Population Health Informatics (Ebook

PDF)
Visit to download the full and correct content document:
https://ebookmass.com/product/population-health-informatics-ebook-pdf/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Population Health 2nd Edition, (Ebook PDF)

https://ebookmass.com/product/population-health-2nd-edition-
ebook-pdf/

Public Health Informatics and Information Systems 2nd

Edition, (Ebook PDF)

https://ebookmass.com/product/public-health-informatics-and-
information-systems-2nd-edition-ebook-pdf/

Health Informatics: An Interprofessional Approach 2nd

Edition

https://ebookmass.com/product/health-informatics-an-
interprofessional-approach-2nd-edition/

Population and Community Health Nursing (6th Edition –

Ebook PDF Version) 6th Edition – Ebook PDF Version

https://ebookmass.com/product/population-and-community-health-
nursing-6th-edition-ebook-pdf-version-6th-edition-ebook-pdf-
version/
Population-Based Public Health Clinical Manual: The
Henry Street Model for – Ebook PDF Version

https://ebookmass.com/product/population-based-public-health-
clinical-manual-the-henry-street-model-for-ebook-pdf-version/

Foundations for Population Health in Community/Public

Health Nursing 6th Edition Marcia Stanhope

https://ebookmass.com/product/foundations-for-population-health-
in-community-public-health-nursing-6th-edition-marcia-stanhope/

Informatics and Nursing 6th Edition, (Ebook PDF)

https://ebookmass.com/product/informatics-and-nursing-6th-
edition-ebook-pdf/

Population Based Public Health Clinical Manual, Third

Edition: The Henry Street Model for Nurses (Ebook PDF)

https://ebookmass.com/product/population-based-public-health-
clinical-manual-third-edition-the-henry-street-model-for-nurses-
ebook-pdf/

Health Professions and Academia-How to Begin Your

Career (Jun 29, 2022)_(3030942228)_(Springer).pdf John
Paul (J.P) Sánchez

https://ebookmass.com/product/health-professions-and-academia-
how-to-begin-your-career-jun-29-2022_3030942228_springer-pdf-
john-paul-j-p-sanchez/
Design Credits: Place header image credit here.

© VLADGRIN/Shutterstock

Foreword
I
n the past two decades, informatics as a terminology has been widely dis­sem­
i­nated. Within the health sciences context, medical informatics and bioinfor-
matics have played an important role in advancing the health services domain
as well as in ­discovering biological associations and informing new treatment
­discoveries. ­Population health informatics is a newer emerging science that prom-
ises to ­influence global health dynamics in a unique and significant way. This
text ­elucidates the ­underpinnings of this terminology, and explains its unique
­parameters and singularly effective applications both from descriptive and inter-
ventional dimensions. The readership of this text will gain new insights and will
be able to use newly acquired knowledge in both theoretical and applied context.
Knowledge gained through this text will inform large data users, health scientists
and researchers, health ­administrators, and policymakers, as well as economists and
modelers. Many of the challenges associated with population health informatics
relate to difficulties in assembling data, combining data sources, identifying inno-
vative approaches to data analysis, and finally, extracting the most relevant and per-
tinent information toward predicting and resolving emergent and prevalent health
problems. Many of these challenges are addressed and demystified in this text, in a
way that is accessible to students, researchers, and practitioners in the field.

Ayman El-Mohandes, MD, MBBCh, MPH

Dean, The City University of New York
Graduate School of Public Health and Health Policy
New York, New York

vii
 Design Credits: Place header image credit here.

© VLADGRIN/Shutterstock

Acknowledgments
T
his book would not have been possible without the wholehearted support
and ­participation of several individuals. First, we would like to thank the
Dean of the CUNY Graduate School of Public Health and Health Policy,
Dr. Ayman El-Mohandes, for his motivation and invaluable support and commit-
ment to helping us bring this book to its completion.
We would also like to thank Chioma Amadi, Research Associate and a doc-
toral student of Epidemiology of CUNY Graduate School of Public Health and
Health Policy, for her valuable assistance in writing a chapter and reviewing the
content of the book. Further, we would like to thank Princy Bhardwaj, MPH,
Environmental and Occupational Health Sciences, and Rinzin Wangmo, MPH,
Health Policy and Management, who provided assistance in reviewing the references­
included in the book and gave us valuable insight about their level of understanding
of the content of the book.
In addition, we acknowledge the extraordinary competence of our Executive
Editor, Michael Brown, and Associate Editor, Danielle Bessette, at Jones & ­Bartlett
Learning, who guided us through the publication stages and provided valuable
advice. Our Senior Production Editor, Amanda C ­ lerkin, and her colleagues adeptly
dealt with a number of challenges to make this book look better than it would have
otherwise.
Finally, we would also like to acknowledge the chapter contributors who
played a very significant role in making this book possible. Despite their hectic
work ­commitments, they shared their expertise by writing the chapters, responding
to inquiries, and modifying the draft chapters as suggested. We are very thankful
to these esteemed contributors who come from various areas of population health
­informatics.

viii
Design Credits: Place header image credit here.

© VLADGRIN/Shutterstock

Contributors
Chioma Amadi, MPH Hadi Kharrazi, MD, PhD
Research Associate, Doctoral Student Research Director
in Epidemiology Center for Population Health IT
CUNY Graduate School of Public Johns Hopkins Bloomberg School of
Health and Health Policy Public Health
New York, New York Baltimore, Maryland
Luk Arbuckle, BSc, MSc Harold P. Lehmann, MD, PhD
Research Manager Associate Professor
Children’s Hospital of Eastern Johns Hopkins Bloomberg School of
Ontario Research Institute Public Health
Ottawa, Ontario, Canada Baltimore, Maryland
Ann Cavoukian, PhD Edward Mensah, PhD
Executive Director Associate Professor
Privacy and Big Data Institute, Health Policy and Administration,
Ryerson University School of Public Health
Toronto, Ontario, Canada University of Illinois at Chicago
Chicago, Illinois
Michelle Chibba, MA
Strategic Privacy/Policy Advisor Katharine H. McVeigh, PhD, MPH
Privacy and Big Data Institute, Director of Research
Ryerson University Division of Family and Child Health,
Toronto, Ontario, Canada NYC Department of Health and
Mental Hygiene
Brian E. Dixon, PhD, MPA, FIMMS
Queens, New York
Associate Professor
Richard M. Fairbanks School of Saurabh Rahurkar, BDS, DrPH
Public Health Researcher Postdoctoral Public Health Informatics
Center for Biomedical Informatics, Fellow
Regenstrief Institute Center for Biomedical Informatics,
Indianapolis, Indiana Regenstrief Institute
Indianapolis, Indiana
Khaled El Emam, PhD
Professor
Department of Pediatrics, Faculty of
Medicine, University of Ottawa
Ottawa, Ontario, Canada

ix
 Design Credits: Place header image credit here.

© VLADGRIN/Shutterstock

About the Editors

Ashish Joshi, PhD, MBBS, MPH
Associate Dean and Associate Professor
CUNY Graduate School of Public Health and Health Policy and the CUNY Institute
for Implementation Science in Population Health
Ashish Joshi is an Associate Dean of the CUNY Graduate School of Public Health
and Health Policy and an Associate Professor at CUNY Institute for Implemen-
tation Science in Population Health. Dr. Joshi’s combined training in medicine,
public health, and informatics provides a unique combination to utilize innovative
­technology-enabled interventions at the intersection of clinical care and popula-
tion health. Dr. Joshi’s journey has been that of an academician, applied researcher,
­administrator, innovator, and entrepreneur to implement sustainable, multi-­sector,
accessible, affordable, reimbursable, and tailored (SMAART) t­ echnology solutions
to address the population health challenges of the 21st century. His research ­interest
focuses on the design, development, implementation, and evaluation of contex-
tually relevant informatics interventions to enhance population health outcomes.
Dr. Joshi utilizes the principles of social cognitive theory, human-­centered design,
and ­information processing theory to develop culturally relevant health tech-
nology solutions that can be adapted to different settings, audiences, and health
conditions. Dr. Joshi has done several population health informatics ­projects in
various countries including the United States, Nigeria, India, Brazil, and Haiti. His
research ­related to mobile and Internet-enabled interventions, population-based
surveillance, consumer health informatics, and health dashboards has been widely
funded by several ­national and international agencies.
Lorna Thorpe, PhD, MPH
Professor and Director of Epidemiology
NYU School of Medicine, Department of Population Health
Lorna Thorpe is Professor of Epidemiology and Director of the Epidemiology
­Division at the NYU School of Medicine in the Department of Population Health.
Her current research focuses on improving modern forms of public health surveil-
lance, as well as the intersection between epidemiology and policy, mostly with re-
spect to chronic disease prevention and management. Dr. Thorpe is on the Board
of Directors for the American College of Epidemiology, has served on Institute of
Medicine committees, and has been an advisor to the Centers for Disease Control
and Prevention (CDC) on population health surveillance issues. Prior to joining
academia, Dr. Thorpe spent 8 years at the New York City Department of Health
and Mental Hygiene, serving as Deputy Commissioner of Epidemiology for much
of that time. Dr. Thorpe began her applied research career as a CDC ­Epidemic
Intelligence Service Officer in international tuberculosis control. Dr. Thorpe

x
 About the Editors xi

c­ ompleted her PhD in epidemiology at the University of Illinois at Chicago, her

MPH at University of Michigan, and her BA at Johns Hopkins University. She has
lived and worked in Asia (China, Indonesia) and published widely on both chronic
and infectious disease topics.
Levi Waldron, PhD, MSS
Assistant Professor
CUNY Graduate School of Public Health and Health Policy and the CUNY Institute
for Implementation Science in Population Health
Levi Waldron completed his education at the University of British Columbia (BSc),
University of Waterloo (MSS), and University of Toronto (PhD). After doing post-
docs at the Ontario Cancer Institute and Harvard School of Public Health, he
took a faculty position in biostatistics at CUNY. He is a technical advisor to the
­Bioconductor open-source project for computational biology, and was a Fulbright
scholar to Italy where he taught applied statistics for high-throughput biology. He
continues to pursue interests in high-dimensional data analysis, particularly the
development of databases and methods for integrating genomics data into cancer
and microbiome research.
 Design Credits: Place header image credit here.

© VLADGRIN/Shutterstock

Introduction
T
he rapid growth in digital data due to the increased usage of mobile phones
and wearable sensors has created an urgent need to develop new, innovative
tools and technologies that can make data meaningful. Population health
­informatics is an emerging field that aims to utilize technology to put into practice
evidence-based solutions to improve population health outcomes across diverse set-
tings. The goal of this book is to present a practical, step-by-step approach on how
to implement evidence-based, data-driven informatics solutions to enhance popu-
lation health. We aim to engage students and professionals across various disciplines
who are interested in using technology as a medium to reduce health disparities
and improve healthcare access and delivery in diverse settings.
The book is broadly divided into four parts:
Part 1: Overview of Population Health Informatics
Part 2: Setting the Stage for Population Health Informatics
Part 3: Specialized Population Health Informatics Applications
Part 4: Other Population Health Informatics Topical Areas
Part 1 begins by describing the need for population health informatics
(­ Chapter 1) and then discusses the workforce’s needs, competencies, and the various
training programs (Chapter 2). Part 2 discusses differences among data, information,
and knowledge (Chapter 3); health information exchange and related interopera-
bility (Chapter 4); informatics-enabled population health surveillance (Chapter 5);
statistical issues (Chapter 6); and opportunities and challenges related to big data
due to the rapid increase in data volume, velocity, and variety (Chapter 7). Chapter 7
also examines the role of cloud computing and population health visual analytics
to facilitate population health data storage, data analysis, and data visualization in
a meaningful format. Part 3 describes the specialized population health informat-
ics applications such as design, development, and system evaluation (Chapter 8);
electronic health records and telehealth applications (Chapter 9); personal health
records (Chapter 10); and the opportunities, challenges, and applications related to
mobile health interventions (Chapter 11). Lastly, Part 4 discusses other key popu-
lation health informatics topics related to the economic value of informatics appli-
cations in population health (Chapter 12); issues related to privacy, confidentiality,
security, and ethics (Chapter 13); and the role of innovations and sustainability in
population health technologies (Chapter 14).

xii
 Introduction xiii

We hope that the information and resources provided in this textbook help
readers to better understand the utilization of information and communication
technology–enabled interventions and innovations in the United States and beyond.
The book fulfills a key component of the new Association of Schools and Programs
of Public Health recommendations for “Critical Components for the Core of a 21st
Century MPH Degree.” The book also equips a new generation of the workforce
with the expertise necessary to make data meaningful and to design, develop, and
evaluate accessible and affordable technology-enabled solutions to effectively
address the population health challenges of the 21st century.

Ashish Joshi, PhD, MBBS, MPH

Lorna Thorpe, PhD, MPH
Levi Waldron, PhD, MSS
 PART 1
Overview of
Population Health
Informatics

CHAPTER 1 Emerging Need for Population Health

Informatics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
CHAPTER 2 Population Health Informatics Workforce,
Competencies, and Training Programs . . . . . 31
© VLADGRIN/Shutterstock

1
 © VLADGRIN/Shutterstock

CHAPTER 1
Emerging Need for
Population Health
Informatics
Ashish Joshi

KEY TERMS
Affordable Care Act (ACA)
American Recovery and Reinvestment Act
of 2009 (ARRA)
Cognitive fit theory
Electronic health records (EHRs)
Geographic information systems (GISs)
Health information technology
Population health
Population health informatics (PopHI)
Public health informatics (PHI)
Social determinants of health

LEARNING OBJECTIVES
■■ Describe the growth of the Internet and social media in the 21st century.
■■ Define population health and its determinants.
■■ Distinguish between population and public health informatics.
■■ Assess the importance of social determinants of health data.
■■ Examine the intersection of technology and health care.
■■ List the challenges and opportunities related to population health
informatics solutions.
■■ List the factors to consider in the adoption and implementation of
population health informatics solutions.

3
4 Chapter 1 Emerging Need for Population Health Informatics

QUESTIONS FOR THOUGHT

■■ What is the significance of social determinants of health to enhance
population health outcomes?
■■ What opportunities does the growing usage of the Internet, mobile media,
and social media have on health?
■■ How can stakeholders and consumers address the challenges related to
implementation of population health informatics solutions in diverse settings?
■■ What opportunities do population health informatics solutions provide to
improve population health outcomes?

CHAPTER OUTLINE
I. Population Health and Its Determinants
II. The Growth of the Internet and Social Media
III. The Intersection of ICTs and Health Care
IV. The Emerging Role of Population Health Informatics
V. Challenges and Opportunities Related to PopHI
VI. Adoption of PopHI Solutions
VII. SMAART: An Innovative PopHI Conceptual Framework
VIII. Conclusion

▸▸ I. Population Health and Its Determinants

D
rivers of health outside the traditional medical care include social,
behavioral, and environmental determinants and need to be addressed
to improve health and diminish health disparities. The section below
­highlights the s­ ignificance of these factors in the improvement of population
health outcomes.

Defining Population Health

Population health describes the health needs of a defined group’s entire life span
(Evans, Barer, & Marmor, 1994). Population health is a linking thread to help under-
stand the determinants of health of populations (Evans et al., 1994). Social, ­economic,
and physical environments; personal health practices; individual capacity; and ­coping
skills all influence health status indicators. In turn, the health status indicators ­measure
population health (Kindig & Stoddart, 2003). Population health is also considered as
a summary measure that includes mortality and health-related quality of life (Field &
Gold, 1998) (TABLE 1.1).
Public health services are typically provided by government agencies and
include the core public health functions of health assessment, assurance, and policy
setting. Several differences exist among the various aspects of Population health and
public health, as shown here. Population health
 I. Population Health and Its Determinants 5

TABLE 1.1 Overview of the Definitions of Population Health

Definition of Population Health Source

Exploring reasons about some Young, T. K. (2005). Population health:

populations being healthier than others Concepts and methods. New York, NY:
Oxford University Press.

Improve health and reduce health Health Canada. (1998). Taking action
inequalities of diverse populations on population health. Ottawa, Ontario:
Health Canada.

Paradigm for understanding why Young, T. K. (1998). Population health:

some populations have better health Concepts and methods. New York, NY:
outcomes than others Oxford University Press.

Focuses on factors that influence the
health of populations over the life course,
variations in their patterns of occurrence
resulting in actions, and policies to improve
health and well-being of populations
Dunn, J. R., & Hayes, M. V. (1999). Toward
a lexicon of population health. Canadian
Journal of Public Health, 90, S7.

Highlight[s the] role of social and Kreuter, M., & Lezin, N. (2001). Improving
economic forces in combination with everyone’s quality of life: A primer on
biological and environmental factors that population health. Atlanta, GA: Group
shape the health of entire populations Health Community Foundation.

Health outcomes of a group of Kindig, D., & Stoddart, G. (2003). What is

individuals, including the distribution of population health? American Journal of
such outcomes within the group Public Health, 93(3), 380–383.

Improve[s] the health of populations Berwick, D. M., Nolan, T. W., & Whittington, J.
as one element in the Institute for (2008). The triple aim: Care, health, and
Healthcare Improvement’s (IHI) Triple Aim cost. Health Affairs, 27(3), 759–769.

Approach that fosters decision making
by policymakers, allowing them to assess
the implications of non-health-related
policies
Bostic, R. W., Thornton, R. L., Rudd, E. C., &
Sternthal, M. J. (2012). Health in all
policies: The role of the US Department
of Housing and Urban Development and
present and future challenges. Health
Affairs, 31(9), 2130–2137.

■■ Is less associated with health departments at the government level (Stoto, 2013)
■■ Includes the healthcare delivery system and is seen as separate from govern-
mental public health (Stoto, 2013)
■■ Is more than the sum of its individual parts (Stoto, 2013)
■■ Includes a broader array of the determinants of health than is typical in public
health (Stiefel & Nolan, 2012)
■■ Has outcomes that go beyond state and local public health agencies and health-
care delivery systems (Ayana, 2016)
6 Chapter 1 Emerging Need for Population Health Informatics

Expand primary Promoting community Provide specific

healthcare training and population-based preventive services
activities

Improve access to
Expand insurance
coverage
Population Health healthcare delivery
system

Enhance prevention Incentives for

Improve quality of
and health promotion workplace wellness
care delivered
measures programs

FIGURE 1.1 The Affordable Care Act

Data from Affordable Care Act. (2011). Federal Sentencing Reporter, 23(3).

The Affordable Care Act (ACA) addresses population health in several ways
(ACA, 2011; see FIGURE 1.1). The ACA defined the affordable care organization
(ACO), which includes clinicians, hospitals, and other healthcare organizations. They
share mutual responsibility for the population of patients with the goal of improv-
ing health outcomes and reducing health costs and inefficiencies. A critical change
is required by key stakeholders at the cultural, operational, and financial levels to
improve population health. Collaboration among a variety of stakeholders (patients,
providers, health plans, employers, government, the private sector, and the local
community) is a vital component of the population health approach to strengthen
care delivery and improve the well-being of individuals and families.

Determinants of Population Health

Multiple determinants, including educational, social, behavioral, and ­environmental
factors, influence population health outcomes (Kindig & Stoddart, 2003; see ­FIGURE 1.2).
Improving population health requires partners across many sectors including public
health, healthcare organizations, community organizations, and businesses (Drum-
mond & Stoddart, 1995). Population health data help organizations to do the following
­(Parrish, 2010):
■■ Identify at-risk populations
■■ Close communication gaps among individuals, public health agencies, and
clinical care
■■ Identify cost-effective healthcare delivery models
■■ Provide access to available public health programs and services
■■ Improve population health decision making
Health and health problems result from a complex interplay of factors. Social
determinants play a key role in the health of each individual. Social determinants
of health have gained importance in recent health policy discussions. Existing liter-
ature has specified the importance of the social determinants of health in improving
the health of populations. Education level, employment, income, family and social
support, and community safety are all components of the social and economic deter-
minants of health (County of Los Angeles Public Health, 2013). Unhealthy behaviors
 I. Population Health and Its Determinants 7

Social and economic

factors (education,
transportation,
poverty, income)
Quality of life

Environmental Multiple
factors (built stakeholders
Cultural context
environment, housing)

Multi-sector
Health behaviors Mortality and
collaborations
(diet, physical life expectancy
activity, smoking)

Technology Continuous
Healthcare services monitoring
(access, quality, and evaluation
and cost) Overall
well-being
Biology and genetics Programs and policies
(age, gender, family
Interventions
history, disease status) Outcomes
Innovations
assessment

FIGURE 1.2 Determinants of population health

Modified Parrish, R. G. 2010. Measuring population health outcomes. Preventing Chronic Disease,7(4): A71. Retrieved from http://www.cdc.gov/pcd/issues/2010
/jul/10_0005.htm

are commonly associated with the lower social and economic position of a popu-
lation or community. Poor education, lack of affordable housing, and insufficient
income affect not just the individuals and families who have fewer resources, but also
all the communities in which they live. Researchers estimate that access to quality
medical care may prevent less than 20% of avoidable deaths. The remaining 80%
of avoidable deaths are attributable to genetics (20%), and social, behavioral, and
environmental determinants of health (60%; Taylor et al., 2016). Improvements in
healthcare resources and other determinants are likely to have a large impact on
prevention and the management of some illnesses (Starfield, 2006).
Gathering social determinants of health data would result in effective risk
assessment to ultimately support population health management. It can help health-
care professionals to identify care gaps. Healthcare organizations can also get better
insight into individual drivers of patient engagement and can match individuals
to specific interventions, preventive services, or resources that are most likely to
enhance outcomes. Social determinants of health have not been sufficiently recog-
nized despite the knowledge of their impact on health outcomes and longevity. The
interventions that address social, behavioral, and environmental determinants of
health are also less developed. There is a need to generate integrated, e­ vidence-based
approaches to have a better impact on health outcome and lowering of healthcare
costs. This gap has slowed health policymakers in promoting innovative models of
care, even though these nonmedical determinants of health are worthy of attention.
Several challenges limit the integration of social determinants of health data. These
impact evidence-based decision making, resulting in barriers to improving overall pop-
ulation health. Some of these challenges are (Robert Wood Johnson Foundation, 2016):
8 Chapter 1 Emerging Need for Population Health Informatics

■■ Limited knowledge of what works best: Clinicians, healthcare providers, pro-

gram operators, and researchers are utilizing data on social determinants of
health to identify the best ways to collate and use these data so that guidelines
can be evidence based.
■■ Lack of standardization and tools: The absence of standard measures for collect-
ing data on social determinants leads to inconsistencies. This limits the analysis
and decisions that can be made using such data.
■■ Limited knowledge in connecting patient, population, and public health data: Devel-
opment of effective, targeted health interventions requires linking of data at mul-
tiple levels, from patient-level to population and social determinants of health.
■■ Health systems need to understand their communities better: Community needs
and requirements to create programs, policies, and interventions need to be
well understood.
■■ Sharing data across sectors: Data sharing and its utility in health decision
making presents a fundamental challenge that involves issues of trust, system
interoperability, sector, and workflows.
■■ Identifying and developing the right technologies: Integrating social determi-
nants of health data into electronic health records (EHRs) has also been a
major challenge. The main alternative to EHRs for the collection, sharing, and
use of social determinants of health data are custom technology, cloud-based
technology, and geo-visual analytics.
Some of the outcomes facilitated by the analysis of social determinants of health data
include the following (Falk, 2016):
■■ Increased advocacy to address health inequalities
■■ Better policymaking
■■ Improved health outcomes
■■ Cost-effective interventions
■■ Leadership action plans that positively impact safety, cost, and clinical outcomes
■■ Improved clinical decision making and evidence-based practice
■■ Improved practice guidelines
Different stakeholders have different interests, which are not often unified. Although
policymakers focus on health policy decision making, advocacy groups typically focus on
improving outcomes related to one disease or its determinant. If the goal is overall health
improvement, individual groups working in silos are not productive ­(Kindig & Stoddart,
2003). Population health improvement as a goal creates an overarching need for a popu-
lation health perspective that encompasses health outcomes across determinants.

▸▸ II. The Growth of the Internet

and Social Media
Information and communication technology (ICT) has continued to proliferate at
a rapid pace. The beginning of the 21st century has ushered in the possibility of an
unprecedented era of scientific discovery and promise. New ICTs are being explored
to effectively and efficiently communicate with, engage, and educate the diverse pub-
lic. Such technologies can be utilized as web-based apps, mobile phones, and alert
systems. Technology continues to improve (Maynard & Harper, 2011). Computers
 II. The Growth of the Internet and Social Media 9

are now available at much lower, affordable prices. The Internet is a massive net-
work, connecting millions of computers (FIGURES 1.3 and 1.4). The World Wide Web
allows individuals to access information via a computer, mobile telephone, tablet,
gaming device, or digital TV (Internet Live Stats, 2017).

4 billion

3 billion
Internet users

2 billion

1 billion

0
93 95 97 9 9 01 03 05 07 09 11 13 15
19 19 19 19 20 20 20 20 20 20 20 20
Year (as of July 1, 2017)

FIGURE 1.3 Internet users in the world

Data from Internet Live Stats. (2017). Internet users by region. Retrieved from http://www.internetlivestats.com/internet-users/

10.3% 9.3%
8.6%

17.1% 3.8% 0.7%

50.2%

Asia 50.2%
Europe 17.1%
Lat Am/Carib. 10.3%
Africa 9.3%
North America 8.6%
Middle East 3.8%
Oceania/Australia 0.7%

FIGURE 1.4 Internet users in the world by region

Reproduced from Internet World Stats. (2017b). World Internet users and 2017 population stats. Basis: 3,731,973,423 Internet users on March 31, 2017. Retrieved from
www.internetworldstats.com/stats.htm. Copyright © 2017, Miniwatts Marketing Group.
10 Chapter 1 Emerging Need for Population Health Informatics

North America 88.1%

Europe 77.4%
Australia/Oceania 68.1%
Latin America
59.6%
/Caribbean
Middle East 56.7%
World, Avg. 49.6%
Asia 45.2%
Africa 27.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Penetration rate

FIGURE 1.5 Internet world penetration rates by regions of the world

Reproduced from Internet World Stats. (2017a). Internet usage statistics: The Internet big picture. Retrieved from http://www.internetworldstats.com/stats.htm

Currently, around 40% of the world’s population has an Internet connection

(Pew Research Center, 2016). As FIGURE 1.5 shows, North America has the highest
Internet penetration rate (88%), and Africa has the lowest Internet penetration rate
(27.7%) (Poushter, 2016; Internet World Stats, 2017a). Nearly half of Internet users
are from Asia (50.2%), as compared to 8.6% in North America.
Mobile and Internet technology use has become a daily, routine activity in most
parts of the world. Internet use is proliferating, especially for obtaining health infor-
mation (Atkinson, Saperstein, & Pleis, 2009). In addition to making and receiving
calls, cell phones are widely used for multiple purposes including sending messages
and capturing pictures and videos. Mobile health technologies constitute one of the
most rapidly growing markets globally. Growth is primarily attributed to an increas-
ing penetration of smartphones, tablets, and other mobile platforms, and the mHealth
Solutions Market is predicted to be worth 59.15 billion USD by 2020 (­ Markets and
Markets, 2017).
The use of mobile devices has transformed many aspects of health care. More than
half of the Internet users in the United States (65%) reported using social ­networking
sites in 2011 (Pew Research Center, 2016) (FIGURE 1.6). Facebook is the most popular
social networking site globally (Capurro et al., 2014), with an estimated 1 b­ illion active
users in total, including 580 million daily users. Twitter, with 500 m
­ illion users world-
wide, detects and predicts events and sentiments by observing users’ posts (tweets) in
real time (Capurro et al., 2014). Social networking sites offer a range of possibilities
for establishing multidirectional communication and interaction, as well as quickly
monitoring public sentiment and activity (Capurro et al., 2014).

▸▸ III. The Intersection of ICTs and Health Care

The advent of ICT has transformed healthcare delivery into patient-centered care.
ICTs allow the delivery of healthcare services, particularly to isolated communi-
ties. Integration of clinical and nonclinical data sources by using ICTs to enhance
­population health outcomes across diverse geographic settings is a growing need.
 III. The Intersection of ICTs and Health Care 11

80

65%
61%
60

46%

40 43%
38%
29%

27%
20 16%

8%
13%
9%
2%
0
2005 2006 2007 2008 2009 20010 2011

Ever
Within the past 24 hours

FIGURE 1.6 Social media use by adults

Modified from Madden, M., & Zickuhr, K. (2011). 65% of online adults use social networking sites. Retrieved from http://www.pewinternet.org/2011/08/26/65-of
-online-adults-use-social-networking-sites/

Policymakers on a global scale are encouraging the use of such technologies to

improve health and healthcare systems. Mobile health technologies, remote wear-
able devices, and sensors have demonstrated immense potential in preventing
­diseases and improving well-being in numerous settings (Capurro et al., 2014).
Future technological innovation is going to keep transforming health care. Previ-
ously, technology played a minimal role in health, and healthcare professionals were
the only way to take care of people (Friede & O’Carroll, 1996). Technology is now
playing a significant role in health management information systems (HMISs), pub-
lic health surveillance, geographic information systems (GISs), and EHRs and
facilitates access to both public health programs and services. Technology is used
to monitor patterns of illness and to detect emerging or imminent threats to public
health (Araujo et al., 2009).
Public health professionals have been among the first users of information
technology. Technology can help providers identify and address nonmedical fac-
tors that affect population health (Institute of Medicine, 1997). More and more
organizations are beginning to record population-level data using cloud-based
12 Chapter 1 Emerging Need for Population Health Informatics

tools and technologies. Mobile devices including smartphones, tablet computers,

and remote monitoring devices have ample potential for use in disease prevention,
early risk identification, healthcare delivery, and timely support to populations liv-
ing in diverse settings (Centers for Disease Control and Prevention, 2006). These
emerging technologies present an opportunity to address global health challenges
in both developed and developing countries. Healthcare organizations around the
globe are forming technological infrastructures that enable several stakeholders
to make better informed, faster decisions and individuals to better manage their
health outside of the hospital setting (Deloitte, 2016). Innovative technologies cover
multiple areas including surveillance for disease, environmental monitoring, pol-
lution mitigation and prevention, behavior modification, screening, and chronic
disease management (Eng, 2004). The wide-scale adoption of health ­information
technology has enabled diverse stakeholders, such as providers, payers, and
­government agencies, to collaborate using new digital tools to improve the health
of defined populations.

▸▸ IV. The Emerging Role of Population

Health Informatics
Informatics is the science of information, where information is defined as data with
meaning (Bernstam, Smith, & Johnson, 2010). Informatics serves as a bridge across
practitioners and professions to support collaboration and electronic communica-
tion. Informatics tools provide benefits to both administrative and clinical aspects
of healthcare delivery and assist in collaborative practice by enhancing communica-
tion across team members. TABLE 1.2 lists some of the key global accomplishments
in the field of health informatics.

TABLE 1.2 Key Global Health Informatics Accomplishments

Year Country Key Accomplishments

1949 Germany First professional organization for Informatics was

founded

1950 United Kingdom Medical Informatics initiated in the UK

1952 United States First computer was used in clinical practice at

the American Society for Clinical Pathology
(Rappoport Arthur M-Bee)

1959 United States First CT scanner was developed by Robert Ledley,

one of the founding fathers of Informatics
 IV. The Emerging Role of Population Health Informatics 13

1960 France Training programs for Informatics in France began

1968 Brazil Computers were first used in Medical care

1987 Hong Kong Hong Kong Society for Medical Informatics

(HKSMI) was established

1988 United States American Medical Informatics Association (AMIA)

established

1989 Switzerland International Medical Informatics Association

formed

1993 Nigeria First International Working Conference on Health

Informatics in Africa

1996 United States A 2-year fellowship program was established

by the Centers for Disease Control and
Prevention

1997 Argentina Biomedical Informatics group was established

2000 New Zealand Health Informatics program established in

New Zealand

2001 Canada Canada Health Infoway was established

2002 Australia Australasian college of health informatics

established

2004 United States Office of the National Coordinator for Health

Information Technology was created

2005 United States National Center for Public Health Informatics was
created by CDC

2006 Saudi Arabia Saudi Association for Health Informatics was

established

2009 United States The Health Information Technology for

Economic and Clinical Health (HITECH) Act
established

2017 India Digital Health Technology Ecosystem incorporated

into National Health Policy

Modified from Ng, S. K., & Wong, L. (2004). Accomplishments and challenges in bioinformatics. IT Professional, 6(1), 44–50.
14 Chapter 1 Emerging Need for Population Health Informatics

Public Health Informatics

Public health informatics (PHI) is the science of applying information-age
­technology to serve the specialized needs of public health (Friede, Blum, &
­McDonald, 1995). PHI is a systematic application of information, computer science,
and technology in the practice of public health (Yasnoff et al., 2000). It addresses
three core functions of public health: (1) assessment of population health, (2) p
­ olicy
development, and (3) assurance of the availability of high-quality public health
­services. The scope of PHI expands beyond conceptualization and design and
­development (Yasnoff et al., 2000).
Members of the public health and informatics community discussed key PHI
issues during the American Medical Informatics Association Meeting that was held
in Atlanta during May 15–17, 2001 (Yasnoff et al., 2001). The issues were related
to funding and governance; architecture and infrastructure; standards and vocabu-
lary; research, evaluation, and best practices; privacy, confidentiality, and security;
and training and workforce (Yasnoff et al., 2001). All stakeholders perceived the
role of information systems to be beneficial in improving the health of individuals
(Yasnoff et al., 2000). Some of the PHI-related challenges included developing inte-
grated national public health information systems, enhancing integration efforts
between public health and clinical care systems, and addressing the concerns of
information technology on confidentiality and privacy (Yasnoff et al., 2001).
A follow-up PHI conference was held in 2011 to revisit the PHI agenda devel-
oped in 2001 (Massoudi et al., 2012). Three key themes were identified: the need to
(1) increase communication and information sharing within the PHI community;
(2) improve evaluation methods, competency training, and the use of public health;
and (3) enhance leadership and coordination to move the field forward. Further
­recommendations included finding ways to strengthen prevention in the public
health and clinical continuum and to build health at the community level (Massoudi
et al., 2012).

Population Health Informatics

The U.S. HITECH Act of 2009 was designed to boost health information technol-
ogy adoption nationwide. President Obama signed the act into law on February
17, 2009, as part of the American Recovery and Reinvestment Act of 2009
(ARRA) economic stimulus bill. Some of the key processes included care coordi-
nation, cohort management, clinician engagement, and reporting and knowledge
management. Managing public health practice effectively and enhancing societal
well-being require multiple resources that provide accurate, high-quality, and timely
information. PHI focuses on population-level, preventive-based information. It also
serves as an applied science in relevant government settings with a central goal of
public health promotion (Yasnoff et al., 2000). PHI is a combination of medicine,
public health, computer science, and information processing (Kukafka, 2005). It has
also been defined as the application of ICTs in public health practice while integrat-
ing health research with information technology (Reeder, Hills, Demiris, Revere, &
Pina, 2011). Application of PHI principles provides unprecedented opportunities to
build healthier communities (Savel & Foldy, 2012).
A paradigm shift toward the area of population health informatics (PopHI)
has begun. This shift is because of the increasing focus on social health determinants
 IV. The Emerging Role of Population Health Informatics 15

and use of technology in health care, combined with stakeholder initiatives including
the ACA, HITECH Act, and other relevant reforms (Vest & Gamm, 2010). PopHI
is the systematic application of information technologies and electronic informa-
tion to the improvement of the health and well-being of a defined community or
other target population (Kharrazi et al., 2017). For a health risk assessment to be
conducted effectively at the population level, aggregate data are needed from a vari-
ety of sources including health facilities, social services, law enforcement agencies,
departments of labor and industry, population-level surveys, and on-site inspec-
tions (O’Carroll, Yasnoff, Ward, Ripp, & Martin, 2003). PopHI can also be described
as an integration of social determinants of health data sources (both clinical and
nonclinical) by combining principles of ICT to enhance population health outcomes
across diverse geographic settings (Joshi, Arora, & Malhotra, 2017; FIGURE 1.7).
The current need for PopHI arises from dramatic improvements in informa-
tion technology, new pressures on the public health system, and changes in health-
care delivery. PopHI systems involve creation, storage, and processing of data to
generate information and knowledge. PopHI facilitates data-driven, well-informed,
evidence-based decision making for populations living in diverse settings. In addi-
tion to the informatics developments, elements of the PopHI system are a means
to generate and process data to achieve meaningful information and knowledge
about geographic areas that have concentrations of unfavorable health indicators
or are composed of populations of underserved groups (Kharrazi et al., 2017). The
development of such systems aims to help stakeholders gather timely and accurate
information about entire population groups and permit assessment of disparities of
health status among different populations (FIGURE 1.8).
PopHI also refers to the application of emerging technologies to improve the
health of populations (Eng, 2004). Some of the challenges that exist in relation to the
PopHI tools and technologies include privacy and security of patient data, confidenti-
ality, quality, sustainability, and the existing technology divide (Eng, 2004; FIGURE 1.9).

Information
systems

Social determinants
of health data
Population
health
data

Clinical care data

Computer
Geographic
science
setting

FIGURE 1.7 Intersections of population health, information systems, and computer science
among populations in diverse geographic settings
16 Chapter 1 Emerging Need for Population Health Informatics

Public health

Government Healthcare
agencies systems

PopHI

Employers Individuals

Insurers

FIGURE 1.8 Diverse stakeholder involvement in PopHI

Big data (increasing

velocity, volume,
veracity, and variety)

Data analytics
Interoperability
and interpretation

Lack of data
Privacy
standards

FIGURE 1.9 Challenges in the use of healthcare technologies

Modified from Harbinger Systems. (2016). Healthcare IT: Role of EDI in Affordable Care Act reforms. Retrieved from http://www.slideshare.net/hsplmkting/healthcare-it
-role-of-edi-in-affordable-care-act-reforms

Despite these challenges, health information technology, including mobile

health technology, holds significant potential for engaging individuals in disease
prevention and health promotion. It provides individuals with the necessary tools
to record their data and make data meaningful. More research is needed to assess
when, where, and for whom the population health technologies are efficacious.
TABLE 1.3 lists the key comparisons between PopHI and PHI.

▸▸ V. Challenges and Opportunities

Related to PopHI
Experts at a symposium sponsored by the National Library of Medicine identi-
fied six key domains of PopHI as significant (Kharrazi et al., 2017). Symposium
attendees included national experts and leading researchers in academia, the public
sector, provider organizations, and the information technology industry. These six
domains were as follows:
 V. Challenges and Opportunities Related to PopHI 17

TABLE 1.3 Distinguishing Between Population Informatics and Public Health

Informatics

Population Health Informatics Public Health Informatics

(PopHI) (PHI)

Context Both governmental and Predominantly governmental

nongovernmental context

Common Total population Total population

intervention Target population Health departments
targets Healthcare organizations
Healthcare systems
Nongovernmental organizations

Main Outreach and prevention Assessment

operational Care integration Prevention
goals Disease management Assurance

Action arm Population health organizations Public health agencies

Care management organizations Not-for-profit and
nongovernmental
organizations

Key Provider and payer systems Federal, state, and local

stakeholders Government and community governments

Key Capturing nonmedical information Expanding public health IT

information Interoperability across sectors systems
challenges Medical and public health
interoperability

Modified from Kharrazi, H., Lasser, E. C., Yasnoff, W. A., Loonsk, J., Advani, A., Lehmann, H. P., . . . Weiner, J. P. (2017). A proposed
national research and development agenda for population health informatics: Summary recommendations from a national expert
workshop. Journal of the American Medical Informatics Association, 24(1), 2–12.

■■ Interoperability and information infrastructure: Having an interoperable plat-

form that can facilitate data sharing can potentially help advance the agenda
of PopHI.
■■ Cross-organization collaboration: Well-established programs or policies for
population health data sharing across diverse stakeholders do not exist.
■■ PopHI-based indicators and metrics: There is a need to have an understand-
ing of how advanced population health metrics can be derived from the health
information technology systems.
■■ Applying PopHI within integrated provider systems: Current state-of-the-art
tools represent an imbalance between focusing on the population vs. individual
providers.
18 Chapter 1 Emerging Need for Population Health Informatics

■■ Computer science and informatics methods for population health: There is a great
potential to utilize some of the computational methods from the field of com-
puter science to address the challenges of population health data integration
and analysis.
■■ Integration of social and nonmedical factors into PopHI systems: Linking social
and other nonmedical information with clinical data can enhance population
health methods and models.
For each of the domains identified, existing challenges and potential oppor-
tunities were assessed, alongside future research directions to address them
(TABLE 1.4).

TABLE 1.4 Challenges and Opportunities Across Population

Health Domains

Challenges and Research and Development

Domains Opportunities Issues

Interoperability Need for a clear, shared Methods for securely and

and information vision for a common,
infrastructure interoperable, and robust
information infrastructure
Need for effective patient
identification methods to
share data across systems
Inconsistent adoption of
interoperability standards
Challenges associated with
silo functions and service
provisions
privately linking patient medical
records across stakeholders
Promote a shared knowledge
base for community health trends
and population decision support
Design end-user tools that
incorporate usability methods
and heuristics
Foster the integration of social
science data into PopHI’s
overarching architecture

Cross- Collaboration challenges Consensus on what data to

organization among stakeholders
collaboration Limited PopHI data use and
exchange agreements
Lack of aligned incentives
Instability of many
partnerships between
private and public
organizations
Difficulty of blending
medical, public health,
and consumer-targeted
interventions.
collect, integrate, and share as
part of PopHI
Discover and share new PopHI
analytic solutions and models
among stakeholders
Define population health
data-sharing methods using
established standards
Develop a set of metrics and
decision support guidelines
Create methods to assess the
quality of shared data and
techniques for linking disparate
data sources
 V. Challenges and Opportunities Related to PopHI
PopHI-based Understanding how new
indicators and data sources, such as
metrics patient-generated data and
unstructured EHR data, can
be utilized
Need appropriate
informatics methods for
improving the reliability,
accessibility, and
comparability of such
measures
Develop a prioritized
population/community
report card
Applying Lack of appropriate
PopHI within population health
integrated electronic quality measures
provider Absence of proof-of-
systems concept and return-
on-investment of
enterprise-level tool
implementation
Up-to-date meaningful
use policy, and a lack of
governance structures for
effective and efficient data
sharing
Computer Heterogeneity and
science and complexity of population
informatics health data sources
methods for Privacy issues associated
population with population-level
health analytics
Limited collaboration
between health information
technology and population
health experts
Lack of standardized data
architectures for population
health
19
Develop actionable predictive
models for population health
metrics
Build a health information
technology framework to capture
and integrate patient-reported
outcomes on the population
scale
Create a methodology to align
existing population health
metrics across programs
Establish a framework to support
the roll-out of new population-
health–focused metrics by
expanding collection of critical
data elements
Integration of practice needs
for population health data
management and governance
Improvement of human factors
and workflow issues for all
stakeholders
Identification of a unifying
framework for PopHI
infrastructure and stakeholder
incentives for adoption
Develop and disseminate a “grand
computing challenge” for PopHI
Encourage collaboration
between computer scientists
and trigger the development of
advanced, innovative methods
Develop synthetic population-level
datasets that can be shared freely
Develop guidelines for large-
scale data sharing as well as
analytic frameworks for non-
health researchers
Advance interdisciplinary
research in applied PopHI
focus areas, such as change
management and workflow
reasoning
(continues)
20 Chapter 1 Emerging Need for Population Health Informatics

TABLE 1.4 Challenges and Opportunities Across Population

Health Domains (continued )

Challenges and Research and Development

Domains Opportunities Issues

Integration Poor understanding of the Solutions need to integrate

of social and information that needs nonpersonal data to person-
nonmedical to remain protected or specific data
factors into confidential when using Develop population-based
PopHI systems nonclinical data decision-support tools for both
public health/community officials
and clinicians
Develop analytic tools that work
across disparate population
health data types

Modified from Kharrazi, H., Lasser, E. C., Yasnoff, W. A., Loonsk, J., Advani, A., Lehmann, H. P., . . . Weiner, J. P. (2017). A proposed
national research and development agenda for population health informatics: Summary recommendations from a national expert
workshop. Journal of the American Medical Informatics Association, 24(1), 2–12.

▸▸ VI. Adoption of PopHI Solutions

Apart from the challenges, opportunities, and research and development issues
related to PopHI, the following 13 overarching themes of PopHI were identified
(Kharrazi et al., 2017):
■■ Policy alignment: There is a need to align the PopHI strategies with desired out-
comes that will facilitate adoption and implementation of appropriate PopHI
solutions.
■■ Data governance: Data governance and data privacy policies need to be in place
to ensure data sharing agreements so that it can further facilitate adoption and
implementation of PopHI solutions.
■■ Data quality: A suboptimal rate of completeness, accuracy, timeliness, reliabil-
ity, or validity of a data source can produce uncertainty when the data are incor-
porated into PopHI solutions.
■■ Data management: Differences in granularity and heterogeneity across various
data sources create many data management challenges.
■■ Sustainability and incentives: Lack of funding and difficulty attracting new
funding streams may affect the scalability of a project and limit the flexibility of
its core business model.
■■ Population metrics: The lack of accurate and reproducible e-metrics may reduce
the effectiveness of PopHI solutions.
■■ Interoperability standards: Limited PopHI standards and interoperability
frameworks affect the development of new PopHI solutions.
■■ Stakeholder collaboration: If stakeholders do not collaborate effectively, this will
produce suboptimal results.
Another random document with
no related content on Scribd:
One instant in close speech
With them he doth confer:
God-sped, he hasteneth on,
That anxious traveller...

I was that man—in a dream:

And each world's night in vain
I patient wait on sleep to unveil
Those vivid hills again.

Would that they three could know

How yet burns on in me
Love—from one lost in Paradise—
For their grave courtesy.

ALEXANDER

It was the Great Alexander,

Capped with a golden helm,
Sate in the ages, in his floating ship,
In a dead calm.

Voices of sea-maids singing

Wandered across the deep:
The sailors labouring on their oars
Rowed, as in sleep.

All the high pomp of Asia,

Charmed by that siren lay,
Out of their weary and dreaming minds,
Faded away.
Like a bold boy sate their Captain,
His glamour withered and gone,
In the souls of his brooding mariners,
While the song pined on.

Time, like a falling dew,

Life, like the scene of a dream,
Laid between slumber and slumber,
Only did seem....

O Alexander, then,
In all us mortals too,
Wax thou not bold—too bold
On the wave dark-blue!

Come the calm, infinite night,

Who then will hear
Aught save the singing
Of the sea-maids clear?

THE REAWAKENING

Green in light are the hills, and a calm wind flowing

Filleth the void with a flood of the fragrance of Spring;
Wings in this mansion of life are coming and going,
Voices of unseen loveliness carol and sing.

Coloured with buds of delight the boughs are swaying,

Beauty walks in the woods, and wherever she rove
Flowers from wintry sleep, her enchantment obeying,
Stir in the deep of her dream, reawaken to love.
Oh, now begone sullen care—this light is my seeing;
I am the palace, and mine are its windows and walls;
Daybreak is come, and life from the darkness of being
Springs, like a child from the womb, when the lonely one calls.

THE VACANT DAY

As I did walk in meadows green

I heard the summer noon resound
With call of myriad things unseen
That leapt and crept upon the ground.

High overhead the windless air

Throbbed with the homesick coursing cry
Of swallows that did everywhere
Wake echo in the sky.

Beside me, too, clear waters coursed

Which willow branches, lapsing low,
Breaking their crystal gliding forced
To sing as they did flow.

I listened; and my heart was dumb

With praise no language could express;
Longing in vain for him to come
Who had breathed such blessedness.

On this fair world, wherein we pass

So chequered and so brief a stay;
And yearned in spirit to learn, alas,
What kept him still away.
 THE FLIGHT

How do the days press on, and lay

Their fallen locks at evening down,
Whileas the stars in darkness play
And moonbeams weave a crown—

A crown of flower-like light in heaven,

Where in the hollow arch of space
Morn's mistress dreams, and the Pleiads seven
Stand watch about her place.

Stand watch—O days no number keep

Of hours when this dark clay is blind.
When the world's clocks are dumb in sleep
'Tis then I seek my kind.

THE TWO HOUSES

In the strange city of Life

Two houses I know well:
One wherein Silence a garden hath,
And one where Dark doth dwell.

Roof unto roof they stand,

Shadowing the dizzied street,
Where Vanity flaunts her gilded booths
In the noontide glare and heat.
Green-graped upon their walls
An ancient hoary vine
Hath clustered their carven, lichenous stones
With tendril serpentine.

And ever and anon,

Dazed in that clamorous throng,
I thirst for the soundless fount that stills
Those orchards mute of song.

Knock, knock, nor knock in vain:

Heart all thy secrets tell
Where Silence a fast-sealed garden hath,
Where Dark doth dwell.

FOR ALL THE GRIEF

For all the grief I have given with words

May now a few clear flowers blow,
In the dust, and the heat, and the silence of birds,
Where the lonely go.

For the thing unsaid that heart asked of me

Be a dark, cool water calling—calling
To the footsore, benighted, solitary,
When the shadows are falling.

O, be beauty for all my blindness,

A moon in the air where the weary wend,
And dews burdened with loving-kindness
In the dark of the end.
 THE SCRIBE

What lovely things

Thy hand hath made:
The smooth-plumed bird
In its emerald shade,
The seed of the grass,
The speck of stone
Which the wayfaring ant
Stirs—and hastes on!

Though I should sit

By some tarn in thy hills,
Using its ink
As the spirit wills
To write of Earth's wonders,
Its live, willed things,
Flit would the ages
On soundless wings
Ere unto Z
My pen drew nigh;
Leviathan told,
And the honey-fly:
And still would remain
My wit to try—
My worn reeds broken,
The dark tarn dry,
All words forgotten—
Thou, Lord, and I.
 FARE WELL

When I lie where shades of darkness

Shall no more assail mine eyes,
Nor the rain make lamentation
When the wind sighs;
How will fare the world whose wonder
Was the very proof of me?
Memory fades, must the remembered
Perishing be?

Oh, when this my dust surrenders

Hand, foot, lip, to dust again,
May these loved and loving faces
Please other men!
May the rusting harvest hedgerow
Still the Traveller's Joy entwine,
And as happy children gather
Posies once mine.

Look thy last on all things lovely,

Every hour. Let no night
Seal thy sense in deathly slumber
Till to delight
Thou have paid thy utmost blessing;
Since that all things thou wouldst praise
Beauty took from those who loved them
In other days.

Printed by T. and A. CONSTABLE, Printers to His Majesty

at the Edinburgh University Press
*** END OF THE PROJECT GUTENBERG EBOOK MOTLEY, AND
OTHER POEMS ***

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright in
these works, so the Foundation (and you!) can copy and distribute it
in the United States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part of
this license, apply to copying and distributing Project Gutenberg™
electronic works to protect the PROJECT GUTENBERG™ concept
and trademark. Project Gutenberg is a registered trademark, and
may not be used if you charge for an eBook, except by following the
terms of the trademark license, including paying royalties for use of
the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as
creation of derivative works, reports, performances and research.
Project Gutenberg eBooks may be modified and printed and given
away—you may do practically ANYTHING in the United States with
eBooks not protected by U.S. copyright law. Redistribution is subject
to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free

distribution of electronic works, by using or distributing this work (or
any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree
to and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be
bound by the terms of this agreement, you may obtain a refund from
the person or entity to whom you paid the fee as set forth in
paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be

used on or associated in any way with an electronic work by people
who agree to be bound by the terms of this agreement. There are a
few things that you can do with most Project Gutenberg™ electronic
works even without complying with the full terms of this agreement.
See paragraph 1.C below. There are a lot of things you can do with
Project Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project
Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright law in
the United States and you are located in the United States, we do
not claim a right to prevent you from copying, distributing,
performing, displaying or creating derivative works based on the
work as long as all references to Project Gutenberg are removed. Of
course, we hope that you will support the Project Gutenberg™
mission of promoting free access to electronic works by freely
sharing Project Gutenberg™ works in compliance with the terms of
this agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms of
this agreement by keeping this work in the same format with its
attached full Project Gutenberg™ License when you share it without
charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside the
United States, check the laws of your country in addition to the terms
of this agreement before downloading, copying, displaying,
performing, distributing or creating derivative works based on this
work or any other Project Gutenberg™ work. The Foundation makes
no representations concerning the copyright status of any work in
any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project Gutenberg™
work (any work on which the phrase “Project Gutenberg” appears, or
with which the phrase “Project Gutenberg” is associated) is
accessed, displayed, performed, viewed, copied or distributed:
 This eBook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this eBook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived

from texts not protected by U.S. copyright law (does not contain a
notice indicating that it is posted with permission of the copyright
holder), the work can be copied and distributed to anyone in the
United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must
comply either with the requirements of paragraphs 1.E.1 through
1.E.7 or obtain permission for the use of the work and the Project
Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted

with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works posted
with the permission of the copyright holder found at the beginning of
this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files containing a
part of this work or any other work associated with Project
Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this

electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg™ License.
1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if you
provide access to or distribute copies of a Project Gutenberg™ work
in a format other than “Plain Vanilla ASCII” or other format used in
the official version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original “Plain
Vanilla ASCII” or other form. Any alternate format must include the
full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing

access to or distributing Project Gutenberg™ electronic works
provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all
 copies of the works possessed in a physical medium and
discontinue all use of and all access to other copies of Project
Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™

electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
the Project Gutenberg Literary Archive Foundation, the manager of
the Project Gutenberg™ trademark. Contact the Foundation as set
forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on, transcribe
and proofread works not protected by U.S. copyright law in creating
the Project Gutenberg™ collection. Despite these efforts, Project
Gutenberg™ electronic works, and the medium on which they may
be stored, may contain “Defects,” such as, but not limited to,
incomplete, inaccurate or corrupt data, transcription errors, a
copyright or other intellectual property infringement, a defective or
damaged disk or other medium, a computer virus, or computer
codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except

for the “Right of Replacement or Refund” described in paragraph
1.F.3, the Project Gutenberg Literary Archive Foundation, the owner
of the Project Gutenberg™ trademark, and any other party
distributing a Project Gutenberg™ electronic work under this
agreement, disclaim all liability to you for damages, costs and
expenses, including legal fees. YOU AGREE THAT YOU HAVE NO
REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF
WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE
FOUNDATION, THE TRADEMARK OWNER, AND ANY
DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE
TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE
NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of receiving it,
you can receive a refund of the money (if any) you paid for it by
sending a written explanation to the person you received the work
from. If you received the work on a physical medium, you must
return the medium with your written explanation. The person or entity
that provided you with the defective work may elect to provide a
replacement copy in lieu of a refund. If you received the work
electronically, the person or entity providing it to you may choose to
give you a second opportunity to receive the work electronically in
lieu of a refund. If the second copy is also defective, you may
demand a refund in writing without further opportunities to fix the
problem.

1.F.4. Except for the limited right of replacement or refund set forth in
paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED,
INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted
by the applicable state law. The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.
1.F.6. INDEMNITY - You agree to indemnify and hold the
Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and distribution
of Project Gutenberg™ electronic works, harmless from all liability,
costs and expenses, including legal fees, that arise directly or
indirectly from any of the following which you do or cause to occur:
(a) distribution of this or any Project Gutenberg™ work, (b)
alteration, modification, or additions or deletions to any Project
Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of

Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers.
It exists because of the efforts of hundreds of volunteers and
donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a
secure and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help,
see Sections 3 and 4 and the Foundation information page at
www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation’s EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West,

Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
to date contact information can be found at the Foundation’s website
and official page at www.gutenberg.org/contact

Section 4. Information about Donations to

the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can
be freely distributed in machine-readable form accessible by the
widest array of equipment including outdated equipment. Many small
donations ($1 to $5,000) are particularly important to maintaining tax
exempt status with the IRS.

The Foundation is committed to complying with the laws regulating

charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and
keep up with these requirements. We do not solicit donations in
locations where we have not received written confirmation of
compliance. To SEND DONATIONS or determine the status of
compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where

we have not met the solicitation requirements, we know of no
prohibition against accepting unsolicited donations from donors in
such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make

any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation
methods and addresses. Donations are accepted in a number of
other ways including checks, online payments and credit card
donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project

Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose network of
volunteer support.

Project Gutenberg™ eBooks are often created from several printed

editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how
to subscribe to our email newsletter to hear about new eBooks.