Three Massachusetts organizations—Children's Hospital of Boston, Cambridge Health Alliance (a system of hospitals and primary care sites in Boston), and the Massachusetts Department of Health-partnered to improve their public health preparedness information systems as a project site of Common Ground: Transforming Public Health Information Systems (Grant ID# 59736).
Common Ground was a three-year, $15 million national initiative of the Robert Wood Johnson Foundation (RWJF), which awarded grants to 31 state and local public health agencies to develop information system requirements and designs and begin the process of implementing these systems in order to meet the challenge of preparedness for bioterrorism, emerging infections, and potential pandemics—and the burgeoning rates of chronic disease.
The Massachusetts grant was one of six focused on preparedness. The goal of these grants was to enable health departments to analyze their business processes, redesign them, and define the requirements for an information system that would improve their emergency response.
Kenneth Mandl, MD, MPH, director of the Intelligent Health Laboratory at the Children's Hospital Informatics Program, was project director of Massachusetts Common Ground. Mandl already had a history of collaborating with both the Department of Health and the Cambridge Health Alliance when the project began.
The Importance of Working Together: The ability of public health agencies to manage resources, including pharmaceuticals, equipment, and personnel, is critical to mounting an effective response to emergencies, whether they are bioterrorist attacks or more common situations, such as an influenza outbreak. During an emergency, agencies need to mobilize those resources efficiently and once the event is over, they need the capacity to track and manage patients.
Such events are not everyday occurrences. However, the same capacity to operate efficiently is required with routine public health functions, such as maintaining immunization registries and conducting outreach for preventive health programs. Mandl and his partners saw the Common Ground framework as a way to define information system requirements for emergency preparedness and to spread those tools more broadly to manage everyday demands.
A history of collaboration. The partner organizations had already collaborated on several projects using syndromic surveillance-a method of detecting symptoms, signs, or behavior patterns indicative of disease in individuals and populations before a confirmed laboratory diagnosis is made. Initial efforts concentrated on early detection of a covert bioterrorist attack, but the team recognized the technology could also be useful for general public health, quality improvement, patient safety, and research
In 2004, they conducted a project addressing the critical need for mechanisms to identify and report acute illness clusters to health departments. Partners, including the Children's Hospital and other Massachusetts clinics, collected emergency department and ambulatory care data, which they communicated to the Department of Public Health via the Massachusetts Homeland and Health Alert Network. This Internet-based application serves as a portal for communication and collaboration, and alerts predefined groups of users involved in emergency response.
The project demonstrated that the network allowed for rapid, efficient alerting and two-way communication among public health and private-sector partners. It also mapped out potential "next steps," such as the need to send alerts to local boards of health to allow them to participate earlier in the investigation process.
The Common Ground Partnership: At the beginning of the project, the partners focused on documenting business processes and defining information system requirements for resource management and patient tracking within the context of emergency preparedness. However, the election of Governor Deval Patrick in 2006, and other changes within state government and the Department of Public Health, led to a reshuffling of priorities.
James Daniel, MPH, was chief information officer in the Department of Public Health at the time and a key member of the Common Ground project team. Patient tracking was not as much of a focus for the newly appointed director of the Bureau of Emergency Preparedness, Daniel recalls, so team members met the state's new priorities by following up on their previous disease surveillance work.
Specifically, they focused on analyzing business processes of the Health and Homeland Alert Network, redesigning them where appropriate to improve data sharing and communication between the state department of public health, and local health departments and boards of health. The team analyzed program governance, system development, system administration, and utilization. The project results will be used to inform the future development of the alerting network, according to Daniel.
Spreading Common Ground tools. Beyond the scope of preparedness, Common Ground teams trained health department staff members in the following programs:
- The Massachusetts Center for Birth Defects Research and Prevention. Business processes in this program had been implemented piecemeal, with duplication of data and redundancies. A thorough data analysis and documentation effort informed the development of prototype solutions and a subsequent request for a new integrated system.
- Development of a new registry system for amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease). After a brief consultation, the grant writer for this new program used existing training material for a self-tutorial, and was then able to develop informative diagrams and supporting material to complete a grant application. The application included an example of the methods that would be used to define information systems.
- The Massachusetts Cancer Registry had long used a system developed exclusively for that program many years ago. However, as cancer registry business processes became more formally defined, a number of other information system options became available. Program staff used Common Ground business-process analysis to ensure that strategies for replacing or extending the existing system were consistent with current business practices.
- The Women's Health Network and Men's Health Collaborative, which target underserved populations in Massachusetts, used Common Ground techniques to clarify their business processes in order to update an antiquated system. The primary goal was to define their business needs and avoid being confused by an outside vendor's efforts to market its information system.
According to Daniel, consulting with the Women's Health Network and the cancer registry were very different experiences. They illustrated an important lesson learned from Common Ground: the value of focusing efforts where people are most amenable to change.
"We were able to very quickly put in a solution that met the needs of the Women's Health Network, but the cancer registry was tougher. The Women's Health Network was very challenging in the beginning because they had a crazy outdated process. With the cancer registry, it was a trust issue, and they never quite got there. They had a high reluctance to give up their existing system, which had gone for years without upgrades."
Grantee Perspective: Common Ground tools have become a standard starting point for all the information technology projects brought to the state's chief information officer for consideration, according to Daniel. Their success demands a firm footing in business-process analysis and the ability to communicate business requirement in a clear, consistent manner.
In addition by documenting many of the core business processes, Common Ground laid the foundation for identifying commonalities in the various programs of the Massachusetts Department of Public Health.
There were challenges, Daniel said, but "We got some of groups to understand they didn't have to have completely siloed information systems even though their work was different. When you break it down through business-process analysis, collecting information on whether or not women got case management is similar to collecting follow-up information for cancer status. A solution that worked for communicable diseases can work for birth defects. Technical solutions are cheaper to create and maintain when commonalities are recognized."
In 2011, Daniel took a leave of absence from the Department of Public Health to serve as the Public Health Coordinator for the Office of the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services. In that position he is using lessons learned from Common Ground to help coordinate national efforts to link public health to electronic health record systems and health information exchanges.
RWJF Perspective: In funding Common Ground, RWJF wanted to strengthen state and local public health departments so that they could perform better in the face of the increasing challenges of bioterrorism, emerging infections and potential pandemics, and burgeoning rates of chronic disease. Meeting these challenges required health departments to develop and use more sophisticated information systems than they currently had.
Many state and local health department leaders ultimately found that the Common Ground tools—business-process analysis and redesign—could be used not only to design information systems, but in quality improvement as well. "That was a benefit that we weren't anticipating." said RWJF Senior Program Officer Pamela G. Russo, MD, MPH. "The application of business-process mapping to process improvement was a huge step toward quality improvement in public health."
Former RWJF Senior Program Officer Terry Bazzarre, PhD, MS, agrees. "Over time, it became clear that the Common Ground approach was an alternative way of doing quality improvement in public health, focusing specifically on how the work gets done and the business processes that contribute to it."