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Connecting Public Health and Clinical Care

January 12, 2015
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Public Health needs to bridge the infrastucture gap to make use of the increasing volume of health information

I recently had a conversation with Marcus Cheatham, Ph.D., health officer with the Mid-Michigan District Health Department in Stanton, on some of the challenges he sees in public health. In addition to his work directing the public health department, Cheatham is co-chair of the Joint Public Health Informatics Task Force (JPHIT), a consortium of public health associations focused on improving public health through informatics, health IT and information exchange.

Cheatham noted that he is a bureaucrat, not an informatician, and said he is grateful that that JPHIT recognizes the need to have a public health worker at the table. As someone who runs  a public health department, he sees what is working in his public health department, and has some insight into the disconnects as well, he said.

For Cheatham, the challenges of public health fall into the buckets of chronic disease and communicable disease. The need for better communication between public health workers and clinicians is at the core of both issues, he said.

He said that efficient data connections between public health departments and clinicians are often lacking. He noted that public health workers constantly find people who have a chronic disease but are not connected to healthcare because of mental, emotional or family issues. Those people need help getting on the insurance rolls, but there also needs to be better communication between public health and the physician, providing him with information not just about the particular chronic disease but also about other issues going on in the patient’s life. “These are the high users of EDs, so the implications of being able to fix it are enormous,” he said.

Part of the problem is funding, Cheatham said. Many health departments are so poorly funded “that it would be a challenge for us to play the role that we could if we could if we had the resources to engage with hospitals that have fantastic technology resources,” he said. Yet he is also concerned if there is not enough institutional will on the hospital side for that to happen. “Given all of the strain that hospital CIOs are under with EHRs and meaningful use, how much energy are they going to put into building connections with the local health departments?” he asked.

“If a hospital said, ‘We want to partner with you and exchange data,’ the health department might not be able to respond,” he said. He added that there also needs to be an understanding of the types of information that is useful to public health.

Cheatham said that the state of Michigan has made significant progress in public health, including a strong immunization registry and disease surveillance system, both of which are a boon to public health as it deals with the requirements of meaningful use.

He is concerned about whether and how public health departments are able to exchange data with healthcare providers. Given that public health suffers from lack of public funding, it needs to demonstrate the impact it has on both healthcare and the insurers’ bottom line, he said.

In his view, if immunizations save money because there is less disease or if a public health nutrition program helps a patient-centered medical home obtain payments under the Affordable Care Act because their patient panel is healthy, then those entities will probably be willing to partner with public health to maintain those services, he said. Otherwise, they are essentially leaving money on the table and healthcare costs will be higher.

For that to happen, he said it’s necessary to “follow the money” from a patient’s visit to the health department, through the record of the EHR to the insurance company database, and demonstrate the value they derive from public health services. “Our systems need to be much more integrated,” he said. While that can’t be done yet, now is the time to lay the groundwork—which calls for vision and action.

Cheatham noted that many of those same needs exist for communicable disease as well. He said there needs to be better systems in place for notifications of reportable diseases, to identify outbreaks when they are happening. The use of such tools, and how well they are being used, is uneven today, he said. Better bi-directional communication is needed to tell providers in the community there is a spike of children coming into the ED with certain symptoms that should raise a red flag. 

He added that Ebola is just one of a long line of communicable disease threats and that there is a need for stronger tools for dealing communicable diseases in all its forms. “It takes too long to get that information back to providers; we need that two-way communication to be strengthened,” he said.