City of El Paso Department of Public Health
DSRIP Project: El Paso Community Health Atlas
Identifying Project and Provider Information:
Title of Project: El Paso Community Health Atlas
RHP Project Identification #: 065086301.1.2
Project Option: 1.5.3 Implement project to enhance collection, interpretation, and/or use of REAL data
Performing Provider Name: City of El Paso Department of Public Health/065086301
Project Description:
The City of El Paso Department of Public Health is proposing a four year developmental effort to establish/use an El Paso Community Health Atlas for describing health status at zip code level and informing researchers, policy makers and service providers.
To achieve more accurate feedback on whether investments into public health are effective, policy leaders and others need reporting systems that tell them: 1) where funds and efforts should be should focused in order to achieve the most leveraged return; and 2) whether or not progress is being achieved. Like many communities, El Paso lacks a user-friendly data repository where this information can be compiled. This project, the proposed El Paso Community Health Atlas, will address that need and produce a comprehensive database that stores present and collected biomarker information linked to zip codes, to establish a baseline against which future data can be compared.
What El Paso does have are numerous data repositories housed within a variety of organizations and institutions, private and public, all storing information about the health and at-risk biomarkers of their respective client populations. Biomarkers are measurable characteristics that reflect the severity or presence of some disease state. They include information like blood pressure, cholesterol levels, body-mass index, and others which are extremely important in assessing the state of health, the progress (or ineffectiveness) of strategies, and the risk of occurrence of more serious conditions. Linking this biomarker data, with other types of data to zip code, i.e., locations allows an even greater ability to focus resources on improving health for residents in areas where the data indicate the risk of worsening, i.e., more expensive health conditions.
In order to establish the infrastructure that will enable policy leaders to make outcome-driven decisions, this project proposes a four-year effort that comprises the following key project activities:
1) Identify organizations that collect health-related data with the end goal of establishing the ongoing mechanisms for accessing the specific information required for this project;
2) analyze the data with the end goal of identifying gaps of information that need to be further surveyed, along with reporting on the trends and patterns revealed by the analysis;
3) Finalize the measurement of biomarkers and reporting of combined data sources to be utilized by the project’s policy and practice group; and,
4) Utilizing the data reported, determine the interventions to be undertaken in specific geographic areas which have the ability to provide the largest return on investment.
Through this project, El Paso’s policy and practice leaders will be able to make decisions that impact public health using real-time data. Resources can be utilized more wisely once the baseline of biomarker data is established for every zip code. Over time, the true value of this critical investment in public health information infrastructure will be realized by enabling public health leaders and community stakeholders to track specific outcomes in cost, quality and effectiveness against the starting baseline.
Phase I
Phase I (DY 2)
· Review of organizations and data resources available at the county and city level, community organizations, hospitals, FQHCs, Public Safety (Police and Fire) Environmental projects, etc.
· Data domains will be compiled and reviewed. These include but are not limited health behavior, clinical care, social and economic factors, as well as physical environment.
· An index will be compiled of organizations in the city and county, the role they play in the community, and services provided.
· Next, a review of the type of data collected by the organizations above will be undertaken to identify what data to include in a data repository. A middleware company will be contracted to assist in identifying ways in which to export data from various systems compliant with HIPAA and security protocols which do not present undue workloads on the participating organizations. The frequency of data exchange will also be determined in order to provide just in time information for analyses.
Phase II.
Phase II will occur in DY 3 of the project and include the integrated analyses of information by zip code.
· Identification of trends and patterns will be reported. Gaps of information will be identified and prioritized for further survey by the project search group.
· Mid-year, DY 3, the research group based on observed trends and patterns will prioritize zip codes to begin sampling of biomarkers measurement to be undertaken. The final goal is to perform statistically significant sampling of all zip codes for comparative analyses.
Phase III
Phase III in DY 4 will finalize the measurement of biomarkers and reporting of combined data sources to be utilized by the project’s policy and practice group.
Phase IV
Phase IV in DY 5 will determine interventions to be undertaken in specific geographic areas based on the information reported in Phase III of the project which have the ability to provide the largest return on investment.
Goals and Relationship to Regional Goals
The overarching goal of this project is to assess data resources, index data by category and map this data by zip code to provide better insight into the health of the populations and sub-populations of El Paso. The ability to access data in a user friendly fashion by researchers, policy makers, public health surveillance teams, service providers and others will effectively lead to improved local understanding of the needs in the community and ways to improve outcomes of the community (clinical, financial, quality and satisfaction).
Population-based data collection and research in the El Paso community will help describe/refine who’s at risk for select diseases by race, ethnicity, language (REAL), physiologic, behavioral, socioeconomic and other factors and who may be protected by one or more of the above factors. Further, specific interventions (health and other) can be studied to identify best practices for disease prevention/management/control in a predominantly Hispanic population. The El Paso Community Health Atlas will inform/and influence health planners, clinicians, and policy makers and, therefore, is translational to all DSRIP health improvement categories.
Project Goals:
To achieve the goal of population health improvement, the collection, synthesis, and use of geographic information as it relates to the multidimensionality of health offers a starting point. This project is aimed at assessing what data are available, the types of data, where the data resides, and gaps of data. Furthermore, taking this data and geo referencing into usable formats for multiple purposes which include but are not limited to the following goals:
· Delineate spatial clusters of: (a) Infectious disease; (b) Chronic Disease; and (c) Risk factors for disease to enable public health and other organizations to respond more timely and effectively, and assist epidemiologists to reveal area patterns.
· Represent health data with geographic associations; investigate patterns of disease.
· Use spatial estimates to transform health data into surface of disease visualizations.
· Create a portal that can be accessed by the public which provides alerts based on certain type of data.
· Merge the following data categories into one data repository (health behavior, clinical care (locations of care sites), social and economic, safety (police/fire), physical environment (parks, recreational facilities, grocery stores, restaurants, and air and water quality) for use by multiple stakeholders.
This project meets the following regional goals:
The Atlas project will provide key statistics, profiles with contextual information and interactive mapping which allows even non-technological users to easily visualize and identify selected areas and themes with ease. Having this powerful resource online means users are able to target existing resources supporting the evidence-base for policy and community related interventions. It also will allow users to search data by theme, geography, list name of indicators, compare areas or search for individual themes. This aligns with regional goals of:
· Overcome language, socio-economic, and monetary barriers to accessing healthcare resources in the region (This is achieved by not only having access to data available if a person is part of current data collection but to reach out to populations we do not have data on and obtain biomarkers.)
· Better manage patients with chronic diseases, such as Diabetes, CHF, Asthma, COPD, and Renal disease to help prevent unnecessary readmission and get patients the care they need to prevent, self-manage, and address in an appropriate setting. (By mapping data which includes information on biomarkers of disease and admission/encounter data by ICD9/10 CM codes targeted outreach and educational interventions can be undertaken)
· Address the issues of Diabetes and Obesity, as they represent major health concerns in Region 15 (By consolidating data researchers and others can not only prioritize the most at risk areas but also look at influencers to these trends and engaging the community to identify strategies for reversing trends.)
· Provide patient education to ensure the population is accessing the right care in the right setting (Data will show by diagnosis code and number of encounters where people and accessing care, as well as the payer mix, zip code of their place of residence, and more. With this data researchers and others can identify particular high risk populations and possible reasons for inappropriate utilization such as inability to obtain an appointment at clinics in the area, transportation issues, poor health literacy, lack of understanding regarding what is available in their community as resources, etc.)
Having the ability to access data rapidly and efficiently is the foundation to be able to identify baseline information; agree on interventions; and measure the effectiveness of interventions.
Challenges:
The challenges associated with creating a centralized data warehouse range from collaboration amongst parties; clear agreement on data to be used; how data will be transmitted; security of data transmission; integrity of data; how data will be used; and who will have access to data. These challenges can be overcome by having a clear plan on indexing what is an available today; assessing gaps in data; and having experienced experts involved in the design of the model that facilitates data exchanges without additional work to participants in a secure platform. A vision for how to make data more user friendly to multiple stakeholders is critical to the project’s success. Merely creating a data warehouse is not the intent of this project and in order to gain buy in from stakeholders, their opinions and needs should be addressed in an effort to make data usable and actionable to meet their needs.
Sustainment of the project must also be addressed after initial funding. As part of this project plan will be ongoing discussion and planning around models of sustainment.
5 Year Expected Outcome for Providers and Patients:
Over a five year work period the Atlas will demonstrate how access to relevant health indicators in a centralized easy to use format will provide the information needed to prioritize and coordinate needed activities to improve population health. The expectation is that there will be:
1. Improved awareness around the status of health in the region by zip code
2. Enhanced understanding of influencers of health
3. Greater coordination amongst stakeholders in efforts to improve health leading to more appropriate spending on programs and projects aimed at specific information about the population and sub-populations of the region.
Starting Point Baseline:
This is a new initiative of the city of El Paso Department of Public Health; hence, baseline is zero (0)
Rationale:
The growth of information technology enables communities and organizations to collect information and exchange it in ways that were not possible before. Previously, policy makers, organizations, and consumers based decisions impacting health on minimal data and good guesses around what was needed and interventions that may make a difference in improving the health of an individual or population. We have an enormous opportunity to not only gather and analyze data to make better informed decisions about what is needed to improve health, but to also utilize resources more wisely and cost effectively to eliminate wasteful spending. Public health should engage community stakeholders and expand the capacity of a community to come together and identify ways in which they can work together towards building a healthier community.
Potential applications of information technology to public health have yet to be implemented. (Yasnoff, Overhage, Humphreys, & LaVenture, 2001) Although the public health community was an early adopter of computer technology, the technology has been applied almost exclusively in pursuit of narrow, categorical applications that cannot easily be integrated into functional systems that can monitor the health of communities and guide improvement efforts (Yasnoff, Overhage, Humphreys, & LaVenture, 2001).
Currently, the exchange of data in health care is being supported by the “Meaningful Use” initiatives by both Medicare and Medicaid for hospitals and health practitioners. The first stage of the Hi-tech Iteration involves the capture and sharing of data electronically. Next is Stage 2 which is aimed at connecting the community and sharing data interorganizationally. Further connecting the person, integrating data, and creating executable knowledge, Stage 3 and beyond intent is to build learning models of health preservation and treatment (improved outcomes) (Intiative, 2012).
Meaningful Use is also tightly tied to the Accountable Care Organizations as we better understand the population by mining data we can identify opportunities for improvement which can lead to better outcomes in a cost effective way and share in the savings and risk.
The project is also tightly aligned with the Institute of Medicine’s work on the biomarker evaluation in health care which includes analytical validation, qualification, and utilization and recommendations for implementing the framework for supporting evidence based decisions and promotion of public health. The evaluation framework is constructed based on the following questions: (1) can the biomarker be appropriately measured, (2) is the biomarker associated with the clinical endpoint of concern, and (3) what is the specific context of the proposed use (Medicine, 2010).