Dr. Bryant Karras, Chief Public Health Informatics Officer at the Washington State Department of Health, is regarded as one of the nation’s foremost experts in the field of public health informatics, and he has served a key role in shaping the field. But he didn’t always intend to end up in this burgeoning discipline. In this episode of the podcast, I talk with Dr. Karras about the arc of his career, from his beginnings as an internal medicine resident who fixed personal computers for his attending physicians, to his work in the present day developing an informatics roadmap for the entire state of Washington.

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JESSICA

Hello. I’m Jessica Hill, and I’d like to welcome you to another episode of Inform Me, Informatics.

Today I’m joined by our producer Piper Hale. Hi, Piper!

PIPER

Hi, Jessica!

JESSICA

Piper, true or false: you recently had a chance to talk to Dr. Bryant Karras, the Chief Public Health Informatics Officer at the Washington State Department of Health.

PIPER

True, and it was so exciting to talk to someone who has been so instrumental to shaping the field of public health informatics! So I wanted to share with you, and our listeners, Bryant’s professional journey—and where it’s taken him along the way. I started the interview by asking how he first became interested in the field.

BRYANT

So I think I became interested in public health informatics before I knew what informatics was, or that it even existed. Before I went to medical school, I was a biomedical engineer and did a lot in computer science and programming. And when I arrived at medical school, this is going to really date me, but the internet and access to the internet—the Gopher Net was pre-world wide web—was this new and exciting thing, and our medical school didn’t have email accounts and a computer lab set up to get access to these resources, and I ran for president of my class on a platform of getting funding to build tools and access for all the medical students to have Gopher Net.

JESSICA

What’s Gopher Net?

PIPER

So I had to look up Gopher Net, and it was this protocol that was used widely at universities in the early ’90s, and it was a competitor of the world wide web, which of course ultimately prevailed and became the internet we know and love today.

JESSICA

So did Bryant’s campaign for technology access work?

PIPER

It did work! And at the end of his medical studies, Bryant took his love of technology beyond his university to a more real-world setting.

BRYANT

By the last year of my medical school, I created an elective, where I was deployed to the public health laboratory for the state of Wisconsin and worked with them to build resources, a pilot project, to use technology at the time that doesn’t exist anymore, called the Apple Newton, kind of the precursor to the iPhone and iPad, to put information about organisms that would be investigated by a public health laboratory, and I was really enthusiastic about the opportunities for public health to also engage and utilize the resources that were out there for dissemination of information and the gathering of information and doing things in a way that are much more dynamic and sustainable, rather than the printed tome that sits on a shelf and becomes out of date as soon as it’s printed.

When I went and did my residency in internal medicine, I again became aware that the very attendings that were training me, I knew more about these resources than they did. They would ask me to come to their home to help them connect their computers to the internet, which by that time, we had the world wide web, and it was eye-opening to me that I, as a junior trainee, had this knowledge base, and I began looking around for, what can we do to advance this?

And that’s when I discovered that there was a sub-specialty in medicine of informatics.

And when I found this—it was the first time I knew that the field even existed as a formal discipline, I thought, OK, this is it, this is what I really should have applied to from the start when I graduated from medical school. This is where I’m needed. And wisely, my mentor there said, “Bryant, I know this is what you’re going to get to, but you need to get that board eligibility in internal medicine in order to get faculty positions down the road.” And he was absolutely right. Be it what it is, I think the main thing that that granted me was that when I ultimately did go and do my fellowship, which didn’t pay very well, I was able to moonlight and practice internal medicine on the side, moonlighting to pay the bills.

PIPER

That’s quite a side gig!

BRYANT

So it was good advice, and I think as my now not having known that I would get back into public health practice, it allows me to be taken more seriously when I’m interacting with clinicians who are trying to set up reporting mechanisms from the electronic medical record system to hospitals trying to connect and do their reporting to public health. Being a physician, having practiced in both those environments, clinics and hospitals, gives me a level of credibility when I’m interacting with those folks, to really help strengthen those relationships.

PIPER

So Bryant did stick out his medical studies long enough to do his residency and become board certified. But after that, he jumped into informatics with both feet.

BRYANT

The informatics fellowship location—I went to Yale University. I was really fortunate to get a stipend to attend there. And, again, focused on some public health opportunities or niches where technologies could be applied both from an immunization forecasting perspective or the creation of asthma guidelines and creation of evidence-based development of an intervention to use in inner urban, inner city asthma populations. It was a really exciting time, and the computational power was getting to the point where you could intervene and have that real-time decision-making support.

JESSICA

Next, Bryant went to the University of Washington and later joined the faculty there of one of the earliest informatics degree programs in the country.

PIPER

His next big career step took him to the Washington State Department of Health. And I’ll let Bryant tell that story.

BRYANT

One of the deputy secretaries approached me and said, “Bryant, what do we need to do to get you to come and do real public health informatics?” And I joked around, “Well, let’s create a position for me that I can do part time while I’m still doing academics!” To my surprise, they did! They carved out a position. I started off doing a part time, and then loved it so much, going from theory and academics, to being able to be doing hands-on work within a real state health department. And that, again, became that exciting time in my life. As my wife said, I was coming home at night excited, the same amount of charge and excitement as when I had been practicing in an inner city hospital and was taking care of patients. And I felt like I was making a difference again. Not that academia isn’t making a difference, but it’s not as immediate of a tangible sense that you’re doing some good to advance the cause. So this whole string of positions and training and experiences, I think have made me who I am, and I’d like to think, make me a good evangelist of what public health informatics is capable of, to help an organization and to advance the field. I’m hoping that a lot of health departments, state and local, can see the value in creating positions within their organizations that can focus on informatics as a strategy that’s more than just IT, it’s that bridge between the domains and the programs and IT, and sees the bigger picture.

My position has evolved over time in the agency, so when they originally carved out a position for me, it wasn’t for the whole agency, I was just the informatics lead for the public health laboratory. And as it happened, when new efforts, or new initiatives started hitting the environment—the ecosphere of our world, meaningful use came, and I came to the leadership of the agency and said, hey, there are these opportunities, the clinical community’s going to need to start doing these reports out of their electronic medical record systems to us, and laboratory and syndromic surveillance and immunization, and we need to be ready for it. We need to get somebody working on this. And foolish me, jumping up and down, saying we needed to be ready for this, they turned to me and said, “OK Bryant, help us get ready for it!”

So I was moved out of just being under one division of the department, and moved up, reporting to the CIO for the agency, trying to get us ready for Meaningful Use across several different divisions within the agency. And then it evolved again to where I am now, that the chief informatics officer reports to the state health officer, and I’m really fortunate to be a peer in the same office as the two state epidemiologists for our agency, and the special assistant on doing healthcare transformation. The four of us being in the same office, reporting to the state health officer, it really makes a lot of sense. It may not fit in the structure for every state agency or local health department, but it’s allowed us to position informatics in a place to help support our state innovation model work, and it’s enabled us to be positioned to advance and respond to the opiate epidemic.

So the largest and most ambitious project that we have in our agency is the creation of—it actually—I’ll blame PHII for this, the creation of, after having done the informatics-savvy self-assessment, we looked at our score, which we humbly did not score perfectly on—we know there’s lots of room for improvement, and we looked at that and said, where do we need to advance ourselves? How do we get to the next level? And we created an informatics roadmap from that assessment to figure out what our next course of action needed to be to bring us up in capacity. And that road map led us to the creation of a new initiative across our whole agency, an enterprise approach to creation of a public health data interoperability program. And creating that program’s been really my focus for the last few years, in terms of building partnerships and getting time volunteered from the vast input we needed across the agency.

One of the most concrete examples of turning information into action to change an outcome stems back to the H1N1 outbreak. Our syndromic surveillance system—first of all, it was able to detect the arrival of the pandemic in the state of Washington, which first popped up in a university in the eastern part of our state that happened to have a start date in the late summer, earlier than the rest of the institutions in our state. We had a lot of people returning back to campus from places that had already been hit. And we were able to see a spike in respiratory illness in that jurisdiction in our syndromic surveillance feeds despite the fact that the clinicians in the influenza surveillance network, who were voluntarily reporting whether or not they were seeing the flu hadn’t reported a spike, and they didn’t report a spike because they were too busy taking care of flu patients to fill in the form to report the spike.

So I think that it was a great example of showing where an investment in an informatics methodology really anticipated an opportunity where automated systems could be present and ready when you needed them, in advance of when you needed them. It would have been too late to set it up after we’d been hit. As that pandemic evolved, and thankfully a vaccine became available, we were again able to utilize that system to help feed to our state epidemiologists critical information about the types of cases that were showing up in emergency rooms, and most notably, a spike in pregnant women showing up to the emergency room with concerns about having an infection, and then investigating and looking at their vaccine status. Even though they were on a priority list to receive the limited supply of vaccine, they weren’t vaccinated. And the state epidemiologist was able to issue a letter that was sent to every OBGYN in the state urging them that our data was showing that their patients were not necessarily following recommended guidelines to be vaccinated against the organism.

JESSICA

Piper, one of the goals of this podcast is to hear stories of informatics in action, and listening to Bryant talk about the projects he’s worked on, I feel like he really has been part of so many different projects that show the role informatics plays in supporting public health outcomes, and really the mission of public health.

PIPER

Yeah, that’s so true! And in his time working in the field, he’s really had a birds’ eye view of how it’s changed and what’s been going on, and so one of the things I was curious about and that I asked him was how he’d seen the field of public health informatics evolve and change in that time.

BRYANT

It has matured, and it has hit a crossroads. I think—I truly believe that there is still a tremendous need for investment in public health informatics. I think it is underappreciated for what it can contribute. Almost as much as the development of the field of epidemiology decades ago transformed the way public health became a science, I think there’s an opportunity here for informatics to really evolve and shepherd public health as it matures into the new public health, the public health 3.0 that is emerging. If we don’t have this expertise, these personnel in the field doing this work, we’ll be left behind as the public health arm of our health infrastructure. The clinical world will keep marching on, advancing and modernizing, and we need to modernize ourselves, and be ready to participate as a fully functioning team member.

PIPER

So at this point, the interview was coming to an end, and I closed by asking Bryant the question that Jessica normally asks our guests: “how do you define public health informatics?”

BRYANT

Public health informatics is that bridge between the public health domain areas and the IT. It’s a space where, to be successful in it, you have to be savvy at both. It’s the advancement and the science of turning data into information and knowledge. We define it by competencies, but it’s more than a set of competencies. It’s a philosophy of trying to really advance and be that bridge between the worlds.

JESSICA

Many, many thanks to Dr. Bryant Karras from the Washington State Department of Health for taking the time to sit down with Piper and record this interview. I had a blast learning about the journey that took him from an engineer to a physician and public health informatics leader!

PIPER

Yes, we’re so very grateful to Bryant for making time for us! He was here in Atlanta for the Informatics Academy’s leadership forum, and he actually had to head to the airport to fly home as soon as our chat was over, so I’m very appreciate that he made time to sit down with me.

JESSICA

This podcast is a project of the Public Health Informatics Institute and the Informatics Academy. Visit phii.org to learn more about all of our informatics work! You can also find us on Facebook and follow us on Twitter @PHInformatics.

PIPER

And if you enjoy the podcast, please consider leaving us a rating on iTunes! Every new rating genuinely makes my day—and it helps other people find us.

JESSICA

The music used throughout our show was composed by Kevin MacLeod. Thanks also go to our production team and our producer, who was also the interviewer, who was also the brains behind this whole episode, Piper Hale.

Oh, and Bryant had some acknowledgments he wanted to share as well.

BRYANT

I want to thank PHII and all of my mentors over the years for getting me to where we are and for all the shoulders that have helped prop up public health informatics to where it’s gotten today. Actually my entire career—I have to attribute to my wife. I wouldn’t have been able to get through medical school without her. I remember nights when I was too tired to study and she would sit up and read to me. There are still days when I’ll turn to her, and go, “what’s that diagnosis?” And Kari’s got it.

PIPER

That is really nice!

JESSICA

That is really nice! Shout-out to the partners out there. And on that heart-warming note: I’m Jessica Hill, and you’ve been informed.

BUTTON

PIPER

And Bryant also told me about an early precursor to Pub Med—want to guess what that was called?

JESSICA

Uh… Pre-Pub Med.

[LAUGHTER]

PIPER

So close! It was called Grateful Med.

[LAUGHTER]

JESSICA

What a long, strange trip the internet has been.

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