While I was at the NACCHO Annual Meeting this past July, I saw a presentation about Minnesota’s e-health initiative. Cathy Gagné from the Saint Paul-Ramsey Department of Public Health and Shirley Schoening Scheuler from the Minnesota Department of Health gave a presentation about their state’s e-health roadmap and the examples of electronic data sharing in various counties. I asked Cathy if she would be willing to be a guest on the podcast to talk more about informatics at the local level. I was very grateful that she agreed to record with me the following month when she was in Atlanta for the Public Health Informatics Conference.

In this episode, Cathy describes ways local health departments, hospitals, clinics and other service agencies can work together to share information and to provide more complete and cohesive care to their clients. She talks about her work with Minnesota’s e-health roadmap, and why individuals remain at the center of her state’s approach to e-health. Cathy also describes how informatics makes it possible to share students’ asthma action plans with school nurses, outlines some of the challenges in designing information systems to support home visiting nurses, and explains why ATD messages are “huge” in her state.

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e (left) with Cathy Gagné (right) at the Public Health Informatics Conference in 2016.

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.

Hi, this is Jessica Hill. I’m excited to share this conversation with Cathy Gagne who is a public health informatics nurse with St. Paul Ramsey County in Minnesota. Cathy also serves as a co-chair for the local public health group as Minnesota’s e-health initiative which supports the adoption and effective use of health information technology across the state. I was very grateful that Cathy agreed to record a conversation with me when we were both in Atlanta for the Public Health Informatics Conference in August.

There are just a couple of terms for us to discuss before we dive into the conversation with Cathy. If you’ve listened to our podcast before, then you’re probably pretty familiar with the terms meaningful use and interoperability. If this is your first episode, welcome. We’re so glad you joined. If you’ve heard other episodes but you’d just like a refresher of the terms, I totally get it. Thanks for listening again.

As part of the American Recovery and Reinvestment Act of 2009, federal money went towards modernizing the country’s health infrastructure. The HITECH Act is a policy that led to what are called meaningful use requirements. These requirements outline how electronic health records need to send and receive electronic health information. Interoperability is a term that describes systems that can send and receive these health data. Cathy will use both of these terms as she describes Minnesota’s e-health initiative and their e-health roadmap.

CATHY

I love working with people. I love the one-on-one relationship and so I was in maternal child health home visiting nursing. Eight years ago, I became the electronic health record coordinator for the home visiting nurses and then three years ago I was a recipient of the Up High funding for informatics so I was able to go back to school and get my informatics certificate. So now I’m an official public health nurse informaticist which is really cool and I’m loving the work.

Minnesota’s e-health initiative started years ago. There is an e-health advisory committee that is…you’re appointed from…by the commissioner of health to advise around a table with multiple different types of professions. So anywhere from either the hospitals, the insurance companies, I represent local public health on that. We meet quarterly and just talk about the issues and how are we going to get this…I mean, at first, years ago it was how are you gonna get everybody to get an electronic health record. And now it is how are we going to talk to each other. Because we understand and when you sit around a table with multiple disciplines, it’s very eye-opening. You understand what each other does. We’re understanding that we each contribute a little bit different lens but our data about the people is so important.

So, what grew out of that is stimulus money that the state received and we around the table have been saying there’s an inequity. Meaningful use providers, doctor run organizations got meaningful use money for electronic health records for interoperability. Public health, long-term post-acute care, behavioral health and social services did not receive money but do a ton of care for the poorest of the people in our state. And so, the roadmap came along to help our four groups be able to figure out how to get to interoperability. There’s pockets of people doing interoperability and doing wonderful work throughout our state but how can we all raise up to that level?

JESSICA

So, I just wanna kind of understand the scaffolding for the specific work that I hope we can talk about in just a minute. So, in Minnesota, there was kind of a priority placed on e-health. So, is that just anything electronic health, the health of robots? What does e-health mean?

CATHY

E-health is electronic health. So, it is the vision of having your health in a system. So not locked on a piece of paper in a drawer but in a system that then when you move from one doctor’s office to another or from public health to a doctor’s office or if you’re developmentally disabled and living in a home, they are your care providers. And so, it’s moving the information from wherever it is to the other organizations and actually the other people. It’s still people helping people but having the computer assistance to be able to know the whole story and to all have the same care plan for the person going forward and working in a coordinated way to be able to support the health and advance the health of every person within the state. Hopefully, within the nation.

JESSICA

That sounds really high-level ambitious but then very specific too. Like, I feel like I can understand as a healthcare consumer myself. I understand all the different places I go and clinicians that I interact with. And so having that continuity of care and coordinated kind of efforts is something I feel like I can really understand because, like, I’m in all those different offices.

CATHY

Yeah. The other piece is that we had to think about…and long-term post-acute care at the table helped us remember is there’s many people who…whether it be disability, age, mental health status and I’m thinking dementia who have someone else caring for them and is in charge of their health although they’re…many times in Minnesota they’re living in a professional secure place for their safety or for their support. And so, it’s also the laypeople who are caring for you, need to make decisions for you, have a vested interest. If you want them involved, you can also have them involved. Now we have huge privacy policies in Minnesota on top of HIPAA. So please remember everything that I talk about is governed with permission of the people who need to give permission. This is not sharing of information or data for the heck of it. It’s sharing it if you want with other people to advance your health.

JESSICA

Next, Cathy explained why engaging representatives across sectors is so important and so powerful when serving individuals.

CATHY

We deal with most and really all of the social determinants of health and we have that information and we know how to assess it because we’ve been doing it for years. And we know why our individuals that we care for can’t take their medicine or are getting bit by bedbugs. And we can share that upward so that when you have 20 minutes in your clinic visit, your provider has a larger picture of you and why you have made the choices that you make. Is it because you don’t have enough food, that you can’t take your medicine? Are you living in a place that’s overcrowded because you don’t speak English but everybody else in this whole apartment complex speaks the same language, has the same cultural background as you? You feel like home. It’s not a house. It’s a home that you’re in. And so it helps open up the eyes of people who work in their office and our individuals have to go to them to what we see when we go to the individuals in their home environment.

JESSICA

The Minnesota e-health roadmap is a framework that outlines specific actions, tools and considerations that clinical providers and community partners can use to accelerate the adoption and use of electronic data sharing. When developing the roadmap, Cathy and her colleagues wrote fictional use cases that were rooted in their experiences working in communities. Cathy explained to me that these use cases outlined how and why data could be shared across agencies.

CATHY

The roadmap was built for our state but it’s built for everyone else too. So, it is on the Minnesota Health Department website. Our stories that we first came up with that we first started with are highlighted so you can kind of see the progression of where…actually, where my organization is now, still using an electronic health record that locks everything inside and can’t exchange information, all the way through the progression of what could be possible for me and what is actually happening throughout the state. We use the story of Carrie and it describes her situation. Carrie is a teenager who is still in high school, has become pregnant, has chosen to parent her child and it’s the progression of information flow around her that links everyone who is helping her so that we are not duplicating information and we are not giving her conflicting information because giving her conflicting information actually is probably causing more harm than good. As we sat around the table for the Minnesota roadmap, it became very obvious that with a different lens we’re saying the same thing in a different way which can be confusing and actually halt someone’s progression towards learning because they’re too confused and don’t know which person to trust.

Because informatics is people oriented, it’s for the individual. So, we wanted to give a face and a name and an identity to each of the individuals.

JESSICA

I asked Cathy for some real-life examples of electronic data sharing across agencies. Oh, one note. In a few minutes, Cathy is going to mention beacon sites. The beacon community program was a program funded by the federal government around 2011 with specific health departments throughout the country. Its aim was to support health IT investment and show how initiatives like meaningful use can help support better care for patients, better health outcomes and lower costs for healthcare.

CATHY

Big picture. Our rural health organizations actually are making more advances in electronic sharing than our metro area. In my small, little county alone I have five hospitals and I think it’s 86 clinics that just serve children who are being served by Medicaid. So, trying to pick one person to interact with and to build an exchange with feels very daunting.

JESSICA

And you’re in a metro area.

CATHY

I’m in a metro area, yes. I am in downtown St. Paul. In my rural areas in my state, they have one organization that’s spread farther apart but because of limited resources, they are already sharing one major electronic health record between the hospitals and the clinics. So, the electronic health record that the counties have and many times in the rural areas it’s multiple counties who have joined together services needs to only make one link. And they know each other.

Many of the smaller counties have banded together and built organizations so that they are decreasing their overhead. It’s called the joint powers agreement in Minnesota. And so, they have one health record. So, you’re really joining one health record to one health record but you’re communicating around a huge geographic area that covers most of the people that you’re caring for no matter what type of organization you are. And so, we have…in northwestern Minnesota they have built that connection and they are actually sharing person centered health information but they’re also sharing community centered health information because they are using their electronic health record through environmental health and some protective services, animals, that type of thing. in southeastern Minnesota, the Mayo Clinic and the counties around them were recipients of the beacon moneys. So, they have actually built in their health system and linked hospitals, clinics, public health and then schools. And they are sharing person centered information wonderfully with permission. The health nurses who go out into the home and do maternal child health have linked with the hospital. And so when a mom or a child goes into the hospital for any reason, the nurse literally gets an alert on her telephone that she needs to look into the health…into her health record messages to see who the information is about. So, it’s still kept secure and locked up but she knows somebody has entered the hospital or has left the hospital. So, deliveries, emergency room, any kind of transfers, she gets a message from.

JESSICA

So, like, on my phone, I get a notification when I have an email. Through the electronic health record, this nurse is getting a notification that she has a message essentially inside the electronic health record so she should check it out and then there’s information on one of her clients and an update on the health status of that person.

CATHY

Exactly.

JESSICA

Oh, wow.

CATHY

Exactly.

JESSICA

So, what does that enable them to do?

CATHY

That enables them to…our clients are very mobile. And so, all of a sudden, they know where they’re at. So, they’ll call them while they’re still in the hospital and set up a next appointment. Getting out into the home early increases breastfeeding rates, you know, increases your chances of catching early something that’s happening with a newborn baby or something that’s happening with a mom whose body is going through huge changes. And it helps you build the relationship with the person so that you can keep seeing them more frequently.

The other piece that the public health nurses who are in the school have loved…and school nurses in Minnesota are public health nurses, is the asthma action plans of all of their kids are on a portal so they can go in when the kid walks in the first day of school, collect off the asthma action plan and walk up to the kid and say, “Open your backpack because I think you have medicines that I am supposed to be having.”

JESSICA

Wow.

CATHY

So, they can anticipate problems, issues quicker.

JESSICA

If a home visiting nurse is meeting with a client and has observed something that would go back in the electronic health record for the provider to know about, that exchange of information can also happen.

CATHY

That can happen but it’s not exchanged at this point in what we call an actionable way. So, I can’t send specific data from fields in my electronic health record to specific fields in their electronic health record. But ADTs are huge in Minnesota. That’s admission, discharge, transfer and it’s a set format of sending information from one health entity to another health entity but it is sent more in PDF type form between the two electronic health records as opposed to being able to be actionable and digested into specific data fields.

JESSICA

That’s funny. I’ve heard about ADTs but I’ve never heard ADTs are huge in Minnesota. What do you mean by that? Like, that they’re just a very common way of communicating?

CATHY

They’re a low hanging fruit. It’s already defined. It’s already set up. So, it’s kind of like filling out a template as opposed to needing to design the template and both sides where you’re gonna exchange information agree on the template. It’s already there and it’s already meaningful use certified, maybe. I’m not sure but it’s a meaningful use mandate portion that we can easily grasp onto and send information back and forth with.

JESSICA

What do you think is next either for St. Paul Ramsey County or other counties in your state?

CATHY

In St. Paul Ramsey County for three years now we’ve been working on getting our own interoperable electronic health record. And I can see the end point to that getting really exciting.

JESSICA

People can’t see that you’re smiling really big right now.

CATHY

It was a three-year journey. Working in government is much different from working in private sector. I’m learning. Building contracts takes a while but we can see it. We’re starting to get excited about it. So, my next job now that the roadmap is kind of winding down and I don’t have to take as big of a portion of that is to play cheerleader and get everybody excited about a huge change in our organization. So, change management leader, here I come.

JESSICA

So why are you excited and what are some of the challenges with that change?

CATHY

Part of the challenge with the change is I work with the home visiting nurses. I have 50 nurses. We have a huge home visiting department. We’re really blessed that way. So, I have women that I work with from age 25 to age 66. So, the…growing up with computers hasn’t happened with everyone. So, it’s generational. It’s also thinking based. Public health nurses go into this business because we build relationships with people and people who are really, really good at building relationships with people are not always really, really good at building relationships with their laptop. And so, it causes some frustration.

The other piece is I have to go back to our software vendors multiple times to remind them of the environment that we’re working in. Software vendors…actually not…the one that we have chosen, it was built out of home visiting. So that’s part of why the huge smile and the excitement. Most software vendors for electronic health records though have built it for the situation where the individual is walking onto the territory of the healthcare provider. So, you’re in an office. It’s clean, it’s orderly. The healthcare provider has control. Home visiting nurses go into the home. My home visiting nurses say, “I can use my laptop when the individual is pregnant and when her baby is really small but the minute her baby starts crawling around or if she has an older child, a toddler, opening up a laptop is pretty much impossible because I have kids crawling in my lap the whole time.” Public health nurses who go into the home, build a relationship with everybody in the home or you’re not allowed to come in the home. So, it becomes very difficult. I’m getting more excited about this because this program will be able to be on an iPad type or tablet type platform. So, you’re bringing in something that looks like a piece of paper that I can put an Otter Box around and make it less destructible so if a toddler gets it, you don’t have to be really worried that they’re gonna break the hinge and you won’t be able to keep going throughout your day. And it’s point and click as opposed to longhand writing so that you can quickly do an assessment. But then you can also open up the tablet and show mom different videos. Our clients love to learn from video as opposed to a piece of paper. And if our clients don’t speak English and we’re using an interpreter, showing a moving video is much easier to describe and to grasp the idea of what you’re trying to educate someone about than trying to go through pictures. So, they’ll have the whole gamut of media available at their fingertips to use while they’re in the home and they’re not having to carry around a backpack full of papers.

JESSICA

We’re at our final question and we ask all of our guests this question which is how do you define informatics.

CATHY

Informatics links individuals and communities with culturally appropriate organizations whether they be professional or lay and all the people involved now have the correct information in a way that they can use it that is very timely and accurate and can provide a collective plan of action to move forward whether you are trying to change an individual, a community, a system. We’re all on the same page and facing the same direction.

JESSICA

Thanks again to Cathy Gagne from the St. Paul Ramsey Department of Public Health for staying late after the close of the Public Health Informatics Conference just so we could record. If you wanna learn more about the Minnesota e-health initiative and check out the resources that Cathy mentioned, go to their website, www.health.state.mn.us\e-health. In case you need that again, it’s www.health.state.mn.us\e-health.

This podcast is a project of the Public Health Informatics Institute and the Informatics Academy. Visit phii.org to learn more. You can also find us on Facebook and follow us on Twitter @phinformatics. Our theme music is called “Carnival Intrigue” and was composed by Kevin MacLeod. Finally, many thanks to our production team. Especially Piper Hill, our producer and our lead navigator on the podcast roadmap. I am Jessica Hill and you’ve been informed.

BUTTON

JESSICA

Okay, one more time. That’s www…

PIPER

Oh, no. The internet broke Jessica.

JESSICA

The internet broke me.

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