Public Health and Big Data

BDK08-1Public Health and Big Data

William Hersh, MDDepartment of Medical Informatics & Clinical Epidemiology

Oregon Health & Science University

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Public health and big data

• Definition, functions, and accomplishments of public health

• Public health informatics• Public health reporting and data• Syndromic surveillance and biodisaster

preparedness

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What is public health?• The “science of protecting and

improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention”– www.whatispublichealth.org

• “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time”– C. Everett Koop, Former US Surgeon

General

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More information on public health• Institute of Medicine (IOM) reports

– The Future of the Public’s Health in the 21st Century (2002)– Who Will Keep the Public Healthy? Educating Public Health

Professionals for the 21st Century (Gebbie, 2003)– For the Public’s Health: The Role of Measurement in Action

and Accountability (2010) – need to collect public health data and act on it

– For the Public’s Health: Investing in a Healthier Future (2012) – need to divert resources from healthcare to maintaining health

• Public health 101 for informaticians (Koo, 2001)• www.whatispublichealth.org

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Core functions and activities• Public health performs its missions through its core functions

– Assessment– Policy Development – Assurance

• Public health activities include– Prevent epidemics and the spread of disease – Protect against environmental hazards – Prevent injuries – Promote and encourage healthy behaviors – Respond to disasters and assists communities in recovery – Assure the quality and accessibility of health services

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Public health perspective• Public health tends to take perspective of health of

populations– One of its basic sciences is epidemiology – study of disease

in populations– However, public health is increasingly involved in other

forms of health promotion and prevention, e.g., obesity, nutrition, etc.

• May result in different perspective than individual care– Population-based view focuses on preventing disease as

well as societal impacts on health– Usually a government (regional or federal) activity

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A famous early public health story

• http://www.ph.ucla.edu/epi/snow.html • John Snow was an early epidemiologist

in the London in the mid-19th century• In 1854, he investigated a rapid outbreak

of cholera in Soho area of London• He found a common characteristic of

those infected: use of water from the Broad Street pump

• Dots represented cases; X’s represented clusters

• Early use of a geographic information system (GIS)

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Great public health achievements in 20th century (MMWR, 1999)

• Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard

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Public health informatics

• Application of informatics to public health• Textbook: Magnuson, 2014• Agenda: Massoudi, 2012• Maturing field: Kukafka, 2007; Araujo, 2009; Edmunds, 2014

– In 2012, US Department of Labor designated CDC Public Health Informatics Fellowship as “Registered Apprenticeship,” laying groundwork for a standard occupational code for public health informaticians, a first for informatics

• Informatics competencies for– Public health workers (O’Carroll, 2002)– Public health informaticians (CDC, 2009)

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Public health informatics competencies (O’Carroll, 2002)

• Three levels of competencies for public health practitioners– Use of information for public health practice– Use of information technology to increase one’s individual

effectiveness as a public health professional– Development, deployment, and maintenance of

information systems to improve the effectiveness of the public health enterprise (e.g., the state or local health department)

• Vary by staff level, e.g., front-line, senior-level technical, and supervisory/management

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Public health informatician competencies (CDC, 2009)

• Public health informatician– Support development of strategic

direction– Participate in development of

knowledge management tools– Utilize standards– Assure needs of projects or

program met– Management system

development and implementation

– Manage IT operations– Participate in applied public

health informatics research– Develop interoperable systems

• Senior-level public health informatician– Lead development of strategic

direction– Lead development of knowledge

management tools– Assure utilization of standards– Assure needs of stakeholders and

users met– Oversee system development

and implementation– Assure effective management of

IT operations– Conduct applied public health

informatics research– Assure systems are interoperable

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Public health has produced many valuable informatics resources

• Leading governmental agency is Centers for Disease Control & Prevention (CDC, www.cdc.gov) – Many informatics efforts brought together under National Center for

Public Health Informatics now folded into the Office of Surveillance, Epidemiology, and Laboratory Services (OSELS)

• Some (of many) resources from CDC– WONDER (http://wonder.cdc.gov) – observations from several dozen

databases collected by US government– EpiInfo (http://wwwn.cdc.gov/epiinfo/) – system for collecting and

analyzing epidemiologic data– Emergency Preparedness & Response Site (http://emergency.cdc.gov)

– for preparation and response to public health emergencies– Traveler’s Health (http://www.cdc.gov/travel/) – for international

travel from US

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More resources from CDC• National Notifiable Diseases Surveillance System (NNDSS,

http://wwwn.cdc.gov/nndss/default.aspx) – Promotes the use of data and information system standards to

advance development of efficient, integrated, and interoperable surveillance systems at federal, state and local levels

• Public Health Information Network (PHIN, http://www.cdc.gov/phin) – key components include– Detection and Monitoring – disease and threat surveillance, national

health status indicators– Analysis – real-time evaluation of live data feeds– Information Resources – access to reference materials, distance

learning, and decision support– Alerting and Communications – enabling emergency alerting and

collaborative activities– Response – management support of recommendations, prophylaxis,

vaccination, etc.

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Informatics challenges for public health

• Study of information seeking behavior and viewpoints of emergency preparedness and management professionals (Turoff, 2008)– Many different resources available and used

(including those mentioned in prior slides)– Difficulty obtaining relevant and current

information at time of need– Desire for more integrated interface or portal –

support for collaboration with librarians and other information experts

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Does public health informatics deal with same informatics issues?

• Adherence to standards and striving for interoperability (Tomines, 2013)– Public Health Data Standards Consortium (PHDSC, www.phdsc.org)

devoted to standards development for public health data• Enterprise/organizational view of information systems and

knowledge management (ASTHO, 2005)• New tools enabling, e.g., “digital epidemiology” (Brownstein,

2009; Salathé, 2012)• Privacy issues trade-offs and their discussion (Lee, 2009;

Demter, 2010)• Non-involvement of public health professionals in EHR and HIE

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A major function of public health is notifiable disease reporting

• Reportable diseases set by CDC in US• Case definitions defined explicitly (CDC, 1990)

– http://wwwn.cdc.gov/nndss/script/casedefHistory.aspx • However, states can modify list, e.g., Oregon reportable

diseases– http://public.health.oregon.gov/DiseasesConditions/Communicabl

eDisease/ReportingCommunicableDisease/Pages/index.aspx

• Timeliness can also vary by state, e.g., Oregon– Immediate (anthrax, plague)– Within 24 hours (rabies, polio)– Within one working day (most others)– Within 7 days (lead poisoning)

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Reporting is a long and active tradition of public health

• 1850 – first US federal mortality statistics reported• 1874 – Massachusetts becomes first state to initiate voluntary

reporting• 1893 – Michigan becomes first state to institute mandatory

reporting• 1961 – CDC becomes responsible for collection and

dissemination of disease reports• 1988 – IOM publishes first edition of The Future of Public

Health• 2001 – Anthrax attacks increase interest and funding in

disease reporting and surveillance

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PatientSeeks Care

Clinical Encounter

Clinician Observes Disease

Local Health Department Reports to State Health Department and/or

State Health Department Reports to Local Health Department and to CDC

State or Local Public Health Reports De-identified cases to CDCPublished weekly in MMWR

Clinician Reports to Local or State Health

Department(1 to 3 days)

Clinician Orders Lab

Tests

Patient Presents to ED, urgent care, or

Hospital

or

Lab Reports Results to State or Local Public Health

(1 to 3 days)

Lab Tests Ordered

Hospital Reports to Local or State Health Department

(1 to 3 days)

or

or

and

or

Patient becomes ill.

May purchase non-

prescription meds.

Public health reporting (courtesy, Laverne Snow, Utah DOH)

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What is typically reported?• Foodborne or waterborne diseases – e.g., Cholera, E. coli,

Salmonella, etc.• Sexually transmitted infections – e.g., Chlamydia, Syphilis,

HIV/AIDS• “Traditional” infectious diseases – e.g., tuberculosis (TB),

meningitis• “Exotic” diseases – e.g., SARS, Creutzfeld-Jakob, etc.• Environmental diseases – e.g., lead poisoning, pesticide

exposures, etc.• Maternal and child health – e.g., infant mortality, birth

defects, etc.

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Despite laws, there is inadequate completeness of reporting

• Systematic review of 33 published reports between 1970-1999 found variation from 9% to 99%, with completeness for AIDS, sexually transmitted infections, and TB higher (79%) than for all other diseases combined (49%) (Doyle, 2002)

• Reasons for clinicians not reporting– Unaware of legal requirement– Lack of knowledge of which diseases reportable– Do not understand how to report– Assumption that someone else will report– Intentional failure for privacy reasons

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Efforts to improve reporting• Strategies for increasing reporting (Silk, 2005)

– Active surveillance when appropriate– Automated, electronic laboratory-based reporting– Strengthening ties with clinicians and other key partners– Increasing use of laboratory diagnostic tests in identifying new cases

• Automated electronic laboratory reporting– Shown to increase rate of reporting in a variety of settings (e.g., Effler, 1999; Panackal,

2002)– Biggest challenges: standards for messaging, structured reporting, and consistent use

of “abnormal flag” (Overhage, 2001)– Adding data from health information exchange identified 4.4 times as many cases as

spontaneous paper-based methods and identified those cases 7.9 days earlier (Overhage, 2008)

• Using EHR data for public health reporting is increasing (Klompas, 2012; Tomines, 2013; Wu, 2014)as is adoption of meaningful use measures for public health reporting (Heisey-Grove, 2015)

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New opportunities for public health informatics

• Personal health record (PHR) – opportunities for health monitoring, surveillance, health promotion, linking to services, and research (Bonander, 2010)

• Mobile phones – especially in developing countries (Freifield, 2010)

• Combining EHR data with local incidence data can improve diagnostic accuracy for Group A Streptococcus (Fine, 2011)

• Digital epidemiology – use of Internet, social media, etc. (Salathé, 2012)

• Crowdsourcing – many potential uses, e.g., knowledge discovery, human intelligence tasking, broadcast search, peer-vetted creative production (Brabham, 2014)