The path to pandemic preparedness has already been forged by Medicaid

Our nation’s public health infrastructure is in shambles. In some cases, it was never built—rendering the public health response stuck in the last century with paper and pencil to track and record disease. 

America’s public health infrastructure is a patchwork of state-based systems cobbled together with community processes, and it has impeded the national response to the COVID-19 pandemic. Lack of appropriate health IT infrastructure, interoperability between systems and misinformation about data sharing rules has cost us lives and devastated the economy. 

In a manuscript recently accepted by the Journal of the American Medical Informatics Association (JAMIA), researchers found that public health agencies’ inability to receive data electronically from hospitals and other providers is the most significant hospital-reported barrier to syndromic surveillance.  

Even when an agency is able to accept and send data electronically, individual state public health laws—combined with general decades-old confusion around HIPAA and privacy rules—continue to stall access to data that leaves state and federal decision-makers flying blind. 

Despite having spent more than $100 billion on healthcare technology systems to digitize healthcare information for care delivery in the past decade, the Federal Government has neglected to provide significant support to the public health sector to do similar work. According to a report published by Trust for America’s Health, only 2.5 percent of all health spending in the nation was allocated to public health in 2017. And as a result, public health agencies across the country sit in states with modern health IT infrastructure but are unable to connect to these systems in any meaningful way. 

As Janet Hamilton, MPH, Executive Director of the Council of State and Territorial Epidemiologists, stated in a recent Tradeoffs interview, “We are still functioning as though in many ways computers do not exist.” 

Getting beyond the carrier pigeon 

The Federal Government has, since declaration of the COVID-19 pandemic, taken steps to support the healthcare industry and find a path forward to modernize public health. Recent efforts, however, do not go far enough. States must be empowered to make the best decisions for their unique environments and citizens, but must also be encouraged to follow federally-supported interoperability standards and best practices to ensure that, as this pandemic continues and we prepare for future events, the nation is not again caught unprepared. 

State public health agencies have already received support for their public health infrastructure from the Centers for Disease Control (CDC). As a part of the CARES Act, $500 million was distributed to the states’ public health agencies in the form of grants. But that may not be enough. For comparison, the Centers for Medicaid and Medicare Services (CMS) has distributed approximately $500 million each year since the enactment of the HITECH Act in 2009 to stand up health information exchange infrastructure. A one-time funding of $500 million to states and localities is likely a fraction of what is required. 

While any funding support for such an endeavor is welcome, the CDC has historically not enforced the use of federal healthcare technology interoperability standards or required that, with use of funds, public health agencies ensure that data can be shared meaningfully back to governors, other state agencies and community stakeholders. Such is the case with this most recent disbursement of grants. New shiny public health systems will be ineffective if proven data sharing standards are not enforced—interface-related issues, as well as different vocabulary standards, were two of the top four barriers to effective surveillance reported by hospitals, according to the JAMIA-accepted manuscript. Investing in new systems without a focus on interoperability standards, compounded with inconsistent public health reporting laws, does nothing to address the issue: state governments and public payers do not have access to their own data. 

And on March 9, 2020, the CMS Patient Access and Interoperability Final rule was published. This rule is the result of years of effort to develop interoperability standards to meaningfully support information exchange for the benefit of patients nationwide. Public health systems should be built according to the same standards, or else we may continue to see disparity in these systems to the detriment of our most vulnerable patients. This regulation was almost prescient in requiring immunizations and lab data to be at the fingertips of over 100 million Americans, but the public health systems providing this data to patients is ill-equipped for the task.

It’s perhaps controversial to suggest that the Federal Government should pass a law to supersede all state public health laws. And there are very good reasons for states having implemented their own laws and data sharing rules. Many of these laws were enacted to ensure public health agencies maintain control of information to protect citizens from stigma related to HIV/AIDS and diagnosed substance use disorders. 

There are other ways to ensure the country is not caught off guard again and hindered by prohibitive data sharing rules in the event of another global pandemic. At the least, states that use federal funding should be required to follow industry-accepted and government-backed health information-sharing standards which in-turn tie to designated outcomes for the technology platforms. There are proven funding vehicles that are able to accomplish this—including Medicaid federal funding participation for public health infrastructure. 

Finally, a tactical, but important, problem exists with pushing lump sums to public health agencies with few strings attached: lack of expertise in large scale technology implementations and deployments. But that expertise does exist within states. The HITECH Act prompted the widescale adoption of health information exchange and other technologies to support providers in achieving Meaningful Use. State Medicaid agencies were—and remain—at the center of this program to stand up health IT infrastructure.

State Medicaid agencies now hold more than a decade’s expertise in developing health IT systems that now meaningfully enable health information exchange for care delivery—they should be tapped to support the development and expansion of public health systems. There is an ever-evolving body of evidence showing how such investments improve quality, and lower cost. In fact, with health systems now stretched to their breaking point, now is the time to provide serious policy support to systems which seem capable of saving Medicare $63 million annually for each therapeutic procedure.

Enabling a massive infrastructure overhaul—the right way

Rather than rush to build shiny new public health systems with recent grants alone, which may be akin to consuming empty calories, agencies need to play wisely to avoid similar problems down the road. In addition to CDC grants, state Medicaid agencies are currently supported by a 90 percent federal matching rate for health information exchange and related health IT projects. But state budgets were stretched thin prior to the pandemic. 

States have the charge to build their own systems but must be supported so that we as a country can ensure the most vulnerable among us are protected and that our frontline providers and government decision-makers can act swiftly and with the most accurate information possible. 

Looking beyond the immediate crisis—the United States is potentially 12 to 18 months away from the largest mass vaccination since Polio. While immunization registries exist, they often do not communicate across state borders. And in most state scenarios , only pediatric providers are connected to these systems, rendering adult vaccinations like influenza and pnuemovax to be siloed in provider offices, an excel spreadsheet within a health department, or a pharmacy that does not communicate the vaccination back to the patient’s primary care physician. 

And if we are to prioritize these vaccinations,  the most vulnerable population will be in long-term care facilities and skilled nursing homes; facilities notoriously left behind from EHR incentive payments and subsequently struggling to keep up with the technical demands of care coordination. Compounding this problem is that the long term and post-acute space is the most disconnected segment of the care delivery continuum, left out of interoperability advances and integration standards. Recognizing the data issues that still exist and are not solved by singular technology approach, it is critical that focused, data-driven investments in the public health infrastructure support this massive scale immunization effort—and that those cross-agency  investments begin immediately. 

To ensure a coordinated effort occurs, we have to turn to look at current investments and evaluate steps government leaders can take to ensure the country is protected from future pandemics and other public health crises. With lawmakers pushing through an additional COVID-19 relief package, there is an opportunity to include language to allow Medicaid technology investments in public health to scale immediately in a manner driven by interoperability standards. There is a precedent for this language in Section 5042 of the SUPPORT Act for opioid technology. 

Lawmakers can increase the Federal medical assistance percentage or Federal matching rate that would otherwise apply to a State under section 1903(a) for FY2020-FY2022 to 100 percent for public health systems for Medicaid providers which meets the interoperability criteria in section 3004 of the Public Health Services Act described in 45 CFR Part 170, which help in the screening, testing, and treatment of communicable diseases and vaccine preventable diseases. 

This effort would ensure that all systems are able to be integrated to EHRs, public health systems, payers and to third party patient apps as authorized via an open application programming interface using Fast Healthcare Interoperability Resource standards supported by HHS in the CMS Patient Access and Interoperability Final Rule. 

Support from Medicaid, along with nearly a decade of expertise and lessons learned from deploying and modernizing large scale technology infrastructure, further ensures the eventual success of this effort. 

Related Reading: A Second Wave: The Unseen Pandemic Facing America Now

Kat McDavitt is Chief of External Affairs for Collective Medical. (@katmcdavitt)

Jaime Bland is Chief Executive Officer of the Nebraska Health Information Initiative (NeHII). (@jaimebland)

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