Toward the National Agenda for Thailand's Public Health Informatics

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Toward the National Agendafor Thailand's Public Health Informatics

Nawanan Theera-Ampornpunt, MD, PhDFaculty of Medicine Ramathibodi Hospital, Mahidol University

Jan 31, 2012 http://www.slideshare.net/nawanan

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Outline• Introduction

U.S.• 2001 National Agenda for PHI• Developments in the past decade

Thailand• Progress in PHI and informatics• The way forward

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Public Health Informatics

• “The systematic application of information and computer science and technology to public health practice, research, and learning” (Yasnoff et al., 2000)

• “The application of informatics in areas of public health, including surveillance, reporting, and health promotion” (Hersh, 2009)

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Shortliffe (2002)

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Hersh (2009)

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PHI and Clinical Informatics

Hospitals & Clinics

Clinical InformaticsEHRs, CPOE,

HIS/CIS, PACS

Public Health Agencies


Biosurveillance, HIE, eHealth,

mHealth

Individual Health

Population Health

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An Agenda for PHI: U.S.

Yasnoff et al. (2001A)

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Yasnoff et al. (2001B)

Origin: AMIA Spring Congress 2001

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Yasnoff et al. (2001B)

6 Breakout Tracks

• Funding & Governance• Architecture & Infrastructure• Standards & Vocabulary• Research, Evaluation, & Best Practices• Privacy, Confidentiality, & Security• Training & Workforce

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Output

• 74 recommendations

Two key themes• Need to engage all stakeholders in

coordinated activities in PHI• Informatics training is needed

throughout public health workforce

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Some Recommendations


Funding & Governance• Fund information management as part of the core public

health budget• Fund vision of information, not IT• Create diverse funding sources• Allocate adequate funding throughout IS life cycle• Dedicated funding for public health IS• Leadership• Planning & management structures that include all

stakeholders• Ensure PH & IT representation in systems planning• Develop a merged superset of PH & informatics

planning & evaluation models• Business case for continuing investment in IS and

information architecture

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Architecture & Infrastructure• Provide Internet access & workstations, as well as

software tools, training, and methods for access to data for public health personnel

• Develop implementation plan for PH information architecture

• Develop a PH data repository from individual records, with process for development of its architectural model.

• Establish procedures for monitoring compliance with audit & evaluation criteria & access control measures in PH data systems

• [Controversial] Unique patient ID• Provide effective communication & workflow

management between public health and health care• Minimize impact of PH data collection on providers

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Standards & Vocabulary• Increase awareness of & participation in standards

development activities within PH workforce• List of existing standards & standards development groups• Identify gaps in coverage of existing standards• Promote consistent use of standards across federal agencies• Increase use of CDC Public Health Conceptual Data Model• Develop new standards for public health reporting• Expansion & maintenance of Dwyer tables for electronic lab

reporting to public health agencies• Develop model state regulations on reportable diseases• Develop implementation guidelines for transmitting electronic

lab reporting messages• Harmonize key guideline formats within HL7• Create database versions of ICD-9-CM & ICD-10-CM to

facilitate automated mapping of clinical terms for reporting & billing

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Research, Evaluation, and Best Practices• Process for developing & disseminating of best practices• Establish standards for performance• Establish a program to fund demonstration projects on best

practices in privacy protection• Link evaluation explicitly to the goals of Healthy People 2010• Standardize outcome measures• Include data quality, economics, transferability, & individual

measures in evaluations• Evaluate existing programs• Develop a research agenda for PHI• Use existing informatics knowledge & methods in PHI research• Involve multidisciplinary teams in PHI research• Include an informatics component in every PH research project• Provide additional research funds to study PHI• Establish & fund research agency for privacy & security

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Privacy, Confidentiality & Security• Create a national forum on privacy policy• Establish community advisory boards for privacy policy• Creation of public health ethics committees• Include front-line workers in public health privacy groups• Develop model wording for PH privacy legislation at all levels• Develop regulations & policies that are dynamic & based on risk• Develop policies for cross-jurisdictional exchange of data• Require all public health data systems to have confidentiality

agreements & privacy board• Develop model security policies• Adopt HIPAA security requirements in public health• Review security preparedness of public health system• Indirect funding options for security

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Training & Workforce• Establish & strengthen academic programs in PHI• Develop competency-based continuing education in PHI• Enhance CDC Public Health Informatics Fellowship Program• Establish instructional guidelines for PHI curriculum• Establish curriculum guidelines for PHI in PH programs• Develop curriculum on data security & privacy• Establish ethical/legal/social issues program in PHI• Involve PH groups when developing PHI curricula• Develop a career track in PHI within informatics• Encourage PH & informatics people to come together• Strengthen AMIA’s Prevention & Public Health SIG• PH & informatics outreach through existing networks• Support development of core competencies in PHI• Examine informatics competencies in other health-related fields• Adapt medical school informatics objectives to PHI• Define PHI

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What Happened Since 2001

• HIPAA regulations went into effect (2003) and become standard practice for health information privacy & security

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What Happened Since 2001• Creation of the Office of the National

Coordinator for Health IT (ONCHIT/ONC) to “develop, maintain, and direct the implementation of a strategic plan to guide the nationwide implementation of interoperable health IT...that will reduce medical errors, improve quality, and produce greater value for health care expenditures” (George W. Bush’s Executive Order, 2004)

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David Blumenthal, MD, MPPNational Coordinator for Health Information Technology (2009 - 2011)

Farzad Mostashari, MD, ScMNational Coordinator for Health Information Technology (2011 - Present)

Robert Kolodner, MDNational Coordinator for Health Information Technology (2006 - 2009)

David Brailer, MD, PhDNational Coordinator for Health Information Technology (2004 - 2007)

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What Happened Since 2001ONC Strategic Plan 2008-2012

2 Goals• Patient-focused Health Care• Population Health

4 Functional components• Privacy & Security• Interoperability• Adoption• Collaborative Governance

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• Regional Health Information Organizations (RHIOs)

• Health Information Exchange (HIE) Organizations

• Nationwide Health Information Network (NHIN)

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“...We will make wider use of electronic records and other health information

technology, to help control costs and reduce dangerous medical errors.”

Source: Wikisource.org Image Source: Wikipedia.org

President George W. BushSixth State of the Union Address

January 31, 2006

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Political Support Behind Health IT

23Source: WhiteHouse.gov

Political Support Behind Health IT

“...Our recovery plan will invest in electronic health records and new technology

that will reduce errors, bring down costs, ensure privacy, and save lives.”

President Barack ObamaAddress to Joint Session of Congress

February 24, 2009

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“Meaningful Use”Incentive Programs for EHRs

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The HITECH Act

Blumenthal (2010)

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Stage 1- Electronic capture of health information- Information sharing- Data reporting

Stage 2

Use of EHRs to improve processes of care

Stage 3

Use of EHRs to improve outcomes

Better Health

Meaningful Use of Health IT

Blumenthal (2010)

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Stage 1 Meaningful Use Criteria

Blumenthal & Tavenner (2010)

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What Happened Since 2001• AMIA’s Prevention & Public Health

Special Interest Group officially becomes Public Health Informatics Working Group*

• PHI competencies developed by CDC (2002, updated 2007 & 2009)*

• PHI textbook published(O’Carroll et al., 2003)*

• PHI career track a reality*• Computers & Internet widely available*• CIOs at all state public health

agencies**From Yasnoff’s PHI 2011 Presentation

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Updated National Agenda

• AMIA 2011 Spring Congress revised a national PHI agenda

• 5 Tracks• Ethics• Technical Framework• Professional Training & Workforce

Development• Research & Evaluation• Sustainability

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Massoudi et al. (AMIA2011)

Output• 62 recommendations

(publication forthcoming)

Three key themes• Promoting effective coordination &

leadership• Improving consistency of PHI through

common terminologies, evaluation methodologies & training

• Enhancing communication & information sharing

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Massoudi & Yasnoff (AMIA2011)

Changes from 2001 Recommendations

• Achieved• Not relevant• New• Evolved

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Some Achieved ItemsFunding & Governance• Fund information management as part of the core public

health budget• Dedicated funding for public health ISArchitecture & Infrastructure• Provide Internet access & workstations, as well as software

tools, training, and methods for access to data for public health personnel

Research, Evaluation, and Best Practices• Use existing informatics knowledge & methods in PHI

researchTraining & Workforce• Enhance CDC Public Health Informatics Fellowship Program• Establish instructional guidelines for PHI curriculum• Develop curriculum on data security & privacy• Strengthen AMIA’s Prevention & Public Health SIG• Adapt medical school informatics objectives to PHI


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Some New Items• Public health business processes to guide systems

development and semantic interoperability• User-centered design• Ensure sharing of public health systems• Integrate PHI research into public health training• Develop & implement innovative PHI training methods• Skills-based training in PHI evaluationEthics track• Have an ethics research agenda• Ensure policy demonstrates utility and value for PHI• Ensure that valid consent processes improve

understanding of benefits as well as risks


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Some Evolved ItemsArchitecture & infrastructure• A national process for investment and its governance• A coordinating agency• Representatives from national organizations• Success stories, use cases• Get PHI into the PH accreditation process• Promote infrastructure investmentStandards• Expand PH engagement and standards development,

implementation and maintenance• Engage in national interoperability initiatives to facilitate

information exchange with PH• No-cost PH licenses for data and vocabulary standards• Support data standards life cycle in PH• Develop tools for mapping across standards & vocabularies


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Some Evolved ItemsCompetencies, training & workforce• Keep competencies current and developing

them further into tiers• Integrate PHI competencies into PH

competencies• Promote use of these competencies in PHI

training programs• Create standardized and recognized PHI job

titles and descriptions• Establish credentialing for PH informaticians• Develop subspecialties within PHI as the

profession evolves• Market and promote PHI and informaticians


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What About Thailand?

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Thailand’s Current StatusKijsanayotin B, Kasitipradith N, Pannarunothai S. eHealth in Thailand: the current status. Stud Health Technol Inform. 2010;160(Pt 1):376-80.

• National policy and strategy on eHealth are still absent, as is the national eHealthgovernance body

• eHealth efforts exist but are largely fragmented

• Urgent need to close the foundational gaps to create sustainable eHealth environment

Enabling factors• Exposure of health practitioners to IT• Use of some information standards

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Thailand’s Current StatusRecommendations

• Creation of a multi-stakeholder, national eHealth authority

• Incorporation of eHealth strategy into the national ICT framework

• Promulgation of health information privacy legislations

• Development of national health information standards

• More systematic capacity building

Kijsanayotin et al. (2010)

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Thailand’s New Developments2011-2012• Governance & National Leadership

• National Health Information Committee

• National Health Information Standards Development Subcommittee

• Engagement & participation of diverse stakeholders in informatics communities & activities

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Thailand’s New Developments2010-2012• Capacity Building & Workforce Development

• ICT students with healthcare exposure(Mahidol University’s ICT & Ramathibodi)

• Biomedical & Health Informatics curricula with PHI focus (Mahidol University Tropical Medicine)

• Strengthening of Health Informatics program at Mahidol University Faculty of Public Health

• Healthcare CIO certificate program (MahidolUniversity’s Ramathibodi)

• Dental informatics certificate program at MoPH’sInstitute of Dentistry

• Ramathibodi’s Medical Data Standards Expos• TMI’s more active academic roles

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Estimate (Partial or Complete Adoption)

Nationwide

Basic EHR, combined inpatient & outpatient settings

49.8%

Comprehensive EHR, combined

5.3%

order entry of medications, combined

90.2%

order entry of all orders, combined

79.4%

Definitions | Estimates

New Research Findings on Health IT Adoption

Theera-Ampornpunt (2011, unpublished)

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The Way Forward

Image Source: Smiletemplates.com

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The Way Forward• Funding & Governance

• $$$• Unified national leadership with full

stakeholder representation• A dialogue toward “PHI National

Agenda”?• Technical Framework

• Architecture & Infrastructure• Vision & Enterprise Architecture for

“ThaiHIE”

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The Way Forward• Technical Framework

• Standards & Vocabulary• Gap identification• Selection & development of

necessary standards• Education & awareness building

• Privacy & Security• Review & revise health information

privacy law• Education & best practices

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The Way Forward• Research & Evaluation

• Research agenda • Systematic support for new research

in Thailand’s context• “Translation” of knowledge from global

health communities to Thailand’s local settings

• A cluster of informatics academicians

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The Way Forward• Training & Workforce

• Strengthening of existing programs• Development of new programs with a

different focus (clinical informatics?)• Clear career path• More formally trained informaticians!!• Most importantly:

• Facilitation of inter-institutional collaboration drawing strengths from various programs for mutual benefits

• As opposed to a “race to the bottom”

50Image Source: http://mortgageloans.com.ng/files/2011/05/WayForward.jpg

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References• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb

4;362(5):382-5.• Blumenthal D, Tavenner M. The “meaningful use” regulation for

electronic health records. N Engl J Med. 2010 Aug 5;363(6):501-4.• Hersh W. A stimulus to define informatics and health information

technology. BMC Med Inform Decis Mak. 2009;9:24. • Kijsanayotin B, Kasitipradith N, Pannarunothai S. eHealth in Thailand:

the current status. Stud Health Technol Inform. 2010;160(Pt 1):376-80.• Shortliffe EH. JBI status report. Journal of Biomedical Informatics. 2002

Oct;35(5-6):279–80. • Theera-Ampornpunt N. Thai hospitals' adoption of information

technology: a theory development and nationwide survey [dissertation]. Minneapolis (MN): University of Minnesota; 2011 Dec. 376 p.

• Yasnoff WA, O’Carroll PW, Koo D, Linkins RW, Kilbourne EM. Public health informatics: improving and transforming public health in the information age. J Public Health Manag Pract. 2000 Nov;6(6):67–75.

• Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M. A national agenda for public health informatics: summarized recommendations from the 2001 AMIA Spring Congress. J Am Med Inform Assoc. 2001 Dec;8(6):535–45.

• Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M, Goodman KW, Gatewood L, et al. A national agenda for public health informatics. J Public Health Manag Pract. 2001 Nov;7(6):1–21.

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Toward the National Agenda for Thailand's Public Health Informatics