1 Identifying Opportunities To Strengthen The Public Health Informatics Infrastructure

Original Scholarship
Identifying Opportunities to Strengthen the

Public Health Informatics Infrastructure:
Exploring Hospitals’ Challenges with Data
Exchange
D A N I E L M . WA L K E R , ∗,† VA L E R I E A . Y E A G E R , ‡
J O H N L AW R E N C E , † a n d
A N N S C H E C K M C A L E A R N E Y ∗,†
∗
College of Medicine, The Ohio State University; † Center for the Advancement
of Team Science, Analytics, and Systems Thinking, College of Medicine, The
Ohio State University; ‡ Richard M. Fairbanks School of Public Health,
Indiana University
Policy Points:
r Even though most hospitals have the technological ability to exchange
data with public health agencies, the majority continue to experience
challenges.
r Most challenges are attributable to the general resources of public health
agencies, although workforce limitations, technology issues such as a
lack of data standards, and policy uncertainty around reporting require-
ments also remain prominent issues.
r Ongoing funding to support the adoption of technology and strengthen
the development of the health informatics workforce, combined with
revising the promotion of the interoperability scoring approach, will
likely help improve the exchange of electronic data between hospitals
and public health agencies.
Context: The novel coronavirus 2019 (COVID-19) pandemic has highlighted

significant barriers in the exchange of essential information between hospi-
tals and local public health agencies. Thus it remains important to clarify the
specific issues that hospitals may face in reporting to public health agencies
to inform focused approaches to improve the information exchange for the
The Milbank Quarterly, Vol. 99, No. 2, 2021 (pp. 393-425)
© 2021 Milbank Memorial Fund
393
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394 D.M. Walker et al.
current pandemic as well as ongoing public health activities and population

health management.
Methods: This study uses cross-sectional data of acute-care, nonfederal hos-
pitals from the 2017 American Hospital Association Annual Survey and In-
formation Technology supplement. Guided by the technology-organization-
environment framework, we coded the responses to a question regarding the
challenges that hospitals face in submitting data to public health agencies by us-
ing content analysis according to the type of challenge (i.e., technology, organi-
zation, or environment), responsible entity (i.e., hospital, public health agency,
vendor, multiple), and the specific issue described. We used multivariable logis-
tic and multinomial regression to identify characteristics of hospitals associated
with experiencing the types of challenges.
Findings: Our findings show that of the 2,794 hospitals in our analysis, 1,696
(61%) reported experiencing at least one challenge in reporting health data to a
public health agency. Organizational issues were the most frequently reported
type of challenge, noted by 1,455 hospitals. The most common specific issue,
reported by 1,117 hospitals, was the general resources of public health agencies.
An advanced EHR system and participation in a health information exchange
both decreased the likelihood of not reporting experiencing a challenge and
increased the likelihood of reporting an organizational challenge.
Conclusions: Our findings inform policy recommendations such as improving
data standards, increasing funding for public health agencies to improve their
technological capabilities, offering workforce training programs, and increasing
clarity of policy specifications and reporting. These approaches can improve the
exchange of information between hospitals and public health agencies.
Keywords: hospital, public health departments, health information technol-
ogy, interoperability, electronic lab reporting, registry, immunization registry.
A
robust informatics infrastructure is critical to
effective public health protection and preparedness in the
United States.1–3 Investment in an informatics infrastructure
enables public health agencies, including local and state health depart-
ments, to monitor the health needs of their populations, conduct rou-
tine surveillance, and rapidly detect and respond to disease outbreaks.4,5
In fact, those state public health agencies that have improved electronic
lab reporting have documented faster receipt of notifiable case reporting,
faster case processing, greater data accuracy requiring less follow-up, and
fewer temporary employees necessary for data entry.6,7
Strengthening Public Health Informatics Infrastructure 395
Health care providers, and particularly hospitals, have an important

role in developing the public health informatics infrastructure. Ear-
lier work demonstrated that hospitals’ engagement in public health
efforts can improve the scope of services that public health agencies
can provide,8 but there are many remaining opportunities for greater
synergies and cross-sector collaboration between hospitals and health
departments.9 For instance, the electronic integration of public health
agencies and hospitals is in line with overall efforts to improve popula-
tion health in the communities they serve.10 This is particularly true for
nonprofit hospitals that are required to assess community health needs
and develop community health implementation plans to meet commu-
nity benefit requirements.11,12 More broadly, connecting hospitals and
public health agencies is part of efforts to modernize and strengthen the
public health system.13
To support the development of these connections between hospitals
and public health agencies, in 2011 the Centers for Medicare and Med-
icaid Services (CMS) included the capability to report essential data to
three public health data systems in the Meaningful Use (MU) incen-
tive program: electronic reportable laboratory results, syndromic surveil-
lance, and immunization reporting. Even though the MU program has
evolved over time, electronic integration remains a priority, given that
the Office of the National Coordinator for Health Information Tech-
nology recently included electronic integration in its 2020-2025 draft
strategic plan.14
The MU program’s criteria for public health reporting for hospitals
have evolved since the MU program began. For MU’s stage 1, the three
public health–reporting capabilities were optional measures, and hos-
pitals were only required to have tested their ability to report to one
of the three systems. In MU’s stage 2, these three reporting capabilities
became required; that is, hospitals were required to have “active engage-
ment” in reporting data to all three public health–reporting systems.15
The CMS defines active engagement as “the provider is in the process
of moving towards sending production data to a public health agency
or clinical data registry, or is sending production data to a public health
agency or clinical data registry.” In 2015, a fourth capability—reporting
data to the specialized disease registry system—was added to stage 2 as
a required measure. Hospitals were then required to have active engage-
ment in transmitting data to three of the four public health systems.
Then in 2018, the MU program was again revised and renamed the
Promoting Interoperability (PI) program. Public health reporting is one

of the four domains of the PI program, and to meet the criteria for PI
stage 3, hospitals are now required to have active engagement with two
of six public health–reporting systems (i.e., electronic reportable labora-
tory results, syndromic surveillance, immunization reporting, electronic
case reporting, and clinical data registry [e.g., the Michigan Surgical
Quality Collaborative clinical registry of general, vascular, and gyne-
cological surgical procedures16 ], and/or public health registry [e.g., the
National Healthcare Safety Network Antimicrobial Use and Antimicro-
bial Resistance registries17 ]).18
The MU program as a whole has been deemed a success in driving
hospitals’ widespread adoption of EHR systems and has contributed to
significant advances in hospitals’ public health–reporting capabilities.19
While data from 2012 showed that fewer than half of all hospitals were
meeting stage 2 MU requirements for public health reporting,20 more
recent data from 2015 show improvements, with more than 60% of hos-
pitals reportedly prepared to meet the PI stage 3 public health–reporting
capability.21 This progress is promising and indicates that hospitals have
improved their abilities to electronically exchange interoperable data,
defined as data that can be shared between hospitals and public health
agencies in a coordinated manner so that it can be accessed and inte-
grated by different information systems.22 Importantly, the evidence
regarding hospitals’ progress does not describe public health agencies’
interoperability status, such as their ability to receive, store, and inte-
grate the hospital data. Nonetheless, statewide efforts to expand data ex-
change through regional health information exchanges (HIEs) continue
to decline,23 with this decline attributable to factors such as resource
deficiencies, technical issues and capacity, and a rapidly changing policy
environment.24,25 Because HIEs have the potential to serve as a conduit
for hospitals to report to public health agencies,26–29 their decline may
result in more hospitals needing to report directly to public health agen-
cies.
Conversely, public health agencies have not experienced similar pol-
icy attention or financial incentives to support investment in informatics
infrastructure.30–32 Not surprisingly, their adoption of informatics in-
frastructure lags behind that of hospitals. For instance, using 2015 data
on local public health agencies from the National Association of County
and City Health Officials (NACCHO), Williams and colleagues found
that only 42% of agencies used an EHR and only 6% were capable of
interoperable data exchange.33 Both local and state health departments

reported a lack of resources to implement informatics infrastructure,
which may be contributing to their limited adoption. While some local
health departments may not provide clinical services, those local health
departments that used EHRs tended to provide a greater range of clini-
cal services and spent more per capita.34,35 Additional research on local
public health agencies has found that technological capabilities across a
range of informatics tools and technologies are clustered in a small num-
ber of public health agencies, leaving other public health agencies and
the populations they serve at a relative disadvantage with respect to their
opportunity to benefit from new technologies.36 With the exception of
a few large cities and counties (e.g., New York, Los Angeles County),
state public health agencies often operate public health informatics sys-
tems and provide information to local health departments as needed.
Despite this structure, there is limited understanding of differences in
states’ public health informatics infrastructure.
This discrepancy between hospital and public health agency infor-
matics capabilities is likely problematic and may be interfering with
the value of requiring that hospitals contribute data to public health
agencies. In fact, the increase in the number of hospitals capable of re-
porting (and obligated to report) data to public health agencies may
be overwhelming those agencies that have limited informatics staff and
related resources. In addition, recently reported improvements in hos-
pitals’ public health–reporting functions may actually disguise gaps in
public health agencies’ successful reporting and receipt of essential data.
To date, no studies have explored hospitals’ and public health agencies’
experiences of and obstacles to sharing these data.
Our article examines hospitals’ challenges in reporting to public
health agencies. Focusing on hospitals highlights their experience estab-
lishing electronic integration with public health agencies and indirectly
enables us to assess the agencies’ informatics capacity, as well as provide
greater insight into those barriers that have been previously explored us-
ing NACCHO data. Identifying and characterizing these challenges can
inform strategies and policies to support necessary changes. In particular,
increased understanding of existing gaps may advance the aims of PI as it
attempts to improve the public health–reporting infrastructure through
hospital-focused efforts. However, hospital-focused policies may do lit-
tle to address barriers that are in the purview of public health agencies.
As such, insight into those barriers may inform federal and state policy
recommendations for improving informatics capabilities and infrastruc-

ture specifically for public health agencies.
Conceptual Framework
The technology-organization-environment (TOE) framework provides
a useful classification schema for exploring hospitals’ challenges in
connecting their informatics infrastructure with public health agen-
cies. Proposed by Tornatzky and Fleisher, the TOE framework con-
tends that an organization’s willingness to adopt an innovation is influ-
enced by these three contextual layers—technology, organization, and
environment—which are interrelated and affect organizational decision
making.37,38
The TOE framework has been used to examine hospitals’39 adoption
of interoperable health information technology (HIT), as well as tech-
nology adoption in other industries.40 First, it describes the technology
context as capturing an organization’s broad technological capabilities be-
yond the specific innovation being studied, which in this case is public
health–reporting capability. A hospital’s technology includes its EHR
and HIE capabilities, as well as newer technologies that can contribute
to its ability to exchange data with public health agencies. For instance,
the Office of the National Coordinator on Health Information Technol-
ogy has promoted improved standardization of data exchange capabil-
ities by providing open application programming interfaces (APIs), as
well as data specification protocols such as Health Level 7 (HL7) Fast
Healthcare Interoperable Resources (FHIR).41 Open APIs can reduce the
transaction costs associated with building exchange interfaces between
members of the health care system (i.e., hospitals and public health agen-
cies). The FHIR data specifications may also enable connecting hospitals
with public health systems to be data element agnostic with a universal
approach that accommodates different reporting needs (i.e., reportable
labs, immunizations, syndromic surveillance, or specialized registries).42
The presence of this technology may affect the technology context.
Additionally, technology vendors play an important role in shaping
the technology context. On the hospital side, EHR vendors develop ap-
plications that meet MU certification requirements, including public
health reporting. Despite these criteria, public health–reporting capa-
bilities may be a relatively lower priority for an EHR vendor than other
criteria more directly focused on patient care. As a result, configuring

an interface and developing reporting capabilities with public health
agencies may be a challenge. Some EHR platforms may not capture nec-
essary data discretely or at all, and others may not use data standards or
protocols that allow automatic reporting.43 Adding to this issue, public
health databases and registries are typically developed and hosted by dif-
ferent technology vendors that may or may not receive input from EHR
vendors. The relationship among the different technology vendors thus
may have important implications for the ability of the different systems
to exchange data electronically.
Second, the organizational context captures the resources and
decision-making processes that result in innovation adoption and im-
plementation. The electronic integration between hospitals and pub-
lic health agencies involves their administrative capacity, availability of
a technically trained workforce, financial resources, and technical sup-
port needs. This layer also considers the relational dynamics of the dif-
ferent parties that support building the technology infrastructure. The
strength of these relationships can facilitate, or hinder, the successful de-
velopment of exchange mechanisms between hospitals and public health
agencies.
Third, the environmental context highlights the important and com-
plex role of policy in the organizational capabilities related to public
health reporting. The policy landscape around hospital HIT is contin-
uously changing as a necessity in order to increase the intensity of HIT
adoption and use over time, which may create uncertainty about invest-
ing in innovative technology. For instance, the MU criteria related to
public health reporting have changed four times for hospitals since the
program’s inception, most recently becoming the PI program.
The policy landscape is considerably less complex for public health
agencies owing to the lack of comprehensive policy and funding ini-
tiatives aimed at improving the agencies’ informatics infrastructure.32
In response to the COVID-19 pandemic, the recently passed Coro-
navirus Aid, Relief and Economic Security (CARES) Act allocated
$500 million to modernize the United States’ public health informat-
ics infrastructure.44 This effort helps address the gap in funding between
hospitals and public health agencies, but it does not explicitly provide an
overarching framework for public health agencies to develop a sustain-
able informatics infrastructure. While many public health–reporting
systems are maintained at the state level, there are not, for example,
clear governance rules dictating the accountability of the state and lo-
cal health departments, nor is there clarity around which federal agency
should oversee public health reporting. This lack of structure can create
questions regarding where hospitals should report data.
Methods
Data and Sample
Our study used a mixed-methods, cross-sectional design with data from
the 2017 American Hospital Association (AHA) Annual Survey, a vol-
untary survey of hospitals’ organizational characteristics. We combined
these data with the AHA Information Technology (IT) supplemental
survey data. Both the AHA Annual Survey and IT supplements are
sent, digitally, to hospitals’ leadership (e.g., chief executive officer, pres-
ident, executive director) of both AHA members and nonmembers and
requested that they be completed by the individual with the great-
est familiarity with the hospital’s characteristics. A paper version was
available, and each hospital received multiple phone calls and email re-
minders. Earlier work has demonstrated that the survey reports are both
a reliable and valid measure of hospitals’ HIT characteristics.45 More
than 90% of all US hospitals complete the annual survey, and 3,542
(56%) of the responding hospitals in 2017 also responded to the AHA
IT survey, which reports data on the HIT capabilities for each hospi-
tal. Our analytic sample included the hospitals that responded to both
surveys and were acute care, defined by CMS as “a hospital that pro-
vides inpatient medical care and other related services for surgery, acute
medical conditions or injuries,”46 nonfederally owned and operated hos-
pitals that treat nonspecialty populations (e.g., pediatric, cancer, long-
term care, psychiatric care).
Classifying Challenges With Reporting to

Public Health Agencies
We classified hospital challenges with reporting to public health agen-
cies by the type of challenge, the responsible entity, and the specific issue
(see Table 1). Specifically, the AHA IT supplemental survey asks hos-
pitals, “What are some of the challenges your hospital has experienced
Table 1. Coding Dictionary Used to Classify Challenges Reporting Data to Public Health Agencies
Level Description Verbatim Example Response

Responsible Entity
Hospital Issues in hospitals’ control or that affect hospitals Many hours of work to prepare reports and data
to meet standards; standards frequently change
Public Health Agency Issues in public health agencies’ control or that Limited resource availability with state and
affect public health agencies county officials
Vendor Issues in EHR vendor’s control Manual chart abstraction required to get quality
data
Multiple Issues whose control or effect cannot be Interface challenges
attributed to a single entity
Issue
Technology
Interface Issues related to the technological exchange HL7 interface issues with [EHR] and public
between a hospital’s EHR and a public health health agencies
a
agency
Technical Issues Issues related to data validation, technical Technical ability to submit electronically
requirements, vocabulary standards,
Strengthening Public Health Informatics Infrastructure
redundancy checking, and auditing or EHR

not collecting appropriate data for reporting
Security Lack of technical safeguards in place to ensure Security capabilities of our state do not match
security [EHR] requirements
Organization
Administrative Incorrect or missing forms or waivers; Corporate parent
information reported at the hospital-system
level
401
Continued
Table 1. (Continued)
Level Description Verbatim Example Response

402
Cost Financial barriers; lack of a value proposition that Cost and understanding of the benefits
a
supports investment in information technology
General Resources Public health agencies unable to electronically State of Nebraska not accepting any information
receive the information
Human Resources Appropriate workforce, expertise, or sufficient Dedicated resource to submit data
numbers of workers; typically related to long
waits/delays with the public health agency
No EHR No or not fully implemented EHR, not Our current EHR state does not meet MU
Meaningful Use compliant requirements; we have not been able to attest
Workflow Hospital not collecting appropriate data for Current hospital workflow sometimes does not
reporting ask the right questions of patients to capture
required data
Environment
Exemption Eligible No available registry to report to, too small to Agencies think we are too small and waive
report to public health agencies, or other factor submissions requirements
that meets Meaningful Use criteria for
exemption from public health–reporting
requirements
Reporting Onerous and cumbersome reporting requirement Understanding the specific details of the
Requirements to the state, uncertainty around Meaningful standards needed
a
Use requirements
Uncertainty Hospital not knowing to which public health Direction from public health agencies can be
agencies to send the information in order to vague and at times not useful
meet Meaningful Use requirements
a
D.M. Walker et al.
Combined with codes from the AHA IT supplement.

EHR = Electronic Health Record, HL7 = Health Level Seven, MU = Meaningful Use.
when trying to submit health information to public health agencies to

meet meaningful use requirements?” The survey allows for multiple re-
sponses, including three discrete options: “Public health agencies lack
the capacity to electronically receive the information” (i.e., general re-
sources); “We use different vocabulary standards than the public health
agency, making it difficult to exchange” (i.e., technical issue); “We do
not know to which public health agencies our hospital should send the
information to meet meaningful use requirements” (i.e., uncertainty); an
open text “other” option; and a response indicating they “have not expe-
rienced any major challenges.” The responses were used to characterize
the challenges of reporting information to public health agencies.
To improve our ability to identify challenges, we coded all verbatim
responses using deductive dominant-directed content analysis,47 em-
bracing elements of the constant comparative method. We began coding
by first applying the three broad codes suggested by the TOE frame-
work to classify the type of challenge: technology, organization, and envi-
ronment. We assigned one of these codes to each “other” response. Next,
two other subcodes emerged from the coding process: the responsible entity
and the issue. The responsible entity code attributed the specific organiza-
tion or agency that the reported challenge pertained to or was responsible
for and included the hospital, public health agency, HIT vendor, or mul-
tiple responsible entities. We coded each response with only one of the
aforementioned responsible entity codes. Organized within the broad types
of challenges, the issue codes describe the specific issue(s) that the hospi-
tal reported and include 12 different issues. We assigned each response
a single primary and multiple secondary issue codes. The coding team
consisted of one experienced coder and one junior coder (DMW and JL),
as well as a third experienced coder (VAY) to resolve any discrepancies.
We created a coding dictionary using an iterative process and reviewed
and discussed the codes throughout the entire coding procedure.
We assigned three issue codes (i.e., general resources, technical issue,
uncertainty) to the response options provided in the AHA survey. Those
hospitals that selected these choices and were missing a responsible entity
code were assigned the responsible entity code most highly correlated with
that response. Specifically, hospitals that selected the AHA IT survey
choice of “general resources” were assigned the responsible entity code of
public health agency; hospitals that selected “technical issue” were as-
signed the responsible entity code of multiple; and hospitals that selected
“uncertainty” were assigned the responsible entity code of multiple. We did
not include in our analysis those hospitals that did not select a response
to the question.
Analytic Approach
Our analysis describes the hospitals that experienced challenges report-
ing to public health agencies. We used chi-square tests to compare char-
acteristics of those hospitals that reported any challenge with those that
did not report any challenges. For our analysis, we chose those hospi-
tal characteristics showing an association with public health–reporting
capabilities in earlier literature:20 bed size (i.e., small, medium, large),
ownership type (i.e., nonfederal government, nonprofit, for profit), sys-
tem membership, teaching status, state and census division, active
health information exchange (HIE) participation, EHR status (i.e., none,
basic, comprehensive),48 and urban location. We then used two model-
ing approaches to examine the association of hospital characteristics with
reporting challenges. First, we used a multivariable logistic regression
model to determine the association of hospital characteristics, includ-
ing states but excluding census divisions, with reporting experiencing
any challenge. Based on this model, we predicted the probabilities of
reporting any challenge for each state. Second, we estimated a multino-
mial model using the four-level categorical outcome of type of challenge
(i.e., none, technology, organization, environment) associated with the
primary issue as the outcome variable and the hospital characteristics,
including census division but excluding states, as the predictors. We
calculated and reported the average marginal effects from the multino-
mial model for each of the four outcomes. Both models include standard
errors clustered at the hospital referral region (HRR) level. Finally, we
compared the frequency of occurrence of each responsible entity and issue
code.
Previous work using the earlier years of the AHA IT supplemental
survey found that AHA IT supplemental survey respondents were more
likely to be large, teaching, and urban than nonrespondents were.49 In
the 2017 survey, we found that responders were more likely to be large
and to be located in the East North Central or West North Central census
divisions (see the Appendix, Table A1). To account for these differences,
consistent with earlier work using these data, we applied inverse prob-
ability weights (IPW).50 IPW weights adjust the sample for hospital
characteristics of nonrespondents (ie, bed size, ownership type, system

membership, teaching status, and census division). All results reported
include these IPW weights. We used StataSE Version 14.2 for all the
analyses.
Results
Characteristics of Hospitals With Public
Health–Reporting Challenges
Overall, 2,794 hospitals responded to both surveys and were included in
the analytic sample. Of those hospitals, 1,696 (61%) reported experienc-
ing a challenge reporting health data to public health agencies. Table 2
compares the characteristics of hospitals that experienced a challenge
with those that did not.
Figure 1 presents for each state the estimated predicted probabil-
ities for hospitals experiencing any challenge from the multivariable
logit model, including hospital characteristics. Hospitals in Washing-
ton DC (25%), Arkansas (28%), New Mexico (32%), Missouri (33%),
and New Jersey (42%) had the lowest predicted probability of reporting
a challenge, whereas hospitals in New Hampshire (87%), North Car-
olina (86%), Utah (85%), Minnesota (85%), South Dakota (82%), and
Wyoming (82%) had the highest predicted probability of reporting a
challenge.
Table 3 gives the findings from the multinomial model examining
the association of hospital characteristics with each type of challenge.
Hospitals with either a basic or comprehensive EHR, or that participate
in an HIE, were 9% and 14%, respectively, less likely to report not expe-
riencing a challenge than were those with no EHR or not participating
in an HIE. Only census divisions significantly affected the likelihood of
reporting a technology challenge, with hospitals in the Middle Atlantic,
East North Central, East South Central, and Pacific more likely to report
a technology challenge than were hospitals in New England. For orga-
nizational challenges, teaching hospitals had a 10% lower likelihood of
reporting a challenge than nonteaching hospitals did. Conversely, hos-
pitals with a comprehensive EHR and those participating in an HIE had
a 15% and a 12% greater likelihood, respectively, of reporting an orga-
nizational challenge, than did those with no EHR or not participating
406
Table 2. Weighted 2017 Characteristics of Hospitals That Experienced Challenges When Submitting Health Information to
Public Health Agencies Compared to Those That Did Not Report Challenges
Overall No Challenges Any Challenge
Hospital Characteristic (n = 2,794) (%) (n = 1,097) (%) (n = 1,696) (%) p-value
a
Bed size <0.001
Small (<99) 2,229 (50.7) 1,270 (45.4) 959 (59.8)
Medium (100–399) 1,715 (39.0) 1,149 (41.1) 566 (35.3)
Large (>400) 454 (10.3) 375 (13.4) 79 (4.9)
Ownership 0.07
Government, nonfederal 611 (21.9) 240 (22.0) 371 (21.8)
Nonprofit 1,743 (62.4) 702 (64.5) 1,041 (61.1)
For profit 439 (15.7) 147 (13.5) 291 (17.1)
Teaching status 146 (5.2) 57 (5.2) 89 (5.2) 0.98
System member 1,862 (66.6) 733 (67.3) 1,128 (66.2) 0.56
Urban 2,107 (75.4) 807 (74.1) 1,300 (76.3) 0.21 b
Census division <0.05
New England (CT, MA, ME, NH, 165 (3.7) 112 (4.0) 53 (3.3)
RI, VT)
Middle Atlantic (NJ, NY, PA) 374 (8.5) 270 (9.7) 104 (6.5)
South Atlantic (DC, DE, FL, GA, 650 (14.8) 456 (16.3) 194 (12.1)
MD, NC, SC, VA, WV)
Continued
D.M. Walker et al.
Overall No Challenges Any Challenge

East North Central (IL, IN, MI, 685 (15.6) 461 (16.5) 224 (13.9)
OH, WI)
East South Central (AL, KY, MS, 371 (8.4) 182 (6.5) 189 (11.8)
TN)
West North Central (IA, KS, MN, 650 (14.8) 488 (17.5) 162 (10.1)
MO, ND, NE, SD)
West South Central (AR, LA, OK, 626 (14.2) 337 (12.1) 289 (18.0)
TX)
Mountain (AZ, CO, ID, MT, NM, 371 (8.4) 213 (7.6) 158 (9.8)
NV, UT, WY)
Pacific (AK, CA, HI, OR, WA) 506 (11.5) 275 (9.8) 231 (14.4)
a
b
p<0.001.
p<0.05.
EHR = Electronic Health Record; HIE = Health Information Exchange.
407
408
Table 3. Marginal Effects of Hospital Characteristics Associated With the Types of Challenges of Reporting Data to Public
Health Agencies
Technology Organization Environment
Hospital No Challenge Challenge Challenge Challenge
Characteristic
Marginal Standard Marginal Standard Marginal Standard Marginal Standard
Effect Error Effect Error Effect Error Effect Error
Bed size
Small (<99) Ref. — Ref. — Ref. — Ref. —
Medium 0.04 0.02 -0.02 0.01 -0.03 0.02 0.01 0.00
(100–399)
Large (>400) -0.04 0.03 -0.01 0.02 0.05 0.04 0.00 0.01
Ownership
Government, Ref. — Ref. — Ref. — Ref. —
nonfederal
Nonprofit 0.00 0.03 0.00 0.01 -0.01 0.03 0.00 0.01
For profit -0.08 0.04 0.00 0.02 0.08 0.04a -0.01 0.01
Teaching status 0.03 0.04 0.05 0.03 -0.10 0.04 0.01 0.01
System member 0.05 0.03 -0.02 0.01 -0.03 0.03 0.00 0.00
Urban -0.03 0.03 -0.01 0.02 0.04 0.03 0.00 0.01
EHR
None Ref. — Ref. — Ref. — Ref. —
Continued
D.M. Walker et al.
Technology Organization Environment

Hospital No Challenge Challenge Challenge Challenge
Characteristic
Marginal Standard Marginal Standard Marginal Standard Marginal Standard
Effect Error Effect Error Effect Error Effect Error
a
Basic -0.09 0.05a 0.01 0.03 0.09 0.05b -0.01 0.01
Comprehensive -0.09 0.04c -0.05 0.03 0.15 0.05c -0.01 0.01
HIE -0.14 0.03 0.02 0.01 0.12 0.03 0.00 0.00
Census Division
New England Ref. — Ref. —a Ref. —a Ref. —
Middle Atlantic 0.13 0.08 0.08 0.03 -0.20 0.08 -0.01 0.01
South Atlantic 0.02 0.07 0.04 0.02c -0.07 0.08a 0.01 0.01
East North 0.11 0.07 0.07 0.02 -0.18 0.07 -0.01 0.01
Central a
East South 0.03 0.07 0.08 0.04 -0.14 0.09 0.02 0.02
Central
West North 0.05 0.08 0.02 0.02 -0.06 0.08 -0.01 0.01
Central
West South 0.10 0.08 0.04 0.02 -0.13 0.08 -0.01 0.01
Central
Mountain -0.06 0.07 0.01 0.02a 0.06 0.07 -0.01 0.01
Pacific 0.00 0.07 0.06 0.03 -0.06 0.07 0.00 0.01
a
b
p<0.05.
c
p<0.01.
p<0.001.
409
EHR = Electronic Health Record, HIE = Health Information Exchange, Ref = Reference.
Figure 1. Predicted Probability of a Hospital Reporting Any Challenge

in 2017
Predicted probabilities adjusted for hospital characteristics.
in an HIE. In contrast to the census division’s findings for technology

challenges, hospitals in the Middle Atlantic and East North Central had
a significantly lower likelihood of reporting an organizational challenge
than did those in New England. No hospital or geographic factors were

found to be associated with environmental challenges.
Classifying Hospitals’ Public

Health–Reporting Challenges
Of those hospitals that reported experiencing challenges, 214 (13%) re-
ported a primary issue related to technology; 1,455 (86%) reported a pri-
mary organizational issue; and 26 (2%) reported a primary environmen-
tal issue (see Figure 2). The majority of technology issues (158, 74%)
were assigned to the responsible entity category of multiple entities. Of
the organizational issues, public health agencies (1,208, 83%) were the
entity most frequently responsible. Hospitals (16, 61%) were the entity
most responsible for environmental issues.
In total, 12 specific issues emerged from the analysis of the data, which
we grouped into the three broad domains of technology, organization,
and environment (see Table 1). For technology-related issues, technical
and interface issues were common in all responsible entities. These is-
sues often overlapped between primary and secondary issues, as many
of the technical issues were related to interface challenges of exchange
between entities. This overlap also increased the number of technology-
related responses categorized as affecting multiple entities, because the
data exchange relies on the connection between a hospital and a public
health agency, and responsibility could not always be attributed to a sin-
gle entity. For instance, several hospitals used the single-word response
“interface.” Many of the interfacing and technical issues, however, could
be attributed to vendors, as often it was stated that the vendor did not
support the data collection (e.g., “We must create custom interfaces to
extract from Meditech and place in required format”) or submission (eg,
“EHR vendor still developing tools”).
Of those hospitals reporting organizational issues, 1,117 (77%) re-
ported challenges related to the public health agency’s (i.e., responsible
entity) general resources (i.e., issue). This issue typically concerned a
public health agency that did not have the technology to accept or sup-
port electronic exchange, for example, “state of Nebraska not accepting
any information.” Organizational issues also often included workforce-
related challenges for both hospitals and public health agencies. Hospi-
tals noted that both they and the public health agencies lacked trained
D.M. Walker et al.
Figure 2. Hospital Challenges in Reporting to Public Health Agencies
Figure includes a break in the Number of Hospitals axis for General

Resources because of the large discrepancy between this and other chal-
Rep. Req’s = Reporting Requirements.

for Each Responsible Entity
lenges.
412
workers (e.g., “limited skilled IT resources”; “[public] health agencies

do not have the staff to implement on their systems”). These limita-
tions were often noted as resulting in delays related to interface testing,
onboarding, and data validation. The cost of the technology (e.g., “ven-
dor charges associated with interfacing/exchanging information costly”)
was also commonly noted as a barrier for hospitals. Cost was used in
context with the hospitals’ unclear benefits and lack of data from the
public health agencies (e.g., “charged $15,000 a year to submit data; we
get nothing back from them; interface costs us an additional $12,000 a
year”).
In the environmental domain, MU reporting requirements were an
issue for each of the responsible entities, although the specific ques-
tions about reporting requirements differed. For instance, the hospitals’
concerns were often related to federal policy requirements (e.g., “confu-
sion between MU and MIPS [Merit-based Incentive Payment System]”),
whereas issues attributed to public health agencies often pertained to
their state’s technical requirements (e.g., “California Cancer Registry
posted a specification but their system does not conform”).
Discussion
Fueled by MU incentives, hospitals have significantly improved their
HIT capabilities over the past decade. However, our findings indicate
that in reporting to public health agencies, most hospitals continue to
face barriers that encompass technology, organizational, and environ-
mental contexts.
Perhaps counterintuitively, we found that hospitals with more ad-
vanced EHRs and HIE were both more likely to report experiencing
a challenge and more likely to report organizational challenges around
exchanging data with public health agencies. To some extent, this find-
ing may be because hospitals with less HIT capacity are not engag-
ing in active exchange and therefore not experiencing any noticeable
challenges.51 In addition, hospitals with more advanced HIT may have
greater technological capabilities than those of public health agencies
and may use data protocols and/or standards and security rules that sur-
pass public health agencies’ resource capacity to accommodate.52,53 For
instance, data from the 2015 Informatics Capacity and Needs Assess-
ment Survey of local public health agencies showed that only 39% of
these agencies were able to receive information electronically from a

hospital.53 Local public health agencies reported that interoperable tech-
nology was expensive, that they had concerns about inconsistent data
standards, and that they had limited IT staff to support implementa-
tion and use.54 Conversely, hospitals with advanced interoperable HIT
may be in a better position to exchange data in narrow private networks
rather than with public health agencies.55
Our findings reinforce the need for public health agencies to develop
technological capacities and their associated workforces.4,27,56,57 Chal-
lenges related to public health agencies’ limited resources to support
technology were by the far the most prevalent barrier that hospitals cited
as causing issues with electronic integration. Developing policy pro-
grams that promote improvements in public health agencies’ resources
for technology would likely have a positive impact and help mitigate
this challenge. Public health agencies’ funding, however, is often scarce
and is also stretched across many programs. Furthermore, public health
funding rarely affords the flexibility to use it to support infrastructure;
instead, it is often tied to specific health issues or programs (i.e., “cat-
egorical funding”) with limits on how it can be used. A report by the
Institute of Medicine in 2012, “For the Public’s Health: Investing in a
Healthier Future,” called for greater flexibility in public health funding.
Nonetheless, a recent review suggests that the funding environment has
not changed substantially since then.58–60
Our findings that both hospitals and public health agencies do not
have enough staff with technical expertise is cause for concern about
how to address this capability across sectors. The Health Information
Technology for Economic and Clinical Health (HITECH) Act that orig-
inally funded the MU program included funds for technical training and
skills development.61 Continuation or new informatics training or ad-
ditions to existing public health degree programs may be useful policy
approaches to strengthen the public health informatics infrastructure.
Alternatives are innovative approaches using online forums and build-
ing communities of practice, as these have been shown to be low-cost,
high-value approaches to facilitating learning and improving technical
skills.62
Our results also underscore the important role of technology vendors
in promoting and making connections between hospitals and public
health agencies, as EHR vendors were often noted as contributing to the
challenges. This finding is consistent with earlier work finding great
variability in EHR vendors’ and hospitals’ MU success.43 Nonetheless,

EHR vendors’ technology expertise may position them to act as guides
for hospitals trying to interface their EHRs with public health agency
registries as well as addressing other PI public health–reporting chal-
lenges. Given our findings regarding hospital EHRs’ and public health
agencies’ interface issues, EHR vendors could seek out new business op-
portunities to develop, or partner with developers of, public health infor-
matics infrastructure. Entering this market would not only help alleviate
technical challenges but also would provide an incentive for vendors to
work with public health agencies to support the development of a public
health informatics infrastructure.
While the TOE framework provided a useful starting place to orga-
nize the challenges reported by hospitals in reporting to public health
agencies, we found that it often siloed issues that overlapped layers. For
instance, cost was categorized as an organizational issue, yet it directly
extended from policy issues in the environment. Likewise, many techni-
cal issues, which were categorized as technology issues, included organi-
zational aspects, such as choices about data standards or EHR vendors.
In that case, technology issues could be resolved by addressing organiza-
tional issues. The TOE framework does not, in its current form, capture
the reciprocal relationships housed between layers and thus may not be
best for the cross-sectoral dynamics of health care. Accordingly, it is im-
portant to consider refining this framework to be inclusive of issues that
crosscut the technology, organization, and environmental layers.
Prioritizing Interoperability in Policy

CMS just released its proposed hospital payment rule, which includes the
scoring methodology for 2021 PI incentives.63 Notably, public health
reporting comprises only 10% of the full score, and hospitals need to
report to only two of the following: syndromic surveillance, immuniza-
tion registries, electronic lab results, public health registries, electronic
case notices, or another specialized registry. This approach may have
been appropriate in earlier years to advance interoperable HIT, but the
COVID-19 pandemic has showed us the importance of reporting to all
these registries, as well as the complications resulting from siloed sys-
tems and the absence of a coordinated reporting system. The financial in-
centives available through PI are a highly influential policy mechanism
and could guide the prioritization for hospitals, public health agencies,
and vendors alike. Without a coordinated mechanism for reporting data
to public health agencies, increasing both the percentage of the PI score
attributable to public health reporting and the reporting requirements
may accelerate improvement in public health reporting and prepared-
ness for future pandemics.
The challenges we documented in this study require that public
health have substantial and consistent infrastructure funding to support
the development of a coordinated, real-time, electronic system for re-
ceiving crucial health data from hospitals. Funding from the CARES
Act is significant and will contribute to needed improvements, yet a
one-time infusion of funding may be insufficient to sustain the develop-
ment of a coordinated public health informatics infrastructure. Consis-
tent investment in public health informatics infrastructure, combined
with workforce development, will help advance the reporting and use
of public health data. Our findings help to provide benchmarks to as-
sess progress attributable to the investment of the CARES Act funds.
Beyond the CARES Act, public health informatics may seek out syner-
gies with accountable health communities to create a sustainable model
for public health informatics.10 These communities, sponsored by CMS,
seek to align health and social services sectors and leverage complemen-
tary resources offered by cross-sector agencies and organizations.13 Pub-
lic health informatics can help support these efforts, and working with
community agencies can help identify new partnership opportunities
that may be able to help secure needed resources.
Limitations
Our study’s findings should be interpreted with a few key limitations in
mind. First, our study has a limited ability to detect changes in technol-
ogy adoption rates over time. Earlier years of the AHA IT supplemental
survey asked hospitals whether they “currently have an electronic system
that allows” them to electronically report to immunization registries,
electronic laboratory submissions, syndromic surveillance, or specialized
registries. However, these questions were dropped from the 2017 survey,
making it difficult to compare adoption rates across time. Removing
these questions also limited our ability to evaluate the potential selec-
tion bias, in which hospitals that do not report to public health agencies
are less likely to report challenges.
A second limitation is that our perspectives on challenges do not in-

clude perspectives from public health agencies. Although important, to
our knowledge, no data source now provides this information. Data from
the Association of State and Territorial Health Officials (ASTHO), in ad-
dition to local health department data from NACCHO, describe issues
related to informatics infrastructure, but no survey questions explicitly
ask about the problems of integrating data with hospitals. The Informat-
ics Capacity Needs Assessment Survey conducted by NACCHO in 2015
provided valuable insight,64 but more recent data are needed to assess
the trajectory of public health agency informatics needs. Even though
our study is indirect, it provides greater granularity and more timely
data than either of these surveys, but more work is needed to gather the
public health agency perspective on these challenges.
Third, some of the open-text responses in the AHA IT supplement
have few details. Further investigation and the collection of richer con-
textual data from both hospitals and public health agencies would im-
prove clarity regarding their electronic integration.
Fourth, our study is limited in scope regarding state-level differences.
While we observed substantial geographic variation in hospitals’ pub-
lic health–reporting challenges across states, we did not assess state-
level factors that contributed to these differences, such as geographic
size, population density, public health spending, socioeconomic envi-
ronment, and policy programs. Adding to the complexity of understand-
ing state variation is a lack of consistency regarding the governance and
reporting structures of state and local health department jurisdictions.
For instance, in Columbus, Ohio, reportable labs and syndromic surveil-
lance are reported to the “local health agency”—which can be either the
Columbus Public Health Department if the individual resides within
the Columbus city limits, or the Franklin County Public Health De-
partment if the individual resides within Franklin County but outside
the city of Columbus. In either case, the local public health agency would
then report to the state-level Ohio Department of Health. But immu-
nization registries are hosted only at the state level. Neither ASTHO or
NACCHO collects data on the jurisdictional oversight of public health–
reporting systems, which can vary significantly across states. Under-
standing public health–reporting system governance will further help
to develop targeted and state-specific policies to improve reporting ca-
pabilities.
Conclusions
To continue to advance hospitals’ public health–reporting capabilities,
a better understanding of the specific barriers that hospitals and pub-
lic health agencies face is essential. The lack of data sharing between
hospitals and public health agencies means delays in response and lost
opportunities to intervene in contact tracing, which is one of the integral
components of a successful response for the current pandemic. COVID-
19 has shone a bright light on the consequences of waiting for a pan-
demic to expedite the integration of a siloed reporting infrastructure.
The challenges documented in this study serve as a baseline for assess-
ing progress toward interoperability and improved reporting. Perhaps
most important is that the majority of challenges reported by hospitals
were attributed to the public health agencies’ general resources. We need
to support public health agencies and bring their surveillance systems
up to speed so that interoperability can occur between those caring for
and those protecting the population.
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Funding/Support: None.
Conflict of Interest Disclosures: All authors completed the ICMJE Form for Dis-
closure of Potential Conflicts of Interest. No conflicts were reported.
Address correspondence to: Daniel M. Walker, Department of Family and

Community Medicine, College of Medicine, The Ohio State University,
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Daniel.Walker@osumc.edu).
Appendix
424
Table A1. Comparison Between Respondents and Nonrespondents of the 2017 American Hospital Association
(AHA) Information Technology (IT) Supplement
AHA IT AHA IT
Total Responders Nonresponders
a
Bed size <0.001
Small (<99) 2,229 (50.7) 1,270 (45.4) 959 (59.8)
Medium (100–399) 1,715 (39.0) 1,149 (41.1) 566 (35.3)
Large (>400) 454 (10.3) 375 (13.4) 79 (4.9)
Ownership 0.07
Government, nonfederal 611 (21.9) 240 (22.0) 371 (21.8)
Nonprofit 1,743 (62.4) 702 (64.5) 1,041 (61.1)
For profit 439 (15.7) 147 (13.5) 291 (17.1)
Teaching status 146 (5.2) 57 (5.2) 89 (5.2) 0.98
System member 1,862 (66.6) 733 (67.3) 1,128 (66.2) 0.56
Urban 2,107 (75.4) 807 (74.1) 1,300 (76.3) 0.21 b
Census division <0.05
New England (CT, MA, ME, 165 (3.7) 112 (4.0) 53 (3.3)
NH, RI, VT)
Middle Atlantic (NJ, NY, PA) 374 (8.5) 270 (9.7) 104 (6.5)
South Atlantic (DC, DE, FL, GA, 650 (14.8) 456 (16.3) 194 (12.1)
MD, NC, SC, VA, WV)
Continued
D.M. Walker et al.
Table A1. (Continued)
AHA IT AHA IT
Total Responders Nonresponders
East North Central (IL, IN, MI, 685 (15.6) 461 (16.5) 224 (13.9)
OH, WI)
East South Central (AL, KY, MS, 371 (8.4) 182 (6.5) 189 (11.8)
TN)
West North Central (IA, KS, 650 (14.8) 488 (17.5) 162 (10.1)
MN, MO, ND, NE, SD)
West South Central (AR, LA, 626 (14.2) 337 (12.1) 289 (18.0)
OK, TX)
Mountain (AZ, CO, ID, MT, 371 (8.4) 213 (7.6) 158 (9.8)
NM, NV, UT, WY)

Pacific (AK, CA, HI, OR, WA) 506 (11.5) 275 (9.8) 231 (14.4)
a
b
p<0.001
p<0.05.
EHR = Electronic Health Record, HIE = Health Information Exchange.
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Original Scholarship

Identifying Opportunities to Strengthen the

Context: The novel coronavirus 2019 (COVID-19) pandemic has highlighted

current pandemic as well as ongoing public health activities and population

Health care providers, and particularly hospitals, have an important

Promoting Interoperability (PI) program. Public health reporting is one

interoperable data exchange.33 Both local and state health departments

recommendations for improving informatics capabilities and infrastruc-

criteria more directly focused on patient care. As a result, configuring

Classifying Challenges With Reporting to

Level Description Verbatim Example Response

redundancy checking, and auditing or EHR

Level Description Verbatim Example Response

Combined with codes from the AHA IT supplement.

when trying to submit health information to public health agencies to

characteristics of nonrespondents (ie, bed size, ownership type, system

Overall No Challenges Any Challenge

Technology Organization Environment

Figure 1. Predicted Probability of a Hospital Reporting Any Challenge

Predicted probabilities adjusted for hospital characteristics.

in an HIE. In contrast to the census division’s findings for technology

than did those in New England. No hospital or geographic factors were

Classifying Hospitals’ Public

Figure 2. Hospital Challenges in Reporting to Public Health Agencies

Figure includes a break in the Number of Hospitals axis for General

Rep. Req’s = Reporting Requirements.

workers (e.g., “limited skilled IT resources”; “[public] health agencies

these agencies were able to receive information electronically from a

variability in EHR vendors’ and hospitals’ MU success.43 Nonetheless,

Prioritizing Interoperability in Policy

A second limitation is that our perspectives on challenges do not in-

7. McClellan M, Gottlieb S, Mostashari F, Rivers C, Silvis L. A na-

30. Lenert L, Sundwall DN. Public health surveillance and meaning-

44. American Public Health Association. APHA applauds passage

56. Miller C, Ishikawa C, DeLeon M, Huang M, Ising A, Bakota E.

Address correspondence to: Daniel M. Walker, Department of Family and

NM, NV, UT, WY)

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