Among the commenters publicly weighing in on the meaningful use Stage 2 notice of proposed rulemaking (NPRM), the Robert Wood Johnson Foundation (RWJF) focused on public and population health (PDF).

Government Health IT Editor Tom Sullivan spoke with RWJF senior program officer Michael Painter, MD, about the promise of an electronic records and exchange infrastructure to advance public and population health, the foundation’s thoughts on what a Stage 2 final rule ought to look like, some of the flare-ups during the public comments period, and the balance federal agencies have to strike between pushing hard enough to effect substantive change and not pushing so hard that health entities cannot react.

Q: What’s the big picture on how Stage 2 can bolster public and population health?
A: One is the fact that the rule directly highlights the importance of this electronic healthcare record infrastructure in support of improving and optimizing population health, maintaining public health. And in the proposed rule for Stage 2 some specific things like reporting directly to public health agencies. It’s important for the public health infrastructure to be able to get ready to receive the electronic information and to be able to act on it. And they’re in the process of doing that as well.

Q: What needs to change in the Stage 2 NPRM to advance public health?
A: The rule is big but with regard to public and population health our specific recommendations were more laudatory about the proposed changes than saying they missed the boat in any particular way. We supported the flexibility to move public health measures from a menu to a core measure. We liked the goal of requiring reporting to a public health agency. Even if not specifically required by law, that was the notion. And then we had some more suggestions to ensure that – not just inhibited by customer practice but specifically prohibited by law. Otherwise we think folks should use the EHR to do that kind of reporting. Those changes were really on the margin and we thought the proposed rule when it comes to public and population health was really right on target, for the most part.

Q: There are some challenges particular to public health agencies, several of which have to do with health information exchange – submitting immunization and syndromic surveillance data to PHA’s, for instance. What are the main HIE challenges public health agencies face?
A: Information exchange in the big picture is extraordinarily challenging. It isn’t remotely simple on the healthcare side and then when you try to expand it to population health and the public health side, it isn’t either because they might not have the direct connections, even cultural or professional connections, to those using the electronic health record. We have to get all those in place as well.

[See also: Big data and public health, part 2: Reducing unwarranted services.]

So on the healthcare side, institutions such as hospitals and clinics can do everything in their power to connect up and start meaningfully using, but that doesn’t mean that the rest of the care partners in the sphere are doing the same thing, so that’s why they’re taking this coordinated exchange emphasis. When you add in public and population health – which historically hasn’t done as good a job at bringing all those factors together and thinking holistically about all this as we should and as they’re starting to do in this rule – that makes it more challenging to exchange information in the public health sphere, even more so than it is in the healthcare sphere. We do not have that even remotely solved in healthcare.

Q: Which brings up another point RWJF mentioned in its comments, that being coordinated care. Is that more of a cultural problem in PHAs than a matter of technology itself?
A: As is often the case, the technology challenges can be really hard but adapting to the cultural changes can be even harder as you suggest. In many respects the care coordination and getting information to those along the continuum of care is technically hard, but we can probably solve that. We have this even bigger challenge to get people to work in ways that they haven’t worked, with other professionals; with their customers – the patients and consumers; with the public.