Perspectives from the Field: Interview with Jeff Levi, July 21, 2014

Perspectives from the Field Interview Series

Interview with Jeff Levi, PhD

Executive Director of the Trust for America's Health and Professor, Department of Health Policy, Milken Institute School of Public Health, George Washington University.

(http://healthyamericans.org/pages/?id=67) 

July 21, 2014

Interviewer: Jane Hyatt Thorpe

Questions:

1) Please introduce yourself and tell us how what you do intersects with health information exchange?

2) How can health information exchange be used to improve public health?

3) What are some barriers or challenges to greater use and exchange of health information in the public health system?

4) What do you see as the most promising solutions to these challenges?

5) How does the current emphasis on use of electronic health records and other health information technology tools to support health information exchange for healthcare delivery affect the use of information in the public health system?

6) Are there ways in which the public health system uses information more effectively than the health care system, and are there lessons to be shared from the public health experience?

Transcript:

Question 1

JHT:  Welcome to the Health Information and the Law Perspectives from the Field interview series. Today, we’re speaking with Jeffrey Levi, PhD, who is the Executive Director of Trust for America’s Health.  Welcome, Jeff. Thank you so much for joining us today. Would you please tell us a little bit about your current position and how it intersects with health information exchange?

JL: Well, Trust for America’s Health does advocacy work around prevention and the public health, trying to encourage a stronger public health system, and we’ve been spending a lot of our time lately on the intersection of public health and the reforming health care system.  Certainly central to that is how health information technology is transforming what we in public health can learn about the public and the public’s health, and also provides new opportunities for partnership with the health care delivery system.

Question 2

JHT: Wonderful.  Can you expand a bit about health information exchange in general and how that can be used to improve public health?

JL: The public health system, until now, has really been dependent on very narrow streams of data – things that have been required by law to be counted (disease surveillance, primarily infectious disease surveillance) and relatively small, but often population-based, studies of other health factors that may be affecting the public’s health. What electronic health records/health information technology affords us is an opportunity to look at much larger sets of data, much more comprehensive sets of data, much greater ability to track people’s lives through the health care system, and really get a much more granular understanding of what is going on in a community. In the past, every time we wanted to learn something new about the health of a population, we’d have to layer on an additional surveillance system, so we’d keep adding one disease at a time.  HIV is a good example – we were doing STD surveillance, HIV came along, we added a very complex HIV surveillance system.  Now hepatitis is a concern, so people are saying that we now need to create a separate, siloed, hepatitis surveillance system.  In fact, we can turn to electronic health records, we can turn to health information exchanges, to provide us a lot of the information that we used to be collecting from these siloed surveillance systems, and learn so much more, not just about the specific conditions that people have, but also, how well they’re accessing care, how well they’re responding to care, and who we’re missing.  And that’s a tremendous opportunity for public health if we know how to take advantage of it.

JHT: It sounds like when you’re referencing larger sets of data, opportunities for potentially big data in this field, more information about individuals as well as communities, population-level data.  Is that part of what you’re thinking too – being able to mine information from very, very large (or “big”) data sets?

JL: That’s right, and I think one of the challenges in public health is that right now, our systems have only allowed us to answer the questions that we have thought of, and when we have new questions, we are creating new systems. Now, we’ll be able to mine this big data to answer new questions as they arise and, if we analyze it properly, to discover things about the public’s health that we might not have thought to ask. 

Question 3

JHT: What are some of the greatest challenges or barriers that you’ve seen to greater exchange of health information in the public health system, whether it be related to uses of specific technology, or you referenced the very siloed approach, but from an overall perspective, what are some of those greater challenges?

JL:   Well, I think the biggest challenge is just technical capacity. Many health departments do not have either the staff or the physical hardware to be able to take advantage of bigger data sets. Many of them have not established the relationships with their local health information exchanges to perhaps do that in a cooperative way. So, we have a large training and capacity problem.  You know, I think one of the big challenges around meaningful use, for example, has been that the public health community has really pushed for more public health measures associated with meaningful use.  On the other hand, the meaningful use exercises often show that there’s no one on the other end at the public health department that can really take advantage of this – there are still some reporting systems and some health departments that are using fax machines to exchange data. So we have a long way to go on the public health side, which requires an investment, in some cases, of resources and, in some cases, training.

Question 4

JHT: So, on the other end of the spectrum, thinking about these barriers and challenges, what do you see as the most promising solutions to these challenges, in terms of hardware or capacity or staff resources?

JL:  Oh, I think the exciting opportunities are twofold.  One, as health departments create stronger relationships with the health care delivery system and with health information exchanges, I think people will see tremendous opportunities. We’ve actually seen an example or prototype of that in the efforts that CDC supported in getting a better handle on data and investigating healthcare-associated infections, which was one of the first times that public health has really been able to utilize electronic health records at a hospital level to do disease investigation and to really mine out the challenges that a particular hospital may be facing. So I think we see the beginnings of that.  And I think the other part that I think is exciting is that CDC has actually adopted a new surveillance strategy to move their existing siloed systems to more of a common platform that can take advantage of the changes in health IT.  So, I think it will take some time to get there but I think we’ve gotten past the point of resistance to change and now are seeing more people moving toward “how do we create the capacity to take advantage of these opportunities?”

Question 5

JHT: You’ve referenced the Meaningful Use program, which provides incentives for uses of electronic health records in the health care delivery system, and obviously, there’s been a lot of focus on encouraging electronic health records and health information technology, particularly as it relates to health care delivery.  Has that emphasis in any way impacted the collection and use of information on the public health side of health care?   So do you think that the current emphasis on the health care delivery side is having beneficial impacts on the public health side?

JL: Well, I think certainly just creating the technological capacity would never have happened with public health alone. I think collecting this level of data would never have happened just with a public health purpose. But I think the flip side is that public health probably has not been as engaged in the design of these systems as might have been preferable, at least from a public health perspective.  So to some degree, public health is coming to the table a little bit late, and therefore, needs to be adapting its requests and its needs to a relatively established system, so I think that’s a little bit of a challenge.  I also think there have always been firewalls between the health care system and public health to some degree, except for when there has been legally mandated reporting, and the privacy issues that public health confronts and the privacy issues that the health care system confronts can often be used as an excuse not to collaborate.  

Question 6

JHT: So, thinking about the use of information on the health care delivery side and the public health side, and understanding your response to the last question that there has been a big push from the health care delivery side, are there ways in which information is being used on the public health side and lessons that can be learned from the public health side that may better inform efforts on the health care system side?

JL: So, I think one example of that is the degree to which in many communities the public health system is using health care data as almost a quality assurance approach.  It could be something like electronic lab reporting, something like hemoglobin A1C results, so you can see by practice who’s doing a better job or not, but also by zip code and by neighborhood to see where there are pockets, in this case, of uncontrolled diabetes, where there can then be community-level interventions. Because the link between public health and the health care delivery system is not just about the health of individuals but also about population health. What public health brings to the table is knowledge, experience, resources, and programs that can intervene at the community level, outside the clinical setting, that can then reinforce what is happening in the clinical setting. We’re not going to get control over the really expensive chronic diseases that are really driving health care demand and health care cost, unless we’re doing stuff inside and outside the clinic.  Using data to help target what needs to be done outside the clinic, I think, can be really innovative and make a difference, and is something that public health is bringing to the health care system as something that can be of benefit to the health care system, so it is a bi-directional advantage.

JHT: Wonderful. Well, thank you so much for your time. We really appreciate it.

JL: My pleasure.

Further Resources:

•       Trust for America’s Health:

–      http://healthyamericans.org/

•       HealthInfoLaw.org materials on quality measurement and reporting:

–      http://www.healthinfolaw.org/topics/65

•       HealthInfoLaw.org materials on public health data collection and reporting:

–      http://www.healthinfolaw.org/topics/67