Using the Web to Improve Public Health Awareness

At the Missouri Dept. of Health, one of our major goals is to speed the identification of potential health threats and their impact on state residents. We have found that information technology can play a strong role in responding to new public health problems and challenges. Specifically, we need to improve reporting of major diseases and health risks from a variety of sources, including medical providers, laboratories, and public health agencies. We must more effectively communicate up-to-the-minute data regarding major changes in health conditions such as the spread of new contagions or identification of abnormal susceptibility among state residents.

The major hurdle is integrating diverse sources of information and universally communicating it. For instance, this is especially critical when new strains of flu or antibiotic-resistant microbes appear. Until recently, that was difficult, if not impossible to do since, within the state health department alone, there were over 60 different standalone computer systems serving individual health programs, running on a variety of platforms. It was hard enough sharing this information internally, even more difficult providing the data to agencies at the county level.

In 1994, the state began to build MOHSAIC (Missouri Health Strategic Architectures and Information Cooperative) to help county health care professionals identify patients that need services, and to integrate the delivery of these services to families. In so doing, we would eliminate redundant data collection and establish consistent data collection standards via an automated system that would be easy to learn. Given the challenge of integrating systems and delivering data, we could not afford to spend excessively on training.

The Solution

Our first step was to implement a network that would connect approximately 1,000 employees of the Department of Health who are located in 13 sites throughout the state. To accomplish this, we installed 11 Compaq Proliant 500R servers, running on the Novell Netware 4.11 LAN operating system. The Department also has 13 IBM RS6000 on the network, which are used for statistical research. Within the buildings, the servers and clients are connected with a 100MB Ethernet. T1 lines are used to connect the major Department of Health sites. The smaller sites are connected via 56-256KB frame relay lines. Once the internal Department of Health network was completed, we began connecting the over 100 local public health agencies located in counties throughout the state. Depending on the size of the agency, 56-284KB frame relay lines are used to install the local agencies. As of May 1998, over 70 percent of these agencies were connected and the rest will be connected by year-end.

For the MOHSAIC application, we selected an IBM SP2 for the server and Oracle for the RDBMS. We installed Information Builders' EDA* middleware to allow the SP2 to access Department of Health legacy data and required data from other state departments, which are located on an IBM ES/9000 mainframe. The client portion of the application is developed using Delphi. MOHSAIC data is downloaded to a WebFOCUS server for reporting.

To have a complete health record on individuals, we need to provide access to private health care providers as well as public health agencies. To initially support private providers, we installed dialup access to a Citrix Winframe server which runs the application. This provides acceptable response time over dialup lines and does not require the department to maintain the client application on thousands of private provider computers throughout the state. Our long-term solution to providing access to private providers is to develop our application as a Web-based application and make it available either on the Internet or on the department's intranet.

Our Methodology

A key ingredient of our success was the iterative approach that we took for rolling out MOHSAIC. We convened a team including high-level representatives from Department of Health divisions, local health agencies, and organizations such as the American Hospital Association. The goal was getting buy-in through the development cycle and agreement that the system met their diverse needs, a major requirement for such a broad-based system.

The team specified the information to be contained, how it would be logically associated or linked, and data naming and format standards to ensure the overall system would be fully integrated and not a diverse patchwork. A new team of users was convened to review each functional module of the system. The system was then fully tested and shaken down by end users before entering production.

MOHSAIC's Functions

The key innovation of MOHSAIC is the methodology used to tie separate pools of information together in a centralized database, and the creation of a robust client/server network giving public health care workers easy access to historical and administrative information. The system gives health care practitioners holistic information, allowing them to analyze any aspect of health care and be proactive in dealing with public health threats. Currently, MOHSAIC includes four components: a registration component tracks demographic information for each patient; a scheduling component helps make and record appointments for services (i.e., immunization, at specific locations); an immunization component records and manages a patient's immunization history from birth to adulthood; an inventory component for vaccine serums identifies inventory type; units of measure, site where inventory is stored, date of delivery, date of dispensation, and inventory remaining.

This initial phase of MOHSAIC will allow Missourians' comprehensive immunization history to follow them wherever they go in the state. Information is taken from new birth records and entered into MOHSAIC so that the child's immunization records can be tracked from birth. Immunization data is entered online from local public health providers and many private providers. Immunization data is also received through electronic data exchange from managed care providers, Medicaid, and many private providers. When fully implemented, the system will maintain immunization records for all children born in the state and will be accessed by schools, physicians, and others with a need-to-know.

Benefits

As of May 1, 1998, MOHSAIC had over 560,000 clients in the system. Of those, approximately 275,000 had at least one immunization record and 2,700,000 vaccines were recorded.

The system has helped health care providers do their jobs more effectively. Peggy Maupin, administrative assistant for the Cole County Department of Health, says MOHSAIC helped reduce the amount of work she has to do to get patients' immunization records, helped her increase the accuracy of her vaccine inventory tasks, and has helped her manage inventory in a much more timely and effective way. "Through MOHSAIC a more complete immunization record is available as other health care providers outside my agency have added data," said Maupin.

MOHSAIC also allows health care providers to determine what percent of the children in the community have been immunized. They can target interventions to the population needing services.

One of the most powerful features of MOHSAIC is its link to other state information systems. MOHSAIC uses the same identification number as the Department of Social Services programs (Medicaid, Aid to Families with Dependent Children, Food Stamps, etc.). When a health care professional enters a patient record, the system checks if the patient is already in the database. If not, the system automatically checks the Social Services database; if found there, the client number is automatically entered into the new MOHSAIC record. If Social Services doesn't have a number, then a new client identification is automatically entered both into MOHSAIC and Social Services. This is made possible by the EDA middleware links to data not in Oracle.

MOHSAIC is changing the way public health care professionals work by centralizing all relevant information and putting it at their fingertips. Health care workers are moving away from paper-based record systems that provided fragmented information, to a comprehensive electronic public health patient record.

Ultimately a person's entire health history and treatment management will be handled by MOHSAIC-like systems. The data will be granular enough to provide electronic charts for checking individual patient histories, yet sufficiently broad to provide population-based information that in aggregate can be used to perform quality analyses, such as vaccination rates, or help formulate or check the effectiveness of specific statewide health policies.

Lessons Learned

Today's health care environment is very territorial in nature, where patients are viewed as clients to be acquired and lost. Thus, many health care organizations are protective of their patient information and hesitant to submit it to other parties. There is also a 'big brother' syndrome: the fear of health care being controlled by one party. This is the basic hurdle to the dream of centralized, integrated medical record systems.

We believe that we are operating in an environment of collaboration and MOHSAIC is working successfully because public and private institutions are putting their fears aside in the name of improved public health. Appropriate confidentiality measures are being implemented to reduce the risk of disclosure of medical information. By partnering with the entire health care community in Missouri (i.e., HMOs, local public health department, the Hospital Association, etc.), health care professionals have become very aware and supportive of our goals.

Another barrier is computer illiteracy and the intimidation that it causes among health care professionals. Many local public health agencies either have antiquated computers or no computers whatsoever. That means that they are unfamiliar with today's PCs and related technologies. Additionally, the workers without PC experience tend to be distrustful of the reliability of computers. We've overcome this through establishing a thorough educational process at each level of use. Furthermore, the emergence of sub-$1,000 PCs is gradually making desktop machines a common fixture, not only throughout our offices, but within households as well.

Throughout the development of MOHSAIC, funding has been an obstacle. A combination of federal and state funds have been used to develop the system; and with a recent grant from the Centers for Disease Control, we have funding to develop a data warehouse that will greatly facilitate new research in health issues. However, we will continue to seek additional funding to support the enhancements that are being suggested now that users are benefiting from the system. The declining costs of PCs and the robustness of Web technologies are proving that the concept of statewide, online public health information networks is affordable. Furthermore, with the power of data warehousing-based decision support, we believe that the concept could also be proven as an effective way to get the most bang for the public health buck.

Future Plans

Six more components are planned that will realize MOHSAIC's full potential by providing complete clinical and administrative information tools to the state's public health care infrastructure.

Included in the other components are: a women's wellness component that will record and administer screenings for breast and cervical cancer and family planning, and counseling (the family planning portion is currently in production); a communicable disease surveillance component that tracks and monitors communicable diseases such as HIV/AIDS, tuberculosis or sexually transmitted diseases (which will be piloted in a few sites beginning in January 1999); a laboratory information management system (implementation began Spring 1998); a case management component (includes licensing of health care providers such as hospitals, home health agencies and emergency medical care providers; and inspectors of public service providers such as child care providers, restaurants, motels, etc.).

Is our society prepared for this application? Our experience shows that the answer is an emphatic yes! Having a centralized, integrated medical record system has long been a dream within the medical and health care community. Every health professional knows how difficult it is to get the full picture of a patient's medical background and getting a complete picture of past and future treatments. Thanks to Internet and data warehousing/middleware technologies, they now know that vision can finally be turned into reality.

(*Note: EDA is now part of iWay Software's product suite)