Immediate State and Local Strategies for a Public Health Emergency

The Coronavirus pandemic is a reminder of the essential role of public health emergency preparedness and response in ensuring the health and strength of our communities.

However, not since the Spanish influenza pandemic of 1918 has there been an infectious disease threat as devastating to our society as COVID-19. Never in our lifetime have we seen high and middle-income countries like China, Italy and the U.S. face the need to ration respirators and lack of testing equipment. Reaching over two million cases globally according to the World Health Organization, the COVID-19 pandemic is testing the strength and resiliency of the global health system and our front-line healthcare workers’ well-being is threatened due to coordination and resource gaps that have been the center of attention.

Though many health IT systems, electronic data and exchange capabilities exist across the globe that could help prevent, detect and respond effectively to a public health emergency, few systems have been optimized to meet surveillance, reporting and other outbreak management needs in response to an emerging disease of this magnitude.

Thus, HIMSS supports states and local communities that open the door to immediately scale up telehealth and electronic case reporting (eCR), and which expand the state and local IT infrastructure and health information exchanges, where they exist. There are many short- and long-term policy and funding mechanisms that state and local jurisdictions in the U.S. can leverage to scale-up their efforts using health IT to combat a public health emergency like COVID-19.

Empower Electronic Case Reporting

Leverage relief funding that supports eCR and that enables cross-jurisdiction sharing of notifiable condition reports—through mandated public statute or regulation—as part of routine public health data submission and query.

1. Given current COVID-19 data collection and aggregation efforts, states should leverage easily scalable solutions like a Centers for Disease Control and Prevention (CDC) Foundation-supported EHR-lite mechanism to ensure consistent quality data reporting to the state health departments and to the CDC. The CDC will be releasing an app for providers that currently do not have the ability to send COVID-19 case reports electronically. The FHIR-based app will connect digital case reports to existing health IT infrastructure, giving public health agencies access to data in real time to improve case management and contact tracing. The use of these IT tools is vital to ensuring that underserved and rural communities are able to respond to the current public health emergency and any future health crisis.
2. States should also prioritize the establishment or expansion of reporting on additional data elements during public health emergency declarations such as bed capacity, workforce, personal protective equipment, etc., where assessment and coordination to handle system surge is supported by data.
3. Moreover, states should mandate that demographic data is captured and shared with state and local public health authorities to support contact tracing, hot-spotting and informed policy decision-making. This activity is especially important as providers leverage point-of-care tests.

Expand Telehealth Services

All states should immediately scale-up telehealth services to reduce the number of individuals using healthcare facilities while at the same time preserving and improving health. Flexible and constructive guidelines for Medicaid can help states account for the uninsured population or those outside of the safety net.

1. While over 40 states have “parity” laws in place for telehealth services, we strongly encourage states to include or expand provisions for both coverage and payment parity for commercial plans and for all Medicaid plans (Fee-for-Service and Medicaid Managed Care Plans). States should set the parameters for reimbursements rather than having each provider individually negotiating their own reimbursement fee for telehealth encounters.
2. States are encouraged to require private insurance carriers to reimburse for telehealth in the same way as an in-person visit. Payments to providers should be the same as an in-person visit and should (1) extend to post-COVID-19 encounters, (2) extend across all health plans in a state’s jurisdiction (Medicare, Medicare Advantage, Commercial, Medicaid Fee-for-Service, Managed Medicaid) and (3) apply to non-COVID-19 related visits, which is essential in supporting vulnerable populations, including patients with chronic illnesses and will likely reduce the burden of providers now and post COVID-19 along with improving population health.
3. HIMSS also encourages states to maintain telehealth expansions for ongoing treatment and remote patient monitoring for persons with chronic conditions and compromised immune systems beyond the pandemic. Virtual care delivery models support the Quadruple Aim by improving access, care coordination, clinical outcomes and supporting patient engagement. The U.S. Department of Health and Human Services created funding mechanisms through Centers for Medicare & Medicaid Services (CMS), CDC, Health Resources and Services Administration and the Federal Communications Commission (FCC) by which states can permanently retain the virtual life-saving connected care models, and increase disease prevention and treatment measures that are essential to combat a public health emergency.
4. State legislatures should move quickly to expand license portability, (i.e., the Interstate Medical Licensure Compact) to make it easier for providers to acquire licenses to practice in multiple states using telehealth in response to the Coronavirus pandemic.
5. States are also encouraged to allow healthcare providers to engage in asynchronous telehealth services, such as store-and-forward, provided that any and all telehealth practices are clinically appropriate, properly documented and otherwise comply with proper standards of care.
6. States should consider permanently including the originating site (the location of the patient) to include the patient's home to boost remote patient monitoring (RPM) during the COVID-19 crisis and these efforts should be extended beyond the 12-24 months following the COVID-19 crisis as a lever to deliver quality care for patients with chronic conditions, reducing their need to visit the emergency department or be admitted to the hospital as an inpatient.
7. We strongly encourage states to maximize their participation in federal funding programs for healthcare telehealth network infrastructure and connectivity offered through the FCC, U.S. Department of Agriculture, and other agencies, with the consideration providing a state funding match is aligned with federal funding.
8. Given the dynamic nature of the Coronavirus pandemic, states should ensure that providers who are not able to make significant investments in modern telehealth technology have a mechanism to reach their patients. HIMSS also encourages states to support telehealth networks that build on peer-to-peer consulting that bring specialty expertise to small or rural providers through Project ECHO or similar programs.
9. Further, states are encouraged to embrace mobile health solutions that support the transmission of patient health information using smartphones or tablets through secure applications while protecting patient privacy. Moreover, the Health and Human Services Office for Civil Rights has made allowances for providers to reach the most vulnerable populations using communications apps for any telehealth treatment or diagnostic purpose, regardless of whether the telehealth service is directly related to COVID-19.

RELATED: Telehealth in the COVID-19 Spotlight

Strengthen Infrastructure

Strengthen the public health and health data infrastructure by using current relief funding to prioritize syndromic surveillance, emergency and environmental data with clinical care documentation using standards-based platforms (e.g., FHIR, etc.).

1. Utilizing the Department of Homeland Security (DHS) Fusion Model, states can make available a set of protocols, methodologies, and tools that support standards-based interoperability and information sharing during crises. This approach allows community partners to leverage needed data sources that may not be currently available to them. The DHS protocols help healthcare leaders understand data ownership and data sharing policies before a public health emergency takes place. In addition, preparedness drills and exercising should take place with all important community stakeholders, in order to validate expectations and responsibilities—maximizing the utility of the incident command structure.
2. States should consider the use of smart health technologies such as artificial intelligence and machine learning to provide predictive analytics with hourly detection as well as continuous monitoring for potential outbreaks leading to greater situational awareness and timelier interventions.
3. Public health communications infrastructure is similarly important, and states should take advantage of the growing availability of mobile phones and internet-based reporting tools that may inform outbreak and diagnostic reporting, particularly where traditional surveillance systems are outdated.

Utilize Health Data Sharing

Leverage Health Information Exchanges (HIEs) or cross-sector health data sharing platforms to collect data across sectors including electronic health record data, emergency room encounters, emergency medical services (EMS) data, public health surveillance data, etc. Such an approach can be useful in creating targeted interventions, public health emergency response plans relating to communicable diseases and to support health impact assessments that policymakers can leverage to make informed decisions during all hazards.

1. States have the authority to declare and deputize an HIE to collect Coronavirus information and should consider the role HIEs may play in enabling automatic submission of syndromic surveillance information to the state health department, and the collection of COVID-19 test data from hospitals, labs, EMS systems and community test sites (e.g., churches, drug stores, other retailers). Such a process could reduce the data reporting obligations of providers.
2. States may also engage HIEs and local and state epidemiologists to create dashboards that leverage aggregated and anonymized location data from social media sources and support the creation of disease prevention maps. Concrete examples of this can be found in the states of Washington and Indiana.
3. Moreover, given the socio-economic impacts of the current public health emergency, states should consider how HIEs can support clinical and public health workforce needs, care coordination, and in the management of data related to the social determinants of health, which are crucial to the delivery of care to vulnerable populations.

Our recommendations clearly point to how health information and technology can be an instrumental and vital part of an all-hazard, global disaster management system. We strongly urge all state and local governments to act now to prioritize these strategies and related resources not only to combat the COVID-19 pandemic but to set the stage for a 21st century health system that is better able to prevent and eradicate insidious health threats.