Tuesday, October 6, 2009

Observations on Public Health

During a dinner conversation at an IHE Meeting, we were discussing some of the problems that public health faces in this decade. To put this into context, I need to set the clock back three years.  At that time,  three different constituencies (Clinical Research, Public Health, and Quality) worked within the IHE Patient Care Coordination domain for an entire year to develop a white paper describing their differences. What they came out with instead was a white paper expressing their similarities.  Public health extended the original paper several steps further, analyzing two different domains within public health to identify their similarities.

They came up with several important functional requirements needed by all stakeholders:
  1. Expressing Criteria
  2. Managing Patient Identity
  3. Gathering Data
  4. Retrieving Additional Data
  5. Filtering and Data Review
  6. Analysis and Evaluation
  7. Mapping
  8. Aggregation and  Reporting
  9. Communication
The next year (after several important discussions about the pronunciation of acronyms), the Quality, Research and Public Health domain of IHE was formed (QRPH -- pronounced Quirf).

Now fast forward three years. Earlier this year we met with several members of the public health community at the PHIN Conference in Atlanta to discuss The Making of an IHE Profile.  During the discussion, we brainstormed several different ideas.  Many of the needs were already addressed in existing IHE profiles (the number of times that I said "IHE has a profile for that" was probably too many, but the point was made).  What came out of that were three ideas reported here which are being discussed in Oak Brook this week.  I'll let you know what happened to these ideas later this week.

Over dinner, we talked about how siloed funding has resulted in a siloed infrastructure (this isn't a new concept, it was identified in the early 1990's by a researcher at John's Hopkins University).  The solution is not to create more silos, but instead to figure out how to rationalize public health.  One concerned, and very much in the know person said "But that will never happen", and she's both wrong and right.  It certainly won't happen tommorrow, nor the next year, or even two.  However, it can be changed over time.  We just need to have the persistence to make it change, and show by example how to do it.  We also need to get people thinking about the future, instead of the last battle we lost.  We are still learning the wrong things in some places.

Take for example, the current H1N1 pandemic.  If you had asked people three years ago what pandemic we would be facing in 2009, I and likely many people working in public health would NOT have said H1N1 Swine Flu, but rather H5N1 Bird Flu. Where did all the money spent to deal with H5N1 Bird flu go, and why isn't that infrastructure effective for Swine Flu?  For that matter, what about all the money that was spent to deal with SARS in the previous decade?  Examine how funding for H1N1 surveillance, education, pandemic planning, et cetera is being awarded.  Huge grants and contracts are being issued, but as public health official told me last month, "That money runs out in June (2010) and we don't know what will happen afterwards...".  It's hard to build and maintain an infrastructure when the funding runs out because the emergency has past us.  We need to think about a sustained funding model for important public health issues. 

All is not lost, because others are learning the right things. One state near me looked at their public health infrastructure a few years ago and realized that if they were able to eliminate the inefficiencies in that state due to the information silos, thereby reducing duplicated infrastructure they could save about of $10 million dollars a year.  Upon learning this, their choice was to spend $5 million a year of that savings to build the right infrastructure that would help solve the problem and save them $5 million a year.  They are now looking at adopting an IHE infrastructure statewide in the service of their population, and won't be the first state to do so (I believe Vermont has that honor).

As I've become engaged in the healthcare space I've learned about two things:  patients and patience.  I no longer look for changes to occur in Internet time.  It takes about five to seven years to go from the initial stages of development for a NEW standard (as opposed to a revision of an existing one), into having several products available on the market using it.  It's going to take that long or longer to make some of the changes we need in public health (they need more than just one new standard).

Please Lord, give me patience  ... NOW!


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