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Diary Entry 1: The Opioid Epidemic

I am an epidemiologist in the state of Ohio, working on the opioid crisis. Currently, we are classifying the opioid crisis as an “epidemic”, meaning that opioid use is significantly above the endemic level for the state. Yearly, approximately 47,000 Americans die due to opioid overdose; over 2 million live with opioid addiction. Approximately half of those living with opioid addiction lack appropriate access to treatment and care. There is currently no “cure” for opiate addiction; those who beat their addictions are in a state of recovery and are subject to relapse. Ohio ranks 2^nd in the country for age-adjusted death due to opioid use and is an epicenter for the opioid epidemic. Despite this, Ohio also serves as a leader in many efforts to address the epidemic.

The opioid epidemic causes extensive damage in the United States, impacting a plethora of domains in both family and community life. The opioid epidemic has led to lost productivity and decreased economic opportunity for addicts, childhood and familial discord and trauma, and a strain on community resources such as first responders, emergency rooms, and hospitals. In Ohio, increased mortality due to the epidemic has led to increased financial, social, and caregiving burden(s) for many families and communities. Resource scarcity has led to financial ramifications for the state and decreased availability of health-related resources. To combat the epidemic, in 2017, Ohio initiated a state-wide acute pain prescribing guidelines in an effort to limit the number of prescribed opioids. In 2018, these guidelines were updated to also address chronic pain management. Ohio has also made naloxone and opioid overdose kits and trainings readily available and provides needle-exchange programs for addicts. Additionally, research at the Ohio State University and Case Western Reserve University focused on opioid use, management, and opioid use disorder lead Ohio to be uniquely poised to positively target and treat the opioid epidemic.

Diary Entry 2: The Public Health Problem

Opioids are an important tool to treat pain, however their association with adverse events and the current opioid epidemic offset much of the value they add. Often, opioid misuse originates from legitimate prescriptions, primarily to manage chronic pain. Unfortunately, many with opioid use disorder turn to other opioids after their legitimate prescriptions run out. This can lead to far-reaching impacts like increased heroin use, the spread of HIV and hepatitis C, and increased morbidity and mortality in the opioid use population.

To help solve the opioid epidemic, I find that the most pressing concern is the prescribing habits of providers. As an epidemiologist, it is important that I have access to clinical and insurance data surrounding opioid use. Information from medical records as well as treatment information from insurance claims can be leveraged to help build a better picture of who is using opioids, and what steps work to address addiction. Access to systems that track and report opioid prescriptions and allow other providers to see prior prescription history will allow practitioners to better identify and address drug-seeking behaviors; Ohio has a state-specific system in place already, from which data could be collected. Additionally, access to the influx of information and data we have surrounding opioid addiction, use, and treatment will allow me to continue to understand safe prescribing guidelines and help set further limits and regulations about opioid prescribing. By being able to look at data and understand the habits not only of opioid use populations, but of prescribers as well, we can further identify at risk individuals from the proscribe pool, and prescribers who are not adhering to current guidelines. In this way, we can influence further change.

Diary Entry 3: Solution Efficacy

Through the use and analysis of data surrounding safe-prescribing guidelines, I have contained the epidemic. While it was not straightforward or easy to get providers to limit their opioid prescribing, and many patients complained that they needed better pain management techniques, the regulation and decrease of opioid prescriptions has helped contain new addictions. Alternative pain management therapies, such as medication, acupuncture, herbal remedies, and existing pain management drugs such as Tylenol, have proved to be effective at managing pain in a similar fashion to opioids.

However, the crisis is still ongoing. While we have curbed the rate of new cases, there are still some new and numerous existing cases of opioid use disorder in the community. Many current opioid users have turned to heroin to feed their addiction. Frequently, heroin is now laced with fentanyl, which further increases morbidity and mortality rates. With increased morbidity and mortality, the burden of the epidemic has remained stagnant despite the decrease in new cases.

Diary Entry 4: Outcomes & Take-Aways

Should a situation like the opioid epidemic occur in the future, it is imperative that we address it earlier. By targeting an epidemic in its infancy, we can ensure that the crisis never reaches the same levels as the opioid epidemic. Additionally, by targeting a crisis at an earlier stage it is easier to treat, impact, and contain. One of the struggles with the opioid epidemic is that it went much further than just prescription opioids. Users began using street drugs as they are less expensive, which led to unexpected complications such as the addition of fentanyl in heroin, adverse ingredients and reactions, and a lack of knowledge about the actual ingredients many users were consuming. This added complexity to the public health response to the crisis.

To allow for a more rapid solution to crises in the future, informatics tools must be fully leveraged. A more interoperable health record system would allow providers and researchers to notice trends earlier. Further, integrating in criminal record databases, and using police resources would allow researchers and public health officials to fully understand the scope of the crisis. Better communication across all aspects of the response team is necessary to successfully combat a future epidemic.

Public health informatics is, perhaps, the original field of informatics research. While today we hear “informatics”, and think of big data, analytics, and health information technology, it is important to remember that public health informatics encompasses more and is more expansive than just data and analysis. Spanning both public health and informatics disciplines, public health informatics touches upon biomedical informatics, health services management and policy, epidemiology, and more. From the creation of mortality tables, to the requirement of documentation and the development of the first computer, public health informatics has been at the forefront of many medical advancements in the last two centuries. In this portfolio, you will find several key components that will aid in your understanding of public health and public health informatics:

1. PHI timeline: I have created an interactive timeline noting important milestones and events in PHI history. Milestones include key events such as Demond Halley’s mortality tables, John Snow tracking the cholera epidemic, and the establishment of the CDC. An interactive timeline was used to allow viewers to advance and rewind the timeline of public health informatics as necessary. Further audio and visual components were added to increase the available information and the viewing experience.
2. PHI Survey: the sample survey focused on cardiovascular disease, a chronic condition one might find in rural areas. Questions begun with basic demographic information, such as age and developed environment of residence. Questions then focused on the individuals’ experience with and knowledge about cardiovascular disease. The survey ends by asking preference-related questions on cardiovascular disease education. If implemented, the survey would be validated through pilot testing. The survey was designed to take under 10 minutes to ensure respondent burden was low. Further, the survey was composed of a variety of multiple-choice and short answer questions, allowing researchers to attain both quantitative and qualitative response data. This format also allows participants to ensure that their thoughts are appropriately represented in their responses.
3. PHI Diary: The purpose of this diary is to understand public health surveillance systems through the viewpoint of a public health official. The diary focuses on the opioid epidemic, going through key facets such as the 1) initial outbreak, 2) public health problem, 3) efficacy of solution methodologies, and 4) outcomes and take-aways for the opioid epidemic and similar situations. The diary was composed from the viewpoint of an epidemiologist working on the opioid epidemic in the state of Ohio. Ohio was chosen as it is the epicenter for the outbreak in the United States, and because it is uniquely poised to target the epidemic. Audio and textual renditions of the diary were made available for viewers to ensure resource usability.
4. PHI “in the news”, Part I: recent news articles were found from the popular press relating to Health Information Exchanges. The articles were summarized and then reviewed from the point of view of a potential stakeholder. The first article reviewed focused on the use of an HIE in New York state, and was reviewed from the viewpoint of a CIO. The second article addressed the global market share of HIEs and was reviewed from the viewpoint of a CDC officer.
5. PHI “in the news”, Part II: recent news articles were found from the popular press relating to components of public health informatics. The articles were summarized and then reviewed from the point of view of a potential stakeholder. The first article reviewed focused on use of technology, specifically EMRs, to improve the work of nurses in Singapore, and was reviewed from the viewpoint of a CIO. The second article addressed a cluster of HIV cases in Cabell County, WV, and was reviewed from the viewpoint of a CDC officer.

Through the creation of this PHI portfolio, I was able to identify key areas of interest in public health informatics and look at different scenarios from the viewpoint of public health informatics workers. Understanding that CIOs might have different priorities than CDC officers or epidemiologists was important: while it is important to attempt to bridge the gaps between stakeholders, it is imperative to focus your presentation and work towards the appropriate stakeholder for the project. If working in a hospital setting, for example, and trying to improve the EHR, it is important to target the CIO and their priorities in your presentations. On the other hand, if you are working for the state to combat the Opioid epidemic, it is likely you would want to focus your work towards CDC officers and epidemiologists.

While creating my portfolio, I realized the importance of integrating mixed media strategies, and ensuring that the viewer and end-users are taken into consideration when creating content. Rather than creating content the way I would prefer to see it, instead I need to focus on the end-user and the stakeholders for a project. For example, while I prefer to use written text, some prefer video or audio for information dissemination. In the PHI portfolio, I was able to use both techniques, hopefully allowing all learners to access and appreciate the content. I additionally found that public health informatics is more trans-disciplinary than I initially realized. Through the PHI portfolio, I was able to leverage and add to my existing knowledge of disciplines. Understanding that public health informatics is not only a growing field, but also one that is continually changing (as evidenced by the PHI in the news assignment) was a crucial learning moment during this experience.

Title: Leveraging technology and informatics to improve the work of nurses

Source: Healthcare IT News

Summary: In this article, experienced nurses from Singapore shared their experiences with using HIT and the EMR to better patient care. Advantages to using technology to support medical care provision include: machine analytics in the collection of patient data (e.g., vital signs), built in escalation protocols and interventions, and improved compliance rates. All of these elements assist nurses in providing the best patient care possible. One hospital in Singapore modified the National Early Warning Score (NEWS), which aids in the identification of patients who are clinically deteriorating. The hospital integrated the system into existing medical devices and tied necessary inputs to pre-existing documentation; this alleviated the need for nurses to dual document or to utilize new technology. The system also integrated with the hospitals’ existing EHR. The system does not relieve nurses and care providers from making decisions, it solely helps support them and gives them the information necessary to best do their jobs. The new process saved time, and decreased ambiguity and subjectivity in clinical decision making. The time savings and increased patient safety held true in LTC settings, as well.

The article also security concerns, focusing specifically on cybersecurity. One of the top concerns is medical device safety in Singapore. As poor security can lead to PHI and HIPPA violations/breaches, it is imperative to safeguard patient information. Network security can be targeted through devices or data elements. By eliminating unauthorized device use, advancing network settings, ensuring patient validity, and bolstering encryption and security, one can help secure health information.

Impact Assessment – CIO Viewpoint: The evidence suggests that the implementation of EHR systems and other associated HIT elements is crucial to improving the safety of patients and care provider workflows. The experience of hospitals in Singapore suggests that by integrating basic functionality – such as the immediate and automated flow of vital information from devices to the health record – we can decrease the time it takes for providers to intake patients, increase the reliability of input data, and leverage the existing decision support and monitoring systems. Further, by using and modifying existing systems – like NEWS – we can increase incident prediction and provide better care for patients and families. While security is a concern, and HIPAA violations are routinely in the news in the US regarding PHI data breaches, by having a strong network and a stable infrastructure, we can offset many of the cybersecurity concerns. The US has standards to help secure information standards from cyberattacks, and by building upon the base standards we can have a safe and secure network.

From a public health informatics perspective, it is imperative that we leverage and improve upon existing technology to better the work of nurses and the outcomes of patients in healthcare arenas. We can use public health informatics techniques, such as data analysis and workflow management, to help streamline these processes. Therefore, it would be my recommendation, as a CIO, to continue to implement HIT functionality, and – whenever possible – to integrate it into existing technology, workflows, and EHRs.

Title: Unraveling an HIV cluster

Source: The Washington Post

Summary: Over 80 cases of HIV have been diagnosed in Cabell County, WV since early 2018; this is significantly above the endemic level of 5-8 cases per year. All cases have been tied to IV drug use, which has led to Cabell County being declared an “HIV cluster”. This cluster, and the IV drug use, is likely tied to the national opioid epidemic. The area is particularly susceptible to HIV and drug use, as it is on the border of both Ohio and Kentucky, both epicenters for the opioid epidemic; by the early 2010s, IV drug use had spiked in Cabell County. Other concerns surround the opioid epidemic in Cabell County. Fentanyl has increasingly been laced into batches of heroin used by the community, and Huntington (a town in the county) was named the “Overdose Capital of America” in 2017. While the county began an active clean needle-exchange program in 2015 in an attempt to curb the transmission of disease, it has not prevented cases of HIV.

Since the rising rates of HIV were identified, public health officials implemented voluntary HIV testing for patients. Two months after testing began, Cabell County was labeled an “HIV Cluster”, which indicated a rise in infection in a population, in this case linked by needle use. A similar trend was previously seen in Scott County, IN (2011-2014), however this cluster was stopped due to the implementation of a needle-exchange program. This is already in place in Cabell County, and had elicited pushback from city officials, leading to a restriction of program resources in 2018. This restriction aligned with when the cluster is thought to have begun.

Impact Assessment – CDC Officer: Clean needle exchange programs have always been controversial, with many suggesting that rather than help alleviate transferable illness, they instead lead to an increase in drug use. Others have suggested that clean needle exchange programs – such as the ones in Scott and Cabell Counties lead to addicts moving into an area, so that they can use drugs and receive free, clean needles. This, the logic goes, leads to an increase in homelessness and crime, and deters homeowners from moving to the area. Needle exchange programs are also notoriously hard to implement well. However, in scenarios like described in this article, it is imperative to take all steps possible to prevent further disease transmission. Leveraging public health informatics and epidemiology to find the cause, officials were able to outline a clear geographic and causal link between patients in the HIV cluster. It follows, therefore, that programs such as clean needle exchange programs be continued to ensure that HIV transmission is stopped. Other communicable diseases, such as Hepatitis, can also be transmitted through shared and unclean needles. It is important that we proactively prevent against said diseases.

Title: New York Health Information Exchange Saves $160 to $195M

Source: EHR Intelligence – xtelligent Healthcare Media

Summary: Due to the use of a statewide HIE in New York, the state announced annual savings of between $160 and $195 million. This estimate assumes that current participants do not use the SHIN-NY (Statewide Health Information Network for New York) system to its full potential; if leveraged appropriately, an estimated $1 billion could be saved per year. Cost savings, the system reports, are associated with “duplicate testing, avoidable hospitalizations and readmissions, and preventable emergency department visits”. SHIN-NY is an example of a HIE system that has been fully embraced in the state of New York. All hospitals and over 100,000 healthcare providers participate, allowing patients and providers to access records regardless of the location. The HIE system also focuses on value-based care and increasing interoperability between different healthcare arenas, such as LTC and behavioral health. The SHIN-NY network, the reporter notes, allows for the secure electronic transfer of patient records and supports improved patient outcomes at reduced costs through “improved care coordination, quality of care, and patient safety”. Going forward, more providers are being encouraged to join the HIE and to increase the connections within the state of New York.

Impact Assessment – CIO Viewpoint: According to the IHI (and building on Berwick’s 2008 article on the Triple Aim), the three most important factors in healthcare today are: reducing the per capital costs of health (cost containment), improving patient experience of care, and improving population health. One way to do this, as shown by the New York example, could be through the use and facilitation of a health information exchange. If SHIN-NY lives up to its potential, and can save $1 billion/year in New York, it will have monumental consequences for the healthcare system. If the HIE is scalable to a national level, we could work to reduce per capita costs while improving both the patient experience and population health. By decreasing unnecessary tests and improving care coordination and safety, a HIE could help impact all three components of the Triple Aim. From the viewpoint of our hospital, it is imperative that we continue to closely monitor the example in New York and of others: if interoperability and the use of a HIE indeed allows us to deliver better care at lower cost, it would be foolish to not utilize the tool. While ensuring the security and confidentiality of patient records would be difficult, it is important to work with computer scientists and informaticists to ensure that our system be safe, feasible, and usable. It is my recommendation that, if the SHIN-NY system is a success, we integrate into a similar HIE.

Title: Health Information Exchange (HIE) Market Size is Expected to Grow Exponentially Due to Raising Demand for Reduction in Healthcare Cost Till 2024 | Million Insights

Source: NBC

Summary: Million Insights, a leader in market research, has projected that healthcare IT will expand substantially in the next 5 years. Health information exchanges (HIEs) will also grow, as the need for information and awareness of HIE technology increases. Current and future governmental incentives for the implementation of technology in healthcare and public health will also contribute to the growth of HIT and HIEs. The HIE market is broken between implementation (hybrid, centralized, and decentralized) and vendor models, and is implemented both publicly and privately; the most popular HIE model is projected to be a private decentralized-centralized hybrid model, combining the best aspects and benefits of the potential HIE systems. The HIE market is segregated into different data exchange patterns, such as those focused on patient control, coordinated care, and unplanned care. Web portal development, interfaces, secure messaging, and improved workflow development all tie into the application and development of new and improving HIEs. HIEs are projected to mostly use web-based systems due to the ease of data and end-user access. North America is projected to have the largest HIE market share, adoption rate, and corporate presence out of any of the geographic categories (i.e., Europe, Asia Pacific, Latin America and MEA).

Impact Assessment – CDC Officer: The growth of health information exchanges and the improvement in the market share is an exciting development for the field of public health informatics. Health information exchanges assist providers and researchers in accessing and analyzing data from discrete geographic areas, and bring together transdisciplinary teams to target improvements in healthcare delivery and quality. By having increased HIE buy-in from key stakeholders, such as doctors, nurses, and administrators, it is possible to have faster access to patient information and data both within and beyond health systems. Timely access to patient records ensures that quality care is delivered, reduces duplicate testing, questions, and work, and can further decrease the rate of medical errors and unnecessary hospital readmissions. The implementation of HIEs throughout the United States will substantially improve patient care, delivery, and public health outcomes. Data compiled through the HIE can also be used to track patient behaviors, and address epidemics: already, we are using interoperable systems to track opioid prescriptions and narcotics. Going forward, we can further this effort to accurately track disease incidence and prevalence and to track care decisions, treatment options/plans, and disease progression. By fully utilizing the technology inherent in a HIE, we improve patient safety and results.

Chronic Condition: Heart Disease

Cardiovascular disease is the leading cause of death in the United States; it is uniquely impactful in rural populations¹. This disparity could be due to cultural, environmental or educational differences, or something else entirely². For example, cardiovascular disease could be more prevalent (and have increased morbidity and mortality risks) in rural areas due to the lack of available treatment specialists, grocery stores to buy healthy foods, and gyms for people to utilize. Cardiovascular disease is defined as: “all types of diseases that affect the heart or blood vessels, including coronary heart disease … stroke, congenital heart defects, and peripheral artery disease”³.

In this survey, I seek to understand current views about cardiovascular disease in rural populations. By understanding knowledge levels pertaining to cardiovascular disease in rural populations, we can target information campaigns and increase the dissemination of information to positively impact those at risk for and those suffering from cardiovascular disease.

To access the survey, please use this link: https://sarahhyman.typeform.com/to/Kl0TSt. Questions are also listed below:

Which of the following best describes your home neighborhood?

• Urban
• Suburban
• Rural 

What is your sex?

• Male
• Female
• Prefer not to say 

What is your age? (numerical input response)

Have you ever discussed heart disease with your doctor? This includes risk factors for heart disease, familial history of heart disease, or any concerns you may have about heart disease. This could either have been with your primary care provider or a specialist.

• Yes
• No

Have you or a family member ever been diagnosed with heart disease?

• Yes
• No
• Unsure/Can’t Remember

How would you rate your knowledge of heart disease? This would include information about diet, lifestyle, medications, risk factors, treatments, etc. (scale of 1-10 response)

Do you think heart disease is a concern in your community?

• Yes
• No
• Unsure 

What do you think the largest contributors are for heart disease in your community? (choose all that apply)

• Access to fresh and healthy food
• Infrequent access to preventative medical care
• Lack of knowledge about heart disease and its associated risk factors
• No areas to exercise (e.g., sidewalks, gyms, etc.)
• Lack of community-based prevention programs
• Other

*Skip logic*: If you answered “other”, please explain: (short answer)

What is your biggest concern about heart disease? (short answer)

*Integrated logic from previous question*: What makes ___ concerning for you? (long answer)

How would you prefer to receive educational information on heart disease? (choose all that apply)

• From my doctor during regular appointments
• Email/Online/Computer-based communication
• Mailed literature
• Phone calls
• Hospital-based education events (such as open houses)

When developing the survey, I tried to keep it short and to ensure all questions were worthwhile. This was to avoid survey fatigue as many respondents will likely be older and may not be entirely computer literate. When developing surveys, you can use a wide assortment of question techniques such as scales, multiple choice, short answer, and more. Because I am utilizing a web-based survey, I also used skip-logic and integrated questions to better form my survey. You could not use these methods in a paper survey.

To validate the survey, we first would need to pilot test it to ensure the questions being asked are appropriate and respondents are engaging effectively. We would then want to check our internal validity and consistency before revising the survey. Our survey would need to be validated for face, content, criterion related and construct validity⁴. To do this, we would use the technique of substantive validity analysis⁵. It is possible the survey could go through several iterations before being utilized in the public. It is incredibly important to ensure that our survey has internal validity to make sure we can draw causal conclusions and we can trust the results from our survey. After the survey is launched, it is important to ensure a representative respondent base so that we can generalize our findings and have good external validity.

References:

1. Taylor, H. A., Hughes, G. D., & Garrison, R. J. (2002). Cardiovascular disease among women residing in rural America: epidemiology, explanations, and challenges. American journal of public health, 92(4), 548-551.
2. Hartley, D. (2004). Rural health disparities, population health, and rural culture. American Journal of Public Health, 94(10), 1675-1678.
3. National Heart Lung and Blood Institute (NIH). (n.d.). Know the Differences: Cardiovascular Disease, Heart Disease, Coronary Heart Disease (p. 1). Retrieved from https://www.nhlbi.nih.gov/sites/default/files/media/docs/Fact_Sheet_Know_Diff_Design.508_pdf.pdf
4. Burton, L. J., & Mazerolle, S. M. (2011). Survey instrument validity part I: Principles of survey instrument development and validation in athletic training education research. Athletic Training Education Journal, 6(1), 27-35.
5. Hinkin, T. R. (1998). A brief tutorial on the development of measures for use in survey questionnaires. Organizational research methods, 1(1), 104-121.

Updated to have Edmund Halley’s mortality tables constructed in 1693 and ENIAC being introduced in 1946 (previously these were erroneously dated as 1673 and 1947 respectively). The title was also updated from “BMI 5760: Public Health Informatics Timeline” to “A Timeline of Advancements in Public Health Informatics”.