Public Health Informatics and the Future of Public Health

I wrote this essay almost six years ago, while I was in graduate school working on my MPH. I stumbled across it recently and thought to share it, especially given the direction in which my career has moved.

Public health informatics represents an exciting area of future growth in public health, where many different disciplines are applied to solving practical social problems. By attaching established public health practices to the rapidly expanding technological tools available in our modern society, whole new avenues of analysis and intervention can be developed for public health practice. Harnessing the information available thanks to this fusion of technology and practice will alter, and may fundamentally change, the function and nature of public health. New challenges will arise with new frontiers in informatics, and preparing for these challenges – by understanding the power of informatics, as well as its limits and dangers – is a necessary task for all public health practitioners.

Public health informatics can be defined as the “Systematic application of information and computer science and technology to public health practice, research and learning.” We can simplify the definition by stating that informatics deals with how to acquire, store, and utilize data in effective ways. A central issue in informatics is, therefore, data – more specifically, the problems associated with gathering data, presenting data, and using data.

As public health practitioners, we make inferences from statistical data. This is a core feature of two of the main domains of public health practice, biostatistics and epidemiology. Anyone who has sat through the introductory classes on biostatistics and epidemiology has learned about the concept of power – how many data points we need to ensure a statistically useful result. Informatics will have to deal with the converse of this issue: how many data points are too many?

Consider the rapid acceleration of computing technology over the course of the 20th century. Even items such as cell phones, ubiquitous by modern standards, have radically altered our society. 25 years ago, carrying around a pocket communication device with worldwide reach was the province of science fiction shows such as Star Trek. Today, these devices are real, and are as commonplace as vending machines and newspapers. If we apply this paradigm of growth to public health, we can see staggering trends. As technology continues to improve, the ability of public health practitioners to gather data will be increased concordantly. The resultant glut of data – a veritable feast of variables, data points, and statistical trends – presents new and, heretofore, unique challenges to public health.

One challenge waiting in the era of increased public health information is the question of what to gather. Gathering data requires us to define, a priori, what exactly “data” is. Informatics may very well make available to us the ability to gather information that was previously inaccessible. However, if we do not utilize the tools of informatics to capture this data – if we do not, in a sense, update our vision of what constitutes data – then there will be little benefit to the increasing power of public health informatics. Similarly, the increased ability of public health practitioners to gather data does not necessarily translate into a moral mandate for such collection. While it is cliché to refer to “Big Brother” watching the population, it is also necessary to note that the increased ease of data gathering carries its own ethical questions about what is a legitimate use of such power and what is antithetical to the existence of a free and democratic society. Addressing these questions should not be done in passing, and is a critical part of ensuring a good future for public health informatics.

Turning away from the gathering of data, we also need to consider what to do with the data we have collected. Experience has shown that human beings have a finite ability to process information, whether as a result of biological constraint or simply how our minds work epistemologically. While it may be a great technological achievement to obtain 50 million data points in an effort to describe a population, this achievement has no practical value if the data is locked away in a spreadsheet so large that it defies human comprehension. The fact that a computer program or database knows thousands of useful things about a patient is only relevant if we can successfully communicate that information to individuals involved in patient care. Such communications can be difficult, as resistance to clinical decision support among physicians has demonstrated.

As these challenges have illustrated, public health informatics faces many struggles in its infancy. At the same time, the promise of public health informatics is striking. Initially, it may appear that informatics is simply using established analytic tools on existing data; from this standpoint, there is nothing at all revolutionary about informatics. This is the position I initially took towards informatics – that it was merely harnessing our existing information and making use of existing tools. While this is certainly a current use of informatics, it would be unwise to mistake this current use as the ultimate use of this field.

As our capacity for data collection, storage, presentation, and use increase, the ability of public health to integrate the individual and the community into a cohesive analytic whole will simultaneously increase. We are now in the position of choosing between taking an individualistic approach to health (emphasized by the medical field and the patient/physician relationship) or a population approach to health (championed by public health practitioners). This is done in part because human beings must specialize in one or the other to be effective. Some of us try to effect change on an individual level, helping one person at a time, while others work to improve the health of a whole population through systemic change. The extensive debate between these two sides leads us to a general consensus, which is that both are important. This conclusion, however, represents something of an unfunded mandate. Medicine and public health are both very important, but we lack the tools to integrate them into a whole.

Informatics represents a potential bridge – built far into the future, of course – which might unite the two disparate fields into a cohesive whole. The dichotomy between medicine and public health is caused, at least in part, because it is nigh impossible to generate a single person who can deal effectively with both fields. There is simply too much data and too much to be done for this to be a practical endeavor. Informatics is, potentially, the tool which can resolve this. With the enough information, and the tools to manage and use that information, we can mesh the dual concepts of “the group is individuals” and “individuals are the group”. The resultant concept, a view that does not force us to choose between one or the other in pursuing knowledge and working for better health, would fundamentally alter both public health and medicine, forever sweeping away the bunkers and battlements of the current time. In this sense, Dr. Kaelber is completely correct: informatics “has the power to transform the field of public health” – and perhaps even the world.

Works Cited
1. Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M. A National Agenda for Public Health Informatics: Summarized Recommendations from the 2001 AMIA Spring Congress. Journal of the American Medical Informatics Association 8.6 (2001).
2. Kaelber D. Personal communication after a lecture for MPHP 506 – The Future of Public Health, Case Western Reserve University. 03 November 2008.
3. Kaelber D. Lecture presentation for MPHP 506 – The Future of Public Health, Case Western Reserve University. 03 November 2008.

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