Strengthening Public Health and Primary CareCollaboration Through Electronic Health Records

Electronic health records

(EHRs) have great potential

to serve as a catalyst for

more effective coordina-

tion between public health

departments and primary

care providers (PCP) in

maintaining healthy com-

munities.

As a system for docu-

menting patient health data,

EHRs can be harnessed to

improve public health sur-

veillance for communica-

ble and chronic illnesses.

EHRs facilitate clinical alerts

informed by public health

goals that guide primary

care physicians in real time

in their diagnosis and treat-

ment of patients.

As health departments

reassess their public health

agendas, the use of EHRs to

facilitate this agenda in pri-

mary care settings should

be considered. PCPs and

EHR vendors, in turn, will

need to configure their EHR

systems and practice work-

flows to align with public

health priorities as these

agendas include increased

involvement of primary

care providers in addressing

public health concerns. (Am

J Public Health. 2012;102:

e13–e18. doi:10.2105/AJPH.

2012.301000)

Neil Calman, MD, Diane Hauser, MPA, Joseph Lurio, MD, Winfred Y. Wu, MD, MPH, and Michelle Pichardo, MPH

ELECTRONIC HEALTH RECORDS

(EHRs) have great potential toserve as a catalyst for more effec-tive coordination between publichealth departments and primarycare providers in maintaininghealthy communities. As promi-nent health risks to the communitycontinue their shift from conta-gious diseases to chronic illnesses,public health departments are in-creasingly focused on conditionssuch as diabetes and obesity. Atthe same time, serious threatspersist from traditional publichealth concerns, such as commu-nicable disease outbreaks.

Primary care providers, andparticularly community healthcenters (CHCs), that provide carefor low-income populations areon the front lines in treating andcontaining both communicablediseases and chronic illnesses thatare more prevalent in these com-munities. Traditional models ofprimary care are also evolving, withincreased focus on community-based approaches in response tochanging financial incentives andformal recognition programs, suchas the Patient-Centered MedicalHome certification offered by theNational Committee for QualityAssurance and the Joint Commis-sion.1,2 Use of these models isfacilitated by the parallel increasein adoption of EHRs.

Federal incentive programshave been a proponent of EHRimplementation and “meaningfuluse” of EHRs among primarycare providers, with targetedfunding to support their adoptionamong CHCs.3 The promotionof health information technology

to improve the public’s health is1 of 5 focus areas for meaningfuluse of EHRs. Finally, 1 of the3-part aims of the Centers forMedicare and Medicaid Services(CMMS) is the improvement ofpopulation health—a goal thatwill only be met through im-proved coordination of primarycare and public health.4,5

In 2003, the potential for ad-dressing community health needswith the aid of EHR data exchangeinitiated a partnership betweenThe New York City Departmentof Health and Mental Hygiene(NYC DOHMH) and The Institutefor Family Health. Together, theseorganizations have developed,tested, implemented, and moni-tored the use of an EHR in meet-ing public health and primary caregoals. NYC DOHMH is one ofthe world’s largest public healthagencies, operating programs indisease control, environmentalhealth, epidemiology, health careaccess, health promotion anddisease prevention, and mentalhygiene. It also makes publichealth-enabled EHRs available toover 2500 primary care providersthroughout New York City as partof its Primary Care InformationProject (PCIP).

The Institute for Family Healthis a nonprofit organization thatprovides care to more than 80 000patients in 26 federally qualifiedhealth center sites in New YorkCity and New York State’s Mid-Hudson Valley. The Institute’sgoal in establishing an EHR sys-tem was not only to enhance thequality of patient care in its ownpractices, but also to improve the

health of the communities itserves. Recognizing that the 2organizations had parallel mis-sions to maintain healthy com-munities, the Institute and NYCDOHMH partnered in EHR dataexchange initiatives to meet theshared goals of improving thesurveillance and managementof both communicable diseaseand chronic disease. Projectsaddressing these goals are de-scribed below.

IMPROVE SURVEILLANCEAND MANAGEMENT OFCOMMUNICABLE DISEASE

Syndromic surveillance, thepractice of monitoring encountersfor symptoms that may representinfectious diseases and otherconditions of public health con-cern, can be facilitated by EHRsthrough automated data report-ing to public health departments.The Institute for Family Healthpartnered with NYC DOHMH tobecome one of the first ambula-tory settings to participate in syn-dromic surveillance.6 Routinelycollected chief complaint infor-mation along with important de-mographic data from Institutepatients are de-identified andtransmitted to NYC DOHMHdaily through a secure encrypteddata transfer mechanism. Respi-ratory illness, fever, diarrhea,and vomiting are the key symp-toms monitored, with analysis todetermine when the incidenceof these syndromes exceeds ex-pected thresholds.

Figures 1 and 2 present thepercentage of patient visits on

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November 2012, Vol 102, No. 11 | American Journal of Public Health Calman et al. | Peer Reviewed | Strengthening Collaboration | e13

a daily and rolling weekly basis inwhich influenza-like illness (ILI)was the documented reason forvisit at all of the Institute’s care

sites in New York City and theMid-Hudson Valley (Upstate), re-spectively, during the H1N1 epi-demic. These data illustrate that

the peak in ILI visits at Upstatesites lagged the peak experiencedin New York City sites by 5months,which guided the Institute to

redistribute immunization re-sources well after the New YorkCity peak. The ability to conductthis type of disease monitoring inreal time has the potential to in-form primary care providers andpublic health departments ofshifting needs during outbreaks.As increasing numbers of healthcare providers implement publichealth---enabled EHRs, publichealth departments have thepotential to receive syndromicsurveillance data that presenta more comprehensive profile ofthe population.

Like many public health de-partments, NYC DOHMH moni-tors the incidence of diseasethrough registries and requiredreporting of notifiable conditions,such as tuberculosis, by healthcare providers. Despite legal man-dates in most states, reportingrates for these conditions arenot optimal.7,8 The Institute facil-itated public health reporting bycreating alerts within its EHR thatremind providers at the point ofcare that a particular diagnosis isreportable and provide a link tothe reporting form. Patient demo-graphics are automatically popu-lated in the form to minimizeproviders’ time and effort in sub-mitting reports.

Institute data on immunizationand lead screening, which mustbe submitted to the city’s publichealth registries, are automaticallyuploaded from the Institute’s EHRsystem to NYC DOHMH, elimi-nating the need for providers orstaff to submit reports. Primarycare providers can use registrydata to look up immunization his-tories for patients in their prac-tices, potentially reducing bothgaps and duplication in immuni-zation schedules.

Findings from epidemiologicalinvestigation by public healthagencies can inform primary care

FIGURE 1—Percentage of patient visits at New York City sites for influenza-like illness (ILI): Institute for

Family Health, June 8–December 4, 2009.

FIGURE 2—Percentage of patient visits at New York State’s Mid-Hudson Valley sites for influenza-like

illness (ILI): Institute for Family Health, June 8–December 4, 2009.

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practices. This information trig-gers message distribution throughchannels such as the Health AlertNetwork in which nearly all largepublic health entities participate,and that may be delivered to thepoint of care through EHRs.9,10

The Institute and NYC DOHMHhave tested and implementedpoint-of-care public health alertsfor a variety of conditions. Forexample, New York City hasissued messages about West NileVirus detection through its HealthAlert Network, which Institutestaff programmed as alerts fortheir primary care providers,prompting them to consider thiscondition for patients presentingwith fever and headache. In an-other example, a NYC DOHMHalert about increased cases ofLegionella in a Bronx neighbor-hood prompted the Institute tocreate an alert to local providersto consider this condition in pa-tients with respiratory symptoms.An order set attached to thealert facilitated urine antigentesting that would otherwise havebeen unlikely. Such alerts canprompt primary care providers totake timely action to appropri-ately treat patients for emergingconditions.

Primary care providers can alsobe encouraged to take an activerole in disease surveillance efforts.During a measles outbreak, Insti-tute providers treating patientswith rash and fever respondedto programmed prompts and col-lected specimens requested byNYC DOHMH at the time patientspresented to the clinic. At theonset of the H1N1 epidemic in2009, clinical alerts requestedthat providers at Institute sitescollect viral specimens for a pilotsurveillance project to determinethe viral etiologies to respiratoryillness in the community.11 Be-cause of the success of this alert,

the Institute has continued toprovide community level samplesfor detecting ILI.

IMPROVE SURVEILLANCEAND MANAGEMENT OFCHRONIC DISEASE

Public health departments willneed new tools and partners toaddress the growing epidemic ofchronic disease. The functionalityof EHRs can be expanded to em-power CHCs and other cliniciansto provide better preventive andacute care through clinical deci-sion supports.12,13 Still, primarycare providers are challenged toincorporate dozens of care guide-lines into practice. The finite re-sources available across the healthcare system make it critically im-portant to have a public healthagenda that prioritizes servicesthat have the greatest impact onhealth.1,14,15

Recognizing this need, NYCDOHMH launched the Take CareNew York (TCNY) initiative in2004.16 TCNY set an ambitiousagenda to prioritize actions tohelp New York City improvehealth in 10 key areas, each ofwhich causes significant illnessand death but is amenable tointervention. NYC DOHMHestablished population-level tar-gets for each of these priorityareas, which include 10 goals forall New Yorkers:

1. Have a regular doctor or otherhealth care provider.

2. Be tobacco-free.3. Keep your heart healthy.4. Know your HIV status.5. Get help for depression.6. Live free of alcohol and drugs.7. Get checked for cancer.8. Get the immunizations that

you need.9. Make your home safe and

healthy.10. Have a healthy baby.

To integrate the TCNY agendainto its primary care efforts, theInstitute collaborated with NYCDOHMH in developing a modelclinical-decision support systemat its practice sites that is orga-nized around these goals. Healthdepartment and Institute staffreviewed each goal in the contextof medical evidence and practiceguidelines. A logic model wascreated for each goal that incor-porated available EHR dataand workflows, and also assessedfeasibility and acceptability inpractice. More than 40 alertsaddressing TCNY goals are cur-rently programmed into the Insti-tute’s EHR. Mindful of issues suchas “alert fatigue,”17 reminderswere engineered to fit into clinicalworkflows and incorporated toolsto facilitate adherence, such asdrop-down order sets, documen-tation screens, links to patienteducation materials, and the op-tion to suppress the alert if therecommendation was not indi-cated for the patient.

Health screening recommenda-tions incorporated into many ofthe TCNY alerts often require caremanagement and follow-up toimprove health outcomes. As partof its health care quality program,the Institute has used EHR datato develop disease registries andreports that enable outreachworkers and care managers toidentify and contact patients whoare overdue for a test, screening,or visit, or have a clinical measurethat requires special attention.Another critical component of theTCNY partnership is a reportingsystem to monitor these measuresat each practice site. A currentreport on all patients with docu-mented HIV test results, corre-sponding to TCNY Goal 4, ispresented in Figure 3. This exam-ple is illustrative of the need tocouple automated alerts with

a supportive health-care deliverysystem. Rates of HIV testing beganimproving markedly in 2011 asthe Institute’s health centers beganto incorporate on-site rapid test-ing, market related messages topatients, and redirect electronicalerts and order sets to nursingstaff to encourage testing prior tothe patient seeing the provider.

Alerts can also guide providersto public health resources towhich they can refer patients. Forexample, the provider alert toaddress smoking, TCNY Goal 2,contains an embedded, prepopu-lated referral form for the Fax-to-Quit line operated by the NewYork State Department of Health.Other possibilities include refer-rals to free mammography andadditional cancer screening pro-grams operated by publiclyfunded or other programs. Thisfunctionality is particularly perti-nent to CHCs that serve patientswhose lack of insurance oftencreates barriers to health services.Public health programs shouldconsider partnering with primarycare providers to use EHRs toinform them of these types ofcommunity programs at the pointof care.

EHR data can be used to iden-tify primary care patients at riskfor developing certain chronicdiseases or the sequelae of existingchronic conditions. Research hasdemonstrated that the data typi-cally stored in EHRs can be usedto identify patients at high risk forcertain diseases and that patientknowledge of increased risk ofdisease may motivate preventivebehavior such as obtaining cancerscreenings or vaccinations.18---20

The Institute has employed clini-cal data in the EHR to identify andreach out to patients at increasedrisk for disease, with initial pro-jects focused on colon cancerscreening and diabetes.

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Another project uses patients’demographic data to screenfor Hepatitis B. Screening forHepatitis B is not recommendedfor the general population; how-ever, screening is indicated forimmigrants from certain countrieswhere prevalence is high.21,22 Us-ing data on patients’ country oforigin, which is part of an organi-zational initiative to collect patientdata at the granular level, the In-stitute implemented an alert forHepatitis B screening that promptsproviders to order appropriatetesting if the patient is from acountry in which Hepatitis B isendemic but has not been testedor diagnosed with this condition.In the first 5 months after imple-mentation, the alert “fired” 32 515times and resulted in the orderingof 785 Hepatitis B surface anti-gen tests, with 10 previouslyunknown cases of Hepatitis Bidentified. Early identification ofchronic infectious diseases in pri-mary care practices can preventadverse outcomes like cirrhosisand liver cancer.

Racial and ethnic disparities inhealth remain a persistent publichealth problem. Minimal progressin this area has been attributed,in part, to a lack of standardizeddemographic data in health caresettings that can identify gaps andpoint toward best practices foreliminating disparities.23---26 Re-cent federal health care reformand health information technologylegislation call for health careproviders to collect data on pa-tients’ race, ethnicity, and lan-guage as part of health systemchange, and lays the foundationfor identifying and addressinghealth disparities throughout thehealth care system.3,27 EHRs canbecome powerful tools in theseefforts when they enable healthquality data to be monitored viapatient demographics at the gran-ular level.

The Institute has documentedpatients’ race, ethnicity, andpreferred language for healthcare in its EHR system since itsimplementation in 2002, with arecent expansion of demographic

data collection based on recom-mendations from The Institute ofMedicine.28 These data enablethe Institute to monitor care pro-cesses and outcomes for patientsin particular racial and ethnicgroups. Progress reports onTCNY measures are run bypatient race and ethnicity, asare disease registries and otherclinical reports. Disparities iden-tified in the HbA1c levels ofInstitute patients with diabetesspurred the development of anenhanced diabetes-care modelthat incorporates outreach andcare management for patientswith clinical indicators outside ofthe recommended range, who aremore likely to be of minority raceor ethnicity. Documenting granu-lar health data is the first step inidentifying gaps in care for whichboth front line providers andpublic health agencies can thenmarshal resources to identifyindividuals and groups experi-encing barriers to high-qualityprimary care and to target publichealth education campaigns.

REVIEW

Multiple sources of health datacan inform the priorities and actionsof public health departments, pri-mary care providers, individuals,and communities, when appropri-ately analyzed and coordinated.EHRs can form the hub of infor-mation exchange as primary careproviders document illnesses thatcan be uploaded to public healthdepartments to monitor diseaseand inform point-of-care decisionsabout treatment through provisionof relevant public health informa-tion. Public health departmentscan use aggregated EHR data,along with other sources of data,to prioritize community interven-tions and public health messages,as well as recommendations forprimary care screenings andtreatment. Individuals and com-munities make daily decisionsabout their health and lifestylesthat are reported to their primarycare providers and to public

health departments through

community surveys and assess-

ments. EHRs can help public

health departments and primary

care providers efficiently coordi-

nate their priorities to ensure that

patients and communities receive

consistent, high-impact health

messages. Data from one point

on the hub can inform action on

another point, forming a commu-

nity health information ecosys-

tem that fosters coordination

of data and health promotion

activities. Figure 4 diagrams the

potential flow of information be-

tween stakeholders.Although the partners in the

initiatives described herein weresuccessful in integrating publichealth and primary care function-ality, there are currently severalchallenges to expanding these col-laborations more broadly. First,

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FIGURE 3—Institute for Family Health office visits in which patients aged 18 years and older have

documented HIV test result or self-reported HIV status: 2009–2011.

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adoption of EHRs among primarycare providers is growing yet lim-ited. Roughly 25% of office-basedphysicians in the United Stateshave a basic EHR system andanother 10% have a fully func-tional EHR system.29 Furthermore,there are many EHR systems inexistence today, and this variabilitycan make it difficult for publichealth agencies to engage withmultiple primary care partners andensure that key communities arerepresented in health partnerships.Standards for the coding andtransmission of public health databy EHRs are in development, butmany such standards have yet tobe developed and others have notbeen broadly adopted by the EHRvendor community and by publichealth departments. Limited re-sources constrain the ability ofpublic health agencies and primarycare providers to collaborate andinnovate.

CONCLUSIONS

Public health departmentsand primary care providers mustintegrate their efforts in the de-velopment of electronic health re-cords if the United States is goingto successfully move from a healthcare system that is based on vol-ume of services to that which isfocused on maintaining healthycommunities. Primary care pro-viders, as “deputized public healthofficers,” have the ability to act asthe eyes of the health departmentin the community. They are mademore efficient and effective in thisrole when supported by publichealth---enabled electronic healthrecords.

Primary care providers, particu-larly CHCs, rely on public healthdepartments to provide the ex-pert guidance and situationalawareness that facilitates effectivehealth care delivery. EHRs provide

a mechanism for health depart-ments to deliver such guidance inreal time, as providers make caredecisions. As public health depart-ments develop new guidelines andpriorities for improving populationhealth, it will be important to con-sider how they can be facilitatedby EHRs in primary care settings.Primary care providers and EHRvendors, in turn, will need to con-figure their EHR systems to alignwith public health priorities. In thistime of rapid health informationtechnology advancement andhealth care realignment, it is criticalthat public health departmentsand primary care providers jointlyplan how to harness the power ofEHRs and achieve the benefits ofintegration. j

About the AuthorsNeil Calman, Diane Hauser, Joseph Lurio,and Michelle Pichardo are with TheInstitute for Family Health, New York, NY.Winfred Y. Wu is with the New York

City Department of Health and MentalHygiene, New York, NY.Correspondence should be sent to Diane

Hauser, Senior Associate, The Institute forFamily Health Program Development/Research, 16 East 16th Street, New York, NY10003 (e-mail: dhauser@institute2000.org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted July 20,2012.

ContributorsN. Calman and D. Hauser conceptualizedthe essay and were responsible for itscompletion in coordination with allcoauthors. All authors contributedintellectual content and participated inthe revision and editing of the essay.

AcknowledgmentsThe projects described in this article weresupported by several federal agencies,including The Centers for Disease Controland Prevention (grant P01 HK000029),the Health Resources and Services Ad-ministration (grant H2LCS18144), andThe Department of Homeland Security(grant 2009-OH-091-ES0001).

The authors would like to acknowl-edge the work of many colleagues at TheNew York City Department of Healthand Mental Hygiene and The Institute forFamily Health who have been integralto the successful collaboration of the 2organizations, as well colleagues at theColumbia University Department ofBiomedical Informatics who have pro-vided and continue to provide expertguidance.

Human Participant ProtectionInstitutional review board approval wasreceived for projects described in themanuscript that involved human researchsubjects.

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FIGURE 4—Exchange of health data between public health, primary care, individuals, and communities.

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