Going public

In some eyes, public health is the poor cousin of the Canadian health care system.

It’s a notion driven by the plain fact that only two per cent of all government health care spending is invested in public health – programs targeted at the health needs of the population as a whole rather than at individuals. Earlier this year, however, the federal government took several steps to address this perceived neglect.

First, it provided an additional $100 million for developing and implementing a pan-Canadian health surveillance system supporting infectious disease prevention and protection activities.

Second, it launched the Public Health Agency of Canada (PHAC), which keeps on top of health issues such as infectious disease outbreaks and public health emergencies.

Third, it appointed Dr. David Butler-Jones as the country’s first chief public health officer and placed him in charge of PHAC. The new agency has two main branches – in Winnipeg and Ottawa – and a network of specialized centres across the country.

Infectious disease surveillance, identifying emerging threats, monitoring trends, and prioritizing health resources allocation are key PHAC responsibilities. From a public health perspective, they are also provincial and territorial priorities.

But none of these tasks can be effectively accomplished without the proper infrastructure, processes and technologies. Which is where the nation-wide rollout of the Integrated Public Health Information System (iPHIS) comes to the aid of public health professionals.

Network nuances This Web-enabled client-management system – the first of its kind in Canada – will be used within and across jurisdictions to maintain and manage client health record and data reporting systems, track communicable diseases, create immunization registries and handle a myriad other tasks.

The iPHIS system is expected to dramatically enhance the capacity of Health Canada, and of jurisdictions, to anticipate, control and prevent public health risks.

“There are more than 500 discrete business functions going on within iPHIS,” said Ron Sussey, senior IT advisor for the Canadian Integrated Public Health Surveillance (CIPHS) program.

CIPHS – which designed and launched the iPHIS product – works with federal, provincial and territorial leaders, public health officials, IT professionals, program managers, as well as medical health officers in an alliance dubbed the CIPHS Collaborative.

Collaborative members understand that timely access to strategic information is the cornerstone of an effective public health system.

The design and capabilities of iPHIS reflects that approach.

“The iPHIS system,” said Sussey, “serves two primary functions: case management and surveillance.” He said case information collected on individuals is aggregated, filtered and turned into data that provincial ministries of health, or Health Canada, can use for surveillance, detecting outbreaks, identifying trends, planning immunization coverage and a host of other tasks.

So far, he said, iPHIS modules have been deployed across most of Western Canada. Some provinces are in the evaluation phase while others have completed the pilot and are preparing rollouts.

“There’s great opportunity for the system to be used internationally as well,” said Sussey, adding that the Bahamas has just finished the pilot and is expected to “go live” soon.

While iPHIS was the first major venture of the CIPHS program, it certainly won’t be the last.

A couple of times a year CIPHS Collaborative members meet to set priorities. One of them is outbreak management. According to Sussey, it makes sense – in terms of both cost and technology – for jurisdictions to join the CIPHS Collaborative. “By working together we save big time, as new components developed for one jurisdiction can be used by others.” He cited a current project with Ontario to develop a major “outbreak” module in iPHIS. “That component will subsequently be made available to other jurisdictions.”

But collaboration is not the only pre-requisite for success. “In an undertaking of this scope it can get pretty crazy, pretty quick,” said Sussey. “So it’s important to have a smart project management process in place as well.”

He said CIPHS had designed and implemented such a process. “We’re cutting our teeth on iPHIS, but we’ll use the same cookie cutter for all our subsequent projects.”

The process, he said, includes a collection and evaluation phase during which data garnered from various sources – help desks, discussions with stakeholders, surveys at private sites, strategic planning sessions and more – is synthesized and analysed.

Groups from affected jurisdictions participate in the analysis right from the start, he said. “Based on that evaluation we do the product planning and go back to the CIPHS Collaborative with plans, costing, options and more for their approval.” Public health experts say the iPHIS system launch is especially significant given the challenges and problems that have dogged the public health sector for nearly a decade.

“In 1997, we took a hard look at the public health environment and were not encouraged by what we saw,” said Debra Gillis, Health Canada’s Special Advisor on the CIPHS program. “The surveillance environment was not a well-integrated effort, while excessive data duplication used up scarce human resources and hiked costs.” Gillis said critical information – necessary for use in surveillance programs – was not available or was lost.

In normal times such a state of affairs can be a challenge. Faced with an outbreak like Walkerton or SARS, the consequences can be devastating.

Public health pangs A report last year on the Renewal of Public Health in Canada (www.hc-sc.gc.ca/english/protection/warnings/sars/learning.html), published in the wake of the SARS outbreak, outlined some of them. In particular, the National Advisory Committee on SARS and Public Health noted that:

• Ontario’s infectious disease tracking and outbreak management software was archaic and could not be adapted for SARS;

• Individual files for cases and contacts were maintained on paper charts that included colour-coded Post-It notes. (Dr. Sheela Basrur, then Toronto’s chief medical officer of health, commented that the city was using 19th century tools to fight a 21st century disease);

• Lack of a modern database accessible to local, provincial and federal health authorities undermined the flow of information to the public and international agencies;

• Agreements for data sharing between different levels of government, and the necessary information technology, were not in place. Public health, the report said, has not benefited significantly from innovative technologies. “Three levels of government are involved in public health, and as the SARS outbreak has demonstrated, public health must be connected to what is happening in clinics, hospitals, and other parts of the health enterprise.”

The report also called for strategies and tools to move information rapidly to and from the clinical and public health frontlines. It called for greater investment in IT, at a policy level, intergovernmental agreements and information standards that give Canada a powerful public health information system. “This must be an integral part of rolling out of any new funding, whether for general public health renewal, or earmarked for infectious disease surveillance and outbreak management.”

Recognizing the importance of private sector collaboration, the report urged the federal government to “foster work

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