Public Health Informatics: A CDC Course for

Public Health Informatics: A CDC Course for Public Health Program Managers Patrick W. O'Carroll, MD, MPH; William A. Yasnoff, MD, PhD; and Wally Wilhoite; Pubic Health Practice Program Office, U.S. Centers for Disease Control and Prevention Information science and technology are critical to the modern practice of public health. Yet today's public health professionals generally have no formal training in public health informatics-the application of information science and technology to public health practice and research. Responding to this need, the US. Centers for Disease Control and Prevention (CDC) recently developed, tested, and delivered a new training course in public health informatics. The course was designed for experienced public health program managers and included sessions on general informatics principles and concepts; key information systems issues and information technologies; and management issues as they relate to information technology projects. This course has been enthusiastically received both at the state and federal levels. We plan to develop an abbreviated version for health officers, administrators, and other public health executives. INTRODUCTION Information science and technology are increasingly critical to the modem practice of public health'-2. The effective use and management of a wide variety of scientific and policy information are fundamental to public health practice', and it is now widely recognized that modem information technology-appropriately deployed and managed-is also essential to the effective practice of public health. As a result, many public health agencies are currently scrambling to acquire and make use of information teclmology. Yet today's public health professionals generally have no formal training in public health informatics-the application of information science and technology to public health practice and research'. Responding to this need, the U.S. Centers for Disease Control and Prevention (CDC) recently developed, tested, and delivered a new training course in public health informatics, designed for mid- to senior-level public health program managers throughout the country. In this article, we describe the goals of this project, the process of developing and testing the course, the nature and scope of the curriculum, and planned next steps. BACKGROUND In the Fall of 1995, the Public Health Practice Program Office/CDC and the National Immunization Program(NLP)/CDC agreed to jointly develop an infonnatics training curriculum for mid-career public health program managers. The first recipients for this would be CDC's public health advisors (PHAs): a group of specially trained public health program managers, many of whom are assigned to state and local health departments throughout the United States. Public health advisors are increasingly called upon to manage the development or procurement of complex information systems, such as statewide immunization registries. The goals of this 2-year effort were to develop a curriculum that would provide PHAs with sufficient training in informatics to allow them to (a) serve as advisors to public health policy-makers and scientists regarding the development and integration of public health infonnation systems, and (b) become effective managers of discrete information technology projects. COURSE DEVELOPMENT In the first year, meetings were held with a variety of key informants in both the informatics and public health communities, to identify and clarify the range and level of competencies to be covered by this new course. From these meetings, a pilot curriculum was developed that was delivered July 22-26, 1996, in conjunction with the Summer Institute for Public Health Practice of the Northwest Center for Public Health Practice, University of Washington (UW) School of Public Health and Coimnunity Medicine in Seattle. Since this was conducted in conjunction with the UW Summer Institute, attendees had the opportunity to take courses addressing other core training needs. Thirteen CDC public health advisors participated in the 1996 course-eight from NIP, three from the Division of Sexually Transmitted Diseases Prevention (DSTDP) in the National Center for HIV, STD, and Tuberculosis 1091-8280/98/$5.00 1998 AMIA, Inc. 472

Prevention (NCHSTP), and two from the Division of Tuberculosis Elimination, NCHSTP. Based on feedback from the 1996 pilot course participants, a revised version of the informatics course was offered at the 1997 UW Summer Institute (July 21-25, 1997). Twenty PHAs participated, representing the Division of HIV/AIDS Prevention, the DSTDP, the Division of Tuberculosis Elimination (all in NCHSTP), and NIP. As in 1996, each afternoon was devoted to informatics training (20 contact hours). Each morning, PHAs attended up to two Summer Institute courses addressing other continuing education needs-an additional 20 contact hours, in such fields as basic epidemiology, small area analysis, health policy development, managing change, public health law, and a public health approach to physical activity. The present curriculum incorporates minor changes based on feedback from the 1997 class. This informatics course has since been delivered several times, not only to other CDC public health advisors and program directors, but also to program managers and directors in several state and local health departments. Although the curriculum continues to improve with experience and student feedback, the basic elements of the course are now stable. RESULTS Goals and objectives of the course The course is designed to enable public health managers to serve as high-level informatics advisors to policy makers and scientists in public health agencies, and to effectively manage discrete information technology projects. Specifically, it is expected that students who receive this training will (a) be familiar with the appropriate roles and domains for computer scientists, epidemiologists, policy-makers and programmers in information system development; (b) be able to think in terms of information systems and underlying technologic infrastructure (information architecture), rather than in terms of individual computer applications; (c) be familiar with current models and processes for developing information systems and for managing information resources; (d) have a basic understanding of computer networking and be able to describe the cost and support implications of various networking solutions; (e) understand the basics of database management systems and current database technology and be able to apply principles of good database design. (f) be familiar with data standards for storage and transmission and understand the domains of public health-relevant standards and standardsetting bodies; (g) understand the respective roles of policy and security in protecting privacy and confidentiality, and place a high priority on addressing privacy and confidentiality issues when designing information systems; (h) be able to use the Internet and the World Wide Web effectively, for acquiring and disseminating infonnation; (i) be able to skillfully manage information technology personnel and projects; (j) be able to evaluate technology options and procure information technology in a costeffective manner; (k) be able to effectively consult with and advise colleagues on proposed information technology projects; and (1) be able to provide leadership toward the development of integrated, cost-effective public health information systems within their public health enterprise. Course pre-requisites Given the paucity of experience with information technologies and informatics among the current public health workforce, few course prerequisites were established. It was clear, however, that public health managers with certain kinds of background, experience, and personal skills and interests would be able to make the best use of this training. We indicated that, ideally, these students should have (a) a substantial familiarity with personal computers (preferably with IBM -compatible computers and the Microsoft MS DOS0/MS Windows0 operating systems-the predominant computing platform in most public health departments); (b) an interest in infonnation systems and information technology; (c) at least a rudimentary familiarity with computer networking; (d) experience in using at least one computerized information system, e.g., the NETSS notifiable diseases surveillance system6 or the CDC WONDER data query system'; (e) excellent "people" skills, especially as they relate to communicating ideas to fellow and senior public health managers, explaining technical issues to non-technical audiences, and managing and encouraging change within public health bureaucracies; (f) experience working in state or local health departments; and (g) a desire to improve the nature and practices of information management throughout the public health enterprise in which they work. 473

Range of material covered In the first part of the course, we provided an introduction to guiding informatics concepts and principles. In particular, after discussing the nature and purposes of public health inforinatics as a discipline, we presented the metaphor of information architecture and its implications for information systems development; and reviewed the concepts and planning constructs inherent in information resource management (IRM) and IRM planning. The second part comprised a series of information science and information teclmology lectures, designed to explain-or at least demystify-key information systems issues and information technologies common to public health practice. Sessions were included on computer networking; data standards; confidentiality, privacy, and security; databases and principles of database design; and the Internet and World Wide Web. The final part focused on management-specifically the management of people, projects, and procurement as related to information systems development. This segment also included lectures and exercises designed to allow participants to integrate and apply the principles and technologies introduced earlier. For example, in one exercise students were asked to critique the information architectures inherent in a variety of CDC-developed information systems and to propose a more coherent architecture for future systems development. Course evaluation and feedback Prior to attending the course, students in the first two cohorts completed a questionnaire designed to assess their familiarity with a variety of information technologies. The data from these questionnaires guided us in selecting which information technologies to include in the training. Students in the first two cohorts completed evaluation forms for each session and for the course overall. In addition, the instnmctors met twice informally with each class to discuss the whether the course was meeting their needs and how it could be improved. There was clear consensus from the first cohort that the material was on target in terms of content but that it was presented at a level and in a sequence which many students could not follow. Based on this feedback the course was re-sequenced and the material adjusted to a relatively more basic level. The session evaluations and group-based feedback from the second cohort indicated that the level and sequencing of the material was now appropriate, and confirmed enthusiastically that the subject matter met their needs. We have since taught the course with only minor modifications at CDC headquarters and in several state public health agencies. In all cases, we have received consistently positive, enthusiastic feedback, with many participants pointedly suggesting that the course should be mandatory for all public health program managers. We have also heard consistently that although it is useful to provide informatics training to mid-level program managers, it is also important to provide such training to those at the executive level (perhaps in an abbreviated form). Participants felt that many health department leaders do not yet appreciate the importance of inforinatics to public health practice. We have not yet undertaken a formal evaluation to measure the effect of the course in terms of attendees' subsequent job performance. Anecdotal information indicates, however, that many have subsequently found opportunities to constructively apply informatics principles and practices in the course of their work. For example, one student reported that the course helped her to convince senior management at her health department to reconsider a costly (and misguided) information systems project they had planned to undertake. Several students indicated that the course might have helped them avoid costly mistakes they had made during past infornation systems development projects. Obstacles to Implementation The most significant obstacle we have faced in developing and marketing the course has been communicating the meaning and relevance of infonnatics to public health. The field of public health informatics is so new that most of those who could benefit from training in this field have not even heard of it. Many students told us they had assumed the course would simply teach them how to use certain software packages, e.g., how to use a Web browser or a particular database management system. Several of the students who became most enthusiastic about the course told us that they had almost declined to take it, since they had not really understood what informnatics was all about. To overcome this obstacle we focused initially on explaining the purposes and nature of the proposed course to opinion leaders at CDC who manage large field staffs of program managers. They helped enlist the initial cohorts of students. 474

Since then, word-of-mouth has proven very effective in building a broader base for the course. Indeed, the next important challenge we face is how to deliver the course to large numbers of public health professionals throughout the country, with very few qualified teaching staff. A distance leaning version of the course (currently in development) is one approach to this challenge. DISCUSSION Across all three of public health's core functions-community health assessment, policy development, and assurance of conditions in which people can be healthy-the use and communication of information is criticalp.there is a compelling need to quickly access, interpret, collate and communicate relevant information for decision-making. There is also a need to collect information (e.g., surveillanuce data) in an accurate, timely, robust, secure and efficient manner, and to store that information in a secure yet useful and accessible form. These needs have come into sharper focus in recent years, due to the related influences of public health practice reform and the advent of managed care in the United States8. Unquestionably, information management and the use of associated information technologies are increasingly critical skills to the modern practice of public health. Yet remarkably little has been done to leverage the enonnous power of modern infornation teclmology to promote more effective and efficient public health practice. Projects such as CDC's Information Network for Public Health Officials (INPHO) are helping to provide the computing and networking infrastructure to allow more effective collection, use, and dissemination of public health data and information4. As the INPHO initiative recogmizes, training for the public health workforce is integral to making information systems a tool for improved public health practice. This course in public health informatics is just one part of a larger effort by CDC and others in the public health community to meet this need. For example, several state health departments are beginning to provide basic, "tools-based" training in the use of key software applications (such as Web browsers), and CDC is also offering fellowships in public health infornatics. Now that the course is developed and tested, CDC needs to work with its public health partners in the states to provide this training as broadly as possible to its target audience of public health program managers. In addition, a modified version of the course should be developed for public health executives (health officers and department administrators). If this executivelevel course is also found to be useful, it should be offered to public health leaders at the federal, state, and local levels. CONCLUSION CDC's new course in public health informatics appears to successfully meet a legitimate and pressing training need among today's public health program managers, many of whom are being tasked to procure or manage the development of complex infonnation systems. An abbreviated version of the course may be needed for health officers and health department directors, to foster a better understanding at the executive level of the importance of modern information science and information teclmology to public health. Acknowledgments We thank the faculty who helped conceive and develop the material for the course and gave generously of their time to teach during the pilot years of its development, including Christianne Biggs, MS; Martha Cicchinelli, MSc; Andrew Dean, MD, MPH; Gail Horlick, MSW, JD; Barbara A. Jensen; Daniel Jernigan, MD, MPH; John Kobayashi, MD, MPH; Stanley Martin, MS; Curt Pederson; Neil Rambo, ML; Joseph Reid, PhD; Robert Sokolow, MBA. We are also grateful to the faculty and staff of the Summer Institute for Public Health Practice at the University of Washington (U`W) School of Public Health, for providing a supportive environment in which to develop and offer this new curriculum We would particularly like to thank Bill Dowling, PhD; James Gale, MD, MS; Joanne Hoover, MD; Gil Omenn, MD, PhD; and the staff of the UW Northwest Center for Public Health Practice. Reprint requests should be sent to Dr. Patrick O'Carroll, Northwest Center for Public Health Practice, University of Washington School of Public Health and Community Medicine, Mailbox 354809. Seattle, Washington, 98195. Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services. The entire curriculumn for this course, including session outlines, references, and presentation 475

files, is available on the World Wide Web at http://healthlinks.washington.edu/inpho/infrmatc References 1. Friede A, O'Carroll PW. CDC and ATSDR electronic information resources for health officers. Am J Infect Control 1996;24(6): 440454 2. Lasker RD, Humphreys BL, Braithwaite WR. Making a Powerful Connection: The Health of the Public and the National Information Infrastructure (Report of the U.S. Public Health Service Public Health Data Policy Coordinating Committee). Bethesda, MD: National Library of Medicine, 1995. 3. Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988. 4. Baker EL, Friede A, Moulton AD, Ross DA. CDC's Information Network for Public Health Officials (INPHO): A framework for integrated public health information and practice. J Public Health Management Practice 1995. 1(l):43-7 5. Friede A, Blum HL, McDonald M. Public health informatics: how information-age technology can strengthen public health. Annu Rev Public Health 1995;16:239-252. 6. CDC. National Electronic Telecommunications System for Surveillance-United States, 1990-1991. MMWR 1991;40(29): 502-503. 7. Friede A, O'Carroll PW, Thralls RB, Reid JA. CDC WONDER on the Web. Proc AMIA Annu Fall Symp 1996;:408-412. 8. Lasker RD, Committee on Medicine and Public Health. Medicine and public health: the power ofcollaboration. New York: New York Academy of Medicine, 1997. 476