Section 0 Overview—e-Health Scenarios - 1
E-health has proven time and time again to be vital to many public health departments’ success. This section provides examples of how e-health was put to good use in four care scenarios to enhance your understanding of how electronic health records (EHR), health information exchange (HIE), and other forms of health information technology (HIT) may help you reach your goals of improving health and health care for those served.
The purpose of these four scenarios is to illustrate possibilities and potential of e-health as you begin to adopt and optimize use of HIT, EHR, and HIE within your own local public health service, and to encourage you to seek support from your state for enhancements to help you achieve the most you can from your chosen technology.Time needed: 2 hours
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Real Life e-Health Use in Public Health
Local public health departments strive to uphold national standards when executing their mission to promote healthy communities (see: These standards reflect significant opportunities for strategic use of HIT, EHR, and HIE to:
1.Monitor health statuses to identify community health problems.
2.Diagnose and investigate health problems and health hazards in the community.
3.Inform, educate, and empower people about health issues.
4.Mobilize community partnerships to identify and solve health problems.
5.Develop policies and plans that support individual and community health efforts.
6.Enforce laws and regulations that protect health and ensure safety.
7.Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8.Assure a competent public health and personal health care workforce.
9.Evaluate the effectiveness, accessibility, and quality of personal and population-based health services.
10.Research for new insights and innovative solutions to health problems.
Local public health departments often work with many different types of partners on strategies to improve the health of individuals, families and their communities. Thus, they can realize tremendous benefits from new technologies such as mobile applications, enhancements to clinical decision support in EHRs, and significantly expanded use of HIE. Real life examples can help illustrate how HIT, EHR, and HIE can intersect within this framework. The scenarios examine the following direct services and care coordination provided by local public health departments:
1.Antepartum care for those needing Women, Infants, and Children (WIC) assistance and other preventive health services to promote healthy pregnancies and births.
2.Postpartum care for those needing WIC assistance and other services, including intersection with social services, to promote maternal health, parenting and child growth and development.
3.Child screening for those children needing assessment of physical, emotional, and developmental milestones, early identification of problems and referrals for early intervention and treatment services, such as medical or dental services, WIC, early childhood intervention services offered through schools, public assistance programs and other types of community support services.
4.Infectious disease management, such as tuberculosis, to promote containment of contagious diseases within families and communities.
Each scenario includes:
- A story illustrating in narrative form how local public health currently uses EHR, and how additional EHR functionality, HIE, and other forms of HIT could be used.
- A template summarizing the narrative story into a structure that illustrates how HIT, EHR, and/or HIE (highlighted in red) are used at each step within the scenario.
- A matrix that identifies the key users and the information used by each of them.
Important Note: These scenarios illustrate how HIT, EHR, and HIE functionality can be used. You may find that your local public health department and/or state do not yet have some of the capabilities illustrated; or your state may have other capabilities that these use cases do not include. Your state may also have requirements for obtaining consent for release of information via HIE that are more stringent than those required under the HIPAA Privacy Rule.
Scenario 1: ANTEPARTUM
Kari is 15 years old and presents at a family planning clinic (FPC) to request a pregnancy test. She has missed two periods. The pregnancy test is positive. The nurse at the FPC learns Kari is attending high school, but is fearful of being teased when the other kids find out she is pregnant. She thinks she may drop out. Her parents do not have much money, and do not have health insurance as her father was recently laid off from work. Kari authorizes the FPC nurse to make referrals to the local public health (LPH) department for Women, Infants, and Children’s (WIC) assistance, and the Family Home Visiting (FHV) program, to Kari’s primary care provider (PCP), and to Human Services to apply for Medicaid. Each of these referrals is conducted via the state-certified health information exchange (HIE) organization (HIO).
At 14 weeks gestation, the public health nurse (PHN) makes a home visit to see Kari. She learns that Kari’s parents are very upset about the pregnancy, but are willing to help out as much as they can. An application for medical assistance has been completed and an appointment is scheduled for WIC. Kari has seen her PCP, and has been told she was 12 weeks pregnant. Upon the recommendation of both the FPC nurse and a referral from the PCP, the FHV program is offered to Kari. Kari agrees to enroll in the FHV program and signs consent forms to allow the PHN to share information with the school, human services, WIC, the PCP, other agencies that might be of help, and with Kari’s parents and father of the baby. This consent information is maintained by the HIO to facilitate future exchanges of health information.
During the visit, the PHN completes a health history intake and exam, and enters the data into the LPH’s EHR. Kari is experiencing nausea and vomiting each morning and has missed several days of school. Her boyfriend is 16 years old and wants her to have an abortion. He is not ready to be “saddled” with a baby. Kari shared that she had been at a party and she had been drinking. She was pretty drunk and is not sure who she might have had sex with that night. Her mom is disappointed, as she didn’t want Kari to end up like her—having to drop out of school, unable to get an education, and stuck in low wage jobs. Kari states she has been smoking for the past year, but does not do any other kinds of drugs. Both of her parents smoke and Kari’s attitude is “What’s the big deal about smoking?”
As she develops the plan of care with Kari, the PHN documents in the EHR that Kari will meet with the PHN and participate in the FHV program, which will incorporate teaching, counseling and guidance related to a healthy pregnancy, preparation for childbirth, and parenting. It will also provide mentoring on how Kari should handle emerging crises, including her friends at school, her parents, and the father of the baby. Kari will try to go to school, but if this doesn’t work out she might consider alternative school. Because Kari has given consent for the PHN to share and coordinate the plan of care with the community-based teen parent case management team, the school, her PCP, and other specified community providers, the PHN is able to send these providers an electronic health summary and plan of care. The PHN also encourages Kari to sign up to use the personal health record (PHR) offered by her PCP so she can track progress on meeting her plan of care. Kari is anxious to learn more about what it means to be pregnant. She does not think she can cut down on her smoking now because she is too stressed out.
At her 32 weeks gestation visit, the PHN continues to support Kari’s involvement with the teen parent case management team involving the school nurse, LPH agency, and human services. Kari continues to participate in the FHV program and has stayed in school. Her PHR diary shows she has decreased her smoking by a half pack daily. Her goal is to have stopped completely by the time the baby is born. She has even convinced her parents to decrease their smoking. During this home visit, Kari informs the PHN that she has been having some premature contractions and that her PCP has put her on bed rest. Fortunately, it is summer so she won’t need to miss school. The father of the baby has not been involved. Kari reports that he wants nothing to do with her anymore. She states “He is denying that he is the father of the baby as he claims other guys have had sex with me, so how do I know he is the father?”
At 40 weeks gestation, the local hospital social worker sends a secure email message to the PHN to inform that Kari delivered a 7-pound, 5-ounce baby girl. Discharge planning is underway.Scenario Template / Name: LPH Antepartum
Description: / Local Public Health antepartum services for pregnant teen
Primary actor: / Public Health Nurse (PHN)
Secondary actors: / Family Planning clinic, Family Home Visiting (FHV) Team, WIC, Primary Care Provider (PCP), Social Services, parents, father of baby, school nurse
Preconditions: / PHN has permission to home visit and share health data with other providers and/or social service agencies.
Post-condition: / Birth of Child
Scenario: / Step / Action
1 / Family Planning clinic refers to FHV Program – secure email
Other referrals made by FP clinic
- WIC appointment, provide dates – paper, phone, patient portal
- PCP appointment – provider portal
- Social services: Medicaid application – paper
2 / Referral from PCP – secure email, HIE
PHN home visit scheduled – phone
3 / Home visit is made
- Designate consent for release of information via LPH EHR, and sent to PCP (HIE), school (fax), human services (HIE), and others
- Document history and assessment – EHR
- Establish care plan and ongoing visit schedule in – EHR
- Encourage involvement of family and father of baby – EHR
- Smoking cessation support – EHR, mobile app, Web resources (QuitPlan, etc.)
4 / Refers patient to teen parent case management team (school nurse, LPH, and human services) – HIE
5 / Share plan of care with teen, parent, case management team HIE
- Send periodic update summaries and risk factors to PCP (HIE)
- Patient updates diary in PHR from PCP, uses mobile app to track cigarette use
6 / Health status
- Patient reports PCP put her on bed rest at 32 weeks due to premature contractions. Document in EHR.
- Document in EHR support for emotional and paternity issues
- Send or receive updates to PCP or others as needed (HIE)
6 / Secure email from hospital social work to PHN re: birth of child
Other: / Case followed through hospital discharge in postpartum care
Scenario 2: POSTPARTUM
At 40 weeks gestation, Kari delivered a 7-pound, 5-ounce baby girl. She is planning to breastfeed. She will be living with her parents. She is 16, so her parents expect that she will also get a part-time job to help with the expenses of the baby. A first dose of Hepatitis B vaccine was administered at the hospital. The hospital sent a referral for continued home visiting services to the local public health department via secure email. Immunization records were sent to the state’s immunization registry via the state-certified HIE organization (HIO).
At her two-week postpartum home visit by the public health nurse (PHN), Kari complains of being very tired. The baby is eating every two hours. Kari’s mom thinks the baby is not getting enough milk and wants her to supplement. The WIC staff has told her she needs to breastfeed more often. At the baby’s two-week checkup she had regained her birth weight and the doctor said everything is just fine. Kari says, “I don’t know who I should listen to. School will be starting in a couple of weeks. I don’t know how I will be able to stay awake, take care of the baby, do my homework, and work. Having a baby really sucks. At first my friends all came over, but now they aren’t coming around because I am stuck here and can’t go out with them.” A referral is made to the Lactation Consultant via secure email. Kari is enrolled via a secure email in the Follow Along Program (FAP), located in same office as the local public health agency. A care plan is established and the plan and assessment are documented in the EHR. Any abnormal findings or concerns can be sent to Kari’s PCP by her PHN via secure email.
At her six weeks postpartum visit, Kari tells the PHN that she has seen her doctor for her six-week checkup. She says: “I am so tired all the time. I don’t feel like doing anything. The doctor thinks I might be having some postpartum depression and thinks I should see a mental health person. I have lost a lot of weight and don’t feel like eating anything. I quit breastfeeding. The baby reacted to the formula. WIC had to contact my doctor to get special formula. You told me I need to get the baby back to the doctor when she is 2 months old. I made an appointment online. Will she have to get shots?” The PHN checked Kari’s clinic via the provider’s portal to verify that the referral was made and obtained the name of the mental health provider.
When the baby is 4 months of age, Kari completes the 4-month Ages & Stages Questionnaire (ASQ) via the LPH agency’s portal. The ASQ goes directly to the LPH EHR. The PHN adds a summary note in the EHR and the ASQ and note are sent to the Follow Along Program via the HIO and to Kari’s personal health record (PHR). A review of the immunization registry via the HIO indicates all recommended immunizations have been given. Kari states that her next appointment is scheduled in two weeks. She says she still feels depressed, is now on medication for depression, and is seeing a psychiatrist monthly. She has returned to school and her grades are good. Her mom is helping with babysitting. Kari is working on weekends. “I make just enough money to buy diapers. I don’t have any time for me. I go to school, I take care of the baby, and I work. My friends are all busy doing fun things. Sometimes I wish I had never had this baby, but then I start playing with her and she smiles and talks back to me and I know that things will get better as she gets older.“
When the baby is 9 months old and the PHN makes a home visit, Kari says, “Can you believe it? Someone turned me in to child protection. My old boyfriend came over to see the baby. He offered to stay with the baby while I ran to the store to get some sodas. When I returned home, the baby was crying and he was so upset. The next day she had some bruises on her arm. Do you think he could have hurt her?” The PHN assessed the baby’s physical condition and Kari’s physical and emotional responses to her baby’s needs. Results are documented in the EHR. Because Kari’s consent for release of information allows the PHN to contact the Child Protection Social Worker about the status of the child protection report, the PHN is able to review this via the HIO. Based upon the social worker’s assessment and actions taken by Social Services, the PHN will plan a follow-up home visit and communicate with the PCP and mental health provider via secure email.Scenario Template / Name: LPH Postpartum
Description: / Postpartum/newborn home visiting
Primary actor: / Public Health Nurse (PHN)
Secondary actor: / Hospital, Lactation consultant, Follow Along Program (FAP), primary care provider (PCP), pharmacy, family, WIC, mental health provider, state Immunization Registry, Child Protection Social Worker
Preconditions: / Public Health Nurse has permission to home visit and share health data with other health care providers and/or social service agencies/WIC.
Post-condition: / Ongoing parenting and child welfare monitoring
Scenario: / Step / Action
1 / Intake/referral from Hospital via secure email
- Consent for release of information signed by patient loaded from hospital EHR to HIE
- Continuity of Care Document (CCD), discharge summary (D/S), and history and physical exam (H&P) for mother and baby retrieved from HIE; CCD to mother’s PHR at PCP
- Hepatitis B at hospital, immunization to Immunization Registry via HIE
- Patient contacted by PHN and home visit scheduled by phone, patient portal
2 / Home visit for mother/baby
- Review/update as applicable consent for release of information via HIE
- Document mother/baby assessment in EHR
- Care plan established w/patient and documented in EHR
- Referral to lactation consultant – secure email, portal
- Referral to Follow Along Program (FAP) – secure email, portal
3 / Follow-up visit
- PCP recommends mental health evaluation for postpartum depression
- PHN verifies referral to mental health by PCP– secure email
- Baby: WIC contacted PCP for change in formula due to intolerance
- Mother scheduled 2 month well child checkup with baby’s PCP – LPH portal
4 / Follow-up visit
- ASQ completed by parent via LPH portal and results are sent to LPH EHR. PHN adds summary note in EHR and sends toFAP database via HIE
- Results that do not fall within the normal standards are sent to PCP via secure email
- PCP sends copy to mother’s PHR
- Verify immunizations through Immunization Registry via HIE
- Mother reports she is on antidepressant, seeing psychiatrist monthly
5 / Follow-up visit
- Mother reports child protection involved. Reports incident w/old boyfriend babysitting and bruises on child’s arms.
- PHN assesses and documents mother and baby interaction
- Contact Child Protection social worker and PCP for case file via HIE
- Plan follow up home visit based on feedback from social worker sent to EHR via secure email
- Notify PCP and social worker of status via HIE
Infant / May need referrals for apnea monitor or other special equipment
Other: / Ongoing child development and parenting support; monitor child and mother
Scenario 3: Early Childhood Screening
Carson is a 3-year-old WIC client who is being seen by a WIC Outreach worker for recertification for WIC assistance along with his mother and younger brother. His mom states that both children are overdue for immunizations and their most recent checkups, but their Medicaid has lapsed. The WIC Outreach worker gives her a Medicaid application so she can reapply. They have a PCP, but without Medicaid they cannot afford appointments. The mom also states that they moved here last year and the boys had some immunizations at a local federally qualified health center (FQHC). The WIC Outreach worker notes these providers in the LPH EHR. The WIC Outreach worker schedules an appointment for Carson and his brother for checkups and immunizations via the LPH EHR. Carson is at the appropriate age for an Early Childhood Screening (ECS), so the checkup will also be his ECS. The WIC Outreach worker affirms that the mom has access to the Internet and is shown how to log onto the LPH portal to complete a health history form and Ages and Stages Questionnaire – Social Emotional (ASQ-SE) prior to the appointment. The worker also has the mom sign up with the state-certified HIE organization (HIO) and supply consent information so health information can be shared with the PCP and others as designated.