1. Ross, David A. ScD

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THE PUBLIC health informatics community has a unique role to play in improving and protecting the public's health through the application of new and improved systems and foundational infrastructure. Experience tells us that implementing information technologies successfully hinges on a combination of expertise woven together with insightful application of organizational change strategies.


The public health information infrastructure of the future will require substantial investment, most of which must come through government action. Securing government appropriations at the federal and state levels, sustained over a long period of time, demands that we articulate the value of the investment and then deliver working systems that meet large health goals.


Factors key to successful implementation need to be recognized widely and embraced in a systematic manner by the informatics community. We know, for example, that it is the introduction of our innovations that forces the organizational change. Thus, we need to be students and managers of organizational change. We know that leadership and executive commitment are vital. Yet most of our major initiatives get launched with half-hearted executive support and less than complete understanding of the strategic health consequences we seek to achieve. Consequently, the burden of making the expected value of informatics investments known falls to us. We must make it known to our leaders and to the public. Thus, we need a communications strategy. No large-scale, strategically directed information initiative should go forward without a well-developed communications plan.


But there is, I believe, a larger and more important aspect of the emerging public health informatics field that must be appreciated and dealt with if we are to be successful in translating technology innovation into public health program innovation and improved population health outcomes. That understanding begins with considering the "public" part in public health informatics. What are the unique consequences of this word to our emerging discipline?


Public health is broad and consequently so must be public health informatics. The National Association of County and City Health Officials defines the public health system as "the arrangement of all publicly operated entities which provide health-related, population-based services-including disease prevention, health promotion, diagnosis, treatment, rehabilitation, policy and research-to promote conditions in which people can be healthy."


In this vast portfolio of responsibilities, informatics can and must make a difference. The events following September 11, 2001, make this truth abundantly clear. We have witnessed a reawakening of public awareness of the need for timely and accurate population-based information. Nonetheless, I suspect that many public health executives are less than convinced that large, continuous investments in systems and technologies will yield a return to the issues they care most about. Changing the mindset of skeptical executives and legislators must be the job of the public health informatics community. Defining the value of needed investment begins with us. We must help public health leaders recognize that the effective application of modern information management should be a central focus of their attention rather than a peripheral concern delegated to others. Five characteristics of public health present unique challenges to this emerging discipline.


First, public health holds an inviolable responsibility to protect the privacy of every citizen. Information technologies by their very nature are intrusive. Congress can and will support the application of technologies that improve health and health care but they must trust that the technologies will not erode the basic liberties upon which this country is founded. The informatics community can serve a key role by explaining how new technologies improve health status while protecting privacy.


Second, public health is a collaborative enterprise owned by many. We have to work collectively. Unfortunately, collective leadership can be at odds with efficient design and good architecture. We cannot engineer by committee and be successful. However, we must remember the context within which public health accomplishes its ends. That is, we foster collaborative leadership, we seek to strengthen partnerships, we seek shared vision, and we seek to engage the community in the change process and to move beyond simply seeking "input." Therefore, we must master a new art form: that of efficient and effective design endorsed by the partnerships and communities we serve.


Third, "public" health is, in effect, a monopoly. We don't have direct competitors. While regulation is a critical role of government and essential to protecting and promoting health, we cannot embed information technologies successfully into the fabric of public health practice with a regulatory mindset. Accountability is self defined.


Fourth, public sector financing skews our view of return on investment. Public health benefit often accrues to the collective public while the costs are borne by a few. While the overall societal benefit or return can be argued to be positive, costs are not distributed uniformly nor are they borne necessarily by those who benefit. Therefore, making our benefit known requires that we look at costs and benefits from the view of every stakeholder.


Fifth, in public health, leadership is frequently in flux at the top of our organizations. By constitutional design, we are directed by political forces. Variable leadership creates large challenges to long-term informatics projects. Projects launched under one leader often end under another. Therefore, broad institutional acceptance of project goals and value are essential to success. Thus, knowing your organization and having strategies that involve many layers of leadership will differentiate the successful from those who merely tried hard.


Given these five realities, what principles should drive us? I put forward four principles for consideration.


1. We must recognize that as a monopoly, public health must self-define standards of service. We need to establish a code of service that would be competitive in the private marketplace. By implementing operational architectures similar to those seen in the best private sector businesses, we will know when a system fails to meet customer expectations and we will have standards of performance that self-correct the shortcomings. We cannot accept "government as usual" to define service agreements. We should not develop systems without a service element that is explicit and endorsed by our constituents.


2. If business value is expected, new system implementations must be understood to be changing a business process. A well-defined business case involves executive leadership in a meaningful way. Investment in information technologies must be understood to be competing against limited resources. We must explain the value and show that a new application holds at least as great a value as competing priorities. Making value of informatics innovations known is not easy; yet as the scale of system investments increases, it will be required.


3. We need to act collectively to build a market of suppliers interested in offering solutions to public health problems. Business principles need to become the next arrow you add to your quiver. We must think of cultivating a cadre of individuals with MPHs/MBAs.


4. We should acknowledge that problems are best solved at the level at which they exist. Local health needs and local public health operations need to be a major focus of our attention. System requirements need to be defined with the first-line user in mind. Thus, we should start with the point at which data originate to define and understand our future systems. We must flip the hierarchy of government on its head if we are to successfully define the next generation of public health systems.



Current public health strategies focus on immediacy and massive investment to strengthen weakened infrastructure. Public health officials, including senior informatics practitioners, must adopt operating principles that will ensure a translation of these funds into a permanent and positive incremental step ahead for public health goals.