ONC, CDC want to fix the fragmented public health system COVID-19 exposed

Photo: Oscar & Associates for HIMSS

LAS VEGAS – Under the Biden-Harris administration, the ONC and the CDC are focused on learning major public health lessons from the pandemic and moving forward rapidly to turn those lessons into action.

That was a major takeaway from a HIMSS21 session this week when National Coordinator for Health IT Micky Tripathi and Dr. Daniel Jernigan, acting deputy director for public health science and surveillance at CDC, took the stage via Zoom for a fireside chat with HIMSS CEO Hal Wolf and HIMSS Senior VP for Government Relations Tom Leary.

“The pandemic, though tragic and frustrating and still very much with us, has also done us the service of pressure testing our IT infrastructure in ways unimaginable just 18 months ago,” Tripathi said.

Unifying a fragmented system

One lesson learned was that the United States needs a unified public health response system, which it very much does not have now.

“Our public health system suffers from not really being a system, which is one of the challenges that we have,” Tripathi said. “And it’s really a loosely cobbled constellation of systems fragmented in a number of different ways.

“Jurisdictionally, where we have federal, state, county, metropolitan, territorial, tribal levels that, you know, that all of you don’t have a single line of authority but are all sort of collaborative partners in a way. So we have a value chain of stratification where you have primitive integration in many ways between massive political and administrative IT infrastructures and then a parallel public health system infrastructure that doesn’t really integrate very well through all of the other structures.”

Jernigan added that fragmented funding is one way that the silos cause problems.

“So much of public health work is done using federal and state funds. But much of the work happens with local, county and city government. So categorical funding leads to categorical programs, that leads to categorical systems and software.

“So we have several funding systems for multiple different things. So when COVID emerged, there was no categorical program for it, and no dedicated staff. So we need to change how we have been supporting our systems and move to supporting common platforms that are flexible, scalable, capitated programming in the hospital.”

Additionally, public health needs to be integrated into the healthcare technology ecosystem.

“We spent billions of dollars to lay a foundation, the EHR systems across the country,” Tripathi said. “We didn’t make corresponding investments in our public health systems to enable us to exploit in the modern age what our systems can offer in terms of information and functionality.”

During the pandemic, one area where this was especially obvious was around data reporting, Jernigan said.

“Reporting is one-way from clinicians and health care systems, and there’s little feedback,” he said. “And so we need to connect public health to the healthcare ecosystem in the same way that providers, labs, pharmacies and others are connected.”

Reporting was also too much of a burden because of the fragmentation of response agencies.

“During COVID conditions and health care providers had to report to multiple government agencies,” Jernigan said. “There needs to be a healthcare system in place that can then send that information on to multiple different state health departments.”

Other lessons learned

Data-sharing barriers also made it hard for the right people to have all the information they needed.

“We need to move past those barriers to data sharing,” Jernigan said. “We need to remove barriers to measure health inequities, so we need to address ways to improve collection and analysis of data to make it easier to characterize social determinants of health and address factors.”

Finally, the public health system doesn’t have the people power it needs to manage this sort of situation.

“We need to build a public health data science workforce,” Tripathi said. “We need to have more training and incentives for joining public health, and have competitive pay for the science workers.”

A first-tier customer

ONC and CDC are working together to address some of these issues. Many of them can be addressed by expanding the work that’s already being done on interoperability.

One area of focus is lab-test interoperability.

“CDC issued two standards for COVID test results,” Tripathi said. “And if you talk to a large provider organization, they’ll tell you they’ve got hundreds of different ways for COVID being represented [by] labs. Why? Because there’s no requirement. And any federal agency can say, ‘Here are two lab codes we want to use.’ There’s no way to enforce that. There’s no way to monitor it.”

Another priority is to add to the U.S. coordinated interoperability standards (USCDI) with an extension specific to public health, as well as to leverage FHIR APIs.

“ONC has a lot of authority over EHR standardization, things like that, we have a lot of levers we can pull in conjunction with the CDC, and we’re starting to hear some pretty good thoughts on how that might be able to work,” Tripathi said.

“Having public health be a first-tier customer of public networks: They’re not today. Thinking of all the data, billions and billions of records over care quality, commonwealth, interoperability today. And public health is a second- and third-tier citizen on those networks.”

A Biden administration executive order has kicked all of this into action. Currently, an interagency work group is working on a report due to be delivered early next year to the HHS secretary, Tripathi said. From there, the secretary will decide on next steps.

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