The pressures of the COVID-19 pandemic revealed gaps in the nation’s public health infrastructure that pose challenges to effective communication between health care providers and public health agencies.  According to ONC analyses of nationally representative survey data from hospitals and physicians collected in 2019, over 70% of hospitals experienced at least one major challenge with electronic public health reporting and less than 1 in 5 primary care physicians—and about a quarter of pediatric and internal medicine primary care physicians—reported electronically exchanging data with public health agencies. It is important to note that ONC’s analysis did not report on physicians’ overall levels of public health reporting—which often occur through manual, paper-based methods—nor does it reflect recent levels of electronic public health reporting which may have improved during the pandemic. Moreover, low rates of electronic reporting may be due, in part, to variation in jurisdictional requirements (i.e., most jurisdictions do not require electronic data submission for public health reporting) as well as PHAs’ capacity to electronically receive standardized data from physicians and hospitals.

Together these findings suggest there is a need to increase rates of electronic public health reporting and improve methods of exchange between health care providers and public health agencies to ensure the availability of complete, accurate, and timely data for ongoing pandemic response and future public health preparedness.

Increasing Electronic Health Information Exchange

At ONC and other agencies within HHS there are numerous ongoing efforts aimed at reducing reliance on paper-based processes and increasing electronic exchange of health information between health care providers and public health agencies, including:

• USCDI+ is a new ONC initiative to support the identification and establishment of datasets, including public health specific datasets, to better address needs specific to public health.   
• The Strengthening the Technical Advancement and Readiness of Public Health via Information Exchange (STAR HIE) program includes multiple collaborations to enhance electronic public health reporting. One of these pilot projects, awarded to the Texas Health Services Authority in partnership with Audacious Inquiry, demonstrates how HIEs can support public health agencies with pandemic response by using the Health Level Seven International (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Health Level Seven International (HL7®) Fast Healthcare Interoperability Resources (FHIR®)
• Situation Awareness for Novel Epidemic Response (SANER) Implementation Guide to standardize situational awareness data elements, extract them from hospital data systems, and enable public health entities to view these data in real-time. data elements, extract them from hospital data systems, and enable public health entities to view these data in real-time.
• ONC’s Health IT Certification Program includes criteria that support electronic public health reporting. For example, ONC recently clarified that automated electronic case reporting functionality, such as eCR Now, can be used to demonstrate conformance with the existing electronic case reporting certification criterion.
• CDC Data Modernization Efforts seek to improve data sharing and interoperability of public health data systems through common standards and reduce burden on clinicians and other frontline workers that report to public health. seek to improve data sharing and interoperability of public health data systems through common standards and reduce burden on clinicians and other frontline workers that report to public health.
• Helios is an initiative launched by HL7 and jointly supported by the CDC and ONC that seeks to advance public health data exchange using HL7 FHIR standard.
• CMS’ Promoting Interoperability Program introduced new requirements for eligible hospitals to report on measures for syndromic surveillance, immunization registry, electronic reportable laboratory result, and electronic case reporting. CMS’ Quality Payment Program introduced new requirements for eligible clinicians participating in the MIPS Promoting Interoperability Performance Category to report on measures for immunization registry and electronic case reporting. Together, these new requirements aim to increase rates of public health reporting among hospitals and clinicians to better support public health agencies’ disease surveillance and vaccination efforts.

There is a silver lining to our findings: physicians who electronically exchanged information with public health agencies were more likely to electronically record social determinants of health (SDOH) data—e.g., employment, education—and behavioral determinants of health data—e.g., alcohol and tobacco use—which can help support public health surveillance and aid populations disproportionately affected by the pandemic. However, we do not know the extent to which these data were recorded in a structured format that could easily be exchanged. Furthermore, given low rates of exchange reported by physicians, it is unclear how often these data were leveraged for public health purposes.

Improving Electronic Exchange of Social and Behavioral Determinants of Health Data

To improve standardized electronic exchange of social and behavioral determinants of health data between health care providers and public health agencies, ONC and our sister agencies support efforts aimed at standardizing the collection and exchange of SDOH data that can be leveraged for individual care coordination as well as public health surveillance. Key examples of these efforts include:

• United States Core Data for Interoperability (USCDI) was recently updated to enable the standardized, electronic exchange of SDOH and sexual orientation and gender identity (SO/GI) data.
• The Gravity Project is a multi-stakeholder collaboration working to develop, test, and validate exchange standards for SDOH data.
• ONC has also supported an SDOH pilot project through Leading Edge Acceleration Projects (LEAP), led by the University of Texas at Austin. The project integrates SDOH data into EHRs to manage the social needs of patients that are identified in clinical settings.

While our recent data briefs highlight challenges to public health reporting prior to the pandemic, efforts underway at ONC and HHS more broadly aim to modernize public health data systems and promote the seamless exchange of information (including social and behavioral determinants of health data) among health care providers and public health agencies. Together, these efforts will provide both the technical infrastructure and the incentives to better support key public health activities during the ongoing pandemic and in future public health emergencies.