TY - JOUR
AU - Whitman,, Greg
AB - Abstract Population-level prevention activities are often publicly invisible and excluded in planning and policymaking. This creates an incomplete picture of prevention service-related inputs, particularly at the local level. We describe the process and lessons learned by the Public Health Activities and Services Tracking team in promoting adoption of standardized service delivery measures developed to assess public health inputs and guide system transformations. The 3 factors depicted in our Public Health Activities and Services Tracking model—data need and use, data access, and standardized measures—must be realized to promote collection of standard public health system data. Bureaucratic, resource, system, and policy challenges hampered our efforts toward adoption of the standardized measures we promoted. Substantial investments of time, resources, and coordination appear necessary for systems to adopt changes needed for collecting comparable service delivery data. Lessons from our process of promoting adoption of standardized measures provide recommendations to support future efforts to measure public health system contributions to the public’s health. public health, public health practice, public health informatics, health information systems, evidence-based practice, public health systems research, information dissemination, health services administration, state government, local government, health policy INTRODUCTION State and local public health agencies are governmental sectors of prevention systems addressing complex individual and population-level health issues to assure equity and the health of populations. Population-level prevention activities, however, are often invisible to the public and excluded in planning and policymaking. Unlike recent tremendous efforts to develop information systems in hospital and clinical settings,1,2 movements to standardize and generate data regarding public health activity have not kept pace. This results in incomplete pictures of health-related inputs, particularly regarding prevention efforts and especially at the local level.3 Regarding inputs of public health service delivery, in 2012 the Robert Wood Johnson Foundation’s Multi-network Practice and Outcome Variation Examination (MPROVE) project (PI-G.P. Mays) took the nation’s first step in establishing an initial set of consistent public health “production measures.”4 These were developed in collaboration with state and local governmental public health professionals in 6 states and regarding 3 domains of local prevention activity (communicable disease control, chronic disease prevention, and environmental health protection).4,5 These measures were capable of more precisely quantifying the scope, intensity, reach, and quality of specific core public health services across states and local health jurisdictions than existing monitoring systems.6 In December 2013, the Robert Wood Johnson Foundation funded the Public Health Activities and Services Tracking (PHAST) team to promote adoption and integration of the MPROVE measures into state and local public health systems as a means to provide shared terminology and metrics across health departments for related planning, comparisons, and aggregation of data. This paper describes the process of promoting adoption of the standardized service measures developed through the MPROVE project, guided by the PHAST model.5 We also share lessons learned during the process, with recommendations for future efforts in measuring public health system inputs.3,7 OUR MODEL AND EFFORTS TO PROMOTE THE ADOPTION OF STANDARDIZED MEASURES Our theoretical model (Figure 1) guided our process of promoting adoption of the standardized public health service measures.5 This model was based on literature review, findings from our early data collection, and interactions with practice partners. Using a dissemination and implementation science framework, our model consists of 3 parts: data need and use (practice), data generation and analysis (research), and data access (bridging the gap).5 Public health practitioners have high needs for data to monitor community issues, conduct planning, and measure performance. Based on these needs, data are ideally generated and analyzed in a way that promotes effective practice. To reduce the gap between these practice and research needs, a channel to connect the 2 is necessary. All 3 interconnected parts are essential to promoting standardized measures. We describe our efforts here as corresponding to each of these interconnected parts.5 Figure 1. Open in new tabDownload slide The Public Health Activities and Services Tracking Model for standardized public health data.5 Figure 1. Open in new tabDownload slide The Public Health Activities and Services Tracking Model for standardized public health data.5 Identifying and responding to “data need and use” (practice) The process of promoting adoption and use of standardized service measures begins with understanding what data are needed and how public health professionals are using existing data. Through frequent communication with public health professionals, including focus groups and interviews from 2014 to 2016 with potential adopters, and over 40 state- and national-level presentations by 2017, we interacted with and received valuable feedback to refine our approach. State leaders and their local public health system counterparts expressed great interest in having and using data more to support planning and communication. They identified a standardized measurement system providing useful data regarding their services as necessary for examining public health program priorities, monitoring quality improvements, and exploring state-wide distributions of service. Only a few states (eg, Washington, with their Activities and Services Inventory)8 had already established standardized reporting systems of local public health services.9 Having a system for comparing their service volume and reach in different program areas with agencies of like size and local characteristics and in other states was also particularly appealing. They frequently described wanting those comparable data to support advocacy, education of stakeholders, prioritizing programs, and preparing for accreditation. Providing analyzed data (research) For the next stage of the process, we identified key state public health leaders to disseminate the standardized measures and encourage uptake into public health information systems. Through presentations, emails, social media, our website, and via national organizations, we identified 22 states who considered adopting these measures. Public health professionals from health departments in each of these states expressed specific interests in compiling and using the measures. We also provided technical assistance to those interested in adopting the measures and developed detailed data specifications and other supporting tools and documentation.4 Of the 22 states identified, only 1 state fully agreed to have their state and local systems work on obtaining data on the measures—some of which they were already collecting and other measures they would need to integrate into their systems. Also, PHAST obtained detailed, local health department (LHD)–level public health service-related data through various other research projects, including a specific national callout via social media for existing childhood immunization-related data that closely met our data specifications for local public health services and outcomes.8,10 As we cleaned and compiled data into formats for further analysis, we identified data quality issues, with many datasets not complete or not matching in years. Even with these limitations, the PHAST team generated rigorous research using some of these measures collected across states,11 developed a dashboard of multistate LHD data specific to immunizations,8 and disseminated findings from these data through policy briefs, social media, and conferences.12 Making data accessible (bridging the gap [between practice and research]) In an effort to make data more accessible, we developed and implemented an online data reporting tool for participating agencies. This tool aimed to gather data in a consistent format and connect the data directly and in a timely way to an interactive visualization dashboard. We also developed data visualization dashboards through a user-centered design approach. We communicated frequently with public health professionals to understand their needs and preferences for visual data presentation.8 During the process of developing our prototype interactive dashboard with county-level toddler immunizations,8 we observed that, by displaying data visually, public health leaders engaged with the data more than with spreadsheets, had a better understanding of the data, and provided strong positive feedback regarding the dashboard and its potential uses for educating stakeholders about service needs. Despite the benefits of using data visualization, structural challenges in public health information systems existed, making it difficult to apply data visualizations to public health practice. Incomplete public health data and inconsistent ways of gathering the data, for example, made it difficult to fully depict population needs. Also, public health professionals needed training on how to use data and data visualization, so that they could facilitate use of data tailored to their local needs. LESSONS LEARNED Lessons learned from our efforts with these standardized measures are described subsequently and support related recommendations (Table 1). Table 1. Recommendations for policy and practice from our lessons learned Expect that substantial investments of time, resources, new technologies, and coordination are needed for state and local public health systems to adopt the changes needed for collecting comparable service data Develop long-term plans for modifying reporting requirements to support data standardization Leverage health department accreditation as a means to drive investment in integrating standardized measures into public health systems to demonstrate use of data, evidence, and effective administrative systems Develop data reporting systems that will capture data, lower public health data management workloads, and encourage regular data collection Work with trained data personnel to employ data visualization as a means to discover public health needs and communicate with policymakers Expect that substantial investments of time, resources, new technologies, and coordination are needed for state and local public health systems to adopt the changes needed for collecting comparable service data Develop long-term plans for modifying reporting requirements to support data standardization Leverage health department accreditation as a means to drive investment in integrating standardized measures into public health systems to demonstrate use of data, evidence, and effective administrative systems Develop data reporting systems that will capture data, lower public health data management workloads, and encourage regular data collection Work with trained data personnel to employ data visualization as a means to discover public health needs and communicate with policymakers Open in new tab Table 1. Recommendations for policy and practice from our lessons learned Expect that substantial investments of time, resources, new technologies, and coordination are needed for state and local public health systems to adopt the changes needed for collecting comparable service data Develop long-term plans for modifying reporting requirements to support data standardization Leverage health department accreditation as a means to drive investment in integrating standardized measures into public health systems to demonstrate use of data, evidence, and effective administrative systems Develop data reporting systems that will capture data, lower public health data management workloads, and encourage regular data collection Work with trained data personnel to employ data visualization as a means to discover public health needs and communicate with policymakers Expect that substantial investments of time, resources, new technologies, and coordination are needed for state and local public health systems to adopt the changes needed for collecting comparable service data Develop long-term plans for modifying reporting requirements to support data standardization Leverage health department accreditation as a means to drive investment in integrating standardized measures into public health systems to demonstrate use of data, evidence, and effective administrative systems Develop data reporting systems that will capture data, lower public health data management workloads, and encourage regular data collection Work with trained data personnel to employ data visualization as a means to discover public health needs and communicate with policymakers Open in new tab Bureaucratic nature of public health departments While well informed by practice, our initial strategy to promote standardized measure adoption through state public health agencies specifically was hindered by the bureaucratic nature of state agencies. Despite broad and persistent efforts and concrete steps toward collecting and sharing local data, and a strong interest and growing awareness by state and local public health officials of the need for standardized activity data, only Washington State implemented the collection of these data. Reasons for others not participating included difficulties of altering current data collection systems, the data collection burden among LHDs, and the lack of resources and time. In some cases, states were preparing to establish some collection of the standardized service measures and related system changes, but due to a change in agency priorities, could not make the time or financial investment to alter their information system structure. In 2015, even Washington State suspended its annual Activities and Services Inventory to focus public health leaders’ attention and resources on major system and policy issues related to system transformations built around the foundational public health services.13 Softened ground and changes to systems In concurrent PHAST efforts related to establishing a uniform chart of accounts (UCOA) (Robert Wood Johnson Foundation Grant #73187), collecting standardized programmatic financial expenditure and revenue data from health departments,14,15 the PHAST team has experienced dramatically better recruitment results. This includes at least 6 states immediately wanting to sign on for our initial pilot UCOA work—a process that also required significant effort regarding data standardization and adoption.14 We conjecture that these very different responses can be attributed to the following. First, the UCOA work has a much longer history of prior funded effort and awareness building that likely “softened the ground” enough among practice leaders to support the time and resource investments related to adoption. Perhaps because of this softened ground, the benefits of employing a UCOA were more apparent to stakeholders than adopting service delivery measures. Second, the service measures adoption project required changes to existing state data collection systems compiling local data, while the UCOA project needs only a crosswalk between data systems, so no data system changes are required. Third, the UCOA pilot-test agencies were provided with a modest stipend and technical assistance, while the service measures adoption project provided only technical assistance. Public health leaders in our projects describe needing comparable standardized measures and data for communicating to stakeholders and for informed decision making. However, supporting related systems for doing so is neither mandatory nor adequately resourced. The move toward health departments seeking accreditation may drive more need for investment in integrating standardized measures into public health systems, as the Public Health Accreditation Board Standards and Measures include standards for which the employment and use of data, evidence, and effective administrative systems are an expectation.16 Policy efforts and system change Data reporting systems must be developed to capture data, lower public health data management workloads, and encourage regular data collection. Data systematically collected and digitalized can then be accessible, timely, and of good quality. Data summaries and statistical analyses combined with data visualization are a powerful tool for discovering public health needs and communicating with policymakers. However, to build usable visualization tools, skilled data personnel and an adequate amount of data are needed. While visualization dashboards and similar tools are far from all that is needed to explain factors related to public health performance, they can draw the attention of audiences by showing existing public health system issues and raising important questions. Public health service measures will also need to evolve as new and complex problems emerge, and as practice changes and varies. When needed, the data should be combined with relevant data from non-health related fields, such as housing and education, to support examining social determinants of health related to public health practice. Demonstrating the value of public health system data to public health professionals and leaders in other sectors is likely to further increase the utility of the data.5 National systematic efforts, however, are needed to sustain further development and uptake of well-defined, standardized, relevant public health service measures—data needed to complete an otherwise incomplete picture of service-related community inputs. Building such measures into reporting systems needs strong policy support and resources. Yet despite the National Academy of Medicine’s recommendation that federal agencies “facilitate the development of a performance measurement system that….include[s] measures of the inputs [e.g., resources, activities, programs] contributed” by agencies responsible for public health protection and health improvement,3 currently no agency or institution has taken responsibility for establishing the policies and resources needed. CONCLUSION Being desirous and aware of the need for comparable public health service data and having common measures developed are important, but insufficient, for encouraging uptake of these measures in practice. Substantial investments of time, resources, technologies, and coordination are needed for public health systems to adopt the changes needed for collecting comparable service data. The 3 factors depicted in our PHAST model—data need and use, standardized measures, and data access—should be adequately realized to promote collection of standard public health system data effectively. Ongoing discussions and efforts to make a case for uptake and use of standardized measures of public health services are needed to soften the ground toward greater advocacy and support for the resources to make related system and policy changes. FUNDING This work was supported by Robert Wood Johnson Foundation grant no. 73270 (BB). ETHICS APPROVAL The University of Washington Human Subjects Division determined that human subjects were not involved in this study. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1 Ohno-Machado L. Electronic health records and health information exchange . J Am Med Inform Assoc 2018 ; 25 6 : 617. Google Scholar Crossref Search ADS PubMed WorldCat 2 Ohno-Machado L. The role of informatics in promoting patient safety . J Am Med Inform Assoc 2018 ; 25 7 : 773. Google Scholar Crossref Search ADS WorldCat 3 Institute of Medicine . For the public’s health: the role of measurement in action and accountability; 2011 . http://iom.edu/∼/media/Files/Report%20Files/2010/For-the-Publics-Health-The-Role-of-Measurement-in-Action-and-Accountability/For%20the%20Publics%20Health%202010%20Report%20Brief.pdf Accessed November 15, 2013. 4 Public Health Activities & Services Tracking (PHAST ). Measures 1.1; 2015 . http://www.phastdata.org/measures Accessed August 1, 2019. 5 Bekemeier B , Park S. Development of the PHAST model: generating standard public health services data and evidence for decision-making . J Am Med Inform Assoc 2018 ; 25 4 : 428 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 6 National Association of County & City Health Officials. The National Profile of Local Health Departments Study Series ; 2017 . http://archived.naccho.org/topics/infrastructure/profile/ Accessed January 30, 2017. 7 Institute of Medicine . For the public's health: investing in a healthier future; 2012 . http://www.iom.edu/Reports/2012/For-the-Publics-Health-Investing-in-a-Healthier-Future.aspx Accessed February 27, 2017. 8 Public Health Activities & Services Tracking . PHAST visualizations; 2015 . http://www.phastdata.org/viz Accessed October 25, 2015. 9 Washington State Department of Health . http://phastdata.org/viz/WA_ASI Accessed December 28, 2017. 10 Robert Wood Johnson Foundation . Dissemination and implementation research in public health settings: Leveraging practice-based research networks to understand the value of public health delivery . Request Proposals 11. https://anr.rwjf.org/templates/external/PHPB3_RFP_Final.pdf Accessed June 25, 2018. WorldCat 11 Bekemeier B , Yip MP , Flaxman A , Barrington W. Five community-wide approaches for physical activity promotion: a cluster analysis of these activities in local health jurisdictions in 6 states . J Public Health Manag Pract 2018 ; 24 2 : 112 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Public Health Activities & Services Tracking. PHAST-selected presentations ; 2018. https://phastdata.org/presentations Accessed June 25, 2018. 13 FPHS Policy Workgroup . Foundational public health services: a new vision for Washington State; 2015 . http://www.doh.wa.gov/Portals/1/Documents/1200/FPHSp-Report2015.pdf Accessed March 18, 2016. 14 Bekemeier B , Singh SR , Schoemann A. A uniform chart of accounts for public health agencies: An “essential ingredient” for a strong public health system . J Public Health Manag Pract 2018 ; 24 3 : 289 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Singh R , Bekemeier B , Leider JP. Local health departments' spending on the foundational capabilities . J Public Health Manag Pract 2019 Feb 14 [E-pub ahead of print] . WorldCat 16 Public Health Accreditation Board. Public Health Accreditation Board: Standards and Measures. Version 1.5; 2013 . http://www.phaboard.org/wp-content/uploads/SM-Version-1.5-Board-adopted-FINAL-01-24-2014.docx.pdf Accessed April 24, 2016. © The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. 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TI - Challenges and lessons learned in promoting adoption of standardized local public health service delivery data through the application of the Public Health Activities and Services Tracking model
JO - Journal of the American Medical Informatics Association
DO - 10.1093/jamia/ocz160
DA - 2019-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/challenges-and-lessons-learned-in-promoting-adoption-of-standardized-66PJ0EYxn4
SP - 1660
VL - 26
IS - 12
DP - DeepDyve
ER -