For the Public's Health The Role of Measurement in Action and Accountability (2011) / Chapter Skim
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2 Needed: An Information Enterprise to Drive Knowledge and Population Health Improvement
2 Needed: An Information Enterprise to Drive Knowledge and Population Health Improvement
Pages 35-66
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From page 35... ...
and the capacities and limitations of the nation's population health statistics and information system, which consists of an array of public-sector and private-sector entities that collect, analyze, and study data and communicate information relevant to population health. The system's familiar components include vital-records systems; surveillance systems (for example, for acute conditions)
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From page 36... ...
In the pages that follow, the committee discusses three sets of challenges, endeavors in which changes are warranted to strengthen the population health statistics and information system: adopting the determinants-of-health perspective at a fundamental level (to complement the health system's predominantly biomedical orientation) ; enhancing responsiveness to the needs of end users; and coordination and cross-sector collaboration at the national level, beginning with the primary federal health-statistics agency -- the National Center for Health Statistics (NCHS)
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From page 37... ...
The lack of semantic exactness regarding health indicators has led to a conflation of two primary meanings: "measures of health" and "measures of performance on health." Many public health or population health data sets (as opposed to data sets used in the clinical care context) called scorecards or report cards are not, in fact, intended for or capable of measuring the performance of public health agencies in a county or state, of other organizations, or of communities in general.
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Figures 2-1a and 2-1b illustrate the population health and clinical care approaches to the sample outcomes of infant mortality and cardiovascular disease (CVD)
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, clinics, insurers, agencies parent-teacher faith-based schools neonatologist, payers, quality associations, organizations pediatric organizations Department of Stakeholders surgeon Education, school districts FIGURE 2-1a Contrasting the multiple-determinants and clinical approaches to addressing infant mortality.
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Measures Treatment: beta blockers, cholesterol management Medical care Medical care Providers, Schools, school Retailers, Government, Political and Planners, Public organizations practitioners, hospitals, boards, legislators, employers social government health (public and insurers, payers, payors, legislators, public health community agencies, agencies, private) , CVD quality community agencies organizations, architects, academia legislators, specialists organizations organizations, employers, community employers parent-teacher faith-based groups Stakeholders organizations FIGURE 2-1b Contrasting the multiple-determinants and clinical approaches to addressing cardiovascular disease.
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From page 41... ...
Multiple factors influence a population's health heavily, but the United States, unlike its neighbor Canada, lacks a systematic national strategy to identify and address the set of social and environmental determinants of health that are most responsible for health outcomes. Several European countries have for many decades collected health data according to detailed socioeconomic categories -- for example, from income rankings to occupational hierarchies (Braveman et al., 2010)
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From page 42... ...
(The new National Prevention, Health Promotion, and Public Health Council created by the ACA offers an opportunity for a "health in all" approach to population health improvement that potentially could involve interdepartmental attention to the underlying causes of poor health in the United States.5) A report by the Department of Health and Human Services (HHS)
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for HHS's Community Health Data Initiative (CHDI) , which has served as a platform for publicizing the HHS Data Warehouse operated by NCHS.
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It is crucial that the population health statistics and information system adopt as its core mission serving decision-makers, not simply compiling or analyzing statistics or serving national-level planning needs. The system, and especially its federalgovernment core, must determine what kinds of information are needed at the community level (through broad consultation)
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From page 45... ...
The population health statistics and information system is producing a surplus of data and indicators that are not all conducive to the assessment of health. Through its CHDI and its NCHS-managed HHS Health Indicators Warehouse, HHS has made great strides in making its data more useful to the public by beginning to develop interactive interfaces and front ends that serve the needs of users.
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Each of the three major federally supported population health statistics efforts -- BRFSS, NHIS, and NHANES -- has its strengths and weaknesses (see discussion in Appendix B) , but they do not, collectively, fully meet the information needs of local decision-makers and communities (for example, BRFSS generally does not allow sub-state-level estimates, and NHANES does not contain state-specific data)
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. A revitalized NCHS could provide leadership for the entire population health statistics and information enterprise (the diverse array of public and private producers, analyzers, and conveyors of population health data)
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, to elucidate the relationships between various inputs, intermediate outcomes, and distal (population health) outcomes, and to improve understanding of the potential effects of various options that may be considered by policy-makers.
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Many data sets and information streams feed into the health system, but the committee asserts that the population health statistics and information enterprise has limitations in the content (for example, useful data and measures available for monitoring progress) , processes, integration, and coordination necessary to maximize its usefulness to the promotion of public health and to inform the contributions of multiple stakeholders in the system.
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. The need for increased coordination is evident in the current state of health data; the proliferation of data sets in the absence of common, standardized health-outcome indicators (indicators of distal health outcomes, such as disease rates, and intermediate outcomes, such as hypertension)
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, and organization structure. Process refers to what is actually implemented, and outcomes are the effects of what was implemented on the health status of patients and populations.
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or as a health outcome in its own right. Some measures of intermediate outcomes may also function as measures of community health, such as measures of walkability and recreational space.
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measures at the state level (and for SUSA, the national and potentially the county level) (Community Health Status Indicators, 2009; SUSA, 2010; University of Wisconsin Population Health Institute, 2010)
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. Various other sets of health-status indicators are available, and a wide array of organizations -- including clinical care quality entities, local governments and local public health agencies, and private-sector groups -- issue regular or sporadic reports on health and clinical care.11 Examples include the Take Care New York program, which reports on 10 select indicators (Summers et al., 2009)
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outlined the HHS challenge of fragmentation and lack of coordination among 212 separate departmental data systems in existence at the beginning of the decade and emphasized that most of the data collection by the department focused on a small proportion of the determinants of health, specifically, on infectious agents and medical treatments. The 2002 document Shaping a Health Statistics Vision for the 21st Century, a major federal-government document on the "healthstatistics enterprise," also described multiple panels and activities and a lack of coordination within the department, pointing out that "multiple initiatives and forums themselves add to the perception of fragmentation and disorganization in the overall health statistics enterprise" (HHS et al., 2002)
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found that expert key informants (including NCHS staff and former and current NCVHS members) believed that the health-information technology effort in medical care had had little or no effect on the population health statistics enterprise despite the 2002 recommendation urging exploration of ways to integrate personal clinical care data with other information streams.
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Other relevant public health data are more difficult, and sometimes impossible, for a public health official to retrieve. Some difficulties are bureaucratic, such as procedural barriers imposed by agencies or companies that require paperwork, data-use agreements, payment of fees, account enrollments, or other special provisions to permit access.
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To ease burdens on a source agency or company, such as clinical care providers that already have exten
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, on evolving needs for data, and on standards and methods for developing measures that can inform public health agencies and stakeholders working to improve population health. As discussed earlier, NCHS already receives the advice of two federal advisory committees, but their membership could be expanded to include representatives of other key government agencies (such as those in education, environment, and housing)
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and new capacities are needed to strengthen the nation's population health statistics and information system. Federal statisti 14 Allocating a greater proportion of the US health dollar for population health would align national action with mounting evidence that socioecologic factors -- the social and physical environment and government policies (protections, prohibitions, defaults, rewards, and incentives)
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However, the nation's population health statistics and information system will need revitalized leadership, including leadership by the nation's primary health statistics agency. That would require updating NCHS's mission to broaden its activities (going beyond improvement in its ability to perform its statutory duties to conducting more research on and interacting with users about, and providing scientific guidance pertinent to, its statistical work and translating NCHS and other data into indicators)
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2009b. Phase I: Report to the National Committee on Vital and Health Statistics, Reconsidering Shaping a Health Statistics Vision for the 21st Century.
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2010a. Community Health Data Initiative.
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. HHS Community Health Data Initiative.
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2008. Health Indicators: A Review of Reports Currently in Use.
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