A useful frame for public health activities is the set of ten essential public health services [13
], which are:
- Monitoring health status to identify community health problems
- Diagnosing and investigating health problems and hazards in the community
- Informing, educating, and empowering people about health issues
- Mobilizing community partnerships to identify and solve health problems
- Developing policies that support individual and community health efforts
- Enforcing laws and regulations that protect health and ensure safety
- Linking people to needed personal health services
- Assuring a competent public health and personal health care workforce
- Evaluating effectiveness, accessibility, and quality of personal and population-based health services
- Conducting research to develop new insights and innovative solutions to health problems
The range of services performed by a given public health organization will depend upon whether it operates at the local, state, or federal level. Through these services, public health agencies seek to protect health, prevent disease and injury, promote healthy lifestyles and behaviors, respond to disasters, and assure accessible, high-quality health services. The innovation potential of PHRs will allow public health organizations to enhance each essential service, thereby building a much stronger and more effective public health system. Here, we discuss PHRs in the context of five of the essential services in the hopes of adding clarity to the issues and energy to the dialogue. This discussion also seeks to provide pointers to how we think some of these envisioned functions could become reality.
Monitoring population health status is a central public health activity. A variety of survey systems, such as the Center for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES) and National Health Interview Survey (NHIS), as well as state and national reporting systems, such as the Behavioral Risk Factor Surveillance System (BRFSS), Pregnancy Risk Assessment Monitoring System (PRAMS), and the National Electronic Disease Surveillance System (NEDSS), provide public health with the ability to assess health trends, identify and respond to emerging threats (eg, salmonella and E. coli) and guide development of interventions and policies that address serious health conditions (eg, obesity, smoking, and tuberculosis). These tools and reporting systems have been in operation for many years and remain essential to assessing health status, measuring disparities, and protecting the public’s health. However, PHRs hold the potential to improve health monitoring and may even foster entirely new approaches to this essential service. For example, through PHRs, individuals could easily, cheaply, and en masse share their health data anonymously with public health agencies, in essence creating “sentinel citizen” networks. Such networks could be both passive, where population data is anonymously analyzed in order to assess the prevalence of health issues, and active, where citizens elect to share targeted health information of interest to public health agencies. These approaches could enhance information gathering and reduce the resources necessary to support current health monitoring systems and further engage individuals as sentinels in protecting their own health and the health of their family, their community, and ultimately, the nation.
In a context where the public is actively and passively sharing health information with public health, this sharing also opens the door to a new kind of bidirectional relationship between individuals and public health, one not part of traditional public health monitoring activities. Currently, one of the few public health survey programs that has a bidirectional relationship with participants is NHANES. A routine part of the NHANES survey process is to synthesize survey findings and package them with a participant’s own health information as a “report of findings,” which is then sent through the mail to the NHANES participant. PHRs have the potential to streamline this process by offering to provide a participant’s health information in electronic form for integration with their other personal health data. By digitizing this process, the potential is created to establish a bidirectional communication channel for information sharing, future opt-in survey involvement, and so forth. While this may not be applicable to most of public health’s traditional survey activities, it does open a novel window on new ways to address public health’s mission.
Finally, a central issue with all health-monitoring activities is data quality. Even with current health monitoring activities, considerable time is spent managing data (ie, cleaning, integrating, and linking) to ensure it is of the highest quality. High quality data is the bedrock of evidence-based public health. PHRs have the ability to put some of these data management processes into the hands of individuals, allowing them to play a key role in maintaining the accuracy of their own personal health information. For example, individuals may identify and alert providers to gaps or inaccuracies in their personal health data ranging from personal characteristics, such as age, to past health events and current medications. Currently, health providers and administrators use such data primarily for administrative and reporting functions such as bill processing, service reimbursement, accreditation, and health monitoring. However, PHRs will allow individuals to monitor the quality of their health data/information and address data inaccuracies with their health providers, resulting in higher quality aggregated population health data reported at the local, state, and national levels. This example is not meant to address the validity or reliability of EMR or PHR data (an area in need of further research). Rather, we wish to highlight the effects that managing the quality of and controlling one’s personal health information could have on the quality of reported data (eg, vital statistics registries and immunization registries). Because clinical data are essential to understanding and addressing population health issues, improving the quality of these data could likely lead to development of more effective public health policies and interventions. A case in point would be birth registries and health information collected on the mother and baby around the birth event. The type and quality of data captured by current registries vary by state. What if a PHR could be created for an infant at birth by the mother through the birth registration process? What if a mother’s PHR could help provide information about her care and other data required at the birth registration (and if the mother did not have a PHR, offer her one through the auspices of the state health department)? These actions would not only strengthen birth registration content and information contained within PHRs, it would also impact the adoption of PHRs by tying them to birth registries. Further, mothers could provide data corrections back to the hospitals thereby compelling them to become more vigilant with regard to accuracy and the quality of health data in general as well as those data that are reported to public health.
Investigate Health Issues
A key public health objective is to shorten the time it takes to identify and control potential health threats, and PHRs hold the potential to increase the speed and improve the efficiency and effectiveness of outbreak investigations. Combining PHRs with current and anticipated tools (eg, location-tagged mobile phone pictures linked to personal health information) could make it much easier for individuals to assist public health with real-time reporting during and after outbreaks and disasters. Individuals could voluntarily share personally identifiable or anonymous health data and information for a time-delimited period to rapidly aid public health officials in identifying and controlling an event. This would provide a convenient and critical feedback loop where individuals could get back information of value in return for sharing their information with public health and contributing to improved population health. Another expanded option would allow individuals to proactively combine their PHR data with regularly available health surveillance data in exchange for receiving timely, personalized, and localized public health alerts and notifications.
Inform, Educate, and Empower
Driven by research and the changing incidence of health conditions, promotion of healthier behaviors is another of public health’s core functions. PHRs offer the potential for deeply tailored health promotion opportunities that could go far beyond current strategies to improve health behaviors. Strategies include, for example, Web-based programs to improve self-management of diabetes or support tobacco use cessation. While such strategies are still relevant, new tools could be designed to use existing PHR data to allow individuals to monitor their data and benchmark their health against those in their zip code, county, state, and nation. Putting nationally representative health data to work in this context could provide the impetus to create healthier communities and homes. Consider the potential of using PHRs to provide individuals with profiles of their neighborhood (eg, parks, bike trails, sidewalks, air quality, and grocery and retail stores within walking distance), along with recommendations tailored to an individual’s health characteristics. For example, could restaurant recommendations be made based on an individual’s BMI, weight maintenance goals, current dietary needs, the day’s level of physical activity, and geographical location?The potential benefits of converging personal health data with other information becomes a powerful tool for helping individuals incorporate healthy behavior into daily living.
Link People to Services
Through PHRs, the process of connecting citizens with needed health services and resources could become more streamlined and tailored to local circumstances [14
]. Using influenza vaccination as an example, the Advisory Committee on Immunization Practices (ACIP) has recommended that individuals at high risk for serious complications receive an annual vaccination (eg, children 6 months to age 19, individuals over 50, those with chronic conditions, and those caring for individuals at high risk for complications) [15
]. With PHRs, alerts could be sent directly to individuals who should receive a vaccination, along with a localized map of nearby clinics offering this service with information on hours, languages spoken, and costs. By sending this information via a mobile device, public health could harness the power of immediacy. In this way, individuals could be reached not just where they live or work, but where they happen to be at any given time during the day. Taking this a step further, PHRs could enable individuals to immediately report receipt of a vaccination (with date, time, and geographic location) to public health monitoring systems, allowing for a more nuanced picture of vaccination behavior trends. Flu vaccination represents only an example of the multitude of service connections enabled by PHRs; other examples include cancer screening, other immunizations, mental health counseling, well-baby services, support groups, and so forth.
Public health’s research agenda addresses key areas of disease and injury burden. Currently this research is carried through extramural partnerships with educational institutions, research institutes, and intramural projects. The emergence of PHRs creates new research opportunities and new ways to partner with the public in the research enterprise. For example, PHRs could support the ability to build longitudinal research panels that could support public health research on the myriad connections between population health and health care (eg, clinical preventive service use) and greater insight into disease prevention and control efforts and outcomes. Additionally, individual self-report data and information could be of great value in refining public health research. For example, research has already suggested that under the right circumstances, blood pressure monitoring could be more accurate when taken at home by educated patients using an approved calibrated device and sent in to the physician’s office as opposed to measurements taken in a clinical setting [16
]. This example suggests an untapped continuum of qualitative to quantitative self-reported health information, which could be used to identify subtle aspects of contextual health behavior and develop more nuanced public health interventions, recommendations, and policies. Such innovation could result in a strengthened relationship with citizens as partners in the public health research process.