A Decade of Data Examined: Progress and Challenges in Electronic Public Health Reporting

The COVID-19 pandemic highlighted deficiencies in the U.S. public health infrastructure, leaving health care providers and public health authorities (PHAs) ill-equipped to collect and exchange timely and accurate information needed to inform rapid response during the public health emergency. The fourth post in our "A Decade of Data Examined" blog series highlights early efforts to incentivize electronic public health reporting by health care providers to support PHAs' public health surveillance and ability to respond to current and future public health threats. We also highlight persistent interoperability challenges and how new and ongoing efforts aim to achieve a future state of seamless and interoperable public health data sharing.

Incentivizing Electronic Public Health Reporting

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized incentive payments to eligible professionals and eligible hospitals and critical access hospitals for the adoption and "meaningful use" of certified electronic health record (EHR) technology through the Centers for Medicare & Medicaid Services (CMS) Promoting Interoperability (PI) Programs (formerly EHR Incentive Programs or "Meaningful Use" [MU]). To promote electronic information exchange between hospitals and PHAs, the PI Programs required electronic reporting to PHAs to improve the timeliness and completeness of data needed to identify potential outbreaks of disease and inform response during public health emergencies.

In 2012, 19% of office-based physicians and 63% of non-federal acute care hospitals reported the ability to submit electronic data to immunization registries and over half of hospitals were capable of electronically reporting syndromic surveillance data (55%) and reportable lab results (57%). These stats represent early adoption of these electronic capabilities before CMS program requirements mandated their use. After 2014, among hospitals and physicians required to adopt and use these certified capabilities, 88% of hospitals electronically reported immunization data, 75% electronically reported syndromic surveillance data, and 85% electronically reported lab results, while over half of physicians electronically reported data immunization registries.

Peeling back the layers we find that not all hospitals and physicians (though required) reported use of these capabilities. A small number of hospitals claimed they could not electronically report these data to PHAs because those jurisdictions could not receive the data electronically, despite hospitals having the certified EHR technology capable of doing so. Many physicians did not report electronically sending immunizations to their local PHA, despite electronic capabilities to do so, because they either did not perform immunizations or, like some hospitals, practiced in areas where PHAs were not able to electronically receive this data. As late as 2019, many hospitals still reported difficulties electronically exchanging information with PHAs. Certified EHRs were widely adopted by these health care providers, however, interoperability challenges between them and PHAs created barriers to exchange and ultimately, as we saw at the start of this decade, difficulties responding to a public health emergency.

Current State

Today, the vast majority of hospitals are engaged in at least one type of electronic public health reporting (Figure 1). As of 2022, more than three-quarters of non-federal acute care hospitals were actively electronically submitting data for immunization registry (90%), syndromic surveillance (86%), and lab (85%) reporting. Additionally, many hospitals reported electronically submitting data for emerging reporting types including public health registry reporting (63%), clinical data registry reporting (51%), and electronic case reporting (47%)-which the CMS PI Program required for the first time in 2022.

Figure 1: Non-federal acute care hospital engagement in electronic public health reporting, 2021-2022

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Source: Richwine, C. Progress and Ongoing Challenges to Electronic Public Health Reporting Among Non-Federal Acute Care Hospitals. ONC Data Brief [Internet]. 2023 June; data brief 66.

Despite high rates of engagement in electronic public health reporting among hospitals, reporting rates are lower among small, rural, independent, and critical access hospitals. Furthermore, in 2022, about three-quarters of hospitals nationally reported experiencing at least one challenge to public health reporting. The most commonly cited challenge was hospitals' perception that PHAs lacked the capacity to electronically receive the information (50%), followed by the technical complexity of interfaces, transmission, or submission process (39%), and costs to exchange (26%).

For office-based physicians, we find that knowledge of and engagement in public health reporting tends to vary by specialty. Data from the 2022 National Physician Health IT Survey, which asks about physicians' use of health IT to access and report immunization data, indicate that a majority of primary care physicians use their EHR (41%) and/or portal outside the EHR (40%) to view immunization data from outside their organization, revealing that even now not all physicians have integrated access to this information within their EHR. Among those who used an EHR to view immunization data from outside sources, about three-quarters reported being able to access data from (77%) and report data to (74%) their state's immunization registry. These physicians also had the highest rates of satisfaction with their access to external immunization information - showing the importance of interoperability between provider and PHA systems.

Efforts to achieve public health data interoperability

Public health information exchange has transformed dramatically over the past decade with many hospitals and physicians actively reporting-or capable of reporting-public health data electronically. However, there continue to be significant gaps in public health data exchange. Analysis of PI Program and survey data reveal interoperability challenges between provider and public health data systems, as well as differences in rates of reporting across provider types. Several efforts are underway to help address persistent challenges to public health reporting and enhance interoperability between health care providers and PHAs.

• More investment and funding available through the CDC's Data Modernization Initiative (DMI) as outlined in the CDC's Public Health Data Strategy, which highlights areas of focus for DMI investment and prioritizes core data streams for electronic exchange.
• Standards development work to facilitate public health data exchange: USCDI+ Public Health and Helios, an HL7 FHIR accelerator.
• Leveraging the services of health information exchange organizations to support PHAs' ability to respond to public health emergencies, as demonstrated through the STAR HIE Program.
• Trusted Exchange Framework and Common Agreement (TEFCA^TM) the public health "exchange purpose" will support secure information exchange between health care and public health.
• Building the Public Health Informatics & Technology Workforce through the PHIT

NEW: ONC's Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-2). To meet the urgent need for greater public health data exchange, ONC's HTI-2 proposes a multi-pronged approach that builds on existing public health certification criteria by:

1. Implementing new functional requirements and requiring adoption of newer versions of standards within existing criteria that support transmission of information to PHAs and bi-directional exchange with immunization registries.
2. Adding certification criteria for new use cases including transmission of birth reporting data to PHAs, expanded laboratory data exchange, and bi-directional exchange with prescription drug monitoring programs.
3. Adding certification criteria for "health IT for public health" that adopt most of the same standards and functional requirements as existing criteria to further enable interoperable exchange between PHAs and health care providers.

Together, these efforts will help address persistent challenges to public health data sharing by investing in public health infrastructure, establishing a governing approach for nationwide health information exchange, and advancing standards to support seamless electronic exchange. You can read more about these various efforts underway in our recently released article, "Plugging Public Health Data into the Health IT Ecosystem to Protect National Health," which describes the benefits and challenges associated with establishing connectivity between public health and health care IT systems, and key policies and activities that will help drive us towards this desired future state of a fully interoperable public health and health care data ecosystem.

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