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Hawaii Raises Legal Smoking Age to 21

Posted By Lola Irvin, Friday, March 18, 2016
Updated: Thursday, March 17, 2016

On January 1, 2016, Hawaii became the first state in the nation to raise the smoking age of tobacco sales and purchases from 18 to 21. The law prohibits the sale, purchase, possession, and consumption of cigarettes, other tobacco products and electronic smoking devices to anyone under the age of 21.

Although 125 cities and counties have similar laws, Hawaii is the first to raise the age limit statewide. Hawaii Governor David Ige proclaimed, “Raising the minimum age as part of our comprehensive tobacco control efforts will help reduce tobacco use among our youth and increase the likelihood that our keiki [children] will grow up tobacco-free.”

Nationally, 95% of adults who smoke began smoking before reaching the age of 21. Similarly, in Hawaii, 86% of current adult smokers started before age 21. About 10% of Hawaii high school youth, and 7% of young adults aged 18 to 20 years currently smoke cigarettes. However, tobacco use is not limited to cigarettes alone. In Hawaii, e-cigarette use has increased six-fold among middle school students from approximately 2% in 2011 to 12% in 2015, and more than quadrupled among high school students during the same time period from about 5% to 22%; 20% of 18-20 year olds used e-cigarettes in 2014.

The timely March 2015 report by the Institute of Medicine (IOM) concluded that raising the tobacco sale age would yield substantial public health benefits. The increase to age 21 would significantly delay the age when young people first experiment or begin using tobacco, reduce the risk that they will transition to regular tobacco use, and increase their chances of quitting if they become regular users.

The Centers for Disease Control and Prevention (CDC) concurred, since numerous studies show that nicotine exposure during adolescence can negatively impact brain development, cause serious addiction, and lead to persistent tobacco use.

In Hawaii, there was widespread support for this landmark legislation from the public health sector, as well as from educators, youth advocates, legislators, public safety representatives, law enforcement, and many community groups that are concerned about the health of Hawaii’s youth.

Raising the smoking age to 21 had the full support of the armed forces in Hawaii. All military branches in the state have directed retail outlets that are located on military properties to stop selling tobacco products, including smokeless tobacco and electronic smoking devices, to anyone under age 21. All military personnel and dependents, as well as other family members, guests and base residents, have been notified to comply with the new law on military bases throughout the state.


Click here to see the print advertisements to announce the
Hawaii Age 21 and the E-cigs in Clean Air laws


The passage of the age-to-21 law was a critical step to promote progress in the fight against tobacco and for Hawaii’s next generation to live tobacco-free.

Lola H. Irvin, M.Ed. is administrator for the Chronic Disease Prevention and Health Promotion Division at the Hawaii Department of Health. Join subcommittees in the Chronic Disease / Maternal and Child Health / Oral Health Steering Committee to participate in chronic disease activities at CSTE and visit the Alcohol and Other Drug Indicators Subcommittee to learn more about related surveillance.

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Washington’s Roadmap to Advance Informatics

Posted By Kim Peifer, Travis Kushner, and Bryant Karras, Friday, March 11, 2016
Updated: Thursday, March 10, 2016

“Data” is a word that we hear or use in every aspect of our lives. In public health, we want a lot of it—it represents the puzzle pieces that we try to work into a picture. The Washington State Department of Health (WA DOH) collects data from a wide array of sources—labs, health clinics, schools, hospitals, and national surveys are a few examples.

Let’s consider the clinician at a health clinic as an example. To fulfill their responsibilities in reporting to WA DOH, a single clinician might share data (paper, fax or electronic interface) through 10 different systems (or more!). We are overwhelming our data source(s) with the burden of number of reports and method of reporting.

Figure 1. The number of connections to other practices that the “average primary care physician” coordinates with (1). Figure by Jeff Horsager (University of Washington Capstone Project, Health Informatics and Health Information Management)
 
Below is a list of systems at WA DOH that each require different data-sharing interfaces (paper, fax, or electronic webpage or automated system). One clinician or health system may need to connect/report to all of these systems, and each must be done separately. The data collected spans the life of the patient. At WA DOH these systems are in four different divisions of the agency.
  • Birth Record
  • Newborn Screening
  • Birth Defects Surveillance
  • Immunization
  • Early Hearing Detection Diagnosis and Intervention
  • Syndromic Surveillance
  • Reportable conditions
    • Communicable (e.g. pertussis)
    • Cancer
    • Blood Lead
  • Death Reporting (EDRS)
  • Trauma Registry
  • Prescription Drug monitoring Program
  • Meaningful Use Registration of Intent
  • Clinician License Renewal

This isn’t just a problem for the party that must establish multiple connections with WA DOH based on the needs of different programs. The maintenance of these systems occupies a huge amount of resources at WA DOH. Currently, the IT team at WA DOH supports 220 systems, 305 applications, and 48 services.

We recognize that this isn’t a sustainable arrangement for our partners or for us, and see a role for public health informatics in generating solutions. The Public Health Informatics Institute (PHII) defines public health informatics as “…the discipline that supports the effective use of information and information technology to improve public health practice and population health outcomes.” We aim to leverage this field to improve scenarios like the one outlined above, and to this end we have generated an Informatics Roadmap.

The Informatics Roadmap is a three-year operational plan to advance public health informatics in the agency, with the broader intention of advancing public health informatics in Washington State.

Development of the Informatics Roadmap began in 2014 with agency-wide qualitative interviews by the WA DOH Informatics Team. We then partnered with PHII as the first real-world user of their tool “Building an Informatics-Savvy Health Department.” The tool was developed by PHII in collaboration with the Minnesota Health Department and the Oregon Public Health Division. The assessment uses the capability maturity model (a registered trademark of Carnegie Mellon University) to assess three core domains:

Figure 2. Components contributing to Informatics capacity (2)
 

We used the tool to determine the current informatics capability within the agency as well as local health jurisdictions in the state. Nine program areas, representing the six DOH agency divisions and three local health jurisdictions (Whatcom County, Seattle & King County, and Spokane), completed the assessment in teams. In total, the Informatics Roadmap engaged 100 participants.

With the results of the assessment as a foundation, the WA DOH informatics team proposed goals and objectives to advance our capabilities. These were vetted at an in-person meeting with representatives from each group, as well as field leaders/subject experts (Oregon Public Health, Minnesota Health Department, and PHII).

Following the in-person meeting, we refined, vetted, and consulted specific program areas/teams to shape the high-level document into an operational plan (including action items and timelines to achieve each objective). Ultimately, we established these goals to advance the capability of public health informatics in Washington:

Figure 3. Components contributing to Informatics roadmap
 
Currently, we are working on a method to track the actions that we have outlined in the Informatics Roadmap, and we plan to meet on a quarterly basis with our state health officer to assess progress in the active items of the current quarter. The effort to synergize agency efforts and actively advance public health informatics in Washington will be challenging, but we look forward to reporting back on our progress!
Figure 4. The Informatics Roadmap team: Kim Peifer, Bryant Karras, and Travis Kushner
 
Endnotes
  1. Primary Care Phisicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination. Hoangmai H. Pham, MD, MPH, et al., et al. 4, 2009, Annals of Internal Medicine, Vol. 150, pp. 236-242.
  2. Public Health Informatics Institute. Informatics Savvy Health Department Resources. Public Health Informatics Institute. [Online] http://phii.org/infosavvy.
 
Kim Peifer, MPH is Applied Public Health Informatics (APHIF) fellow, Travis Kushner, MPA is Public Health Data Exchange program coordinator, and Bryant Karras, MD is chief informatics officer in the Washington State Department of Health. For more information about surveillance and informatics, join the CSTE Surveillance/Informatics Steering Committee. To learn how to become a fellow in the APHIF program, visit the Project SHINE webpage.
 

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Advocating for CSTE Member Needs in Washington, D.C.

Posted By Joe McLaughlin, MD, MPH, Friday, March 4, 2016
Updated: Thursday, March 3, 2016

Advocating for the needs of the applied epidemiology workforce nationally is a fundamental component of CSTE’s mission. For this reason, Executive Board representatives visit our nation’s capital each year to meet with federal decision makers and partner organizations. This year, participants included: Vice President Al DeMaria of Massachusetts, President-Elect Megan Davies of North Carolina, Secretary-Treasurer Sarah Park of Hawaii, Surveillance/Informatics Member-at-Large Kathryn Turner of Idaho, and President Joe McLaughlin of Alaska. Accompanied by Executive Director Jeff Engel and guided by Washington Representative Emily Holubowich, CSTE convened and attended nine meetings.


During our visit, CSTE representatives met with CDC’s Washington, D.C. office, the Office of the National Coordinator for Health Information Technology, the Veterans Health Administration, the Office of Management and Budget, the office of Congressman Mike Simpson of Idaho, the Pew Charitable Trusts, and the de Beaumont Foundation.


Our meetings this year coincided with both the release of President Obama’s budget proposal for Fiscal Year 2017 and a House Foreign Affairs Subcommittee hearing on the Zika virus outbreak. The president’s proposed FY 2017 budget, which will inform the official budget to be passed by Congress, sees a $194 million-dollar decrease in CDC funding from FY 2016. At a CDC Coalition meeting at APHA, CDC Director Tom Frieden underscored how the many thousands of lives saved through public health programs often go unacknowledged without the continued advocacy of national partners. Dr. Frieden addressed the implications of the administration’s proposal, including increased funding for antibiotic resistance, prescription drug overdose, and gun violence prevention research. Dr. Frieden also emphasized the following FY 2017 funding priorities: antimicrobial resistance, Good Health and Wellness in Indian Country, and prescription drug overdose prevention.


At the Zika virus House hearing, Dr. Frieden emphasized the urgent need for $828 million to strengthen national systems for Zika virus prevention and response. If awarded, a portion of this funding would support vectorborne infrastructure at state, territorial, and local health departments. CSTE has endorsed the president’s request for $1.9 billion in emergency funding for the Zika virus response. Click here to read the requests for the House of Representatives and the Senate.



State Epidemiologist of Alaska Joe McLaughlin, MD, MPH is the president of CSTE. To learn more about CSTE’s advocacy activities, visit the CSTE website and cutshurt.org.

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An Important and Long-Awaited Opportunity

Posted By Sonja A. Rasmussen and Renee Bougard, Friday, February 26, 2016
Updated: Friday, February 26, 2016

“I was very excited to learn that public health departments around the country can now use Block Grant funding to support increased access to library services. The availability of journals, publications, and up-to-date science will be a huge boon to the public health workforce at the state and local levels.”

- Tim Jones, State Epidemiologist, Tennessee Department of Health


It was just this January that CDC and the National Library of Medicine announced that public health departments can now use funding from the CDC Preventive Health and Health Services (PHHS) Block Grant to access journals, publications, the latest evidence, and additional resources through the Public Health Information Access Project (PHIAP) of the National Library of Medicine. The mechanism was developed through the Centers for Surveillance, Epidemiology and Laboratory Services at the Centers for Disease Control working with partners inside CDC and outside the agency.

The goal of the project is to provide low-cost access to high-value, evidence-based resources to improve public health practice in state public health departments. Costs must be tied to state work plans.

In 2015, CSTE reported on its year-long assessment on the scientific writing needs and trends for applied epidemiologists. CSTE’s Applied Epidemiology Scientific Writing Trends, Needs, and Recommendations, 2014 noted that just over half the respondents reported access to peer-reviewed literature (55%), oftentimes through academic appointments. One of the recommendations from the report was to encourage scientific writing partnering with libraries or universities to ensure access to peer-reviewed literature.

Jones noted the same limitations for his colleagues in Tennessee. “Up until now, access at our health department has been limited to a handful of federal assignees or folks with faculty appointments somewhere, and there is widespread enthusiasm at all levels here about this new initiative to expand that access. I think it will enhance our ability to make more rapid, evidence-based decisions and policies, as well as encourage publication and wider dissemination of reports on the important work being done on the front lines of public health.”

Access to library services through PHIAP is already making a difference in state health departments around the country.

“Here in Connecticut, we modify our Youth Risk Behavior Survey and this year, staff at our State Department of Education wanted to capture information about students experiencing housing insecurity. We know there is health and academic risk in this vulnerable population. Having the resources available through the Public Health Information Access Project greatly helped us find relevant research on this topic to better inform our survey development workgroup.”

− Connecticut Department of Public Health

“Having resources to learn the microbiological and medical/epidemiological facets of what my customers are dealing with helps me ask better questions and collect better data, which drives better decisions (and ultimately, better health outcomes and longer lives – which is why health departments exist in the first place). Thanks again for doing what you are doing to make our jobs easier, and our people healthier.”

− Colorado Department of Public Health and Environment Lab

“I just used this fabulous resource to help me find published information on metrics for evaluating patient navigation during diagnosis and treatment of breast and cervical cancer and the cost effectiveness of cancer patient navigation and….I hit the jackpot. No more ‘you must be subscribed to download the full text…’ It was well worth my 90 minutes of training.”

− Connecticut Department of Public Health


We’re very pleased this collaboration is making these services available to all who need them. If you’re interested in obtaining access to library resources for your state health department, talk with the people at the state that develop the block grant funds budget about possibly including this item in your state work plan.
 
Sonja A. Rasmussen, MD, MS, is director of the CDC Division of Public Health Information and Dissemination and editor-in-chief of the Morbidity and Mortality Weekly Report. Renee Bougard, MLIS is outreach librarian at the NN/LM National Network Office of the NIH/National Library of Medicine. For information about PHIAP or how to access library services, please visit: http://nnlm.gov/phiap.

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The Illinois Experience: The Perspective of Illinois Department of Public Health’s CSTE Fellows

Posted By Justin Albertson, Whitney Clegg, and Andrew Beron, Friday, February 19, 2016
Updated: Wednesday, February 17, 2016
Untitled Document

Illinois covers 58,000 square miles and is home to 13 million people, making it the fifth most populous state in the country. The city of Chicago draws travelers from across the globe, with 50.2 million visitors in 2014 alone—many of whom enter Chicago via one of the world’s busiest airports, O’Hare International Airport. While a majority of the state’s population resides in the Chicago metropolitan area, the nation’s third largest, the state is also populated by smaller cities and rural countryside. Illinois’s size, large population, and diverse city and rural residents contribute to a number of infectious disease and public health-related challenges. In the past two years alone, Illinois has had to respond to suspect cases of Middle East Respiratory Syndrome (MERS), Zika virus, and the need to screen travelers from West Africa for Ebola.

As CSTE Applied Epidemiology fellows, we have been able to participate in numerous infectious disease outbreak investigations across the state. In a sense, we’ve been able to act as a rapid response team, quickly addressing important public health issues in Illinois to implement control measures and promote disease prevention. Elements of outbreak response include data collection, management, analysis; implementation of outbreak control measures; and communication and coordination with public health partners and stakeholders. In 2015, we conducted on-site investigations for seven outbreak events, including:

  • Measles among infants at a child care center in suburban Chicago
  • Group A Streptococcus infections among residents and staff at a long-term care facility
  • Invasive MRSA infections among patients receiving epidural steroid injections at a pain management clinic
  • Meningococcal disease among men who have sex with men in the Chicago area
  • Laboratory specimen contamination with Geotrichum, a rare fungus, causing a pseudo-outbreak at a large hospital
  • Legionellosis at a large veterans’ home
  • Necrotizing enterocolitis among infants being cared for in a neonatal intensive-care unit
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These investigations helped to identify needed control measures, to pinpoint infection control deficiencies at long-term care facilities, and to facilitate distribution of vaccines to susceptible populations. The CSTE Applied Epidemiology Fellowship program has provided support to Illinois to respond to pressing public health needs across the state quickly. It has allowed us to gain expertise and skills in outbreak investigations and epidemiologic methods.

Justin Albertson, MS, Whitney Clegg, MD, MPH, and Andrew J. Beron, MPH, MLS(ASCP)CM are fellows in the CSTEApplied Epidemiology Fellowship. For more information on how to host fellows or become a fellow, visit the Applied Epidemiology Fellowship page on the CSTE website.

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Colorado’s Family Planning Game-Changing Program

Posted By Jody Camp, Friday, February 12, 2016
Updated: Thursday, February 4, 2016
Beginning in 2008, the Colorado Department of Public Health’s (CDPHE) Family Planning Program (FPP) received an eight-year, private donation to the program. Through the privately funded Colorado Family Planning Initiative (CFPI), the FPP expanded access to the most effective long-acting methods of contraception, specifically intrauterine devices (IUD) and contraceptive implants, throughout the state. The results have been astounding:
  • Since the start of the Colorado Family Planning Initiative, the birth rate for young women ages 15 to19 has been cut nearly in half, falling 48 percent between 2009 and 2014.
  • A similar downward trend can be seen among women ages 20 to 24, with birth rates dropping 20 percent between 2009 and 2014.
  • The number of repeat teen births (teens giving birth for the second or third time, etc.) dropped 58 percent between 2009 and 2014.
  • The abortion rate among women 15-19 fell by 48 percent and among women 20-24 by 18 percent between 2009 and 2014.
“Similar to Colorado, Mesa County’s unintended pregnancy rate continues to decrease. However, our teen birth rate is 30% higher than the state. As a result of Colorado LARC funding, Mesa County efforts to address unintended pregnancy have been successful. In 2015 our LARC procedures were double those in 2014 and triple from 2013. Because of Colorado LARC funding, we are able to keep units in stock, allowing for same-day attention to patients. We know through experience that asking clients to wait several days for an appointment or asking them to return for subsequent visits increases the likelihood they’ll not follow through with a procedure. The LARC program is one of the few public health efforts to have measurable community impacts in a fairly short amount of time.”

Jeff Kuhr, PhD, Executive Director, Mesa County Health Department
CDPHE’s LARC Program has brought a local and national spotlight to the effectiveness of long-acting, reversible contraceptive use and the health, economic and social impacts it makes to society. The following are a few highlights:
  • The Family Planning Program (FPP) submitted a journal article to Guttmacher Institute’s Perspectives on Sexual and Reproductive Health. The article entitled, "Game Change in Colorado: Widespread Use of LARC Methods and Rapid Decline in Births among Young Low-Income Women".
    https://www.guttmacher.org/pubs/journals/46e1714.html
  • To assist with the dissemination of the journal article, Colorado Governor, John Hickenlooper, and CDPHE Executive Director, Dr. Larry Wolk, co-hosted a press conference at the Colorado Capitol Building in July 2014. The press attention was overwhelmingly positive, including these examples:
Looking to the future, the Family Planning Program aims to build on its past successes and ensure the sustainability of the LARC program. Most recently, the FPP is working on a potential project to fund school-based health centers that provide family planning services. In addition, relationships are being built with birthing hospitals around the state to partner on post-partum LARC insertion. CDPHE has also submitted a request to Colorado's Joint Budget Committee to increase funding to the CDPHE Family Planning Program to sustain this momentum.
Jody Camp, MPH is Family Planning Section Manager at the Colorado Department of Public Health and Environment. To learn more about Maternal & Child Health epidemiology, join the MCH Subcommittee and explore related activities.

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Using Cyberspace to Address Infectious Syphilis in Rhode Island

Posted By Thomas E. Bertrand, Friday, February 5, 2016
Updated: Thursday, February 4, 2016

Mirroring national trends, Rhode Island has observed an upswing in infectious syphilis cases in recent years among gay, bisexual, and other men who have sex with men (GBMSM). In 2005 there were just 14 cases of infectious syphilis among GBMSM in Rhode Island. This number increased to 80 cases in 2014, a 417% increase. Many of these cases are individuals who use cell phone apps and online websites to meet their partners. With the goal of reaching these individuals “where they are at,” the Rhode Island Department of Health (RIDOH) embarked on an internet-based campaign to promote syphilis prevention and testing, with some encouraging results.

 

The first step of the campaign was to create a webpage entitled “Sexual Health Information for Gay Men” (www.health.ri.gov/sex/for/gaymen/) on the RIDOH website. This page provides simple health recommendations for syphilis prevention and testing, as well as links to other helpful sites that provide GBMSM-specific local information, such as finding a gay-friendly doctor using www.men2menri.org.

 
A campaign was developed with input from local GBMSM community groups and patients at STD clinics, who recommended that the advertisement be simple, eye-catching, and non-judgmental. Using successful examples from Denver Public Health, an ad was adapted and used as part of a six-week “run” on eight popular websites and cell phone apps (e.g., Manhunt, GRINDR, Scruff) that GBMSM use to meet partners.


Upon launch of the campaign, the RIDOH “Sexual Health Information for Gay Men” webpage jumped into the top ten most-viewed pages on the RIDOH website and stayed there for the duration of the campaign, with an average of 206 visitors per day. Approximately 92% of the hits to the webpage were attributed to mobile phone usage. During this time, visits to the www.men2men.ri.og website experienced a 125% rise, and the number of patients visiting The Miriam Hospital STD clinic that named the RIDOH website as a referral source increased substantially. Based on local GBSM population estimates, it is projected that 20% to 25% of GBMSM in Rhode Island saw the campaign ad and clicked through to the RIDOH website.
 
This project demonstrated that an online public health campaign targeting GMSM may be effective in directing a significant proportion of the MSM community to a health department website and subsequently prompting them to access STD/HIV clinical services and additional web-based sexual health information.
Thomas E. Bertrand, MPH, MA is chief of the Center for HIV, Hepatitis, STD, and TB at the Rhode Island Department of Health in Providence, Rhode Island. To learn more about CSTE activities in STD epidemiology, explore the STD Subcommittee and other Infectious Disease subcommittees.

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Motivating for Continuous Quality Improvement

Posted By Kelly Gerard, Friday, January 29, 2016
Updated: Friday, January 29, 2016

Denver Public Health, the host-site agency for my fellowship, is driven by an internal desire to improve its processes and outcomes. This desire is achieved through Continuous Quality Improvement (QI), an ongoing effort to increase an agency’s approach to manage performance, motivate improvement, and capture lessons learned in areas that may or may not be measured as part of the public health department accreditation process. Denver Public Health’s approach to QI is guided by Lean. Lean is a systematic approach, based on the Toyota Production System of Lean principles and tools, with a defined improvement process to identify and eliminate waste such as inefficiency, error, and redundancy.1 Through a Lean-driven QI process, Denver Public Health improves the efficiency, effectiveness, quality, or performance of services, processes, capacities, and outcomes.2

Awarding QI Efforts

Denver Public Health established a Quality Committee to oversee efforts related to QI projects, staff QI training, customer satisfaction, and related communications. It is a multi-disciplinary committee with representation from all divisions.3 The Quality Committee is also responsible for selecting recipients for the Oppy Award. The Oppy Award provides recognition to teams and programs for exceptional QI projects. Projects are voted on by the Quality Committee each month, and Oppy travels to each winner to be proudly displayed. Winners are encouraged to decorate and add “flair” to Oppy. A picture of Oppy with the award winners is taken and shared on the agency’s intranet site and on bulletin boards throughout the department. The mascot represents the core values of continuous quality improvement and encourages and promotes a QI culture in public health.
 
Example QI Projects that have won the Oppy Award:
  • Screening, Brief Intervention, Referral to Treatment (SBIRT) process improvement in the STD Clinic to identify, reduce and prevent problematic use, abuse and dependence on alcohol and illicit drugs 4
  • Text message reminders for travel patients in the Immunization and Travel Clinic
  • Personnel Grant Management (PGM) system in the Public Health Administration team
  • Travel authorizations process improvement by a cross-departmental team to simplify and standardize the travel authorization process
  • Vaccine preventable disease response by Epidemiology and Preparedness and Immunization and Travel Clinic teams
  • Email best practices by a cross-departmental team to reduce the burden of email and improve the consistency of emails originating from our department
  • Optimizing the Grant Tracking Database by the Public Health Administration team and Kelly Gerard
 
Call to Action
QI in public health is a continuous and ongoing effort to focus on improvement activities that are responsive to community needs and improving population health. 5 Public health departments wanting to achieve measurable improvements should consider adopting Lean principles and tools and promoting a QI culture. Successful implementation of QI requires a commitment throughout all levels of the organization. An effective way to engage and motivate employees is through internal awards, such as the Oppy Award, to acknowledge QI efforts throughout the department.
 
References
  1. Lean Systems Improvement, Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs, Denver Health, 2012.
  2. Public Health Foundation and the National Public Health Performance Standards Program, Acronyms, Glossary, and Reference Terms, CDC, 2007.
  3. Denver Public Health, Performance Improvement Plan, 2015.
  4. SAMHSA-HRSA Center for Integrated Health Solutions, accessed from web: http://www.integration.samhsa.gov/resource/sbirt-resource-page
  5. Riley, Moran, Corso, Beitsch, Bialek, and Cofsky, Defining Quality Improvement in Public Health, Journal of Public Health Management and Practice, January/February, 2010.
Kelly Gerard, MSHI, RHIA is an Applied Public Health Informatics Fellow at Denver Public Health, Denver Health in Denver, Colorado. APHIF applications are due Monday. To apply for APHIF, HSIP, and I-TIPP fellowships, please visit the Project SHINE website.
 

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Raleigh to Bamako: CSTE Influenza Surveillance International Consultancy

Posted By Lauren Thie, Friday, January 22, 2016
Updated: Tuesday, January 12, 2016

CSTE provides international consultancies for its members to support CDC programs. You may have a colleague who went to West Africa to help support Ebola efforts through CSTE. When I joined CSTE in 2011 as a new North Carolina health department employee, I had recently returned home from some international work. I let CSTE know I would be interested in international consultancy, and what my skills were. Through the CSTE international consultancy program, I was able to assist in an influenza epidemiological surveillance review in Bamako, Mali in September 2015.

I received training for the influenza surveillance review in advance of my departure. CSTE colleagues experienced in surveillance reviews offered their expertise and documents from their previous reviews in West Africa. CDC-CSTE calls were held to offer me training for the consultancy. CDC shared background documents on Mali’s influenza work. North Carolina public health has a strong history of international consultancy and influenza work, and colleagues shared their wealth of experience. I left for Bamako in early September feeling prepared.

Mali is located in West Africa, sharing borders with 7 different countries. It is south of Algeria, west of Niger, north of Burkina Faso and Cote d’Ivoire, and east of Mauritania and Senegal. Mali is twice the size of Texas and is home to 15 million people. Bamako is the capital city, located in western Mali. Bamako’s population is two million and is the sixth fastest growing city in the world.

The CDC Influenza program and the Center for Vaccine Development Mali planned the surveillance review itinerary and most of the logistics. During my week in Bamako, I used the CDC surveillance tool to document Mali’s influenza surveillance program in laboratory, Influenza-Like Illness (ILI), and Severe Acute Respiratory Illness (SARI) surveillance sites, and nationwide epidemiological surveillance. I recorded what Mali’s influenza epidemiologists, clinicians, and laboratory scientists shared with me about their budding program. With the help of CDC colleagues in Atlanta and Accra, I reported to CDC on the overall system, SARI, ILI, laboratory, data, a SARI sentinel site visit (Gabriel Toure Hospital Pediatric Department, Bamako), and an ILI site visit (Commune I, Bamako).

My international consultancy work with CSTE and CDC on influenza surveillance was inspiring. Professionally, I was impressed by my public health colleagues in Bamako. I have done several public health projects in lower resource settings and this was by far the most impressive I have seen. With time, I believe the Mali influenza program will be an example in West Africa. I am grateful to CSTE, CDC, and the Center for Vaccine Development Mali for an outstanding epidemiology experience during my September 2015 visit.


Touring the Center for Vaccine Development Mali’s (CVD-Mali) laboratory, which performs influenza testing. Left to right: Dr. Boubou Tamboura (CVD-Mali laboratory director, Bamako, Mali), Dr. Talla Nzussouo (CDC epidemiology and laboratory regional advisor based in Accra, Ghana), me (Lauren Thie, NC Division of Public Health, CSTE member), Thelma Williams (CDC project officer, based in Atlanta, USA).


Lauren Thie, MSPH is an Environmental Program Consultant in Occupational and Environmental Epidemiology at the North Carolina Division of Public Health. For more information on international consultancies, please contact CSTE. CSTE is seeking epidemiologists for rapid Ebola deployment in West Africa, including Portuguese and French speakers.
 

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ICD-10 Coding for Contraceptives in Oregon

Posted By Rachel Linz, Friday, January 15, 2016
Updated: Tuesday, January 12, 2016
The Reproductive Health Program in Oregon is a little different than in most other states. Not only do we administer a Title X grant (Title X of the Public Health Services Act, signed into law by President Richard Nixon in 1970, is the only federal funding dedicated solely to family planning services), but we also administer a Section 1115 family planning demonstration waiver through the Centers for Medicare and Medicaid Services (CMS), despite being within our state’s Public Health Division rather than our state’s Medicaid office. Our waiver is called Oregon ContraceptiveCare, or CCare, and covers family planning and contraceptive management services for individuals who are U.S. citizens or lawful permanent residents with household incomes up to 250% of the federal poverty level and who are not enrolled in the state’s Medicaid program. The RH Program’s provider network includes all local public health departments in the state as well as Planned Parenthood health centers, university health centers, community health centers and School-Based Health Centers, totaling 150 clinics statewide. Through our entire provider network, we serve over 80,000 clients annually.
One area of focus for the Oregon RH Program has been to increase access to long-acting reversible contraceptives, or LARC methods. These include contraceptive implants and intrauterine devices, are effective for up to 3-10 years depending on type, and have failure rates similar to sterilization methods (see Figure 1). In fact, LARC methods are about 20 times more effective at preventing pregnancy than birth control pills! We provide technical assistance and training for clinicians and billing staff regarding insertion and removal of LARC devices, billing, reimbursement and maintenance of device stock on site, and best practices regarding client counseling techniques to increase client success with their methods, regardless of which method a client chooses.
As all readers of CSTE Features no doubt know, the United States transitioned to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) on October 1, 2015. For the Oregon RH Program, we are fortunate that our clinical data collection is narrowly focused and we only require diagnosis codes for visits under CCare, not for Title X (which covers a broader scope of services than CCare). Because of CMS requirements, CCare visits must include a primary diagnosis code indicating that contraceptive management was the primary purpose of visit (V25 codes under ICD-9, Z30 codes under ICD-10). To assist our provider network in managing the transition, we created a crosswalk that includes the ICD-9 codes for each contraceptive method alongside the appropriate ICD-10 code, as well as the Healthcare Common Procedure Coding System (HCPCS) supply codes associated with each method type (see Figure 2).
The biggest challenge with coding for the Oregon RH Program under ICD-9 has continued under ICD-10: several contraceptive methods do not have their own unique codes. We’ve all heard about new ICD-10 codes that have been created to document very specific types of injuries in specific locations, but what has not been in the news is the fact that the most effective LARC method, the hormonal implant (<0.5% failure rate) actually lost its unique codes that it had under ICD-9! Of the 18 different contraceptive methods available in the U.S., only four have their own specific diagnosis codes: intrauterine devices, oral contraceptives, injectable contraceptives, and natural family planning. Both female and male sterilization methods use the same diagnosis codes.
Our solution, which aligns with recommendations from national family planning and coding experts, is the following: for hormonal methods that do not have their own specific codes (the contraceptive implant, patch and ring), to use the codes for “unspecified” contraceptives (Z30.019 for initial encounter, Z30.40 for follow-up or surveillance encounters). For less effective methods that do not have their own specific codes (cervical cap, diaphragm, sponge, female and male condoms, and spermicide), we recommend using codes for “other” contraceptives (Z30.018 and Z30.49). This way, although we cannot determine specific contraceptive methods from diagnosis codes alone, we can determine the approximate level of effectiveness. The bottom line is that other information, such as HCPCS codes and National Drug Code (NDC) numbers, is required to determine exactly which contraceptive methods are dispensed. Additional ICD-10 codes may become available in the future, but for now, tracking ongoing use of certain long-acting methods remains a challenge.

Figure 1. Contraceptive method effectiveness. Most effective methods include the contraceptive implant, intrauterine devices, and sterilization methods. Moderately effective methods include injectables, pills, patches, rings and diaphragms.

Figure 2. A portion of the Oregon RH Program’s ICD-9/ICD-10 crosswalk. Under ICD-10, the hormonal implant lost its unique diagnosis codes while injectable contraceptives gained unique codes. Other methods such as the diaphragm have never had their own unique codes.

Rachel Linz, MPH is an Informatics Training in Place Program (I-TIPP) fellow and senior research analyst with the Reproductive Health Program at the Oregon Health Authority. To learn more about ICD-9 and ICD-10, join subcommittees in the Surveillance/Informatics Steering Committee.

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