Chapter 8: Public Health, Government, and Nonprofits

Introduction

Public health organizations monitor population health, prevent disease outbreaks, and coordinate emergency responses. Unlike clinical care delivery, public health operates at the population level, requiring large-scale data integration, surveillance systems, and cross-jurisdictional coordination.

This chapter explores public health IT systems, surveillance infrastructure, emergency preparedness, and the unique challenges of government and nonprofit healthcare organizations.

Public Health IT Landscape

Core Public Health Functions

Public Health Information Network (PHIN)

CDC's Framework for Data Exchange:

• Standards: HL7 v2 (ELR, syndromic), FHIR (case reporting)
• Vocabulary: SNOMED CT, LOINC, RxNorm
• Messaging: PHINMS (secure messaging), Direct Protocol

Surveillance Systems

1. Syndromic Surveillance

Purpose: Early detection of outbreaks via pre-diagnostic indicators

Data Sources:

• Emergency Department (ED) Visits: Chief complaint, ICD-10 diagnosis
• Over-the-Counter (OTC) Sales: Antidiarrheal, fever reducers
• School Absenteeism: Unexplained absences
• EMS Calls: 911 dispatch data

Syndromes Monitored:

• Influenza-like illness (ILI)
• Gastrointestinal illness
• Respiratory distress
• Rash/fever

Systems:

• BioSense 2.0 (CDC): National syndromic surveillance platform
• ESSENCE: Electronic Surveillance System for Early Notification of Community-based Epidemics
• RHAVE: Real-time Hospital Available Beds for Emergencies

Workflow:

graph TD
    HOSP["Hospital ED"]
    MSG["HL7 ADT/ORU message"]
    GW["Public Health Gateway"]
    SURV["Surveillance Platform"]
    CLASS["Syndrome classification<br/>(NLP on chief complaint)"]
    AGG["Aggregate, detect anomalies<br/>(statistical control charts)"]
    ALERT["Alert epidemiologist<br/>if threshold exceeded"]

    HOSP -->|sends| MSG
    MSG --> GW
    GW --> SURV
    SURV --> CLASS
    CLASS --> AGG
    AGG --> ALERT

2. Electronic Lab Reporting (ELR)

Purpose: Automated reporting of notifiable diseases from labs to public health

Reportable Conditions (examples):

• Immediately Reportable: Anthrax, botulism, plague, viral hemorrhagic fevers
• Routine Reportable: Tuberculosis, syphilis, gonorrhea, chlamydia, Lyme disease
• COVID-19, Influenza: Added during pandemic

HL7 ELR Message:

• OBR Segment: Test ordered (e.g., COVID-19 PCR)
• OBX Segment: Test result (positive/negative)
• PID Segment: Patient demographics

Challenges:

• Data Quality: Missing patient demographics, addresses
• Deduplication: Same patient reported by multiple labs
• Timeliness: Delays in transmission (target: <24 hours)

3. Electronic Case Reporting (eCR)

Purpose: Automated triggering and reporting of cases from EHRs to public health

FHIR-Based eCR Workflow:

1. Trigger: EHR detects reportable condition (e.g., positive COVID test)
2. Evaluate: Reportability determination (based on jurisdiction rules)
3. Create Report: FHIR eICR (electronic Initial Case Report)
4. Submit: Send via FHIR API to public health agency
5. Response: Reportability Response (RR) sent back to EHR (guidance for provider)

Benefits:

• Reduce provider burden (automated vs. manual form completion)
• Faster reporting (real-time vs. days delay)
• Complete data (structured EHR data vs. incomplete forms)

Disease Registries

Immunization Information Systems (IIS)

Purpose: Track vaccinations to ensure complete immunization, prevent duplicates

Data Collected:

• Patient demographics (name, DOB, address)
• Vaccine administered (CVX code), dose, date
• Lot number, expiration date, manufacturer
• Administering provider/facility

Use Cases:

• Provider Query: Check patient's immunization history before administering vaccine
• Reminder/Recall: Identify patients due for vaccines, send reminders
• Coverage Rates: Calculate vaccination rates by geography, age group

Standards:

• HL7 v2.5.1 VXU message: Vaccine update
• HL7 v2.5.1 QBP/RSP: Query/response for immunization history

Cancer Registries

Purpose: Track cancer incidence, survival, treatment patterns

Data Sources:

• Pathology Reports: Diagnosis, tumor characteristics
• Treatment Records: Surgery, chemo, radiation
• Follow-up: Recurrence, survival status

Standards:

• NAACCR (North American Association of Central Cancer Registries): Data dictionary
• HL7 CDA: Exchange format for pathology reports

National Programs:

• SEER (Surveillance, Epidemiology, and End Results): NCI cancer surveillance
• NPCR (National Program of Cancer Registries): CDC cancer registry program

Social Determinants of Health (SDOH)

SDOH Domains

SDOH Screening and Referrals

Screening Tools:

• PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences)
• Health Leads Screening Toolkit
• AHC-HRSN (Accountable Health Communities Health-Related Social Needs)

FHIR Representation:

• Observation: SDOH screening responses (LOINC codes)
• ServiceRequest: Referral to community resource (e.g., food bank)
• Task: Track referral completion

Platforms:

• Unite Us: SDOH referral network
• Aunt Bertha (now findhelp.org): Community resource directory
• NowPow: Social care network

Emergency Preparedness and Response

Outbreak Management

COVID-19 Lessons Learned:

Emergency Operations Centers (EOC)

Functions:

• Situational Awareness: Real-time dashboards (cases, hospitalizations, ICU capacity)
• Resource Coordination: Ventilators, PPE, staffing
• Communication: Public health alerts, provider guidance
• Mutual Aid: Cross-jurisdiction support

Systems:

• WebEOC: Emergency management platform
• Veoci: Cloud-based EOC
• Juvare (EMTrack, EMResource): Hospital capacity, patient tracking

Health Alert Network (HAN)

Purpose: Rapid dissemination of alerts to public health officials, providers

Delivery:

• Email, SMS, fax
• Integrated with EHR in-basket (CDS Hooks)

Message Types:

• Health Alert: Immediate action required (e.g., contaminated drug recall)
• Health Advisory: Important info, no immediate action
• Health Update: Ongoing situation update

Data Integration and Architecture

Public Health Data Flows

graph TD
    SRC["DATA SOURCES<br/>EHRs | Labs | Hospitals | Pharmacies | Vital Records"]
    GW["PUBLIC HEALTH GATEWAY<br/>• PHINMS • Direct Protocol • FHIR API"]
    SURV["SURVEILLANCE & REGISTRY SYSTEMS<br/>Syndromic | ELR | Immunization | Disease Registries"]
    VIZ["ANALYTICS & VISUALIZATION<br/>Dashboards | GIS Mapping | Statistical Detection"]

    SRC -->|HL7 v2, FHIR, Flat Files| GW
    GW --> SURV
    SURV --> VIZ

Data Quality Challenges

Deduplication:

• Same patient reported by multiple sources (hospital, lab, provider)
• Probabilistic matching (name, DOB, address) without universal ID

Geocoding:

• Convert addresses to lat/long for hotspot mapping
• Address quality varies (P.O. boxes, incomplete addresses)

Timeliness:

• Balance completeness vs. speed
• ELR delays due to manual lab processes

Key Performance Indicators

Surveillance Metrics

Equity Metrics

Implementation Checklist

✅ Data Integration

• ELR Implementation: HL7 v2.5.1 interfaces with labs, mapping to LOINC
• Syndromic Surveillance: HL7 ADT feeds from hospitals, syndrome classification
• eCR: FHIR-based case reporting, reportability determination logic
• IIS Integration: VXU messages from EHRs, QBP/RSP for immunization history queries

✅ Surveillance and Analytics

• Deduplication: Probabilistic matching algorithm, manual review queue
• Geocoding: Address validation, lat/long assignment for mapping
• Dashboards: Real-time visualization (Tableau, Power BI, custom)
• Aberration Detection: Statistical process control, machine learning anomaly detection

✅ Emergency Preparedness

• EOC Platform: WebEOC, Veoci for situational awareness, resource tracking
• HAN Integration: Alert dissemination, EHR CDS Hooks integration
• Surge Capacity: Scalable infrastructure (cloud), pre-negotiated contracts

✅ Equity and SDOH

• SDOH Screening: Implement screening tools (PRAPARE), FHIR Observation mapping
• Community Referrals: Integrate with Unite Us, findhelp.org
• Stratified Reporting: Dashboards by race, ethnicity, geography, SES

Conclusion

Public health IT enables population-level health monitoring, outbreak response, and health equity initiatives. Successful systems require robust data integration, real-time analytics, and cross-jurisdictional collaboration.

Key Takeaways:

• Surveillance: ELR, eCR, and syndromic surveillance enable early outbreak detection
• Standards: HL7 v2 (legacy) and FHIR (modern) for public health reporting
• Equity: SDOH screening and community referrals address root causes of disparities
• Emergency Response: Real-time dashboards, EOC platforms, and HAN for coordination
• Data Quality: Deduplication, geocoding, and timeliness are critical challenges

Next Chapter: Chapter 9: Core Healthcare IT Solutions