Integrating Informatics Principles in Public Health

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Integrating Informatics Principles in Public
Health

• Barbara L. Massoudi, MPH, PhD
• bmassoudi_at_rti.org
• Janise Richards, MS, MPH, PhD
• jrichards_at_cdc.gov
• APHA Continuing Education Institute,
• 134th Annual Meeting Exposition
• November 5, 2006

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Making Sense of Informaticspeak
3
Overheard at various meetings

• Our goal is to professionally leverage other's
  mission-critical infrastructures

• In other words were going to steal your really
  good stuff!

4
Overheard at various meetings

• It is our job to synergistically restore
  error-free information in order that we may
  conveniently simplify scalable sources because
  that is what public health professionals expect

Were not really sure of what this is but we
know it needs to be accurate, easy to use, and
able to grow!
5
Overheard at various meetings

• It is our business to interactively provide
  access to prospective catalysts for change so
  that we may seamlessly promote value-added
  paradigms

We think it means somebodys responsible for
making some important changes happen we just
dont know who!
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Overheard at various meetings

• We authoritatively integrate performance-based
  meta-services such that we may continue to
  proactively revolutionize cost effective
  materials in order to solve business problems

Integration is key and we can bring things
together that you never knew you had or needed
and charge lots of money to do it!
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Agenda for Today

• Introduction to Public Health Informatics
• Key Issues in Informatics
• Information Systems Planning
• Change Management, Project Management
  Informatics Analysis
• Case Study

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Introduction to Public Health Informatics

• Definitions, Approach, and Analysis
• Janise Richards, MS, MPH, PhD

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Public Health Informatics What is it?
A Definition
Public health informatics is the systematic
application of information and computer science
and technology to public health practice,
research, and learning. What does that mean????
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What is Public Health Informatics?
A Definition
Public health informatics is the systematic
application of information and computer science
and technology to public health practice,
research, and learning.
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What is Public Health Informatics?
Information science
Theories in information science try to explain
how we think, store, retrieve, and transmit
information.
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Information Science
Wisdom
Knowledge
Information
Information
Data
Data
Data
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Information Science
Definition of Data

• Data undigested observations and unvarnished
  facts
• Fact, text, graphic, image, sound
• Without meaningful relation to anything else
• A thing

Cleveland, 1983
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Information Science
Definition of Information

• Information organized data
• Formatted, filtered, organized, structured,
  interpreted, summarized data
• data meaning information
• Relates to a description, definition or
  perspective (what, who, when , where)

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Information Science
Definition of Knowledge

• Knowledge information that has been organized,
  internalized and integrated with experience,
  study, or intuition
• Case, rule, process, model, ideas
• Rules and procedures that guide decisions and
  actions
• Information application knowledge
• Comprises of strategy, practice, method, or
  approach (how)

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Information Science

• Vocabularies - A vocabulary is a set of words
  known to a person or other entity, or that are
  part of a specific language
• Classifications - A classification consists of
  tables of subject headings and classification
  schedules used to assign a class number to each
  item being classified
• Taxonomies - A hierarchical taxonomy is a tree
  structure of classifications for a given set of
  objects it may also apply to relationship
  schemes other than hierarchies, such as network
  structures.. A taxonomy might also be a simple
  organization of objects into groups, or even an
  alphabetical list. In current usage taxonomies
  are seen as slightly less broad than ontologies.
• Ontologies seek to describe the basic
  categories and relationsh of being or existence
  to define entities and types of entities within
  its framework.

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Information Science MeSH (controlled
vocabularies)
Diseases Digestive System Diseases
Abdominal Pain Biliary Tract Diseases
Digestive System Abnormalities Digestive
System Fistula Digestive System Neoplasms
Esopageal Diseases Gastrointestinal
Diseases Liver Diseases Pancreatic
Diseases Peritoneal Diseases
Abnormalities    Abnormalities, Drug Induced  
  Abnormalities, Multiple         Alagille
Syndrome         Angelman Syndrome
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Information Science
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Information Science Semantic Network (Ontology)
STYT001OrganismA1.1Generally, a living
individual, including all plants and
animals.Homozygote Radiation Chimera
Transgenic Organismsorgm STYT002PlantA1.1.
1An organism having cellulose cell walls,
growing by synthesis of inorganic substances,
generally distinguished by the presence of
chlorophyll, and lacking the power of locomotion.
Plant parts are included here as well.Pollen
Potatoes Vegetablesplnt STYT003AlgaA1.1.1
.1A chiefly aquatic plant that contains
chlorophyll, but does not form embryos during
development and lacks vascular tissue.Chlorella
Laminaria Seaweedalga
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What is Public Health Informatics?
A Definition
Public health informatics is the systematic
application of information and computer science
and technology to public health practice,
research, and learning.
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What is Public Health Informatics?
Computer science
Is the systematic study of algorithmic processes
that describe and transform data and information
including the theory, analysis, design,
efficiency, implementation and application
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What is Public Health Informatics?
Computer science

• A foundational concept in computer science is
  the algorithm-- a precise sequence of
  instructions

• Basically, a computer program is an executable
  algorithm

• A second foundational concept in computer
  science is the data structure, or an abstract
  representation of information

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Computer Science

• Algorithms - is a procedure (a finite set of
  well-defined instructions) for accomplishing some
  task which, given an initial state, will
  terminate in a defined end-state
• Data models - is a concrete representation of an
  information model. It represents the entities,
  properties, relationships and operations defined
  in an information model in a manner that allows
  actual instances of those entities to be managed,
  manipulated, stored, operated upon and verified
• Natural language processing - Natural language
  generation systems convert information from
  computer databases into normal-sounding human
  language, and natural language understanding
  systems convert samples of human language into
  more formal representations that are easier for
  computer programs to manipulate
• Expert systems/artificial intelligence/decision
  support systems

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Computer Science
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Computer Science
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What is Public Health Informatics?
Information Technology
Information technology is the development and use
of hardware, software, and supporting
infrastructure to manage and deliver information.
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What is Public Health Informatics?
Public Health Practice
Public Health Foundation, 2003
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Public health and informatics
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Creative acts people in Informatics do

• formulate models for acquiring, representing,
  processing, displaying or transmitting health
  information or knowledge
• develop computer systems that use the models to
  deliver the information or knowledge
• install information technology systems to support
  the models
• assess outcomes regarding the effects to the
  overall health care system

Friedman, 1995
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Public Health Workforce and Informatics
3 Classes of Informatics
Use of information (per se) for professional effectiveness Use of information technology for personal effectiveness
Development of information systems to improve the effectiveness of the public health enterprise

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Expertise level needed by Workforce Segment
Use of info technology
increase personal effectiveness
Development and
management of Information systems
Front-line
Sr.-level
Superv./
Staff
Technical
Managers
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Public Health Workforce and Informatics
Public Health Workforce
13 topical areas
Digital Literacy Electronic communication
On-line information access Use of information
System development Project management
Procurement Accountability
Research Standards
Databases  Human resource management
Confidentiality and security systems   Confidentiality and security systems  
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Public Health Workforce and Informatics
Public Health Workforce
Competency examples
All staff Utilizes information technology for full range of electronic communication appropriate to their programmatic area.
All staff Applies relevant procedures and technical means to ensure confidential information is appropriately protected.
Sup./Mgmt Utilizes proven informatics principles and practices when managing information technology projects.
Tech-Sup./ Mgmt Participates in the development of new and enhanced databases for public health and applies principles of good database design.
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Why is informatics important to public health?

• We can do it the hard way or the right way, but
  either way the application of information
  technology to public health practice is inevitable

OCarroll, 2001
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Public Health Informatics Needed approach

• Multidisciplinary/collaborative
• Systematic
• Applied
• Integrated
• Management
• Project
• Change

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Public Health Informatics Applications not
Public Health Specific

• Electronic Data Collection
• Collaborative tools
• Geographic Information Systems (GIS)
• Data Visualization tools
• Knowledge Management Systems (KMS)
• Electronic Health Record (EHR)
• Decision Support Systems

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Public Health Informatics Applications Specific
to Public Health

• Registries
• Electronic Lab Reporting
• Electronic Disease Surveillance
• Early Event Detection
• Program Monitoring and Evaluation

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Loonsk, 2004
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PHIN

• The Public Health Information Network

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• The many public health stakeholders
• The many data streams
• The need for rapid communication!

CDC and Other Federal Organizations
Pharmaceutical Stockpile
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Early Event Detection BioSense, NEDSS
Base System, PAM Development Platform, Call
Triage and Tracking Outbreak Management Outbreak
Management System Connecting Laboratory
Systems Laboratory Response Network Results
Messenger, LUNA Partner Communication and
Alerting Partner Communication and Alerting,
Epi-X Countermeasure Administration and
Response Countermeasure Response Administration,
VAC Man Cross Functional Components PHIN
Directory, PHIN Messaging Service, PHIN
Vocabulary
Federal Health Architecture Consolidated Health
Informatics, NHII
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Common GroundRobert Wood Johnson Foundation
(RWJF)

• Purpose
• Transforming Public Health Information Systems
  will support state and local public health
  agencies' collaboration in two areas
• 1) to prepare agencies to analyze and redesign
  their business processes and
• 2) to develop collaborative requirements
  definitions for information systems to strengthen
  public health agencies that will help to improve
  preparedness and chronic disease prevention and
  control.

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Key Issues in Informatics

• Standards, Vocabularies and Strategic Planning
• Barbara L. Massoudi, MPH, PHD

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Standards Vocabulary
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Standards in Informatics

• Why use standards?
• Exchange data and share information efficiently
  (HIE within RHIOs/NHIN)
• Correctly interpret data (Males1 or 0)
• Improve data quality (Allows for easy grouping)
• Collaboration opportunities (Multi-state
  outbreaks)
• Handle more complex information (Laboratory
  reports)

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Standards in Informatics

• Everyone benefits from a common approach to
  representing and exchanging public health data
• Those who collect it from outside sources
• Those who enter it into electronic format
• Those who analyze it
• Those who verify the findings
• Those that communicate the information for public
  health interventions

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A Figure of Speech

• Conversation
• Vocabulary
• The words you choose to use
• Content standards
• Grammar
• The way you put the words together
• Format standards
• Context
• The environment where you have the conversation
• Software, hardware, and resources required for
  data exchange

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Vocabulary

• Big tables of codes that describe things
• Numbers as county codes (FIPS)
• Reportable diseases as numbered codes
• ICD-9, ICD-9 CM, ICD-10 codes for underlying
  cause of death
• Vocabularies can be
• Locally-defined vs universally-defined
• Lumpers vs splitters

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Vocabulary Examples

• LOINC-Logical Observation Identifiers Names and
  Codes (www.regenstrief.org/loinc)
• Developed for billing purposes in early 1990s
• Gathers concepts into a single code
• 13951-9 Serum EIA for Hep A Antibody
• PHIN standard for reportable disease test
  requests
• Codes not assigned in systematic or hierarchical
  way the actual number is meaningless

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Vocabulary Examples

• SNOMED CT-Systematized Nomenclature of Medicine
  Clinical Terms (www.snomed.org)
• Pathologist developed mid 1960s
• Teases out concepts into atomic elements
• Enzyme immunoassay, Serum, Hepatitis A
  Virus, Antibody
• PHIN standard for reportable disease test results

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Vocabulary Examples - UMLS

• UMLS - Unified Medical Language System
  (1994-present) (http//www.nlm.nih.gov/research/um
  ls/)
• Goal To integrate systems by allowing the
  mapping of concepts to different standardized
  vocabularies and the development of vocabularies
  in biomedicine and health that have not been
  previously developed

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Vocabulary Examples - UMLS

• Metathesaurus - Very large, multi-purpose, and
  multi-lingual vocabulary database that links all
  included vocabularies
• Lexicon A dictionary-like database organized by
  concept or meaning with attributes that help to
  define its meaning
• Semantic Network A database of biomedical and
  health related concepts, their various names, and
  the relationships among them

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Grammar

• The way you put words together is important
• The disinfectant is contaminated with blood
• The blood is contaminated with disinfectant
• Critical in Natural Language Processing (NLP)
• Can be
• Storage (database) or Message (transmissions from
  one database to another over a network)
• Flat files or Relational databases

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Grammar Examples

• Storage comma-delimited, tab-delimited, MS
  Access, SAS
• Message HL7-Health Level Seven (www.hl7.org)
• Clinical and administrative data
• Standardizes format and protocol
• Defines the sequence in the message for data
  elements as well as the data type
• Currently implemented in immunization and cancer
  registries, emergency department reporting, and
  lab reporting

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Grammar Example

• HL7 allows multiple patients per message,
  multiple orders per patient, multiple tests per
  order, multiple results per test, etc.
• MSH\LABMED-SOUTHWEST68D089677CLIA
• PID178893565DOEJOHN490 Elm StPhoenixAZ
• OBR105099409000220738STD SCREENL
• OBX1CE5292-8RPR-SYPHILISLNG-A200POSITIVES
  NM
• OBX2CE6487-3GONNORRHEA ANTIGENLNG-A201NEGA
  TIVE
• OBX3CE14468-3CHLAMYDIA ANTIGENLNG-A201NEGA
  TIVE

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Context

• Along with the vocabulary and format, there needs
  to be an infrastructure to support the data
  exchange
• Data model
• Communication (business rules, protocols, etc.)
• Security software
• Support staff
• Standard approaches to implementation of
  interoperable systems are needed

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Context Example

• What is the NHIN?

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National Health Information Network (NHIN)
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Nationwide Health Information Network

• Nationwide system
• Interoperable Exchange of Data, Information,
  Knowledge (ultimately)
• Secure
• Containing multiple Regional Health Information
  Organizations (RHIOs)

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NHIN - RHIOs

• RHIOs at the regional / local level
• Provide
• Leadership
• Oversight
• Governance
• Funding Coordination

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Regional Health Information Organizations (RHIOs)

• AKA Health Information Exchanges (HIEs)
• AKA Local Health Information Infrastructure
  Initiatives (LHIIs)

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NHIN

• Overall Issues that must be (are) being
  addressed
• Organization and Business Framework
• Privacy and Security
• Legal Issues
• Management and Operational Considerations
• Standards and Policies to Achieve
  Interoperability

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Privacy, Security Confidentiality
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Background

• Technology versus people/practices?
• Technology
• Always a moving target
• Excellent track record overall
• People
• Human errors in judgment
• Social engineering
• Lack of standardization in laws across states
• Good record in public health

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NHIN Privacy Security Project

• AHRQ, ONC (HIT) collaborative initiative with 34
  states/territories
• Goals
• Identify both best practices and challenges
• Develop consensus-based solutions for
  interoperable electronic health information
  exchange (HIE) that protect the privacy and
  security of health information, and
• Develop detailed implementation plans to
  implement solutions.
• Nationwide report due early summer 2007

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HIPAA

• Health Insurance Portability and Accountability
  Act (1996) (www.hipaa.org)
• Improved efficiency and effectiveness of
  healthcare through standardization of shared
  electronic information including financial and
  administrative data
• Improved privacy of personal information
• Public health exemption

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HIPAA

• Two rules
• Security rule
• Need for hardware security, access security, and
  transmission security
• Privacy rule
• Need for de-identified data to provide for
  patients privacy of personal information

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HIPAA

• Personal identifiers that cannot be included in
  shared data
• Names, address, zip codes
• Telephone numbers, Fax numbers, Email addresses
• Birth date, admission date, discharge date, date
  of death, age
• Social security numbers
• Medical record numbers, Health plan beneficiary
  numbers
• Account numbers, Certificate/license numbers
• License plate numbers
• Device identifiers and serial numbers
• Web URL, IP address numbers
• Biometric identifiers
• Full face photographic images
• Any other unique identifying number,
  characteristic, or code

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Strategic Planning

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Strategic Management Framework
YOU
71
Strategic Planning I

• How does it fit with other kinds of planning?
• Strategic Plans
• Sets the direction
• Tactical Plans
• Establish and maintain the direction
• Operational Plans
• Carry out the directions

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Strategic Planning II

• Dimensions of Planning
• Type of Plan
• Strategic, Tactical, Operational
• Organizational Scope of Plan
• Individual, Work Group, Organizational Unit,
  Enterprise
• Time Frame/Planning Horizon
• Immediate, Near-term, Mid-term, Long-term
  (traditionally)
• Who do we involve?
• Individuals at all levels of the organization
  (internal)
• Stakeholders - the individuals and constituencies
  that contribute, either voluntarily or
  involuntarily, to an organizations success and
  programs, and that are therefore its potential
  beneficiaries and/or risk bearers (internal and
  external)

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Strategic Planning III

• Who do we involve?

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Informatics Strategic Planning I

• Unique characteristics to public health
• Usually reactive environment
• Driven by governmental policies subject to
  political influence
• Independence and interdependence of various
  public health agencies
• Financial and resource constraints programmatic
  funding cycles unfunded, mandated programs
  difficulty defining return on investment
• Short term leadership horizon in contrast to the
  continuous business of public health chronic
  workforce issues

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Informatics Strategic Planning II

• Informatics Strategy - A definition of the
  structure within which information, information
  systems and information technology is to be
  applied in some organization
• Why have one?
• Information systems are expensive!!!
• Information systems need to be tied to strategic
  business objectives to be useful
• Limited time and other resource investments must
  yield the best value

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Informatics Strategic Planning III

• Enterprise Architecture - an explicit, common and
  meaningful structural frame of reference to
  enable efficient business processes and
  information systems planning for public health
  agencies and partners.

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Enterprise Architecture (EA)
The use of EA as a focal point for strategic
action and IT systems design is a critical
success factor contributing to organizations
effective use of IT to meet mission goals.
Source Graphic by Gartner Consulting
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Making Public Health Informatics Work

• Change, Projects, and Analysis
• Janise Richards, PhD, MS, MPH

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Managing change
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Types of Change

• Operational
• Strategic
• Cultural
• Political

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Helping Change Happen

• Resistance to Change
• Change vs changer
• Lack of skills or knowledge
• Loss of perceived or real power
• Negative attitudes towards organization
• Negative attitudes towards change agent
• Magnitude of change

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Helping Change Happen

• A suggested strategy
• Inform all potentially affected people in writing
  of the upcoming change
• Survey/interview a sample of those affected by
  the change to determine the issues regarding the
  change
• Use this feedback to develop or modify the change
  process strategy, if needed
• During implementation of change process strategy,
  interview a sample of those affected to determine
  any new issues recursive process
• About 6 months after change has been made,
  conduct an assessment of new process

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Managing Projects
84
Project Management

• Define project concept problem to be solved
• Develop project plan
• Develop resources and support
• Build team
• Establish milestones and deliverables
• Implement project plan
• Monitor progress and make adjustments as needed
• Complete project if ongoing project, establish
  a logical endpoint annually
• Examine product
• Determine accomplishments
• Outline challenges and unexpected opportunities
• Develop a lessons learned document

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Project Management
Strategic Transitions, 2005
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10 Ways to fail as a project manager

1. Take a hands-off approach
2. Do not get involved in individual tasks
3. Let issues drift and remain unresolved
4. Be unwilling to list to suggestions for change
5. Be overfocused on specific project management
   tools
6. Measure milestones by accomplishment, not quality
7. Focus on relationship with management and not
   with project team
8. Attempt to micromanage project and not delegate
9. Make too many changes to schedule
10. Develop an overly general project plan without
    detailed tasks, milestones and timelines.

Lientz, 2002
87
10 Ways to succeed as a project manager

1. Know what is happening in the project in detail
2. Be able to make decisions
3. Understand issues including importance and
   meaning to project
4. Develop alternative actions and implement them
   when needed
5. Communicate effectively with team and management
6. Be able to criticize yourself and take criticism
   from others
7. Understand the trade-offs between project needs
   and organizational needs
8. Manage your time well
9. Maintain up-to-date project documentation
10. Have patience, a sense of humor and vision for
    the project

Lientz, 2002
88
Requires
Systems thinking!
There is more than one way to approach this
analysis
Who?What?When?Where?Why?How?
How well?
89
Zachman Framework
90
Popkin/Zachman Framework
http//government.popkin.com/frameworks/zachman_gr
id.htm
91
A review!
Function How? Business Process Model Functional Process Chart Process ? Resources
Data What? Sematic Model Conceptual Data Model Business Entity ? Business Relationship
People Who? Work Flow Model Organizational Chart People ? Work Product
Network Where? Logistics Network Business Concept Location ? Linkage
Time When? Master Schedule Object State Transition Business Event Time ? Business Cycle
Motivation Why? Business Plan Business Rules End (objectives) ? Means (strategy)
92
The PPT framework
93
Steps to analysis

• Getting started
• Current status
• Goal/vision
• Transition to implementation

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Getting started

• Determine scope, objectives
• Determine approach/methodology
• Identify project team
• Develop project workplan
• Obtain commitment/resources

95
Current status where are we today?

• Organizational structure
• Document organizational goals and objectives
• Preliminary functional business model
• A function is any set of actions performed in the
  course of conducting business
• A function is defined by its parts
• Functiontaskprocessactivity

96
Current status where are we today?

• Organizational structure
• Gather recent organizational charts
• (including originating and partner organizations)
• Department names and location
• Peoples titles/position
• Peoples names and contact information
• Reporting lines (direct and indirect)
• Number of people in department
• Indicate relationships between organizational
  units

97
Current status where are we today?

• Document organizational goals and objectives
• Review organizational goals and objectives
• Determine organizational critical success factors
• Identify any political or controversial factors
• Produce report of findings for review and
  confirmation by administration

98
Current status where are we today?

• Preliminary functional business model
• Include all domains (major functional area)
  within organizational structure
• Divide each functional area into its subfunctions
  (important to take time and careful notes when
  conducting this step)
• Decompose functions using an iterative process
  until all functional areas and connected
  sub-functions are identified
• Examine functions to determine if a new
  categorization or hierarchy of the functional
  business model appears to better describe the
  functions
• Use an iterative process with team and
  stakeholders to determine if new functional
  business model

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Current status Lab Information Flow Example
IDPH Laboratory
Tomines, 2004
100
Goal and Vision what needs to change?

• Review functional analysis
• Identify and interview/survey all stakeholders
• Analyze information gained to identify
  significant findings and opportunities
• Develop project goal and vision
• Review project goals and vision with all
  participants

101
Goal and Vision Lab Info Flow
Tomines, 2004
102
Transition to Implementation what needs to
happen?

• Meet with stakeholders to discuss project
  implementation
• Develop appropriate sequence of actions
• Systems/applications that create data should be
  developed before systems/applications that use
  data
• Develop a plan for conversion from existing to
  new system
• Maintain project monitoring

103
What are informatics principles that must be
applied in public health?

• Infrastructure
• Integration
• Interoperability
• Strategic Planning
• Vision
• Business process
• Management
• Project
• Change

104
Working groupsInformatics Analysis
105
Some Online Resources

• http//www.phii.org/
• http//endingthedocumentgame.gov/
• http//toolkit.ehealthinitiative.org/
• http//healthit.ahrq.gov
• http//www.cdc.gov/biosense/
• http//www.cdc.gov/phin/

106
Debrief and Evaluation