Interoperability: Too Narrow a Frame For Public Health

Since the inauguration, the Biden administration has shined a spotlight on US public health systems, highlighting the urgent need to re-center science in the COVID-19 response, attend to health equity, and invest in modernizing federal, state, and local public health data infrastructures. 

The administration is thankfully not starting from scratch, but building on the momentum of (pre-pandemic) calls for modernization. Succeeding at these efforts is clearly non-negotiable, but if history is any guide, success will be neither quick nor easy. That's okay. But we should enter this project cognizant of how consequential the task before us is, both domestically and internationally. We must commit to weaving the pursuit of health equity and justice into our 21st century public health policy. Achieving this will require dedicated, interdisciplinary, and imaginative attention. Without it, we will be hobbled by misaligned incentives, turf wars, data harmonization headaches, and efforts to balance seemingly irreconcilable principles until the next pandemic takes us by surprise - without ever having contemplated whether the systems we have built are actually capable of showing us what we seek to know.  

Current proposals to modernize US public health surveillance data systems are integrally intertwined with ongoing clinical IT modernization efforts. Thanks to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the 21st Century Cures Act of 2016, some data consequential for public health (for example notifiable disease case reporting, syndromic surveillance, and laboratory information) are to be seamlessly and interoperably shared between the health care system and the public health system. Collaborative efforts, such as the Digital Bridge Initiative, seeking to operationalize the vision are ongoing. But while public health reporting from clinical EHRs is necessary - it is not sufficient. Achieving even the public health vision embedded in US Health IT interoperability initiatives is far behind schedule and not sufficiently responsive to needs of public health practice - as our experience with the current pandemic sadly demonstrate. 

At this moment in history, deliberation of the goals, values, incentives, and nuances of public health deserves its own spotlight, not just the light cast by peripheral inclusion in the wider clinical conversation around EHR interoperability. Although the task ahead is admittedly monumental, I believe the modernization of our public health data systems deserves no less than our national attention about what is at stake.