By, Dr. Arthur Davidson, Director of Public Health Informatics, Denver Public Health
I learned quickly working for Denver’s public health department that when you have good and meaningful local data—not just citywide data, but data broken down by neighborhood and city council districts—people pay attention. There are 79 distinct neighborhoods and 11 council districts in Denver; to paint a picture of health, disease and challenges across the city, we ideally need to know and be able to share what is happening in each one of those neighborhoods.
For example, with the help of several new data systems, we have identified that the childhood obesity rate is unequal and variable across neighborhoods. In some areas, the rate can be incredibly high and in others surprisingly low. We also are able to determine that those areas with higher childhood obesity rates tend to be communities with lower mean income, limited access to parks, and fewer healthy food options. Knowing this should change the way elected leaders make policy decisions or community advocacy groups focus investments in policies and systems that modify the environment.
As a public health agency, we too make strategic decision around how we allocate limited public health resources across our jurisdiction. For example, with this type of information, Denver Public Health and Denver Environmental Health have been targeting areas for grocery store investments and building new parks for residents to become more physically active.
Expanding Access to and Use of Public Health Data
In the last few years, with meaningful use investments in electronic health records (EHR), it has become clear that public health should be able to provide more localized data and conduct top notch health surveillance within even smaller areas.
For some time, Kaiser Permanente (KP) in Colorado has been tracking outcomes for medical interventions among their enrolled members, with considerable success: they have some of the highest rates of blood pressure control in the nation. More recently, Denver Public Health, Denver’s Federally Qualified Health Centers (FQHC) and other community health clinics have partnered with KP to create secure registries for sharing clinical information among healthcare providers, patients, public health organizations and communities.
The registries will result in better health status monitoring, help target interventions, treat patients more appropriately, compare data across neighborhoods, and track outcomes. These collective registry efforts permit us to see what is and is not working on a population level beyond just the results of one particular healthcare provider or community intervention. Through EHR and other health information technologies, we can provide tailored individual health services while also informing policy, systems or environmental recommendations for specific communities.
For instance, the newly emerging Body Mass Index (BMI) registry, (funded by KP Community Benefit and The Colorado Health Foundation), will be able to map how BMI changes within schools or neighborhoods when more physical activity opportunities are introduced or as nutrition programs improve school meals. Through the registry, public health will be able to monitor how interventions help children be healthier, neighborhood by neighborhood, or make adjustments, if the intended outcome is not being observed.
Another registry, on cardiovascular disease (CVD), supported by a Centers for Disease Control and Prevention (CDC) Community Transformation Grant (CTG), gathers information from KP and Denver Health populations and tracks patient CVD risk factors (i.e., hypertension, hyperlipidemia, use of statins and tobacco status) across Denver’s neighborhoods.
In addition, with Master Tobacco Settlement funding, KP, Denver Health, Children’s Hospital of Colorado, and several other FQHC are creating a state-wide tobacco use and cessation registry that will assist in sending e-referrals from the EHR to the Tobacco Quit-line and provide a feedback loop for measuring the impact of tobacco cessation programs.
A fourth and most recently funded registry uses the same underlying infrastructure. This Agency for Healthcare Research and Quality project intends to combine KP and Denver Health data around mental health disease and map it for Denver County. In recent community health assessments, there was a dearth of information around mental health disparities by neighborhood. This type of mental health registry could be a key resource for identifying the magnitude of mental health problems and where mental health services are needed most.
In total, these registries will allow public health to better identify the areas of highest needs and engage patients and communities as partners in advocating for health improvements. With increasingly more complete registries, and superimposing environmental asset and barrier data, Denver should have a more thorough public health picture, which goes beyond merely stating the city’s obesity rate but rather defining specific neighborhoods where the entire community can align resources to address a variety of policy, system and environmental barriers.
More broadly, data may be used in a variety of ways. For instance, registries can inform public officials. By providing council members with information on their neighborhoods and the risks facing their constituents, they become more motivated to create policies which make the healthy choice the easy choice. Data can also be used to obtain support and investment from city agencies and departments by identifying which areas might benefit from better park maintenance or more effective street lighting, for example.
In addition, going forward, we would like to produce these data and publish them so that community organizations, advocacy groups and other groups that care about communities can use the information to speak for people who might not have avenues to talk with policymakers.
Superimposed on registry maps for behaviors, conditions or health, our goal is to map community assets and barriers. You might see that in neighborhood A there is a 40 percent obesity rate and neither recreation centers nor grocery stores and a low walkability index. While none of this will be earth shattering news, since we know how obesity relates to other socioeconomic determinants, we will be able to inform, create collective action and point people to solutions. Basically, we can show where health problems are occurring, which environmental assets are in place and what barriers to healthy choices exist.
One other important use for the data is at the individual patient level. I was a family doctor at a community health center for more than 20 years. Often, in the 11 minutes I had to actually talk to a patient, I’d say, “your weight is a bit high, you need to go out and exercise.” It would have been helpful if I could generate a specific report from the EHR that uses these community asset mappings so the patient would receive a personalized prescription: “if you walk following these specific street directions for x minutes, at this speed you’ll burn 100 calories” or “if you go to this recreation center, you can do these exercises.” One day, hopefully soon, the registry will be able to link directly to these types of interventions.
Obviously, the registries require massive input, resources and funding from different state and community level organizations. In essence, this work is dependent on effective and longstanding partnerships where a circle of trust has been established to share data.
Much of this effort would not have happened without the key resources and partner organizations, including those involved in the Community Transformation Grant. The CTG has enabled us to move toward the goal of tying clinical data to the resources available in communities. This funding provides an opportunity for organizations to link rich clinical data on defined populations and correlate the health status observations with environmental and social factors–that’s pretty unusual. One day, that should be the new norm for public health and registries, as a monitoring system, should support both clinical and community interventions to improve the public’s health.