Electronic Health Records and US Public Health: Current Realities and Future Promise

Electronic health records (EHRs) could contribute to improving population health in the United States. Realizing this potential will require understanding what EHRs can realistically offer to efforts to improve population health, the requirements for obtaining useful information from EHRs, and a plan for addressing these requirements. Potential contributions of EHRs to improving population health include better understanding of the level and distribution of disease, function, and well-being within populations. Requirements are improved population coverage of EHRs, standardized EHR content and reporting methods, and adequate legal authority for using EHRs, particularly for population health. A collaborative national effort to address the most pressing prerequisites for and barriers to the use of EHRs for improving population health is needed to realize the EHR’s potential.The potential contributions of electronic health records (EHRs) to clinical care, on the one hand, and to population health and public health on the other, were delineated in the United States in the 1990s and early 2000s.1–4 (Population health is defined as “The health outcomes of a group of individuals, including the distribution of such outcomes within the group”5^(p381); public health is “The practices, procedures, institutions, and disciplines required to achieve the desired state of population health.”6^(p138) For other definitions used in this article, see appendix, available as a supplement to the online version of this article at http://www.ajph.org.) Data flows would be simplified and streamlined, and burdens on data providers and data collectors reduced; EHRs would enable collection of data just once, which then could be repurposed for multiple uses.The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) established national legal authority permitting, though not requiring, “covered entities” to transmit individually identifiable health information from EHRs and health care transactions to public health authorities. The Privacy Rule authorizes public health authorities to receive such information for the purpose of preventing or controlling disease, injury, or disability and for specified uses including “reporting of disease, injury, and vital events” and “conducting public health surveillance, investigations, and interventions.”7^(p2) Covered entities can also disclose deidentified data and limited data sets, as defined in the Privacy Rule.7Whereas the Privacy Rule established national legal authority for sharing EHR data for specific public health purposes, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 established funding for sharing specified EHR data with public health authorities. The EHR Incentive Program mandated under HITECH provides Medicare and Medicaid incentive payments and penalties for specified “meaningful uses” of EHRs.8 For the first stage of meaningful use implementation, EHR systems certified under HITECH must be able to perform 3 functions for public health population-based programs: interfacing with immunization registries to transmit electronic data as directed by public health agencies; electronically recording, modifying, retrieving, and submitting syndromic surveillance data; and electronically recording, modifying, retrieving, and submitting reportable clinical laboratory results using Health Level Seven standards.9 The second stage of meaningful use adds 2 more functions: identifying and reporting cancer cases to a state cancer registry, and identifying and reporting specific cases to a specialized registry (other than a cancer registry).10 For those public health purposes currently included within HITECH’s meaningful use provisions, initial data and transmission standards are specified.9 Through January 2011, the Office of the National Coordinator issued $548 million in grants to help states develop health information exchanges for transmitting electronic health data among health care providers, and with Medicare, Medicaid, and public health agencies.11In addition to the HIPAA Privacy Rule and the HITECH meaningful use provisions, long-standing state statutes and regulations require transmission of health care provider data for specified surveillance and civil registration purposes, such as reportable diseases and conditions, vital records, and cancer registries. State legal authority typically also enables collection of data in response to threats to public health.Our purpose in this article is fourfold: (1) to describe briefly current US efforts to use EHRs for population and public health; (2) to identify potential contributions of EHRs to population and public health; (3) to delineate barriers and prerequisites to achieving those potential contributions; and (4) to suggest next steps for realizing this potential.