Lawrence Hanrahan, PhD, MS, a Wisconsin native, has been the director of public health informatics and chief epidemiologist in the state's Division of Public Health since 2006. In that capacity, he provides scientific leadership to integrate statewide public health communications, informatics, distance learning, epidemiology, and surveillance programs.
He was also project director of Common Ground: Transforming Public Health Information Systems, a three-year, $15 million national initiative of the Robert Wood Johnson Foundation (RWJF). In December 2006, RWJF awarded Common Ground grants to 31 public health agencies, including the State of Wisconsin Department of Health Services. As one of 10 Common Ground agencies to focus on chronic diseases, the department analyzed and redesigned business processes and defined the requirements for an information system that would improve their capacity to prevent and control chronic disease. (Other grantees worked on emergency preparedness; some worked on information system capacity improvement.)
Head's Up on Common Ground: Hanrahan's interest in improving health information systems began well before he earned his doctorate. In 1975, just out of college, he began working for the Wisconsin state Department of Labor analyzing statistics on occupational injury and illness surveillance for workers compensation. His earliest projects examined the association between chemical exposures and occupational illnesses, such as dermatitis.
"We used computerized information systems back then to get the data we need to analyze; but it's more complicated today than it was 40 years ago. The field of informatics has developed in response. What epidemiologists do is study content. Informatics is the method."
Hanrahan had a "head's up" on Common Ground for a couple of reasons. He had been the project director for an RWJF InformationLinks grant awarded to the Wisconsin Department of Health Services in 2006. InformationLinks was an RWJF national program designed to give public health departments a "place at the table" in the development of health information exchanges-electronic data networks that make it possible to share health-related information among organizations.
"InformationLinks had really started us thinking about public health participation in clinical information data exchange," said Hanrahan. "The question was how do we become a player? What can we get from data exchange and what value can we add?" Hanrahan shared his insights when he was invited to a one-day workshop by RWJF to brainstorm what Common Ground would look like.
The Challenge: Wisconsin's Public Health Information Network is the information technology platform for all public health surveillance programs in the state. Unlike most programs within the department, however, the chronic disease program was not using the network to transmit data and generate reports.
Beyond that limitation, Hanrahan said the health department had a "silo-ization" problem. "A lot of different programs approached data differently. We wanted to work more collaboratively to produce more coordinated reports on chronic diseases like asthma and diabetes."
Hanrahan was interested in using Common Ground funding to better understand why chronic disease programs were not using the network to share electronic medical information and then to identify potential efficiencies. Timing was good for a launch of Common Ground in Wisconsin. The Centers for Disease Control and Prevention (CDC) recognized that the problem of silos was partly of its own making, a result of categorical funding streams for different chronic disease programs. CDC had begun funding demonstration programs to emphasize chronic care integration, and Wisconsin was a pilot site. Hanrahan was able to "set activity from Common Ground into that."
Integrated chronic disease risk-factor reporting. Hanrahan started by bringing together a group of core chronic disease programs. "We started with asthma, diabetes, obesity, cardiovascular disease, and arthritis. We didn't have everyone at the table because we wanted to keep it a manageable size."
The initial focus was asking whether chronic disease programs had a uniform approach to producing and consuming data from the Wisconsin Behavioral Risk Factor Survey, a telephone survey of state residents ages 18 and older carried out in conjunction with the CDC.
Staff found that epidemiologists in each program looked at behavioral risk factors, such as whether a person smokes or is overweight, and put together an analysis using their own desktop statistical program. "One of the early things we did was line these reports up and as soon as we did that we saw that everything was a little different; the diabetes report differed from the cardiovascular disease report. That made it difficult for consumers at the local health department level to compare the two. It was apples and oranges.
"Through Common Ground, we were able to come up with an integrated chronic disease report. We had a number of different outcomes, depending on the chronic disease, but regardless of the outcome, we had the same kind of statistical approach in generating the data."
On the downside, Hanrahan admits, "it was a one-time report. Truth be told, we are not entirely ready to make the switch to being on the same page, analyzing data the same way, so we haven't really achieved data integration."
To move towards that goal, the Division of Public Health created a strategic plan in August 2009 to determine how best to use public health information and technology. The strategic plan, Hanrahan says, "has the potential to transform the way data are analyzed, shared and the results disseminated across public health in Wisconsin by removing barriers to data sharing and collaborative activities, increasing the capacity for data integration, and making data more readily available for analysis and reporting."
The committee Hanrahan assembled under Common Ground continues to work on the goals and objectives outlined in the strategic plan. "It's a work in progress," Hanrahan acknowledged in 2012, but that work continues.
Exchanging clinical data with primary care clinics. Public health agencies and primary care clinics are required to share information about "reportable" conditions, such as HIV/AIDS or tuberculosis, but exchanging data on non-reportable chronic diseases, such as asthma and diabetes, was new for Wisconsin, as it was for most of the country in 2006.
Hanrahan noted, "Moving forward required both a cultural shift for public health practitioners as well as additional financial resources, and fortunately we could secure both. The carrot was the growing national emphasis on improving health care quality and controlling costs through health information exchange and the use of electronic health records."
The additional inducement the state needed to move forward was a $400,000 Medicaid Transformation Grant from the Centers for Medicaid & Medicare Services (CMS), which supported a pilot project linking clinical care and public health through electronic health record exchange.
Common Ground laid the foundation for the pilot, according to Hanrahan, because it got epidemiologists together to agree that data exchange was a good idea. "But truth be told, without the Medicaid Transformation grant, we would have only had a report that said this is what ought to be done. With the CMS funding and additional support from the CDC we were able to implement the project—but we wouldn't have had the additional support if it hadn't been for Common Ground."
This project used the three-part Common Ground Collaborative Requirements Development Methodology (DCRM). CRDM looks first at how work is being done (business-process analysis), then how it could be done better (business-process redesign), and finally how information systems could support the new processes (requirements development).
The Division of Public Health team created a data set on more than 192,000 patients seen in family clinics throughout Wisconsin from 2007 to 2009. Patient data on asthma, diabetes, obesity, and influenza were linked to some 6,000 community-level variables (e.g., education, median income, economic hardship index, employment, availability of fresh food) and consumer behaviors (e.g., consumption of fast foods, smoking).
The team was able to map pockets of increased asthma and diabetes, information that clinicians can use to make decisions about how to treat patients at risk. Because this systems approach examines diseases within their biological, psycho-socioeconomic, environmental, and community contexts, it is likely to provide a better understanding of what can be done to improve health care quality and population health, according to a recent project publication.
Looking back, Hanrahan noted "we really articulated our theory and practice-and our spirit and vision-of data exchange. The spark of an idea that started with InformationLinks was refined through Common Ground, giving us a clearer picture of what public health's role is in health information exchange. It's not just to be passive consumers, inundated by data, but to provide services back to clinicians."
The big challenge: financing health information exchanges. The lack of resources helps explains "why we're still not there in reaching the goal of integrating the flow of information within the department of public health or exchanging data with external clinical care partners," said Hanrahan.
"Another challenge is that clinical data is different and more complex to analyze than other kinds of data, such as claims data. Although we've accomplished a lot with our asthma and diabetes analytics, we've still only scratched the surface. Looking at diabetes and asthma prevalence in terms of behavioral risk factors, like smoking, is important but the bigger question is who's getting better, who's getting worse, and who never budges.
"To get at that question, we need to do longitudinal data analysis and we've never done anything like that in public health. Physicians are very excited about that possibility because it might inform how they treat patients, but again, money is a problem."
Grantee Perspective: Common Ground's impact was three-fold, Hanrahan said. "The idea of coming together was critical. National Program Director Dave Ross, ScD, came up with an African proverb that became a slogan for what we were doing. 'To go fast, go alone. To go far, go as a group.' With tight budgets, health departments are very thinly staffed. It's hard to get people to commit time to come together and do the hard thinking as the clock is ticking. So people go fast to get things done. The Common Ground collaborative methodology was a way to move forward and go far together.
"Second, in public health informatics we focus on analytics. We've made considerable headway there, but when you look at our reports, how we process data, it's still at a fairly basic level. We were trained to do more but tend not to because of inefficiencies in the way we work. The Common Ground idea of changing work processes, so that what was hard one day is easy the next, was fundamental.
"The final and most important impact was taking the Common Ground collaborative approach and business tools and demonstrating them in the new world of clinical electronic health records, an area that we in the public health department had no experience with prior to Common Ground."
Common Ground, coupled with additional federal support, enabled Wisconsin to create a framework for two-way clinical data exchange between public health and primary care clinics, according to Hanrahan. He also indicated that the state also improved its capacity to describe risk factors and determinants of disease by demonstrating a common analytic approach with asthma and diabetes.
"We believe that through data exchange each domain improves the other," said Hanrahan. "Public health is getting much better surveillance data and clinicians receive information about risk factors that allows them to make better decisions that ultimately result in better clinical care."
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."