INTRO

JESSICA

Public Health Informatics is the science and the art of taking raw data and turning them into useful information for health policies and programs. It takes all those data out there and turns them into knowledge of how people can live healthier lives. But how does this process work?

My name is Jessica Hill, and I work at the Public Health Informatics Institute in Atlanta, Georgia. This podcast is my quest to learn about informatics and how it’s made people’s lives better. How has it made my life better? And, really, why does it matter? So I’m ready. Inform me, informatics.

JESSICA

This is Jessica Hill, and I am here in the office of Dr. David Ross at the Public Health Informatics Institute. Dr. Ross is our director and leader, and he is my boss’s boss’s boss. So hopefully this will go well. But he goes by Dave. And so, Dave, thank you so much for agreeing to be our first guest. It really means a lot to us. And so would you let us know how you got into informatics? Like, what does that path look like for you?

DAVE

So why am I doing this? Yeah. Why am I doing this? People have said, you know, “Dave, how can you be so passionate about something like informatics? My gosh.” Well, so very…

JESSICA

Does your wife say that?

DAVE

She doesn’t even want to know. But she’s a school teacher. She’s never really wanted to know.

I think I have to go back, wind back, why am I even in public health? It starts there. I was, 45 years ago, working in the missile business as an aerospace engineer, pretty far away from anything that would be public health or medicine, and doing work at a time that was pretty exciting. You remember the Gemini and Apollo moon shots and all that? And the Cold War and strategic nuclear missiles and stuff. I’ve worked on all that. So I was both a systems engineer and an aerospace engineer and along the way became a systems engineer who became a pretty serious programmer with necessity.

But I was looking for more meaning in my life than how we perfect missiles to work, and particularly those that are strategic nuclear missiles, which are designed to destroy mankind. To be really honest, I…

JESSICA

I mean, did you think about that every day? You were like, “This is what my work is”?

DAVE

I did. I thought a lot about that, is that what I am about is the business of optimizing destruction. But that’s another story.

But, anyway, I was seeking some meaning in my life, and I happen to have a wonderful, lucky, fortunate interaction with Dr. Abe Lilienfeld, who was the chair of the epidemiology department at Johns Hopkins. And Abe put before me an idea that I would never have otherwise been aware of, and that was that you can do things to help the health of entire populations that doesn’t involve you going to medical school and being a doctor to a person. Because that was the other thing I was contemplating, should I go to medical school? And I wasn’t particularly obsessed with any given disease and was trying to think what… “I’m a young person. What do I do?”

JESSICA

Do you mind me asking, like, how old were you then? You had finished your doctorate of science, right?

DAVE

That was when I was… No, no, that’s… So Abe was the one who convinced me to go get my doctorate of science. I was a missile engineer.

JESSICA

So where were you in your career?

DAVE

I was early, young. I was 25 with, you know, several years of experience doing some pretty serious missile stuff. And along that way, I become a state-of-the-art programmer with the state-of-the-art systems that only the defense world at that time had. And Abe presented to me this idea that systems engineers and technically oriented people like I was could bring skills to this discipline called public health, and it was about doing things that affected the health of whole populations. An idea just absolutely captured me and blew me away, is that, what? You could do things that would change the health of thousands to millions of people?

And at the time, the smallpox campaign, the smallpox eradication campaign, was going on, and that was a really easy example to understand is like, “Yeah, I have a smallpox vaccination on my arm. You don’t.”

JESSICA

No, I don’t.

DAVE

My kids don’t. I do. Because I could’ve gotten smallpox. In my cohort, a lot of people did. In my cohort, people got polio. I had a friend I saw in an iron lung. So I saw those sorts of things and realized, like, wow, you could do things that absolutely impact the health of thousands and millions of people in a really positive way, and that seemed to be a better idea than figuring out how to obliterate mankind.

JESSICA

That story is so inspiring to me, because it’s about wanting to help whole populations, but it’s also about your personal relationship with one person that really changed the path of your life.

DAVE

Yeah, so Abe totally changed the direction of my professional career. I ended up going to Hopkins on a fellowship, which I was very lucky to have. A NIH fellowship paid for my whole graduate school. And in the course of that, being a technical math science person, I really appreciated data and gathering and manipulating data, and I was also a computer science professor, because I was a programmer at a level that most of the faculty simply weren’t. So I learned also that IT is a young person’s sport. So I came as a graduate student and was also made a professor because I knew more programming than the faculty did because they were not exposed to the same stuff I had been exposed to.

JESSICA

So was your course of study, was the word informatics a term that you used then, a label?

DAVE

No, the word did not exist. The word did not exist. I was in math sciences and operations research and biostatistics, and actually, a sub-discipline of information science. How do you mathematically quantify the information in a set of data? But in doing all of that became much more involved in a range of epi studies and health services research and clinical research work, which have ultimately led me into the Hopkins Health Services Research Center that was done jointly with the Public Health Service and which I eventually ended up running. And then one thing led to another and ended up acting a stint for several years as vice president at one of the Hopkins hospitals called Wyman Park Health System.

And then was recruited to CDC and did environmental health research and then marched my way, always back to having a facility with data and systems and supporting, you know, core public health studies at CDC. And that led me ultimately to thinking about the information infrastructure of public health and that it was very inadequate and there was this thing called the internet that was coming along, and we should be ready for it. So that’s what got me into it. And then working at clinical information systems when I left CDC. So then in and out of healthcare and public health in various ways.

And it is an evolving discipline, and that’s what you will see, is people in this field have come from various other disciplines within public health or healthcare and migrated their interest towards these technologies and the use of them. And that’s how information technologies generally are changing our world, aren’t they? There are a lot of physicians that are becoming medical informaticists and leaving clinical care and working on the technology side.

JESSICA

Was there a similar moment, so you were like, “Okay, I want to make a shift, and I’m not so jazzed about weapons of mass destruction, so I am looking for something else”? Was there any other shift in your career that you would say was really sentinel to where you ended up today?

DAVE

Yeah, it’s when I shifted from healthcare delivery. So I was vice president of a hospital, and that is a very challenging job to do. Healthcare delivery is really tough. And it’s a good career, and it’s turned out to be very remunerative for people who stayed in it. Getting more involved in really public health practice, that was a very significant shift.

This sort of brings me to a beginning point, which is what’s informatics, right? I tell people it’s about getting the right information to the right people at the right time in a form they can use to make productive decisions, productive decisions about either a person, a case, which could be like, what shot do I give this kid? Or about a population status kind of issue. But public health does a lot of different things, so it has a lot of different data and information needs. Therefore, almost anybody in public health could actually be asking an informatics question because it’s so integral to supporting how programs could run well.

JESSICA

Well, that’s actually a question that I had because…so for me as somebody who’s trained in public health, but I didn’t work directly in informatics, you know, earlier in my career. The idea is, in the public health process, your first step is you gather your data, and your second step is you figure out what your data are telling you about whatever…either, one, to help you identify the problems or if there’s a specific, you know, area you want to focus on. So I get confused even still now, like, what is the difference between that and informatics?

DAVE

It’s very blurry. And in a way, I think calling informatics a field is a bit problematic because it’s so tied to other fields. Think of it this way. What are your options on getting your data? What are your options about how to define the data so that they become a digital asset later beyond your use?

JESSICA

What do you mean by digital asset?

DAVE

Okay, so I’ve collected some data, if I code the data in a way that is a standardized representation of that content, then other people can use it later. If I make it my own quirky code, like I’m going to code all males a 9 and all females a 77, now, why would anybody do that? Well, there’s no reason, but somebody might.

JESSICA

Probably somebody has.

DAVE

And all of a sudden, if they don’t give you an index to say this is what those data mean, then it’s useless, right? So it’s a non-asset. It maybe helped them uncover what they were trying to learn, but it means nothing to anybody else.

JESSICA

So it’s kind of the difference between having an eye towards this one problem you want to solve and kind of understanding that we’re gathering information and we might not know all the ways that we’ll use it?

DAVE

That’s part of it. I think there’s another basic premise you have to think about with information a lot of people lose sight of. In an information world, the value of information goes up with its use. Think about this. If you and I were farmers, and we bought a tractor…

JESSICA

We’re going hungry. If you and I are farmers, we have trouble.

DAVE

Oh, no, I’m a good farmer. I’ll feed you.

JESSICA

Okay, thank you.

DAVE

No, if we were to go buy a tractor, a tractor is a depreciating asset. The more you use it, the more it wears out.

JESSICA

That makes sense.

DAVE

At some point, you use it enough, it’s worn out, and either you totally rebuild it or you throw it away. So it’s a depreciating asset. Think about information. You invest in creating it once, so if you want it to increase in value, you keep reusing it, or you make it usable to other people in other ways.

JESSICA

But isn’t that what’s scary about informatics, is people are like, “Well, I didn’t know my information was going to be used in all these different ways.”

DAVE

Yeah, of course, it could be. Yeah, yeah, of course. So that’s why we have whole area in the area of informatics of sort of sub-expertise about data use, data access agreement, all the legal and human subjects, reviews, issues tied to data. That’s…

JESSICA

So it’s starting to feel kind of fuzzy to me.

DAVE

Yeah, it is.

JESSICA

As we’re, like, now talking bigger and bigger.

DAVE

It has very fuzzy boundaries. I think what we’re seeing is the world’s merging and public health is merging to where there’s going to be kind of an epi informatics data scientist. It’s going to be…really, it’s going to be a job. Because think about people who, if I said, let’s do an analysis of some huge data sets, the classic big data problem. Like, let’s mine Twitter to understand how the tobacco companies are using social media to influence smokeless tobacco, or what do they call it, vapor or something. You’re talking about millions and millions of records coming from new, unstructured sources.

JESSICA

And in different languages, and… Yeah.

DAVE

That’s different than the training you had. You didn’t with, with that…

JESSICA

I didn’t have that training.

DAVE

With my example, you’re not defining the sample size and the sample parameters and the characteristics of who you’re going to sample. You’re delving into all this data and trying to learn something from it. It’s a new emerging discipline. It’s a new emerging discipline for biostatistics and for epidemiology, and the technology pieces of it are informatics. So who’s in charge of that?

JESSICA

Are you in charge of that as the director of the Public Health Informatics Institute?

DAVE

No. I’m in charge of saying I think we belong mucking around in that world because there’s something to be learned that would inform the public’s health. So is that an informatics problem, is that an epi problem, or is that some new data scientist person’s problem? I think these fields necessarily blend together, and I don’t find it to be productive to try to slice them into unique, separate domains.

JESSICA

So, I mean, I feel like I conceptually understand what you’re talking about, but could you give me a specific example maybe from your personal life where you feel like, “Okay, this was…I was just walking down the street being Dave Ross, and then I realized, oh, this is an informatics problem, or this is an informatics opportunity”?

DAVE

Well, the ones, the problems that happen all the time are where people are trying to be clear about what they’re trying…or need to get clear about what they’re trying to do to where they use some form of automation or information technology to support their needs, right? That is absolutely so uniform.

So what is an example? The CHAMPS project. One of the things we’re working on is figuring out how to have a panel of different experts, like a pathologist, an epidemiologist, and maybe a primary care doctor, all look at a set of data about a child who died and together come up with a cause of death.

JESSICA

Are they physically together, or are they looking at the same record?

DAVE

They most likely will not be physically together. So we have to do a number of things. One, we have to give them the data individually to review the case and have them document their answers, and then we have to bring them together probably virtually as a team, have them review what one another has done, and see if they can reach consensus decision.

Now, that sounds easy, but as we dig into it, they’re saying, “Well, give us a computer program that helps support that.” So what does that mean? It means you first ask, “Well, which data do we want to present to these people?” Data about the verbal autopsy that was done in the country. Data about the laboratory results that were gathered when the child was, say, admitted to a hospital or a healthcare facility. Data about their home living environment, their family and environmental context, right? Because these things could matter about why the kid died. And the pathology data.

Okay, so which data, and where are these data going to come from, and how do we want to present them to the reviewer, right? What do we want them to make out of these data? What do we want them to record? How are we going to show that? Do they want to see the high-resolution images that the pathology people develop? Do they want to just trust the pathology report? All these are questions that the informaticists ask as translators between the science people who want to solve this problem and us producing a tool that will actually be useful to them.

JESSICA

So at the institute, would we call that defining your information needs, like your…

DAVE

Yes.

JESSICA

Okay, so you’re defining your requirements, what you’re…

DAVE

You’re defining your requirements, and that’s going to allow you to get very precise about the design, and then you can go ahead and make decisions about the architecture, the hardware and the software that, you know, what platforms are we going to use, and then you produce the tool.

JESSICA

Okay, so that’s an example of what informatics looks like. And can you define what CHAMPS means?

DAVE

Oh, that, yes, that means the Child Health and Mortality Prevention Surveillance network. The network, so it’s CHAMPS network.

JESSICA

Oh, the CHAMPS network, okay.

DAVE

But it’s a network of sites, surveillance sites, that are being established in Sub-Saharan Africa and South Asia. And this is a large and long-term initiative of the Bill and Melinda Gates Foundation, so that’s what CHAMPS is, and people can go to champshealth.org if they want to know more.

But that kind of a situation is one where we’re starting with a blank canvas, and we have to ask lots of requirements questions. We have to define lots of work streams and, from that, tease out what the system support needs would be, both for capturing data. So let me give you an example. Think about what would you do to capture the data if you had to interview parents of a child who died? How would you do that? So that’s both a sociological problem, right?

JESSICA

Yeah, what are you asking exactly? Like, how that interview would go.

DAVE

How that interview would go and how would you record the data so that the data can be used within the CHAMPS team but also made globally accessible to other researchers around the world.

JESSICA

So there needs to be sort of consensus about what bits of information are the most important to capture.

DAVE

That’s right.

JESSICA

Knowing that you only have a limited amount of time with the family.

DAVE

That’s right. So you have to be absolutely clear about what you’re going to gather, how you’re going to record it. Is it blobs of text, or is it discrete data fields? And if it becomes discrete data fields, how are you going to encode that, right? And then you have to understand all that, and then you have to be able to build a tool that could actually be used while I’m having this conversation with the parent, right? And you know how conversations go.

JESSICA

In the most sensitive kind of way.

DAVE

Just like ours is not necessarily linear, and absolutely, we’re not…just so listeners know, we’re not following a script.

JESSICA

That would be a frightening script, but yeah.

DAVE

Right? Yeah. But…and that’s how conversations go. So imagine the tool that really is useful to the person collecting the data. And that person, we have to know about that person, too, don’t we? We have to know is that person highly educated, highly skilled, or is that a community health worker who’s maybe trained how to do this interview, trusted by the community, but not necessarily highly educated?

JESSICA

And the words that maybe end up on the computer screen aren’t exactly the words that would resonate with the parents, so you’ve got to figure out how you’re asking about it.

DAVE

Maybe not, so you have to figure out… Absolutely.

JESSICA

And that’s an informatics question?

DAVE

That’s an informatics problem.

JESSICA

I didn’t know that.

DAVE

Yeah.

JESSICA

I thought that was, like, a sociological problem.

DAVE

It is, and I would argue that informatics is about 95% sociology and about 5% information science.

JESSICA

That’s true. You did tell me that, like, my second day.

DAVE

Yeah, right. There’s a good example of it.

JESSICA

Thanks again to Dr. David Ross for being our first guest. Dave is the director of PHII until he takes over as CEO and president of the Task Force for Global Health in 2016. We recorded a lot more of our conversation with Dave, and in the next podcast, we’ll hear more about the field of informatics and how it strengthens public health practice.

DAVE

Right? Informatics holds the mirror up to the community and says, “This is us. Are we happy with the picture we see?”

JESSICA

Thanks also to Kathryn Turaski of Residence Marketing who designed our logo. Our theme music is called “Carnival Intrigue” and was composed by Kevin MacLeod. “Inform Me, Informatics” is a project of the Public Health Informatics Institute and the Informatics Academy. You can find out more if you go to phii.org. You can also find us on Facebook and follow us on Twitter @PHInformatics.

Finally, many thanks to our production team, especially Sarah Gilbert and Jessica Cook. Piper Hale produced and edited this episode and is an all-around super-duper wonder woman extraordinaire. I’m Jessica Hill, and you’ve been informed.

[BUTTON]

DAVE

And so are we going to have a musical entree into this or anything?

JESSICA

Yeah.

DAVE

What kind of music is it?

JESSICA

Free online music.