work. Staff in the field use access the applications using tablets. --Internal web server and web-site to deliver communication and reporting tools for staff. Enterprise version of Crystal reports is the department standard for all applications and allows easy access to reports for all staff. Other tools such as the Delivery database and staff directory are available on the internal web. As such tools are needed and designed, they can be deployed with minimal orientation using the website. We have started to work on easy ways for staff to access policies and accreditation activities using the website. Originally, the department's GIS mapping tools were located on this server. However, the City has improved and expanded their resources, so the Department is coordinating with that effort. All published reports, maps, charts and graphs are accessible to staff on the website. --Key reporting tools were selected and implemented. They work with all the applications, databases and resources. Requirements for the original applications included the capacity to work with standard reporting tools such as Crystal Reports and GIS. The reporting tools help us integrate all the information and organize it to support decision-making. The following are our key tools: Crystal Reports enterprise; LogiXML Dashboard; GIS/ ESRI --A normalized database for assessment data was created in the last year. Our epidemiologist and programmer worked together with state staff to create scripts and protocols for each type
This project addresses core public health infrastructure by developing and implementing informatics resources that support and enhance our department's ability to accomplish its mission. Understanding the nature and function of the Department's work; our stakeholders, partners and customers; and the legal authority and responsibilities is critical to effective PHIT work. The most critical factor for success is to develop a strategy that encompasses the entire health department operation and MISSION. A strategy that is not based in a clear understanding of the mission and vision for the health department will not successfully navigate the changes inherent to local health departments and information technology over time. The use of informatics resources to support and enhance a local health department cannot be reduced to a single solution or application or even to a set of solutions or applications. However, it is possible to examine the general needs of local health departments and identify some basic commonalities or critical decisions that must be made. Local health departments provide direct services, enforce and regulate, monitor, assess and collect data, respond to outbreaks or environmental hazards, convene communities to address health risks and promote policies that improve health. No single software solution supports all of these tasks. Federal and state initiatives have continued to create systems that operate as silos at the local level. It became quite clear that waiting for federal or state initiatives to develop solutions was not answer. However, the work nationally to adopt standards for data and messaging will greatly enhance our local health department's ability to share data. We evolved a series of requirements that were included as part of all requests for proposals and software development criteria. We actively sought out vendors whose business model was based on staying current with national standards for interoperability. We worked to identify the most relevant standards for each application. We made a core decision early in the process that we did not wish to be the IT nor the ultimate content experts. This decision meant that we looked for off the shelf products that would meet our requirements.
Agency Community RolesThis practice was primarily developed and implemented by the local health department. The effort was led by the Division Manager for Information and Fiscal Services along with strong support from the Health Data and Evaluation Division. The Health Director provided strong leadership, funding and confirmed key decisions and investments. All division managers and supervisors were active participants in identifying needs and reviewing the overall strategy. Division and program leaders advocated for representation and inclusion of their requirements in the overall PHIT strategy for the department. The basic strategy was presented to the Board of Health periodically. Collectively, the Health Director and the Division Managers adopted the basic conceptual framework and strategy. For each application of solution, a very inclusive approach was used. For requirements development and for implementation, a structured methodology assured that all staff impacted by the application had the opportunity to review and provide input. A Steering Committee was created to provide oversight and guide the project. Workgroups were created that represented all programs, work areas and staff. Super users were identified and assigned to the workgroups. One of the responsibilities of the super user was to review questions, information and recommendations with their work groups to bring back to the Steering Committee. All of the work was documented and maintained in files on line that were available to all affected staff to view. One of the sub goals for every project was to review work flow and work processes and evaluate for effectiveness and efficiency. We took advantage of the opportunity to look at opportunities for re-engineering business processes to improve our overall ability to serve the public. We chose not to "computerize" the way we always had done the work—unless that was the most efficient process we could identify. In one instance, we invested a year in redesigning our clinic work processes and programs. When we finally implemented the electronic medical record, the transition was much smoother than we could have anticipated. By the time an application is implemented, staff using it have helped to document the work process, tested the application using "use cases" to verify functionality, completed training and had the opportunity to provide input at all the steps. Costs and ExpendituresOur primary goal for Public Health Information Technology and Management has been to develop and implement informatics resources that support and enhance our department's ability to accomplish its mission. Objectives include improving quality, cost effectiveness, efficiency, reporting and evaluation capacity. Through on-going analysis of need, evaluation of available resources (staff, funding and technology) as well as past successes and failures, we evolved a workable strategy. The strategy includes overarching principles, basic design elements and a conceptual framework. These provide guidance for informatics staff and department decision-makers for all levels of resource investment and implementation. What may be most unique and innovative about our approach is the consistent, practical application of these basic principles and design elements over the past fifteen years. No one decision or application is entirely unique or even groundbreaking. However, the accumulated impact of a strategic approach to informatics resources has positioned our department well for the 21st century. Our target population is the staff of the health department and by extension all the people served by the various department programs. 90% of the department programs are directly supported through specific applications, 100% of staff use information technology tools. 85% of direct services are supported by information technology at the point of service. The current status of our Public Health Information Technology Strategy is described below. It includes: --Four major point of service applications -EMR (direct nursing, medical and case management services) -Dental medical record systems (direct dental services) -Permits Plus (regulation and enforcement for Environmental Health) -Animal Control (regulation and enforcement --All point of service applications support in-house and remote work. Staff in the field use access the applications using tablets. ImplementationObjective / Tasks Time line Objective 1: Acquire, adapt or develop, support and maintain information management (IM) applications for all direct service activities. Applications must support work at the point of service and meet departmental standards for data integrity, interoperability, portability and accessibility as well as all program specific requirements for confidentiality and security. -1- Create a framework for IT needs and goals (2001) 6 months -2- Create a strategic IT plan 6 months -3- Identify business areas and common functions (2001, 2002) -4- Identify business areas which require IM support and prioritize. -5- For each business area 9-15 months • Develop requirements o Work flow analysis o Business Process analysis (stakeholder, user, reports, interoperability & document management) o Identify internal and external partners and investigate investing in a common solution o Requirements consistency with IT framework and principles o Research available technology and solutions (that require minimal customization) • Publish RFP / solicit proposals • Evaluate, Interview, Test and Select vendor; negotiate contract • Set-up and Implementation • Training and documentation (on-going) • On-going vendor management (on-going)   Objective 2: Establish standards and protocols (both technological and operational to ensure that data is collected, used and maintained in ways that assure: integrity of data, confidentiality, security, interoperability, portability and accessibility. -1- Create a framework for IT needs and goals (2001) that includes: • Guiding principles: Standards, Point of service, off the shelf, interoperability • Relationship of IT strategy to the mission, goals and strategy of the department, 10 essential services, state and national public health direction, and other stakeholders) • Critical decision points, policy guidance, criteria for decision-making 6 months -2- Create and maintain strategic IT plan (2001; updated: 2005, 2008, 2010) 2-6 months -3- Create, maintain and update performance measures, reports and other tools to monitor adherence. On-going -4- Create / exploit opportunities to integrate guiding principles into the "way of doing business" or organizational norms of the department (On-going) • Presentations, training includes modeling the value of the principles • Work process analysis and evaluation – assure that analysis includes the application of the guiding principles • RFP review—guiding principles are translated into criteria for the review • In-house developers must demonstrate adherence to the principles • Monitor new initiatives throughout the department and identify ways that use of the guiding principles can improve effectiveness and outcomes On-going -5- Participate in/stay informed of local, state and national public health informatics initiatives and developments On-going -5- REPETITION! REPETITION! REPETITION! (I've been doing it for 25 years) Objective 3: Identify and implement tools to report data and information for use by decision-makers. -1- Sounds deceptively easy—but real value is dependent on a foundation of information that follows the guiding principles and criteria: Standardized, Organized logically / we have created normalized data from assessment data, Accessible to reporting tools & Well-documented See above -2- Guiding principles and criteria for all applications include standards related to reporting capacity and interoperability with common reporting tools (e.g. Crystal Reports) Apply to all information acquisitions -3- Create Intranet – Internal Web for department—provide web-based access to services without need for each user to learn how to use specific software • Develop services—many support functions can be delivered using this tool • Deploy services and continue to support • Evaluate requests for new functionality for broader applicability 1 year initial New services: 1 day to 6 months -4- Research, solicit, purchase, deploy enterpris
Our goal was to develop and implement informatics resources that support and enhance our department's ability to accomplish its mission. And through our objectives we hoped to improve quality, cost effectiveness, efficiency, reporting and evaluation capacity In 2001, the objectives included: --Develop a model of an Integrated Data Management System for Lincoln-Lancaster County Health Department. Identify the existing components and those that need to be developed. --Acquire, adapt or develop, support and maintain information management applications for all direct service activities. Applications must meet departmental standards for data integrity, interoperability, portability and accessibility as well as all program specific requirements for confidentiality and security. --Establish standards and protocols (both technological and operational) to ensure that data is collected, used and maintained in ways that assure: integrity of data, confidentiality, security, interoperability, portability and accessibility. --Develop and expand data reporting and visualization capacity of staff. This objective also included: za) Design and developed a web-based query interface on the intranet to allow search and retrieval of datasets; b)Data will be available for reports and analysis from service encounter data bases and from reference data (population-based and geographic)through a shared intelligent search engine; and c)Establish and support standard off the shelf software for reporting and analysis. --Develop and maintain adequate technical computer support for systems, equipment and users. We are presenting updated and summarized objectives for this report. The first objective did not change. -- Acquire, adapt or develop, support and maintain information management applications for all direct service activities. Applications must meet departmental standards for data integrity, interoperability, portability and accessibility as well as all program specific requirements for confidentiality and security. Performance measures that we use to evaluate our progress include: a) PHIT plan that includes support for all direct service activities b) Approved RFPs (Requests for proposals) to solicit software solutions to support direct service activities c) Acquisition and implementation of software solutions -All programs and staff providing direct service are using the software solutions -Software solutions meet department requirements for data integrity, interoperability, portability and accessibility.   Results: za)Public Health Information Technology Plan and Project Priorities developed, approved by Health Director and published internally. Initial plan in 2001, updated in 2005, 2008 and 2010. b)RFPs developed and distributed to vendors for Environmental (2005), Dental (2007/2008) and Nursing Services (2008/2009). c)Contracts and funding approved and finalized for purchase of each application. Applications implemented in 2005, 2008 and 2009. i. The Environmental Health Application is fully implemented for the Food, Water and 75% of Solid Waste programs. It is implemented for complaints and emergency response. Still in process are the Special Waste Inventory and Permit program and the Title V Clean Air Emissions Program. ii. Dental Program is 95% paperless with the addition of digital radiography in 2009. iii. 100% of direct services provided by nurses, physicians, outreach workers and health educators are utilizing the electronic medical record. About 10% of staff are not currently using the tool at the point of service.We are currently working to refine the templates to increase adoption. d. Documentation includes: published plan, RFPs and system work processes and work flows. Management reports continue to be developed using Crystal Reports to review data collection processes and practices.
There is significant stakeholder commitment. The use of information technology has become integral to how we conduct our business. On-going support and maintenance is a part of our annual budget as a core operating cost. New development or major enhancements may require that we identify other revenue options. We have committed infrastructure funding from the state tobacco settlement dollars that pay for 2.0 FTES (developer, support & maintenance, GIS application development) and 2.75 FTEs are part of our core infrastructure funding from local tax dollars and indirects from grants. We have been able to stretch resources for specific projects using appropriate program funding sources (grants, contracts and fees). Implementation of the Dental Practice, Electronic Health Record and Environmental applications improved revenue recovery sufficiently to convince funders that the approach was viable, efficient and overall either reduced costs or were revenue neutral. The strategic, structured and systematic approach we have used has helped us weather a number of serious setbacks. This included a major failed project when a vender was unable to deliver as promised. The disciplined approach meant that we had the necessary support of the city's infrastructure (purchasing, risk management and legal) to help us negotiate the best resolution. The recovery of some of the costs enabled us to move on and research, redesign and re-invest in a solution that moves us into the future. While no organization wants to experience a failed project; it can also provide the impetus to make significant improvements. Before this, we had not thought to seriously explore the capabilities of electronic health record systems. We also learned firsthand the benefits of a following a structured approach. Our plan and our efforts have gained momentum with each successful implementation. The early time gap between implementations was several years. In the past three years we have done a major implementation each year (Dental practice system 2008; Electronic Medical Record 2009; Dashboard / Reporting application 2010). We are currently developing a Time Tracking Application to replace a number of legacy systems and approaches. It will be deployed in September 2011. The deployment of the dashboard / reporting application and capability has enabled us to display information in a timely manner and organized to support decision-makers and users. This deployment has hooked all our stakeholders. In giving each stakeholder immediate access to timely information that they need, we have created value on value. While, long term success is dependent upon dynamic links to valid, structured data and information systems; Exploiting the ease of reporting for users is creating a growing demand. The effect on our stakeholders is not limited to our immediate department and internal users. A number of our primary funding sources at the local level and state level are becoming very invested in these outcomes and products. Maintaining this commitment will require adherence to the systematic, disciplined approach we have developed as well as to the principles and guidelines. One of the elements that has not been mentioned that is critical to maintaining stakeholder involvement is an active presence at local, state and national discussions that impact public health informatics. Staying in touch with the initiatives and trends that will impact your stakeholders and drive demand for changes, enhancements or new development is very important. Increasingly, it is possible to be involved through professional organizations such as NACCHO or the Public Health Data Standards Consortium. There a host of working groups on public health informatics initiatives that do most of their work on-line and through conference calls. At a minimum, knowing the resources and checking key websites regularly for new information can help you in working with your local stakehold
 
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