A Mixed Methods Assessment of the Implementation of Electronic Health Records in Local Health Departments

Background: Electronic Health Record (EHR) implementation has seen great advances in health care, but the movement is leaving public health agencies behind. EHRs have shown improvement in operational and societal outcomes when implemented. Scarce allocation of resources, lack of trained staff, and security are limiters to implementation, despite the varied benefits of EHRs. The objective of this research is to establish a comprehensive view of EHR implementation in local health departments (LHDs) through assessing the status of implementation, benefits, barriers, and strategies to overcome challenges. Methods: This research uses a mixed methods approach to assess 49 key-informant interviews and 324 web-based surveys from leaders and primary users of informatics within LHDs. These data assist in the evaluation of current practices, capabilities, and needs of LHDs. The qualitative interviews are coded by themes and sub-themes using NVivo software. Using SPSS and SAS analytical software, survey logistic regression and descriptive statistics the quantitative data were analyzed. Results: The majority of the LHDs do not have EHR implementation activity and are using non-EHR systems for data storage. Approximately 42 percent of LHDs implemented a type of EHR system. The most frequently mentioned benefits of EHR implementation are care coordination, retrieval or managing information, track outcomes of care, increased efficiencies, and accurate records. However, the barriers are costs or financial resources, resistance to change, no clinical services, lack of training, and low priority. LHD characteristics individually, significantly associated with the implementation of EHRs at least at the 0.05 significance level are: hardware allocation and acquisition within a central department in the LHD, hardware allocation and acquisition at county or city IT department, type of internet, and organizational activities related to informatics within the LHDs. For LHDs who have not implemented EHR systems, almost half have selected a system and are in the process of implementation. Conclusion: Despite the barriers of costs and resistance to change of EHR implementation in LHDs, the leaders are optimistic about the future of EHRs in LHDs even making plans for future implementation. Successful implementation is influenced by the level of control of informatics and organizational activities related to informatics

A Mixed Methods Assessment of the Implementation of Electronic Health Records in Local Health Departments

Background: Electronic Health Record (EHR) implementation has seen great advances in health care, but the movement is leaving public health agencies behind. EHRs have been shown to improve operational and societal outcomes when implemented. Scarce allocation of resources, lack of trained staff, and security have are limiters to implementation, despite the varied benefits of EHRs. The objective of this research was to establish a rich view of EHR implementation in local health departments (LHDs) through assessing status of implementation, benefits, barriers, and strategies to overcome challenges. Methods: This research used a mixed methods approach to assess 49 key-informant interviews and 324 web-based surveys from leaders and primary users of informatics within LHDs. These data were used to assess current practices, capabilities, and needs of LHDs. The qualitative interviews were coded by themes and sub-themes using NVivo software. Logistic regression and descriptive statistics were obtained through analysis using SPSS of the quantitative surveys. Results: The majority of the LHDs had no EHR implementation activity and were using non-EHR systems for data storage (58%). Approximately 42 percent of LHDs had implemented a type of EHR system. The most frequently mentioned benefits of EHR implementation were care coordination, retrieval or managing information, track outcomes of care, increased efficiencies, and accurate records. However, the barriers were costs or financial resources, resistance to change, no clinical services, lack of training, and low priority. LHD characteristics significantly associated with the implementation of EHRs included, a population size of 1,000,000 or more; access to high-speed internet; having Broadband ISDN or Fiber Optic Ethernet internet connection; various levels of IT control, organizational activities related to informatics, informatics activities performed, and informatics uses. Conclusion: Despite the barriers of costs, resistance to change, and low priority of EHR implementation in LHDs, the leaders were optimistic about the future of EHRs in LHDs even making plans for future implementation. As mentioned in both qualitative and quantitative results, having a champion or super user within the LHD can vastly improve the likelihood of successful implementation of EHRs in LHDs

STD Services Delivery Arrangements in Georgia County Health Departments

Background: Uniformity, standardization, and evidence-based public health practice are needed to improve the efficiency and quality of services in local health departments (LHDs). Among the highest priority and most common public health services delivered by LHDs are services related to sexually transmitted diseases (STDs) and sexually transmitted infections (STIs).Objective: The purpose of this study was to examine potential variations in the delivery of sexually transmitted disease (STD) services among county health departments (CHD) in Georgia, to determine if potential variations were due to varied administrative practices, and to understand delivery arrangements so that future cost studies can be supported.Methods: Web-based surveys were collected from 134 county health departments in Georgia in 2015.Results: Screening for gonorrhea, chlamydia and syphilis occurred in all the surveyed CHDs. Sixty-eight percent of the CHDs had one or more staff who performed investigations for persons already screened positive for STDs. Partner notification services provided by the CHD staff occurred in only 35 percent of the surveyed CHDs.Conclusions: Variances regarding diagnostic methodologies, work time expenditures, and staff responsibilities likely had an influence on the delivery of STD services across Georgia's CHDs. There are opportunities for uniformity and standardization of administrative practices

Electronic Health Records and Meaningful Use in Local Health Departments: Updates From the 2015 NACCHO Informatics Assessment Survey

Background: Electronic health records (EHRs) are evolving the scope of operations, practices, and outcomes of population health in the United States. Local health departments (LHDs) need adequate health informatics capacities to handle the quantity and quality of population health data. Purpose: The purpose of this study was to gain an updated view using the most recent data to identify the primary storage of clinical data, status of data for meaningful use, and characteristics associated with the implementation of EHRs in LHDs. Methods: Data were drawn from the 2015 Informatics Capacity and Needs Assessment Survey, which used a stratified random sampling design of LHD populations. Oversampling of larger LHDs was conducted and sampling weights were applied. Data were analyzed using descriptive statistics and logistic regression in SPSS. Results: Forty-two percent of LHDs indicated the use of an EHR system compared with 58% that use a non-EHR system for the storage of primary health data. Seventy-one percent of LHDs had reviewed some or all of the current systems to determine whether they needed to be improved or replaced, whereas only 6% formally conducted a readiness assessment for health information exchange. Twenty-seven percent of the LHDs had conducted informatics training within the past 12 months. LHD characteristics statistically associated with having an EHR system were having state or centralized governance, not having created a strategic plan related to informatics within the past 2 years throughout LHDs, provided informatics training in the past 12 months, and various levels of control over decisions regarding hardware allocation or acquisition, software selection, software support, and information technology budget allocation. Conclusion: A focus on EHR implementation in public health is pertinent to examining the impact of public health programming and interventions for the positive change in population health

Understanding Forced Sex During Adolescence: An Exploratory Study of Risk and Protective Factors

The overall purpose of this study was to explore predictors of forced sex among a sample of middle school students. Youth Risk Behavior Surveys were distributed to middle school youth in southeast Florida. Data were analyzed using descriptive statistics, Chi-Square Automatic Interaction Detector (CHAID), and logistic regression. In the final CHAID model, the segment most at risk was comprised of youth who had been harassed for being gay, lesbian, or bisexual and youth who had experienced dating violence. Past exposure with violence yielded the highest association with forced sex. Moreover, having multiple sexual partners, use of prescription drugs, and experiencing harassment for being gay, lesbian, or bisexual are predictors of forced sex. This study has implications for school-based prevention of forced sex through the identification of risk and protective factors that can be targeted with evidence-based interventions

Characteristics of Local Health Departments Associated with Their Implementation of Electronic Health Records and Other Informatics System

Background: Information technology and information systems (IT/IS) play a critical role in the daily operation of local health departments (LHDs). Assessing LHDs’ informatics capacities is important, especially within the context of broader, system-level health reform efforts. Research Objective: This study assesses a nationally representative sample of LHDs’ level of adoption of information systems, technology, and the factors associated with adoption/implementation. Specifically, five areas of public health informatics were examined: electronic health records (EHRs), health information exchange (HIE), immunization registry (IR), electronic disease reporting system (EDRS), and electronic lab reporting (ELR). Data Sets and Sources: Data from NACCHO’s 2013 National Profile of LHDs was used. Descriptive statistics and multinomial logistic regression were performed for the five implementation-oriented outcome variables of interest, with three levels of implementation. Independent variables included infrastructural capacity, financial capacity, and other characteristics theoretically associated with informatics capacity. Study Design: This study uses a cross-sectional survey research design. Principal Findings: Thirteen percent of LHDs had implemented HIEs. About 22 % had implemented EHRs, 47% ELR, 72.2% EDRS, and 82% had implemented Immunization Registry. Significant determinants of health informatics adoption included provision of greater number of clinical services, greater per capita public health expenditures, having health information system specialists on staff, having larger population size, having decentralized governance system, having one and more local boards of health, and having top executive with greater number of years in the job. Conclusions: The capacity of LHDs to use real-time, local data and information is critical. Many LHDs do not have this capacity. This may be due to lack of specialized staff, availability of data systems, or a host of other political or organizational constraints. This is especially the case for smaller jurisdictions. Cross-jurisdictional sharing or regionalization of some informatics and surveillance functions may be a reasonable approach to address these shortfalls. Implications for Public Health Practice and Policy: A combination of investment in public health informatics infrastructure, additional training of new informatics staff and existing epidemiologists, and better integration with healthcare systems is needed to augment LHD informatics capacity and ensure governmental public health can meet the information needs of the 21st century

Consumer Perspectives on Maternal and Infant Health Apps: Qualitative Content Analysis

Background: Despite the popularity of maternal and infant health mobile apps, ongoing consumer engagement and sustained app use remain barriers. Few studies have examined user experiences or perceived benefits of maternal and infant health app use from consumer perspectives. Objective: This study aims to assess users' self-reported experiences with maternal and infant health apps, perceived benefits, and general feedback by analyzing publicly available user reviews on two popular app stores-Apple App Store and Google Play Store. Methods: We conducted a qualitative assessment of publicly available user reviews (N=2422) sampled from 75 maternal and infant health apps designed to provide health education or decision-making support to pregnant women or parents and caregivers of infants. The reviews were coded and analyzed using a general inductive qualitative content analysis approach. Results: The three major themes included the following: app functionality, where users discussed app features and functions; technical aspects, where users talked about technology-based aspects of an app; and app content, where users specifically focused on the app content and the information it provides. The six minor themes included the following: patterns of use, where users highlighted the frequency and type of use; social support, where users talked about receiving social support from friends, family and community of other users; app cost, where users talked about the cost of an app within the context of being cost-effective or a potential waste of money; app comparisons, where users compared one app with others available in app stores; assistance in health care, where users specifically highlighted the role of an app in offering clinical assistance; and customer care support, where users specifically talked about their interaction with the app customer care support team. Conclusions: Users generally tend to value apps that are of low cost and preferably free, with high-quality content, superior features, enhanced technical aspects, and user-friendly interfaces. Users also find app developer responsiveness to be integral, as it offers them an opportunity to engage in the app development and delivery process. These findings may be beneficial for app developers in designing better apps, as no best practice guidelines currently exist for the app environment

Characteristics of Local Health Departments Associated with Implementation of Electronic Health Records and Other Informatics Systems

Objective: Assessing local health departments’ (LHDs’) informatics capacities is important, especially within the context of broader, systems-level health reform. We assessed a nationally representative sample of LHDs’ adoption of information systems and the factors associated with adoption and implementation by examining electronic health records, health information exchange, immunization registry, electronic disease reporting system, and electronic laboratory reporting. Methods: We used data from the National Association of County and City Health Officials’ 2013 National Profile of LHDs. We performed descriptive statistics and multinomial logistic regression for the five implementation-oriented outcome variables of interest, with three levels of implementation (implemented, plan to implement, and no activity). Independent variables included infrastructural and financial capacity and other characteristics associated with informatics capacity. Results: Of 505 LHDs that responded to the survey, 69 (13.5%) had implemented health information exchanges, 122 (22.2%) had implemented electronic health records, 245 (47.5%) had implemented electronic laboratory reporting, 368 (73.0%) had implemented an electronic disease reporting system, and 416 (83.8%) had implemented an immunization registry. LHD characteristics associated with health informatics adoption included provision of greater number of clinical services, greater per capita public health expenditures, health information systems specialists on staff, larger population size, decentralized governance system, one or more local boards of health, metropolitan jurisdiction, and top executive with more years in the job. Conclusion: Many LHDs lack health informatics capacity, particularly in smaller, rural jurisdictions. Cross-jurisdictional sharing, investment in public health informatics infrastructure, and additional training may help address these shortfalls

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity