Applications of health information technology (health IT) are now widespread in the form of electronic medical records (EMRs), greatly reshaping the practice of clinical pediatrics. Population health stands to benefit greatly from the data produced by the alignment of pediatrics with other social determinants of health: medical care, genetics, individual behavior, social and physical environment. Before this potential can be realized, population health information models must be integrated into the design and evolution of EMRs and other data sources.
Key points
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Pediatric clinical care incorporates many of the social determinants of health into clinical practice; this alignment positions pediatricians to help address many health disparities.
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Health information technology and electronic medical records (EMRs) use by pediatricians support medical care delivery; other areas of population health require growth in the types of data and application of informatics.
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Clinical informatics can address health disparities by promoting EMR features that support population health, development of population health information systems, and semantic health information exchange.
Introduction
Over the last decade, electronic medical records (EMRs) have been implemented and studied at an unprecedented rate, providing increased collections of longitudinal clinical data as well as automated reporting. There has also been increasing engagement of patients in accessing their own health data, and a fundamental shift in the stewardship and use of that health data. However, a great section of pediatric patients and pediatricians remain underserved in their exposure to some of the most promising aspects of technology for this purpose—that of the impact on population health.
Large amounts of data pertinent to population health are generated outside of medical care venues but are not yet systematically incorporated into patient decision-making. True semantic interoperability that allows for relevant data exchange is still in its infancy. Hospitals and health systems struggle to balance limited resources for maintaining necessary security and operations of their EMR systems, while providers and patients await the promise of patient-specific plans and data that will help realize the full potential of “going digital.” Health systems and physicians are reaching outside of traditional health care venues to develop strategic efforts to address population health—either in how it is assessed and measured or how it will be impacted by their efforts.
In this article, the tenets of population health are explored, including the digital divide, how population health aligns with pediatric practice, successful applications of technology to pediatric population health issues, and the challenges that must be overcome for pediatricians and their patients to benefit from technology.
What is population health?
Modern models of population health have become widespread in the last decade, defined in 2003 by Kindig and Stoddart as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Determinants of population health outcomes include medical care, individual behavior, social environment, physician environment, and genetics. Although the delivery of medical care consumes the most resources, successful public health interventions target the determinants that can be changed and reduce inequalities between populations. By reducing health disparities and inequities among different groups of people, the negative impact of the social determinants can be controlled and mitigated and the greatest impact on outcomes realized.
The World Health Organization (WHO) reported in 2008 that social determinants of health were the main cause of health inequities in all countries and were responsible for the most diseases and injuries. This finding is particularly poignant in the United States, where many resources are dedicated to delivery of medical care rather than improvements that may provide population health benefits.
Population health aims to improve the health of the entire population, and the definition of health expands to accommodate this idea. Many population health policies approach a broad definition of health put forth by the WHO in 1946 as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Thus, many consider the population health composed of outcomes, patterns of health determinants, and the interventions that link the two ( Fig. 1 ).
One of the most prominent examples of a public health awareness campaigns is the Healthy People 2020 outreach project. Launched in December 2010, the project outlined a decade-long plan to improve the health of all American citizens. Healthy People has worked since the 1980s on community collaborations, informed health decision, and the impact of prevention.
Healthy People identifies approximately 1200 objectives divided into 40 public health topic areas. The project also identifies a set of leading health indictors as social determinants of health and divides them into 12 topics, seen in Box 1 . Among the lead federal agencies partnering with Healthy People is the Office of the National Coordinator for Health Information Technology. As of March 2014, many of the leading health indicators were listed as “target met” (15.4%) or “improving” (38.5%). Many of the population health determinants align closely with elements of standard pediatric care.
| Access to health services | Nutrition, physical activity, and obesity |
| Clinical preventive services | Oral health |
| Environmental quality | Reproductive and sexual health |
| Injury and violence | Social determinants |
| Maternal, infant, and child health | Substance abuse |
| Mental health | Tobacco |
What is population health?
Modern models of population health have become widespread in the last decade, defined in 2003 by Kindig and Stoddart as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Determinants of population health outcomes include medical care, individual behavior, social environment, physician environment, and genetics. Although the delivery of medical care consumes the most resources, successful public health interventions target the determinants that can be changed and reduce inequalities between populations. By reducing health disparities and inequities among different groups of people, the negative impact of the social determinants can be controlled and mitigated and the greatest impact on outcomes realized.
The World Health Organization (WHO) reported in 2008 that social determinants of health were the main cause of health inequities in all countries and were responsible for the most diseases and injuries. This finding is particularly poignant in the United States, where many resources are dedicated to delivery of medical care rather than improvements that may provide population health benefits.
Population health aims to improve the health of the entire population, and the definition of health expands to accommodate this idea. Many population health policies approach a broad definition of health put forth by the WHO in 1946 as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Thus, many consider the population health composed of outcomes, patterns of health determinants, and the interventions that link the two ( Fig. 1 ).
One of the most prominent examples of a public health awareness campaigns is the Healthy People 2020 outreach project. Launched in December 2010, the project outlined a decade-long plan to improve the health of all American citizens. Healthy People has worked since the 1980s on community collaborations, informed health decision, and the impact of prevention.
Healthy People identifies approximately 1200 objectives divided into 40 public health topic areas. The project also identifies a set of leading health indictors as social determinants of health and divides them into 12 topics, seen in Box 1 . Among the lead federal agencies partnering with Healthy People is the Office of the National Coordinator for Health Information Technology. As of March 2014, many of the leading health indicators were listed as “target met” (15.4%) or “improving” (38.5%). Many of the population health determinants align closely with elements of standard pediatric care.
| Access to health services | Nutrition, physical activity, and obesity |
| Clinical preventive services | Oral health |
| Environmental quality | Reproductive and sexual health |
| Injury and violence | Social determinants |
| Maternal, infant, and child health | Substance abuse |
| Mental health | Tobacco |
The digital divide
The social determinants of health are also broadly impacted by access to Internet and other digital tools, sometimes called the “digital divide.” Access to the Internet aligns with other disparities and relates to determinants of health in a balance. For example, access to Internet can increase access to medical care, but is related to one’s physical and social environment. The Pew Internet Project first assessed this disparity in 2000 and provided updated findings in 2012. One in 5 American adults surveyed do not use the Internet. Those with a disability, less education, and lower household earnings were least likely to have Internet access. Senior citizens and those who spoke Spanish as a primary language were also less likely to have Internet access. Of note, the Pew study also illustrated an increase in the use of mobile devices to access Internet services overall. Eighty-eight percent of American adults have a cell phone, and other Internet-capable mobile devices are also growing. Health care organizations in particular are beginning to use mobile strategies to reach undeserved groups and narrow the gap in Internet accessibility.
Although health information technology (IT) can improve information and even access to promote equity, it cannot reverse deep rooted disparities that lead to gaps in health and health services. Current health IT is well suited to identifying these inequities and informing possible solutions, particularly in the use of EMRs. Indeed, the largest investment of applying technology to population health concerns remains EMRs. As EMR development continues, there has also been rapid development of innovative health-related applications of health IT.
These applications, including applications on mobile devices, 3-dimensional printers for prosthetics and complex surgery planning, and social media to connect communities and support initiatives, must become an adjunct to EMR uses to improve health. EMRs impact the delivery of medical care, but cannot address all the social determinants of health. Data arising from sources external of the medical care delivery venues will be key in the success of population health information models and EMR population health solutions.
Alignment of pediatric practice with population health
The practices, procedures, institutions, and disciplines required to achieve population health are tied closely to essential elements of pediatric practice. This alignment can be described in 4 key examples: the value pediatric places on social determinants of health, the practice of the well child examination, correlation of pediatric preventative care on adult health outcomes, and extension of care into non-health care venues.
First, pediatrics has a large body of research supporting the concept of social determinants as related to child health and adulthood. Although experts in the delivery of medical care, pediatricians have also incorporated interventions, advocacy, interventions, and education into their standard practice. Pediatric research identifies key points in development which have a disproportionately high impact on outcomes. These key points are particularly influential, temporary detailed social determinants of health. Children exposed to adverse living environments (such as violence, abuse, or parental depression) have an increased risk of cardiovascular disease, depression, and suicide. In addition, a stressful living environment can increase the chances of adopting health-adverse behaviors (smoking and substance abuse).
Pediatrics has also incorporated advocacy as a core value, which involves engaging communities and evaluating individual patient needs. This practice emerged as a critical part of clinical care because it reflects the reality of a child’s life; it happens to correlate with many social and economic determinants of health as well. For example, recommending a dietary change in order to combat the risk of obesity aligns with a clinical practice guideline; however, this recommendation will be less successful if made to a lower income family that does not have a grocery store or access to fresh produce in their neighborhood.
Second, a pediatric well child examination and history compass data elements about home life and community, which tend to be more extensive and nuanced that the history obtained from an adult patient. This finding is particularly evident in the high-risk assessment screening frequently used in adolescent patients, known as the HEADSS (high-risk assessment of adolescent) assessment. Additional examples of data gathered as part of routine well child care aligns with population health determinants is seen in Box 2 .
| Well Child Care Assessment | Topics Addressed | Population Health Determinant |
|---|---|---|
| Preventative care | Vaccination | Medical care |
| Social history | School performance | Education |
| Social history | Living environment | Physical environment |
| HEADSS | Home safety | Physical environment |
| HEADSS | School performance, goals, and attitude | Education, social environment, and individual behavior |
| HEADSS | Activity, physical exercise, employment | Individual behaviors |
| HEADSS | Drug use | Social environment, individual behavior |
| HEADSS | Sexuality, sexual activity, history of pregnancy or sexually transmitted diseases | Social environment, individual behavior |
| HEADSS | Mental health | Social environment, individual behavior |
| Nutrition | Diet | Local food systems and agriculture; social environment |
| Developmental screening | Early childhood development | Medical care |
Third, a key portion of pediatric care remains the link between child and adult health outcomes. Anticipatory guidance places emphasis on developing autonomy and the deferred benefits of teaching coping skills and making choices to promote health. Healthy habits that start in childhood can directly correlate with adult wellness.
Finally, pediatric practice involves communicating with school settings and assessing community resources, particularly for education. This expansion of pediatric care beyond the traditional walls of a clinic or hospital not only increases the benefit to the nonsick population but also can shape the policies that drive funding and resources, so that “health” rather than “health care” (or “medical care”) has a priority within public and population health priorities.
How has pediatric care and population health been supported by health information technology?
Most of the examples of health IT impacting population health outcomes are rooted in the delivery of medical care. This is not due to lack of awareness of the need for comprehensive population health information models and records, but is more a reflection of the information one is able to glean from the implementation of EMRs as the most prevalent example of health IT. Even with widespread EMR adoption, gaps exist which shape the available examples of success.
In a survey administered in 2012, a majority (79%) of pediatricians who responded indicated they were using an EMR, indicating a significant increase from the previous survey 5 years before. However, only 31% had basic functionally, and only 14% had a fully functional EMR. Even within EMR adoption, disparities exist. Providers seeing a high number of public insurance patients were more likely to use an EMR, most likely because of their eligibility for meaningful use (MU) of financial incentives; smaller practices (solo or 2 physician) were least likely to adopt an EMR at this point in time.
The survey of ambulatory pediatricians reflects an overall lower adoption rate and adoption of basic instead of full functionality, which can also be seen in national data from the Office of the National Coordinator (ONC). Fig. 2 illustrates office-based physicians that attested successfully to MU; the distribution is heterogeneous, ranging from no physicians in geographically remote areas to high adoption scattered throughout the country. In contrast, Fig. 3 illustrates hospital adoption, which is nearly uniform nationally.
Despite the implementation gap in EMR adoption between hospitals and office-based physicians, health IT in general has great potential in reducing disparities, facilitating behavior changes, and improving health care. With time, this should inform and enrich public health efforts, thereby enhancing health outcomes. In a brief report in 2010, the ONC outlined how health IT might address current disparities and particularly address needs in underserved communities ( Table 1 ).
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