Equity and Accessibility of Washington State's COVID-19 Digital Exposure Notification Tool (WA Notify): Survey and Listening Sessions Among Community Leaders.

BACKGROUND: In November 2020, WA Notify, Washington State's COVID-19 digital exposure notification tool, was launched statewide to mitigate ongoing COVID-19 transmission. WA Notify uses the Bluetooth proximity-triggered, Google/Apple Exposure Notification Express framework to distribute notifications to users who have added or activated this tool on their smartphones. This smartphone-based tool relies on sufficient population-level activation to be effective; however, little is known about its adoption among communities disproportionately impacted by the COVID-19 pandemic or what barriers might limit its adoption and use among diverse populations. OBJECTIVE: We sought to (1) conduct a formative exploration of equity-related issues that may influence the access, adoption, and use of WA Notify, as perceived by community leaders of populations disproportionately impacted by the COVID-19 pandemic; and (2) generate recommendations for promoting the equitable access to and impact of this novel intervention for these communities. METHODS: We used a 2-step data collection process to gather the perspectives of community leaders across Washington regarding the launch and implementation of WA Notify in their communities. A web-based, brief, and informational survey measured the perceptions of the community-level familiarity and effectiveness of WA Notify at slowing the spread of COVID-19 and identified potential barriers and concerns to accessing and adopting WA Notify (n=17). Semistructured listening sessions were conducted to expand upon survey findings and explore the community-level awareness, barriers, facilitators, and concerns related to activating WA Notify in greater depth (n=13). RESULTS: Our findings overlap considerably with those from previous mobile health equity studies. Digital literacy, trust, information accessibility, and misinformation were highlighted as key determinants of the adoption and use of WA Notify. Although WA Notify does not track users or share data, community leaders expressed concerns about security, data sharing, and personal privacy, which were cited as outweighing the potential benefits to adoption. Both the survey and informational sessions indicated low community-level awareness of WA Notify. Community leaders recommended the following approaches to improve engagement: tailoring informational materials for low-literacy levels, providing technology navigation, describing more clearly that WA Notify can help the community, and using trusted messengers who are already engaged with the communities to communicate about WA Notify. CONCLUSIONS: As digital public health tools, such as WA Notify, emerge to address public health problems, understanding the key determinants of adoption and incorporating equity-focused recommendations into the development, implementation, and communication efforts around these tools will be instrumental to their adoption, use, and retention.

WA Notify: the planning and implementation of a Bluetooth exposure notification tool for COVID-19 pandemic response in Washington State.

Bluetooth exposure notification tools for mobile phones have emerged as one way to support public health contact tracing and mitigate the spread of COVID-19. Many states have launched their own versions of these tools. Washington State's exposure notification tool, WA Notify, became available on November 30, 2020, following a one-month Seattle campus pilot at the University of Washington. By the end of April 2021, 25% of the state's population had activated WA Notify, one of the highest adoption rates in the country. Washington State's formation of an Exposure Notification Advisory Committee, early pilot testing, and use of the EN Express system framework were all important factors in its adoption. Continuous monitoring and willingness to make early adjustments such as switching to automated texting of verification codes have also been important for improving the tool's value. Evaluation work is ongoing to determine and quantify WA Notify's effectiveness, timeliness, and accessibility.

Understanding optimization processes of electronic health records (EHR) in select leading hospitals: a qualitative study.

BACKGROUND: Little is known about optimization of electronic health records (EHR) systems in the hospital setting while adoption of EHR systems continues in the United States. OBJECTIVE: To understand optimization processes of EHR systems undertaken in leading healthcare organizations in the United States. METHODS: Informed by grounded theory approach, a qualitative study was undertaken that involved 11 in-depth interviews and a focus group with the EHR experts from the high performing healthcare organizations across the United States. RESULTS: The study describes EHR optimization processes characterized by prioritizing exponentially increasing requests with predominant focus on improving efficiency of EHR, building optimization teams or advisory groups, and standardization. The study discusses 16 types of optimization that interdependently produced 16 results along with identifying 11 barriers and 20 facilitators to optimization. CONCLUSION: The study describes overall experiences of optimizing electronic health records in select high performing healthcare organizations in the US. The findings highlight the importance of optimizing the EHR after, and even before, go-live and dedicating resources exclusively for optimization.

Completeness and timeliness of notifiable disease reporting: a comparison of laboratory and provider reports submitted to a large county health department.

BACKGROUND: Most public health agencies expect reporting of diseases to be initiated by hospital, laboratory or clinic staff even though so-called passive approaches are known to be burdensome for reporters and produce incomplete as well as delayed reports, which can hinder assessment of disease and delay recognition of outbreaks. In this study, we analyze patterns of reporting as well as data completeness and timeliness for traditional, passive reporting of notifiable disease by two distinct sources of information: hospital and clinic staff versus clinical laboratory staff. Reports were submitted via fax machine as well as electronic health information exchange interfaces. METHODS: Data were extracted from all submitted notifiable disease reports for seven representative diseases. Reporting rates are the proportion of known cases having a corresponding case report from a provider, a faxed laboratory report or an electronic laboratory report. Reporting rates were stratified by disease and compared using McNemar's test. For key data fields on the reports, completeness was calculated as the proportion of non-blank fields. Timeliness was measured as the difference between date of laboratory confirmed diagnosis and the date the report was received by the health department. Differences in completeness and timeliness by data source were evaluated using a generalized linear model with Pearson's goodness of fit statistic. RESULTS: We assessed 13,269 reports representing 9034 unique cases. Reporting rates varied by disease with overall rates of 19.1% for providers and 84.4% for laboratories (p < 0.001). All but three of 15 data fields in provider reports were more often complete than those fields within laboratory reports (p <0.001). Laboratory reports, whether faxed or electronically sent, were received, on average, 2.2 days after diagnosis versus a week for provider reports (p <0.001). CONCLUSIONS: Despite growth in the use of electronic methods to enhance notifiable disease reporting, there still exists much room for improvement.

Notifiable condition reporting practices: implications for public health agency participation in a health information exchange.

BACKGROUND: The future of notifiable condition reporting in the United States is undergoing a transformation with the increasing development of Health Information Exchanges which support electronic data-sharing and -transfer networks and the wider adoption of electronic laboratory reporting. Communicable disease report forms originating in clinics are an important source of surveillance data for public health agencies. However, problems of poor data quality and delayed submission of reports to public health agencies are common. In addition, studies of barriers and facilitators to reporting have assumed that the primary reporter is the treating physician, although the extent to which a provider is involved in the reporting workflow is unclear. We sought to better understand the barriers to and burden of notifiable condition reporting from the perspectives of the three primary groups involved in reporting workflow: providers, clinic staff who bear the principal responsibility for reporting, and the public health workers who receive and process reports from clinics. In addition, we sought to situate these findings within the context of the future of notifiable disease reporting and the potential impacts of electronic lab and medical records on the surveillance system. METHODS: Seven ambulatory care clinics and 3 public health agencies that are part of a Health Information Exchange in the state of Indiana, USA, participated in the study. Data were obtained from a survey of clinic physicians (N = 29), interviews with clinic reporters (N = 11), and interviews with public health workers (N = 9). Survey data were summarized descriptively and interview transcripts underwent qualitative analysis. RESULTS: In both clinics and public health agencies, the laboratory report initiates reporting workflow. Provider involvement with reporting primarily revolves around ordering medications to treat a condition confirmed by the lab result. In clinics, reporting is typically the responsibility of clinic reporters who vary in frequency of reporting. We found an association between frequency of reporting, reporting knowledge and perceptions of reporting burden. In both clinics and public health agencies, interruptions and delays in reporting workflow are encountered due to inaccurate or missing information and impact reporting timeliness, data quality and report completeness. Both providers and clinic reporters lack clarity regarding how data submitted by their reports are used by public health agencies. It is possible that the value of reporting may be diminished when those responsible do not perceive receiving benefit in return. This may account for the low awareness of or recollection of public health communications with clinics that we observed. Despite the high likelihood that public health advisories and guidance are based, in part, on data submitted by clinics, a direct concordance may not be recognized. CONCLUSIONS: Unlike most studies of notifiable condition reporting, this study included the clinic reporters who bear primary responsibility for completing and submitting reports to public health agencies. A primary barrier to this reporting is timely and easy access to data. It is possible that expanded adoption of electronic health record and laboratory reporting systems will improve access to this data and reduce reporting the burden. However, a complete reliance on automatic electronic extraction of data requires caution and necessitates continued interfacing with clinic reporters for the foreseeable future-particularly for notifiable conditions that are high-impact, uncommon, prone to false positive readings by labs, or are hard to verify. An important finding of this study is the association between frequency of reporting, reporting knowledge and perceptions of reporting burden. Increased automation could result in even lower reporting knowledge and familiarity with reporting requirements which could actually increase reporters' perception of notifiable condition reporting as burdensome. Another finding was of uncertainty regarding how data sent to public health agencies is used or provides clinical benefit. A strong recommendation generated by these findings is that, given their central role in reporting, clinic reporters are a significant target audience for public health outreach and education that aims to alleviate perceived reporting burden and improve reporting knowledge. In particular, communicating the benefits of public health's use of the data may reduce a perceived lack of information reciprocity between clinical and public health organizations.

Participatory design of an integrated information system design to support public health nurses and nurse managers.

OBJECTIVES: The objectives of the study were to use persona-driven and scenario-based design methods to create a conceptual information system design to support public health nursing. DESIGN AND SAMPLE: We enrolled 19 participants from two local health departments to conduct an information needs assessment, create a conceptual design, and conduct a preliminary design validation. MEASURES: Interviews and thematic analysis were used to characterize information needs and solicit design recommendations from participants. Personas were constructed from participant background information, and scenario-based design was used to create a conceptual information system design. Two focus groups were conducted as a first iteration validation of information needs, personas, and scenarios. RESULTS: Eighty-nine information needs were identified. Two personas and 89 scenarios were created. Public health nurses and nurse managers confirmed the accuracy of information needs, personas, scenarios, and the perceived usefulness of proposed features of the conceptual design. Design artifacts were modified based on focus group results. CONCLUSION: Persona-driven design and scenario-based design are feasible methods to design for common work activities in different local health departments. Public health nurses and nurse managers should be engaged in the design of systems that support their work.

Leveraging health information exchange to improve population health reporting processes: lessons in using a collaborative-participatory design process.

INTRODUCTION: Surveillance, or the systematic monitoring of disease within a population, is a cornerstone function of public health. Despite significant investment in information technologies (IT) to improve the public's health, health care providers continue to rely on manual, spontaneous reporting processes that can result in incomplete and delayed surveillance activities. BACKGROUND: Participatory design principles advocate including real users and stakeholders when designing an information system to ensure high ecological validity of the product, incorporate relevance and context into the design, reduce misconceptions designers can make due to insufficient domain expertise, and ultimately reduce barriers to adoption of the system. This paper focuses on the collaborative and informal participatory design process used to develop enhanced, IT-enabled reporting processes that leverage available electronic health records in a health information exchange to prepopulate notifiable-conditions report forms used by public health authorities. METHODS: Over nine months, public health stakeholders, technical staff, and informatics researchers were engaged in a multiphase participatory design process that included public health stakeholder focus groups, investigator-engineering team meetings, public health survey and census regarding high-priority data elements, and codesign of exploratory prototypes and final form mock-ups. FINDINGS: A number of state-mandated report fields that are not highly used or desirable for disease investigation were eliminated, which allowed engineers to repurpose form space for desired and high-priority data elements and improve the usability of the forms. Our participatory design process ensured that IT development was driven by end user expertise and needs, resulting in significant improvements to the layout and functionality of the reporting forms. DISCUSSION: In addition to informing report form development, engaging with public health end users and stakeholders through the participatory design process provided new insights into public health workflow and allowed the team to quickly triage user requests while managing user expectations within the realm of engineering possibilities. CONCLUSION: Engaging public health, engineering staff, and investigators in a shared codesigning process ensured that the new forms will not only meet real-life needs but will also support development of a product that will be adopted and, ultimately, improve communicable and infectious disease reporting by clinicians to public health.

Uptake of meningococcal vaccine in Arizona schoolchildren after implementation of school-entry immunization requirements.

OBJECTIVES: Meningitis and bacteremia due to Neisseria meningitidis are rare but potentially deadly diseases that can be prevented with immunization. Beginning in 2008, Arizona school immunization requirements were amended to include immunization of children aged 11 years or older with meningococcal vaccine before entering the sixth grade. We describe patterns in meningococcal vaccine uptake surrounding these school-entry requirement changes in Arizona. METHODS: We used immunization records from the Arizona State Immunization Information System (ASIIS) to compare immunization rates in 11- and 12-year-olds. We used principal component analysis and hierarchical cluster analysis to identify and analyze demographic variables reported by the 2010 U.S. Census. RESULTS: Adolescent meningococcal immunization rates in Arizona increased after implementation of statewide school-entry immunization requirements. The increase in meningococcal vaccination rates among 11- and 12-year-olds from 2007 to 2008 was statistically significant (p<0.0001). All demographic groups had significantly higher odds of on-schedule vaccination after the school-entry requirement change (odds ratio range = 5.57 to 12.81, p<0.0001). County demographic factors that were associated with lower odds of on-schedule vaccination included higher poverty, more children younger than 18 years of age, fewer high school graduates, and a higher proportion of Native Americans. CONCLUSIONS: This analysis suggests that implementation of school immunization requirements resulted in increased meningococcal vaccination rates in Arizona, with degree of response varying by demographic profile. ASIIS was useful for assessing changes in immunization rates over time. Further study is required to identify methods to control for population overestimates in registry data.

Public Health Practice within a Health Information Exchange: Information Needs and Barriers to Disease Surveillance.

INTRODUCTION: Public health professionals engage in frequent exchange of health information while pursuing the objectives of protecting and improving population health. Yet, there has been little study of the information work of public health workers with regard to information exchange. Our objective was to gain a better understanding of information work at a local health jurisdiction before and during the early stages of participation in a regional Health Information Exchange. METHODS: We investigated the information work of public health workers engaged in disease surveillance activities at a medium-sized local health jurisdiction by conducting semi-structured interviews and thematically analyzing interview transcripts. RESULTS: ANALYSIS OF THE INFORMATION WORK OF PUBLIC HEALTH WORKERS REVEALED BARRIERS IN THE FOLLOWING AREAS: information system usability; data timeliness, accuracy and completeness; and social interaction with clients. We illustrate these barriers by focusing on the work of epidemiologists. CONCLUSION: Characterizing information work and barriers to information exchange for public health workers should be part of early system design efforts. A comprehensive understanding of the information practice of public health workers will inform the design of systems that better support public health work.

Timeliness and data element completeness of immunization data in Washington State in 2010: a comparison of data exchange methods.

Health information systems receive data through various methods. These data exchange methods have the potential to influence data quality. We assessed a de-identified 2010 dataset including 757,476 demographic records and 2,634,101 vaccination records from Washington State's Immunization Information System (IIS) to describe timeliness and completeness of IIS data across several data exchange methods: manual entry, HL7, and flat file upload. Overall, manually-entered data and HL7 records were more timely than records imported as flat files. Completeness, though very high overall, was slightly higher for records arriving via flat file. Washington State IIS users, including clinicians and public health, rely on its data to inform patient care and determine population coverage of immunizations. Our results suggest that although data element completeness in systems like Washington's IIS will likely not be immediately or significantly impacted by provider's migration to HL7 connections with IISs, timeliness could be substantially improved when using HL7 connections.

Reusable design: a proposed approach to Public Health Informatics system design.

BACKGROUND: Since it was first defined in 1995, Public Health Informatics (PHI) has become a recognized discipline, with a research agenda, defined domain-specific competencies and a specialized corpus of technical knowledge. Information systems form a cornerstone of PHI research and implementation, representing significant progress for the nascent field. However, PHI does not advocate or incorporate standard, domain-appropriate design methods for implementing public health information systems. Reusable design is generalized design advice that can be reused in a range of similar contexts. We propose that PHI create and reuse information design knowledge by taking a systems approach that incorporates design methods from the disciplines of Human-Computer Interaction, Interaction Design and other related disciplines. DISCUSSION: Although PHI operates in a domain with unique characteristics, many design problems in public health correspond to classic design problems, suggesting that existing design methods and solution approaches are applicable to the design of public health information systems. Among the numerous methodological frameworks used in other disciplines, we identify scenario-based design and participatory design as two widely-employed methodologies that are appropriate for adoption as PHI standards. We make the case that these methods show promise to create reusable design knowledge in PHI. SUMMARY: We propose the formalization of a set of standard design methods within PHI that can be used to pursue a strategy of design knowledge creation and reuse for cost-effective, interoperable public health information systems. We suggest that all public health informaticians should be able to use these design methods and the methods should be incorporated into PHI training.

Applying the XForms Standard to Public Health Case Reporting and Alerting.

Notifiable condition reporting and alerting are two important public health functions. Today, a variety of methods are used to transfer these types of information. The increasing use of electronic health record systems by healthcare providers makes new types of electronic communication possible. We used the XForms standard and nationally recognized technical profiles to demonstrate the communication of both notifiable condition reports and patient-tailored public health alerts. This demonstration of bi-directional communication took placein a prototypical health information exchange environment. We successfully transferred information between provider electronic health record systems and public health systems for notifiable condition reporting. Patient-specific alerts were successfully sent from public health to provider systems. In this paper we discuss the benefits of XForms, including the use of XML, advanced form controls, form initialization and reduction in scripting. We also review implementation challenges, the maturity of the technology and its suitability for use in public health.

A Lab-EMR interoperability profile as an eHealth architecture component for resource-constrained settings.

Implementation of computerized systems in resource-constrained settings have been gaining traction as a means of improving the delivery of health care, the use and reuse of information, and providing a standards-based capacity for assessing the process and impact of health care. In a resource-constrained environment, systems are often implemented as stand-alone entities focused on specific care activities (for example, delivering antiretroviral therapy). As such, in many countries, taking a generalized approach to linking electronic medical record systems with laboratory information systems (EMR-LIS) is an important area in which to achieve interoperability. In this paper we describe a scenario of use and information interaction interoperability profile based on our experience implementing EMR-LIS integration in two resource-constrained settings. Of significance, the profile emphasizes queued matching in order to avoid mutual dependence while achieving interoperability between systems.

IUPHAR-DB: the IUPHAR database of G protein-coupled receptors and ion channels.

The IUPHAR database (IUPHAR-DB) integrates peer-reviewed pharmacological, chemical, genetic, functional and anatomical information on the 354 nonsensory G protein-coupled receptors (GPCRs), 71 ligand-gated ion channel subunits and 141 voltage-gated-like ion channel subunits encoded by the human, rat and mouse genomes. These genes represent the targets of approximately one-third of currently approved drugs and are a major focus of drug discovery and development programs in the pharmaceutical industry. IUPHAR-DB provides a comprehensive description of the genes and their functions, with information on protein structure and interactions, ligands, expression patterns, signaling mechanisms, functional assays and biologically important receptor variants (e.g. single nucleotide polymorphisms and splice variants). In addition, the phenotypes resulting from altered gene expression (e.g. in genetically altered animals or in human genetic disorders) are described. The content of the database is peer reviewed by members of the International Union of Basic and Clinical Pharmacology Committee on Receptor Nomenclature and Drug Classification (NC-IUPHAR); the data are provided through manual curation of the primary literature by a network of over 60 subcommittees of NC-IUPHAR. Links to other bioinformatics resources, such as NCBI, Uniprot, HGNC and the rat and mouse genome databases are provided. IUPHAR-DB is freely available at http://www.iuphar-db.org.

Extending functionality of and demonstrating integrated surveillance for public health within a prototype regional health information exchange.

At the HIMSS 2008 conference we demonstrated how multi-jurisdictional public health surveillance and monitoring processes could be supported and expedited through integration with a prototype health information exchange.

Informatics and communication in a state public health department: a case study.

State and local health departments are witnessing growth in the area of informatics. As new informatics projects commence, existing methods of communication within the health department may not be sufficient. We gathered information about roles and communication between a development team and a user group working simultaneously on an informatics project in a state public health department in an effort to better define how communication and role definition is best used within an informatics project.

Assets and liabilities of the Burn Model System data model: a comparison with the National Burn Registry.

OBJECTIVES: To determine whether the Burn Model System (BMS) population is representative of the larger burn population and to investigate threats to internal and external validity in a multicenter longitudinal database of severe burns. DESIGN: Cohort data for the BMS project have been collected since 1994. Follow-up data have been collected at 6, 12, and 24 months postburn. The demographic and burn characteristics of the BMS population were compared with those of patients in the National Burn Registry (NBR). SETTING: The BMS, which collected data for these analyses from 5 regional burn centers in the United States, and the NBR dataset, which is a registry of information collected through the Trauma Registry of the American College of Surgeons and includes data from 70 hospitals in the United States and Canada. PARTICIPANTS: BMS study participants were severely burned patients treated at 1 of the 5 participating burn centers. We compared the BMS population with that of the NBR both in total and filtered to include only patients with comparable injuries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparable demographic and burn characteristics contained in both the NBR and the 5-center BMS longitudinal database and baseline and follow-up distributions of demographic variables and burn characteristics in the BMS database. RESULTS: Although minor deviations in demographic distributions were found between the BMS and NBR and between discharge and follow-up populations, our results show that the BMS population sample is internally and externally valid and is adequate for answering research questions. CONCLUSIONS: Cohort studies examining long-term outcomes have the potential flaw of using a nonrepresentative study population. The BMS population was found to be sufficiently representative, but future analyses will require cautious and purposeful application of statistical adjustment strategies.

Burden of burn: a norm-based inquiry into the influence of burn size and distress on recovery of physical and psychosocial function.

This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.