Public Health Systems Research is the discipline that examines the organization, financing, and delivery of public health services and the impact of those activities on population health. The AcademyHealth PHSR Interest Group, which has grown to over 2,000 members, marked its tenth anniversary this week with a series of panel discussions about the field. NewPublicHealth spoke with two key presenters: Paul Erwin, M.D., co-principal investigator of the National Coordinating Center for PHSSR at the University of Kentucky; and Bridget Booske, senior scientist at University of Wisconsin’s Population Health Institutes and deputy director of the County Health Rankings.

NewPublicHealth: What did your presentation highlight?

Paul Erwin: I’m talking about health coalitions and in particular, examining health coalitions from the perspective of their being the organizing corollary for a local public health system. That’s important because health and health outcomes are the result of a number of different complex factors and if we want resolve these major problems, they can’t be solved by one entity alone. It’s all of the organizations, and individuals and entities that impact the health of the public at the community level.

NPH: And what is your current focus at the National Coordinating Center for PHSSR Research?

Paul Erwn: I’m working on providing a practical perspective on research, on the translation of research. In the last few months, we’ve gathered a working group together of people who have experience in the practice and academic worlds to answer questions such as who is successfully translating research into practice, how is it being done, what are the barriers, best practices and models for how we can support the practice world in this key area.

Taking this focus has importance in several key areas such as public health accreditation [which will launch in the fall of 2011.] One of the standards for accreditationhas to do with advancing new knowledge. The work we’re doing now at the Center has implications regarding improving the practice world’s capacity to deliver on this particular standard.

NPH: Bridget, what research did you present to the Interest Group?

Bridget Booske: The work is on media response to the release of the County Health Rankings in 2010, which is very important in terms of trying to engage broad segments of the community. The media is a key resource for reaching other stakeholders. We learned that we got very broad coverage in the better resourced communities, so we have to get more media coverage in less resourced communities. It’s harder to reach small media, but we need to keep working at it.

NPH: In what ways is the media coverage of the County Health Rankings important?

Bridget Booske: We want the media to continue to help us with the initial coverage, of the County Health Rankings, but we also have found that follow-up stories and letters to the editor to continually get the message out will only helps us improve the health of the community.

And it’s not just about getting the governmental public health folks, to write those letters and op-eds; we’ve had pretty attention grabbing op-eds from other key players such as hospital CEOs and head of local chambers of commerce. That’s great. We want to get other voices in there as well.

NPH: What input are you looking forward to from research colleagues at the PHSR Interest Group meeting?

Bridget Booske: I’m looking forward to getting input from other researchers in terms of how we really assess what we’re doing with the County Health Rankings. We have a logic model that says we’re trying to get attention from the media and have people use the information toward broad community attention and then to in turn implement evidence-based policies. We know we can get the media and we need researchers to help us with the rest of the logic model and ultimately to help improve what we do.

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Effective management of modern public health emergencies requires coordinated efforts of multiple agencies representing various disciplines.

That’s the focus of the paper “Achieving Public Health Legal Preparedness: How Dissonant Views on Public Health Law Threaten Emergency Preparedness and Response” that won the award for Article of the Year at the Public Health Services Research Interest Group at the AcademyHealth Annual Research Meeting.

The author, Anda Botoseneanu of the University of Michigan, argues that organizational culture differences between public health and emergency management entities can impact vital collaboration across agencies.

Botoseneanu and her colleagues conducted over 140 interviews with officials at both public health and emergency management offices and found conflicting approaches to law. The authors say the public health approach is characterized by a perceived uncertainty regarding legal authority over preparedness planning tasks, an expectation for guidance on interpretation of existing laws and concern about individual and organizational liability. The emergency management approach was found to have a perception of broad legal authority, flexible interpretation of existing laws and ethical concerns over infringement of individual freedoms and privacy.

Botoseneanu concludes that distinct interpretations of preparedness law interfere with effective collaboration and that clarification of legal authority mandates and guidance on interpretation of current federal and state laws are needed.

Dr. Botoseneanu’s paper was selected for its “contribution to the understanding of public health systems, its new insights into the field of Public Health Services and Systems Research and for its potential to advance the field and change current thinking,” said Debra Perez, M.A, M.P.A, Ph.D., interim Assistant Vice President for Research and Evaluation at the Robert Wood Johnson Foundation, which funds the interest group.

For more information on the topic, the Public Health Law Network and the Public Health Law Research Program, both funded by the Robert Wood Johnson Foundation, have published work on legal issues surrounding emergency preparedness.

Could the rocketing use of smartphones be a boon for population health surveys? Trent Buskirk, an associate professor of biostatistics at the St. Louis University School of Public Health, thinks so.

At a panel about Innovations in Population Health Surveys at AcademyHealth's Annual Research Meeting, Buskirk noted that the opportunity to use smartphones for surveys is increasing now that 85 percent of U.S. households have a cell phone--and 37% of those cell phones are smartphones.

Added to the opportunity is the increasing use of health care apps that many consumers are now using which creates a data collection opportunity. Survey researchers could ask app developers for data, such as how many people downloaded a smoking cessation app.

Buskirk says the prevalence of apps also give researchers a model for a survey tool for smartphones, since so many users have now become accustomed to app functionality.

Buskirk and colleagues conducted a small study that invited computer users already members of an online panel that responded to surveys to reply to a new survey either by computer or iPhone. Buskirk says important findings included:

• Fewer incomplete questions, which is a common problem with most surveys
• Loading time for the first screen on the iPhone takes about a half a second longer than on the computer, which is important to know “because if respondents get aggravated they might drop the survey all together,” says Buskirk
• Surveys may need programming more sophisticated than just questions to support app-like experiences
• Smartphone surveys may be especially useful for hard-to-reach or specialized populations. For example, 61 percent of physicians, Buskirk says, now use an iPhone.
• Smartphone surveys will likely need a “save” option, rather than just a submit button. Buskirk says one responder was in a helicopter while responding and some participants took four days to complete the survey because they work on multiple things simultaneously. “You’ll lose responders if they move to another task and then have to start the survey from scratch” he noted
• Developers will need a new way to track how long people spend on each survey, since a smartphone user population may not complete the questionnaire in one sitting
• Smartphones can also be used by survey professionals in the field, perhaps by downloading data from tracking devices participants use such as how many steps they take or how often they monitored glucose levels.

Weigh In: How long would you spend on a smartphone answering a survey?

A key session at this week’s AcademyHealth Annual Research Meeting focused on research priorities in the women’s health agenda. Several organizations, including the National Institutes of Health, the Agency for Health Care Research and Quality, and the Institute of Medicine have been assessing progress in women’s health research and have identified strategies for promoting advances.

One of those focusing on the women's health agenda is Carolyn Clancy, M.D., director of the Agency for Health Care Research and Quality, who was a presenter at the session. NewPublicHealth spoke with Dr. Clancy about opportunities in women's health for rethinking how the clinical care system and public health system work together.

NewPublicHealth: Why is there a current focus on the women’s health agenda?

Dr. Carolyn Clancy: Women in this country tend to live longer than men, but sicker. They are more likely to have chronic illnesses, multiple illnesses, and frankly to have the social determinants of health stacked against them in terms of income and education. A startling proportion of women over 65 are dual eligible--eligible for both Medicare and Medicaid, largely because of income. And what that means is that no matter how you look at chronic illness, not only do they have more of it, but they tend to have more severe chronic illnesses. This is an area where I think there is a huge opportunity for rethinking how the clinical care system and public health system work together.

NPH: What’s needed—new research topics or more information on the topics that are known?

Dr. Carolyn Clancy: Good question. Every place I go people in health care tell me they feel like the ground is shifting beneath their feet. We want to shift from doing more stuff to more quality. I don’t think we can get to where we need to be unless we rethink our efforts. Where can clinical health do better, where can public health do better, and how do we reinforce each other’s efforts. It’s not just more, more, more. So far, on the quality side, which has a good overlap on population health, we’ve taken an approach of keep doing what you’re doing but add on these activities. Now I think we need to rethink that, particularly for chronic illness.

NPH: And how does that happen?

Dr. Carolyn Clancy: That’ s the big question and there is no clear path. It’s likely to look different in different communities and regions of the country. At AHRQ, we have a site called AHRQ Innovations Exchange that encourages collaboration. It’s about people sharing their experiences in rethinking what’s needed ahead.

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Public Health Services and Systems Research is a featured topic at the 2011 AcademyHealth Annual Research Meeting in Seattle this week. Additionally, the AcademyHealth Public Health Services Research Interest Group will soon be holding its tenth anniversary meeting to share findings on topics including health disparities and best practices for public health systems.

To discuss the state of the PHSSR field, NewPublicHealth spoke with Debra Perez, Interim Assistant Vice President for Research and Evaluation at the Robert Wood Johnson Foundation, who is a key presenter at the AcademyHealth ARM this week.

NewPublicHealth: Tell us about the Robert Wood Johnson Foundation’s investment in Public Health Services and Systems Research.

Debra Perez: The Foundation has been investing in PHSSR since about 2004. We started our investment with support of the AcademyHealth PHSR Interest Group, as a matter of fact. That brought together about forty or so researchers to the AcademyHealth Annual Research Meeting. Subsequent to that, we expanded our work to broaden a connection with the practitioner community. The Interest Group meeting has grown to over 100 today. And our work has expanded with AcademyHealth as well to include training and support for people interested in doing PHSSR work.

Beyond that, we have done extensive work with the University of Kentucky, which heads the National Coordinating Center for PHSSR. Under them we have collaborated on data harmonization with three membership organizations of public health: the Association of State and Territorial Health Officers; the National Association of County & City Health Officials; and the National Association of Local Boards of Health. All of these organizations conducted profiles biannually or whenever they could get funding. So some of our investment in PHSSR was about stabilizing the funding source for these very critical data sets.

Our work has also included annual solicitations for investigator-initiated projects in PHSSR. We went from a $75,000 grant in 2004 to about a $60 million investment today.

NPH: AcademyHealth refers to Public Health Systems Research, while the Robert Wood Johnson Foundation refers to Public Health Services and Systems Research. Why is that?

Debra Perez: We felt it was important to include services in the definition. We didn’t want people to think of systems as something abstract. It was under the leadership of Jim Marks, senior vice president and group director of health of RWJF and formerly of the CDC. Jim pointed out that we wanted people to know what we meant by connecting systems to services. What we mean is that when you study food safety or vaccine programs or other issues under public health, it’s important to look at the infrastructure, workforce, governance, finance and general organization to better understand the quality of those services.

NPH: The Academy Health Public Health Services Research Interest Group is celebrating its tenth anniversary. What kind of growth in participation have you seen?

Debra Perez: The number of participants at the annual meeting has grown to over 100, but that’s just in-person. They have a broad electronic network of close to 1,500 . These ten years have been growth years, a burgeoning field that continues to grow and blossom. And we’re very proud of that.

NPH: You’ll be discussing the PHSSR research agenda at this meeting?

Debra Perez: Yes, there will be an opportunity to weigh in at the Interest Group meeting and we’ll also vet the research agenda at the upcoming NACCHO meeting and we’ll be looking for additional vetting opportunities.

NPH: How was the agenda developed?

Debra Perez: It has been a deliberate, exhaustive process to determine the research agenda in the four content areas: infrastructure, finance, data and technology, and workforce. Each group participated in at least two webinars and we did an exhaustive and systematic review of the literature, and this research agenda is identifying gaps. We hope to complete it by the end of the summer.

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Creating an agenda on your smart phone? An app development challenge? Using Twitter feeds as study data? All this and more was highlighted at the opening day of the AcademyHealth Annual Research meeting yesterday in Seattle.

Embracing innovation in approach and technology was a key focus of AcademyHealth CEO and President Dr. Simpson’s opening remarks to the meeting attendees.

“While AcademyHealth and the field we represent enjoy broad support and respect among those who know us well, there remain significant opportunities to educate policymakers about the work we do and its impact,” Dr. Simpson said.

Strategies to achieve this impact, said Dr. Simpson, include remaining relevant by embracing innovations and new opportunities.

The keynote speaker for the opening session was Molly Coye, M.D, M.P.H., Chief Innovation Officer at the UCLA Health System. Coye said new technologies are important because they support engagement, not just dissemination.

A key example she noted was an observational study conducted by patient members of a community called PatientsLikeMe. Following publication of a small study showing that lithium might slow down symptoms of ALS, patient members created their own observational trial to see if the drug would help them.

Although they weren’t able to replicate the earlier study results, the PatientsLikeMe data was published in Nature Biology, a peer-reviewed journal. Said Coye: “This has the potential to change who pays for research – prompting industry, foundations and providers who need information to support it and to generate new tools and sources of information.”

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What's the latest in health services research and current health policy issues?

You'll be able to find out at the AcademyHealth Annual Research Meeting, which takes place June 12-14 in Seattle. The annual meeting has been the premiere forum for health services research for close to thirty years. Key topics this year include health reform and using social media to disseminate research.

At the conclusion of the meeting, the Public Health Services Research Interest Group, funded by the Robert Wood Johnson Foundation, will be celebrating its tenth anniversary. Speakers include Debra Pérez, M.A., M.P.A., Ph.D., Interim Assistant Vice President for Research and Evaluation at the Foundation. You’ll be able to follow coverage of the conference here on NewPublicHealth.org.

In advanceof the Annual Research Meeting, NewPublicHealth spoke with Lisa Simpson, M.B., B.Ch., M.P.H., president and CEO of AcademyHealth, and David Colby, Ph.D., vice president of Research and Evaluation at the Robert Wood Johnson Foundation.

NPH: What are the key topics that will be discussed at the Annual Research Meeting?

Dr. Simpson: There is a rich set of presentations this year, as in other years. We’re lucky to receive terrific abstracts and presentations. One area where I’m particularly interested to hear and learn more is around what’s happening at the community level and the efforts on the ground to transform the delivery system. Some of those efforts are working very collaboratively with local public health and reaching beyond the traditional boundaries of medical care. For example, understanding how health information technology and different payment approaches are facilitating these newer organizational financing and collaborative models.

NewPublicHealth: From both your perspectives, can you talk about the intersection of health services research and public health services research?

Dr. Simpson: This is the tenth anniversary of the annual meeting of our Public Health Services Research Interest Group and we are reflecting on the progress we’re making in this field, how much public health services research is part of the family of health services research and how integral it is to advancing health. We have to have evidence to improve the delivery of care and the prevention agenda for population health. That’s where I think the future is going. I would also comment that increasingly we’re seeing alignments and recognition within the more traditional medical care delivery system of the need to focus on population health and the need for partnership and even more collaboration between the health system and the public health system.

Dr. Colby: Health services research is a young field and it’s a field that is interdisciplinary. So the boundaries around health services research are more like a fuzzy set than a brick wall. We have a strong tradition of looking at delivery, quality, and access in the medical care system. Yet the goal of many members of AcademyHealth, as expressed by David Kindig, M.D., the former chair, is to study how to maximize the health of individuals and the health of populations. The AcademyHealth board adopted a definition of health services research which included the impacts of social effects and personal behaviors on health and well-being. This means that research needs to focus on all the inputs into health from the health care system, personal behavior and characteristics, and the environment. There is a recognition that you have to take into account all of these things to influence people’s health.

Dr. Simpson: I agree with David. As a pediatrician we especially focus on factors outside of medical care and the health of children in particular is so dependent on that multidisciplinary approach to understand what works to maximize and optimize health outcomes for children and their families and their communities. There really are those fuzzy boundaries.

NPH: What is the conversation that needs to take place between health services delivery and public health?

Dr. Colby: Articles written in the early 1990s showed the most important inputs into the health of the public are not from the medical care system. If we want to improve the health of Americans, we have to be working on those areas that will produce the most leverage, and that is improving where people live, learn, work and play.

Dr. Simpson: As we think about public health, increasingly I think that we understand that what contributes to the health of the public goes well beyond public health departments or what is traditionally thought of as the institutions of public health. We’re seeing employers having a dramatic stake in public health, promoting employee wellness and health promotion and disease prevention. We’re seeing the health care delivery system moving more and more toward health as part of the triple aim which focuses on improving population health, the patient experience of care and cost. It is about how communities exist and structure their community institutions well beyond public health and health delivery--from transportation to food, the environment and the built environment--all of these contribute to achieving the health of the public--and so health services research is expanding its methods, approaches and data sets to bring in information that captures the dynamics and influences on the child, the family, the community. In that way, we are better able to tease out and understand the policy levers and the interventions that can optimize health outcomes.

Dr. Colby: One example is that the Federal Reserve became very interested in the impact of community development on the health of Americans. They have held several conferences around the country about the interface between what they do in housing and other policies and the health of Americans.

NPH: What do you think the Federal Reserve’s contribution can be that another entity might not be able to contribute?

Dr. Colby: When the Federal Reserve starts talking about health issues, it’s a ‘wow.’ The Fed controls significant amount of money that can be used to improve the health of Americans. Where and how you build houses, parks, sidewalks, and grocery stores will have an impact on health of Americans.

NPH: There are two sessions at the annual meeting that are devoted to helping researchers disseminate their findings. Are researchers finding it more or less difficult to get their information out to the stake-holders that need it and then make its way to the field?

Dr. Simpson: I think the answer is, like so many things in health policy, it depends. Our field is growing and vibrant. Our membership is at the highest point ever, almost 4,500, and we represent a very diverse field.

I think that there are many journal opportunities, and depending on which journal you’re working with, the competition and the difficulty in getting your work published in an academic journal varies tremendously--as might the delay in publication between when you have your findings and when it actually appears online. But I think that increasingly, researchers are recognizing that there need to be, and there are, many other venues for getting their findings into the hands of the decision makers who need evidence.At the same time, journals are moving toward more timely reviews and expedited online publishing.

There are also many other ways that researchers have been working increasingly to get their evidence into action--and we support a number of those methods. For example, learning networks where we identify a policy need and researchers and experts who have been publishing and working in that area and we bring them together. These networks create an opportunity for a researcher to very directly inform policymakers about their area of expertise and passion. Another example is the HCFO--Health Care Financing and Organization--a program of The Robert Wood Johnson Foundation managed by AcademyHealth. As the national program office for HCFO, we bring researchers together with their targeted users and audiences in small, focused discussions where you can really delve deeply into what is known and what is not. These sessions not only get information to the user more quickly, they actually help the researchers better understand what evidence is most needed. So, together with our members, we are really looking in very different ways to achieve our goal of moving knowledge into action.

NPH: Canyou talk about the impact of social media on evidence dissemination?

Dr. Colby: Health services researchers have to get used to social media for three separate purposes. One purpose is getting information out to people. Reporters follow tweets and that’s where they pick up some emerging stories. Obviously, the reporters will call up and get more in-depth information beyond 140 characters but Twitter provides the lead.

Another purpose is that social media tools are going to provide data for health systems researchers. For example, a project that we funded published an article on following tweets to figure out the impact of certain diseases, and an earlier article we funded used Google searches to show the spread of a disease. These studies represent a new epidemiology, which lets you know what’s going on before you get the official records.

Finally, I think that these social media tools are going to be very important in helping people improve their health. You could have an app on your phone that reminds you that you have to do specific things on a daily basis to improve your health.

Dr. Simpson: To build on what David has said, we see social media as the newest tool in our tool kit to support our mission of moving knowledge into action. I think there is enormous potential for the field to embrace these technologies and push them even further. In fact, one of the things that we’re announcing next week at an Institute of Medicine meeting around newly available data, and also at the Annual Research Meeting, is the REACH--Relevant Evidence to Advance Care and Health--Challenge. The REACH Challenge, which we are sponsoring in partnership with Health 2.0, offers a prize of $5,000 to a team of researchers, developers and other specialists who takes evidence-based research and data and translates them into an application that advances health and care.

This is really the future. Apps and social media are clearly an exciting new strategy for evidence dissemination and a new way to reach the audiences we need to target.

AcademyHealth has focused a lot more on social media in the last couple of years. You can follow us on Twitter, at @academyhealth or with the hashtag #ARM11 for the annual research meeting. We also have a blog at blog.academyhealth.org. And also new this year at the Annual Research Meeting is what I call "American Idol meets AcademyHealth," where we’re asking people at the meeting to choose their favorite poster presentation for inclusion in a first-ever “virtual poster session” by texting their vote to us. So we’re really trying to expand our approach and the various methods we use to engage our various audiences. At its core, it’s about matching up the content and the evidence with the medium and the messenger and the audience, and aligning all of these points so you’re delivering the right information in the right way to the right customer at the right time.

NPH: Will you both be tweeting at the meeting?

Dr. Simpson: David will be tweeting and I’m going to start learning how to tweet at the meeting!

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