September 18, 2007

The Honorable Michael O. Leavitt\
Chairman\
American Health Information Community\
200 Independence Avenue, S.W. Washington, D.C. 20201

Dear Secretary Leavitt:

The Population Health and Clinical Care Connections Workgroup (PH/CCC)
encompasses a broad perspective of population health and is described
using five interrelated domains: Public Health Surveillance and
Response; Health Status and Disease Monitoring; Population Based
Research; Population Based Clinical Care; and Health
Communications/Education.

The recommendations in this document fall predominantly under the domain
of Public Health Surveillance and Response. Future recommendations will
be required to better address the remaining four domains. The Population
Health and Clinical Care Connections Workgroup (PH/CCC) has the
following broad charge:

**Broad Charge for the Workgroup:** Make recommendations to the
Community that facilitate the flow of reliable health information among
population health and clinical care systems necessary to protect and
improve the public\'s health.

**The Workgroup's deliberations highlighted a number of key issues with
respect to the broad charge:**

-   

-   Public Health infrastructure at the local, state and federal levels
    needs to be modernized to meet current and emerging threats by
    increasing the flexibility, functionality, and interoperability of
    systems that support public health.

> While public health has made progress in the last several years toward
> developing information systems to support program specific needs, many
> of these systems have followed a pattern of program specific funding
> that constrained the scope of the solution (e.g., HIV surveillance
> systems cannot adapt to serve other communicable disease surveillance
> needs). Resulting solutions are "siloed" and unable to scale to large
> complex outbreaks and events. As evidenced in the last decade alone --
> SARs, monkeypox, anthrax, and natural disasters such as hurricanes
> Katrina and Rita, public health emergencies are becoming more routine.
> Testimony has shown that point or targeted solutions built in response
> to an emergency, often relying on inexpensive and readily available
> technologies such as Microsoft Access and/or Microsoft Excel, scale
> poorly in large scale emergencies requiring complex contact tracing,
> data or information sharing across jurisdictions, and cross source
> data linking. Robust, scalable solutions that integrate detection with
> investigation and response are largely unavailable to public health
> agencies; resulting vulnerabilities could be mitigated by thoughtful
> development of a strong public health infrastructure founded on
> interoperable systems that support routine use but are designed to
> scale and adapt to emergencies. A strong public health infrastructure
> available across all jurisdictions and levels of public health,
> regardless of size, will go far toward reducing the wide variation in
> deployment of information technology that exists in public health
> today.
>
> However, before interoperable systems are developed, functional,
> security, and interoperability criteria must be in place. The lack of
> criteria for public health systems is the next key issue.

-   

-   Functional, security and interoperability criteria, and
    certification thereof, will establish the basis for developing
    flexible, information systems that can be certified for
    functionality to support public health activities.

> Public health agencies at different jurisdictional levels of have
> disparate business needs and different capacities. Across local health
> departments there are significant capacity disparities. Large
> municipal health departments may have substantially more resources
> than their smaller rural counterparts yet each are expected to provide
> similar services. Activities supported by information systems differ
> across public health jurisdictional levels. For instance, outbreak
> investigations are comprehensively carried out and conducted at the
> local or state setting, with federal assistance being requested when
> needed. Key local functions (e.g., case triage and management,
> epidemiologic investigation, contact tracing and tracking of
> laboratory diagnostics) must be incorporated in information system
> solutions. All levels of public health should collaboratively define
> criteria for interoperable systems to effectively support public
> health functions.
>
> Variable organizational responsibilities across public health
> jurisdictional levels complicate efforts to standardize
> communications. While functional requirements may differ across
> jurisdictional levels, common data needs exist for all levels; a key
> difference is in how the data are used and analyzed by each level.
> Data standard requirements are necessary to ensure content and
> transmission uniformity across organizations involved in public
> health. Our goal should be to limit the variation in capacity across
> similar jurisdictional levels while promoting interoperability across
> all levels.

-   Consistent implementation of nationally recognized data standards,
    common vocabulary standards and definitions, and systems available
    to support response are needed across organizations involved in
    public health.

> Standards to support public health functions related to response
> should be prioritized for harmonization by HITSP. Certification
> criteria should be established to evaluate software solutions for
> functionality that support public health. This reinforces
> recommendations 1.1 and 1.2 submitted to AHIC by the PH/CCC workgroup
> and accepted in March 07[^1]. These recommendations commit to
> development of an approach, including development of additional and
> more detailed use cases to support standards identification and
> methods to measure certification criteria. There is insufficient
> emphasis and resources within public health, to support the HITSP and
> certification processes to ensure there is capacity to harmonize
> standards and develop certification criteria for AHIC population
> health use cases. Software developed for public health response would
> need to adhere to HITSP harmonized standards, and meet certification
> criteria. This would promote standardized, interoperable solutions
> suitable for broad use and should curtail current redundant
> development pathways.

-   The value to clinical care for including public health as an
    integral partner in HIT should be clearly articulated and widely
    distributed.

> This issue reiterates the need for a public health business case as
> indicated in recommendation 1.0 of the PH/CCC March letter to AHIC^1^.
> Public health should be considered as more than just a recipient of
> clinical information but also as a source of information to clinical
> care. Clinical care provides case reports, adverse event reports and
> clinical data to appropriate public health entities, as well as
> providing updates to registries (such as immunization registries),
> public health adds value to data derived from multiple sources (e.g.
> clinical care, veterinary, FDA, environmental sources), and makes this
> information available to clinicians to assist them in decision-making.
> Treatment recommendations, guidelines, assistance during vaccine
> shortages as well as updates to case definitions and the notifiable
> conditions list are examples of information provided back to clinical
> care.
>
> The business case should encompass integration with clinical decision
> support (CDS) tools in EHRs and EMRs. The integration would not only
> prompt for reports to be sent to public health, but also provide
> clinical reminders from public health such as, treatment
> recommendations and guidelines or vaccinations that are due. The AHIC
> CDS Planning group focuses on CDS integration and the PH/CCC workgroup
> supports these and the other national efforts that exist in this
> space.

This letter provides both context and recommendations for how these
issues can be addressed to implement informational tools and business
operations to support real-time nationwide public health event
monitoring and rapid response management. The overarching
recommendations strive to address the key issue of strengthening public
health infrastructure. The area specific recommendations are aimed at
addressing the key issues of defining criteria and standards for
information systems that support public health.

**BACKGROUND AND DISCUSSION**

The threat of significant naturally occurring or man-made health events
is a critical issue for the nation. Once an event has been detected, the
ability to manage the event, determine the appropriate response, quickly
mobilize resources and administer countermeasures can save lives.

The real-time nationwide public health event monitoring and rapid
response management is addressed through four underlying priority areas.
These priority areas were defined and ranked by the Workgroup based on
an iterative process in 2006. The prioritization was followed by a
visioning exercise to baseline the current state, and establish
mid-state (by 2010) and end-state (2014 and beyond) visions for each
priority area. After Biosurveillance, the PH/CCC Workgroup defined and
recommended the implementation order for the following priority areas:

1.  Case Reporting

2.  Bi-directional Communications

3.  Response Management

4.  Adverse Events Reporting

Recommendations in the priority areas of Case Reporting and
Bi-directional communication were made to AHIC in March, 2007. The
Workgroup then turned deliberations to the priority area of Response
Management. The recommendations in this letter are based on Workgroup
input, and informed by testimony given on March 29th and June 15th,
2007. Testimony and the resulting recommendations focus on four
interrelated aspects of response management:

1.  Outbreak and event management

2.  Laboratory response

3.  Countermeasure allocation, tracking, distribution and administration

4.  Automated integration with registries

The overarching recommendations and the recommendations in the four
aspects of response management are aimed at addressing the key issues
described in this letter. As stated earlier, the key issue around a
business case for data/information exchange between public health and
clinical care has been covered under an earlier recommendation letter.

These recommendations seek to increase the adoption and modernize 
public health information systems by making them fully functional
(certified), and interoperable (standards compliant), in order to
support the business processes required by local (\~ 3000,) , state and
territorial ( \~ 57) and federal ( CDC and other) Governmental public
health authorized organizations.

**RECOMMENDATIONS:**

1.  **Overarching**

> The overarching recommendations are divided into two main areas. The
> first targets improvements in infrastructure by developing informatics
> expertise in the public health workforce The PH/CCC workgroup endorses
> the effort to train 1000 public health informaticians by 2010 and
> provide informatics leadership training to 1000 public health
> executives. The workgroup endorses the concept of and placement of
> chief public health informatics officers in each state health
> department.
>
> The second recommendation provides clarification for, and endorses use
> of, preparedness and other funds for building infrastructure in public
> health agencies and labs. This recommendation strives to move away
> from funding by program function which has exacerbated the diversity
> seen in existing systems, and move toward building modular systems
> that adhere to common interface specifications. Both recommendations
> seek to close the disconnect between information technology and public
> health program areas that has contributed to the inadequate
> infrastructure issue facing public health today.
>
> **Recommendation 1.0: CDC, in collaboration with AMIA, and working
> with Schools of Public Health and other informatics fellowship
> programs should enhance and promote the public health domain of the
> AMIA 10X10 initiative to advance public health informatics workforce
> development. The public health informatics competencies developed by
> the University of Washington and CDC, and other applicable work,
> should be used as a basis for this initiative to train 1000 local and
> state public health leaders by 2010.**
>
> []{.mark}
>
> **Recommendation 1.1: HHS should work with CDC and other federal
> agencies to include language in contracts, grants and cooperative
> agreements to ensure:**

-   **Funds can be invested in advancing information systems and IT
    infrastructure required to support their implementation and
    interoperability. This language should explicitly include publicly
    supported clinical systems (e.g., HRSA and CMS) and public health
    infrastructure (e.g., PH Labs, registries, and surveillance
    systems).**

-   

-   **In order to meet the requirements of the Executive Order:
    Promoting Quality and Efficient Health Care in Federal Government
    Administered or Sponsored Health Care Programs**[^2]**, funds can be
    used for technical support, to cover the cost of on-going system
    maintenance, and for updates and enhancements to provide
    functionality and adhere with interoperability specifications.**

-   **Metrics should be collaboratively developed with state and local
    public health partners to assess the ability of public health
    information systems to interoperate and support public health
    investigation and response.** **These metrics should measure and
    monitor interoperability, usability, flexibility, quality,
    completeness and timeliness of data, as well as system functionality
    to support:**

    -   **outbreak and event management**

    -   **countermeasure allocation, tracking, distribution and
        administration**

    -   **integration of laboratory information**

    -   **bi-directional exchange of data across clinical care and
        public health**

2.  **Outbreak and Event Management**

Outbreaks vary in size and complexity, and can extend across local
jurisdictions, state lines, and national borders. The SARS outbreak in
Toronto[^3] and the monkey pox[^4] response in the U.S. illustrate the
need to have systems with the ability to identify and triage suspected
cases, collect initial clinical, demographic and laboratory data on
suspected cases, support laboratory diagnosis both in the clinical and
public health laboratory sectors, collect relevant epidemiologic data to
identify important common exposures (such as places, persons,
gatherings, conveyances, or vectors) and support contact tracing and
infection control, including: tracing, monitoring and possible
quarantine of individuals exposed to a person with a communicable
disease. Systems must be in place to manage complex relationships
between cases, contacts and potential exposures. Methods for real-time
tracking of these linkages should provide public health officials with
the ability to know who to investigate, manage, offer prophylaxis,
isolate, quarantine, and/or treat.

Testimony to the PH/CCC workgroup expressed a common theme; systems to
support outbreak and event management are needed for use by public
health. Criteria for these systems should be defined collaboratively,
and the solutions should be both flexible and scalable to be used
routinely and during emergencies. A freely distributable version of
outbreak and event management software that integrates well across
jurisdictions should be made available for use by public health
departments.

> **Recommendation 2.0: By March 2008, CDC with ASTHO, NACCHO, CSTE,
> APHL and other appropriate groups, should update and refine criteria
> for functionality, security and interoperability of systems that
> support outbreak management at local, tribal, state and federal
> levels. The criteria should:**

-   **Be minimal but sufficient to support the needs of managing complex
    outbreaks**

-   **Ensure interoperability with other systems (e.g., other outbreak
    systems, laboratory information systems (LIS), electronic medical
    records (EMR), and surveillance databases)**

-   **Provide a starting point for a freely distributable software
    implementation and ongoing development and maintenance**

-   **Use as a starting point the AHIC Use Cases, the HITSP
    Interoperability Specifications, and the PHIN Functional
    Requirements for Outbreak Management.**

> **Recommendation 2.1: CDC, with input and assistance from state and
> local public health officials should support the development and
> testing of software systems designed to support the public health
> investigation and management of complex outbreaks of communicable
> disease and other health events** **(e.g., CDC Outbreak Management
> System, state or commercially-developed systems), including
> identification of important exposures, laboratory diagnostics, contact
> tracing and indication for preventive countermeasures such as
> infection control, isolation, quarantine, prophylaxis or treatment.**

-   **Facilitate the development of standards, shared architectural
    components and implementation guidance for possible and confirmed
    case exchange and make available to public health partners by
    October 2008.**

-   **Develop, or commission the development or acquisition of, and
    support the maintenance of a freely distributable software
    implementation to support local, tribal, state and national agencies
    to manage outbreaks. The criteria for this software implementation
    would be based on the collaboratively defined criteria defined in
    recommendation 2.0 above. This software should be available no later
    that March 2009.**

-   **Develop test sites to measure the level of interoperability
    between EMR. LIS, surveillance and software developed for outbreak
    management.**

**3. Laboratory Response**

Laboratory testing plays an important role in multiple domains related
to this report including Public Health Surveillance and Response, Health
Status and Disease Monitoring and Population Based Clinical Care. While
much attention has been placed on electronic laboratory reporting for
notifiable diseases (ELR), the full breadth of laboratory testing from
which actionable information can be derived extends to other processes
associated with laboratory testing including requests for testing
services and physician orders. The ability to electronically exchange
test orders and test results facilitates multiple functions including
the rapid identification of outbreaks of disease, the monitoring of the
health of a population and the generation of data essential for response
to a public health event and ongoing situational awareness. Testimony
illustrated that during an outbreak or event, laboratory test volume can
dramatically escalate, requiring the test loads be balanced among
laboratories in different jurisdictions. This was observed during the
anthrax events of 2001 when the Laboratory Response Network (LRN)[^5]
laboratories tested over 125,000 samples representing over 1 million
separate laboratory tests. The reporting, aggregation, and analysis of
the results from the many labs performing the testing was complex and
unsupported by electronic exchange between organizations involved in the
response. Significant human effort was required to consolidate and
reconcile data, activities that can be largely eliminated through
adoption of standard approaches to electronic laboratory test ordering
and reporting. The anthrax events, followed by SARs and more recently
the numerous food borne outbreaks (E. coli in spinach, salmonella in
peanut butter) illustrate the need to develop and broadly adopt common
specifications and processes to enable specimen and results tracking and
corroboration among public and private laboratories and public health
partners. Infectious diseases are not the only challenges facing public
health laboratories. Following the impact of Hurricane Katrina,
laboratory services provided by the Louisiana Public Health Laboratory
had to be shifted to other distant sites including the Iowa State
Hygienic Laboratory. The testimony not only called attention to the need
for collaboration among labs and public health partners, but also the
need for federal agencies to coordinate requirements and harmonize
requirements across the entire United States.

Coordination of reporting requirements from clinical, veterinary,
environmental and public health laboratories to state and federal
agencies would reduce the current reporting burden on labs and clear the
path to define standards and vocabulary for automated exchange of test
results. In June 2005, the department of Homeland Security established
the Integrated Consortium of Laboratory Networks (ICLN) with a
Memorandum of Agreement, to promote harmonization and coordination
across multiple laboratory networks affiliated with federal agencies
(LRN-B, LRN-C, NAHLN, FERN, eLRN, etc.). The ICLN includes 10 federal
departments/agencies including Agriculture, Commerce, Defense, Energy,
Health and Human Services, Homeland Security, Interior, Justice, State,
and the Environmental Protection Agency. The ICLN's mission is to create
a U.S. homeland security infrastructure with a coordinated operational
system of laboratory networks that provide timely, high quality, and
interpretable results for early detection and effective consequence
management of acts of terrorism and other events requiring an integrated
laboratory response. The workgroup recommends support of the interagency
coordination efforts of the ICLN.

While federal agencies play an important role in confirmation and
investigation of disease outbreaks or public heath events, the majority
of sentinel data is generated either within the community laboratory or
the local or state public health laboratory. The lack of uniform process
and standards significantly hinders the ability of federal agencies to
coordinate the response effort and limits efforts at the local and state
levels to share information efficiently. Therefore a significant need
exists to harmonize data reporting standards and guidelines among local,
state and federal agencies. Testimony addresses significant progress
being accomplished by the CDC and APHL in pilot projects directed toward
achieving a uniform approach to electronic exchange of laboratory test
orders and results reporting. The workgroup recommends the expansion of
these efforts with the goal of achieving an integrated laboratory system
focused on public health.

To achieve these collective goals the workgroup further recommends:

[]{.mark}

> **Recommendation 3.0: By June 2008, CDC in collaboration with APHL,
> CSTE, ASTHO, NACCHO, and other appropriate organizations should
> identify any types of data, codes and relationships needed (beyond
> those specified in the HITSP EHR / Biosurveillance lab result
> message), necessary to:**

-   **Support test orders to and result reporting from public health
    labs**

-   **Support the coding of public health conditions in the HITSP lab
    message**

-   **Support result reporting of veterinary and environmental data**

-   **Support unambiguous linkage of laboratory data to clinical and
    public health records**

> **The scope of this effort should be inclusive of the additional
> public health laboratory response requirements not included in the
> AHIC EHR Laboratory and Biosurveillance Use Cases (e.g. orders and
> results for veterinary, environmental and food specimens). This effort
> should include at a minimum, the AHIC Biosurveillance Minimum Data Set
> (MDS) and the** **HITSP lab result message  as well as the HITSP
> planned additions. An analysis should be done to identify possible
> additional domain vocabularies to support the expanded scope for
> public health laboratory response. The CDC should identify new
> priorities from this work and advance them through the PH/CCC
> workgroup for incorporation into the national agenda process.**
>
> **Recommendation 3.1: HHS, in conjunction with state and regional
> health information exchanges,** **public health and clinical
> laboratories, should develop the infrastructure and architecture for
> unambiguous unique identification of medical service providers in
> association with the NHIN initiative. This should include ensuring
> that registries of medical service providers exist and that registry
> lookup capability is developed and available to laboratories for
> routing laboratory data back to the originating requestor, and to
> other appropriate parties, to support national electronic laboratory
> data exchange.**
>
> **Recommendation 3.2: By October 2008, HHS, in collaboration with
> APHL, private laboratories, and other federal laboratories, should
> establish regional or national capabilities to receive and route
> laboratory results to all appropriate recipients simultaneously.**

-   **Define the processes and approaches for consolidated receipt and
    routing of laboratory results**

-   **Support a proof-of-concept demonstrating an efficient regional or
    national mechanism for the acquisition of laboratory test order
    information as well as dissemination of test results to appropriate
    public health and clinical care providers.**

-   

**4. Countermeasure** **Allocation, Tracking, Distribution and
Administration**

Response Management includes interventions (i.e., isolation and
quarantine) as well as acquisition and allocation of supportive
countermeasures (e.g., treatments, prophylaxis, and provisions) during a
pubic health response. Tracking activities include monitoring shortages
and apportioning countermeasures during a shortage, administration
management, distribution of resources, and coordination of potential
assets through the commercial sector supply chain

Some of the same issues exist in the area of countermeasures as noted in
other public health activities:

-   Standards are currently incomplete or not available to support
    countermeasure needs across jurisdictional units. Standards should
    include a set of uniform minimum data elements, common vocabulary
    and defined relationships between the data elements; operational
    guidance to include system redundancy, security, and reliability;
    and should consider methods to handle materiel identification such
    as bar coding standards.

-   Information on the availability of countermeasures in the commercial
    supply chain is, at times considered to be sensitive and proprietary
    information of commercial organizations; not readily sharable with
    public health.

-   While countermeasure distribution systems are available for tracking
    and follow-up, they are not well-integrated. There are few
    Commercial Off The Shelf (COTS) products available to support
    countermeasure administration and follow-up.

-   Customization of a COTS product can be cost prohibitive and still
    not guarantee that the final product will meet the organization's
    requirements nor interoperate with other jurisdictions or vendor
    resources.

-   Hospitals have developed and implemented electronic tracking systems
    that do not interoperate with public health resources or
    informational needs. During testimony specific local health
    departments mentioned limited capacities to fund interfacing with
    community providers and partners as it would detract from capacity
    to provide ongoing public health services.

-   Legal concerns persist regarding provision of clinical data (e.g.,
    hospital system data) to public health officials for active
    surveillance.

-   There is a need for obtaining as much information as possible during
    an outbreak or event so that you know what materials are available,
    who has them, and where the greatest need exists.

-   Information gaps exist in the supply chain, for example information
    doesn't come back from treatment centers to Point of Distribution
    (POD) sites.

Because outbreaks and events are not limit to jurisdictional boundaries,
systems must interconnect both horizontally and vertically. During a
response, secure exchange between the private sector and public health
may be needed across jurisdictions and national borders. To be
effective, this requires comparable growth toward integration and
interoperability in both public health and the private sector; a need
which the AHIC process strives to fulfill. Although it is recognized
that data needs to be exchanged across jurisdictions during an
emergency, it is also important to recognize that data must be shared on
a routine basis. In 2004, 14% of population moved domiciles at least
once. Additionally, annually a significant portion of the population
changes domiciles on a temporal basis, such as college students and
'snowbirds'.

> **Recommendation 4.0: By March 2008, CDC with ASTHO, NACCHO, CSTE,
> APHL, FDA, and other appropriate groups, should update and refine
> criteria for functionality, security and interoperability of systems
> that support countermeasure apportionment, tracking, distribution and
> administration at local, tribal, state and federal levels. The
> criteria should:**

-   **Be minimal but sufficient to support the needs of managing
    countermeasures during a response**

-   **Ensure systems are interoperable with other systems (such as
    outbreak systems, vendor managed inventories, point of distribution
    software, fatality management tracking systems, monitoring tools for
    quarantine and isolation electronic medical record (EMR), and
    surveillance databases)**

-   

-   **Provide a starting point for a freely distributable software
    implementation and ongoing development and maintenance**

-   **Develop a series of detailed use cases that support
    interoperability for countermeasure and response.** **Use as a
    starting point the AHIC Use Cases, the HITSP Interoperability
    Specifications, and the PHIN Functional Requirements for
    Countermeasure Response and Administration**

> **Recommendation 4.1: By April 2008, CDC should convene a meeting to
> include representation from clinical partners, manufacturers, and
> distributors to understand the resources that are available in the
> private sector and develop strategies to exchange information on the
> availability of and demand for resources at any given time.**
>
> **Recommendation 4.2: By December 2008,** **HHS** **should facilitate
> the development of standards, shared architectural components and
> implementation guidance through the national agenda** **for the**
> **exchange of countermeasure information and make available to public
> health partners.**
>
> **Recommendation 4.3: By June, 2008, HHS should facilitate development
> of national administrative or legal approaches for routine and
> emergency inter-state data exchange of countermeasure and immunization
> information.**

-   **Address business propriety data concerns of relevant commercial
    supply chain** **entities.**

-   **Develop a blanket agreement to provide federal support for sharing
    of data and resources when it is necessary.**

-   **Communicate to the hospital risk management staff and privacy and
    confidentiality officers in clinical care settings to alleviate
    concerns about public health access to clinical data.**

**Automated Integration with Registries**

During a response, registries may be used for multiple purposes, and the
potential for additional uses should be explored. Registries of
emergency response volunteers, credentialing, and those responders with
appropriate immunization status may be used to identify personnel
prepared to participate in a response. Similarly, during a response,
registries may be used to track people given countermeasures, being
monitored (e.g., quarantine) and those requiring long-term follow-up.
Immunization registries played a key role after hurricanes Katrina and
Rita in providing vaccination records for displaced children; saving an
estimated \$4.6 million dollars in potential revaccination costs.[^6]

In the area of immunization registries, the infrastructure for these
systems known as Immunization Information Systems is partially
established. The IIS information infrastructure is in place in a number
of States and includes characteristics that should be endorsed and
extended. In general registry systems should be population-based and
adopt industry standards-based techniques for data communication.

Capabilities developed in more established registries such as the
infrastructure of IIS and the clinical data exchange of cancer
registries could be leveraged to improve integration with both clinical
and public health registries during a response. The first step is to
facilitate dialog to discover short-term and long-term benefits that
could be realized from automating integration with registries. The
second step is to prioritize potential advances, and communicate
efficiencies that could be realized, with the appropriate parties.

> **Recommendation 5.0: By March 2008, CDC should convene a group of
> public health registry experts such as immunization, cancer, trauma,
> donor, chronic disease, and others to determine how the established
> capabilities and unique attributes of existing registries could be
> used in public health response.**
>
> **Recommendation 5.1: By October 2008, CDC should develop a
> communication plan based on discussion and recommendations from the
> March 2008 meeting. The overall goal of this plan is to communicate to
> public health officials the available registry resources for use
> during an emergency response.**

These recommendations are supported by information obtained through
research and testimony to the Population Health and Clinical Care
Connections Workgroup which is contained in the supporting documents
available at
[http://www.hhs.gov/healthit/](http://www.hhs.gov/healthinformationtechnology/).

Thank you for giving us the opportunity to submit these recommendations.
We look forward to discussing these recommendations with you and the
members of the American Health Information Community.

Sincerely yours,

/s/

John R. Lumpkin, MD, MPH

Co-Chair, AHIC Population Health and Clinical Care Connections Workgroup

Sincerely yours,

/s/

Julie L. Gerberding, MD, MPH

Co-Chair, AHIC Population Health and Clinical Care Connections Workgroup

Glossary

Infrastructure: Infrastructure includes at least the following: policy,
governance, workforce,hardware, software, services (for authentication,
routing, transport, directory).

ICLN: Integrated Consortium of Laboratory Networks

Medical Service Providers: include anyone who may be a recipient of
laboratory data or information, including but not limited to,
clinicians, dentists, veterinary labs, environmental labs.

PHLIP: Public Health Laboratory Interoperability Project

[^1]: Include March letter reference

[^2]: <http://www.whitehouse.gov/news/releases/2006/08/20060822-2.html>
    \[Accessed Sep 2007\]

[^3]: Wallington T, MD, Berger L, MD, et al. Update: Severe Acute
    Respiratory Syndrome \-\-- Toronto, Canada, 2003 Morbidity and
    Mortality Weekly Report. 2003: 52(23);547-550

[^4]: State and local health departments. Monkeypox investigation team,
    CDC. Update: Multistate Outbreak of Monkeypox \-\-- Illinois,
    Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. Morbidity and
    Mortality Weekly Report. 52(25);589-590

[^5]: Centers for Disease Control and Prevention, Atlanta, Ga. **The
    Laboratory Response Network Partners in Preparedness.** Available
    from URL: http://www.bt.cdc.gov/lrn/examples.asp \[Accessed Sep
    2007\]

[^6]: **Immunization Information Systems Use During a Public Health
    Emergency in the United States,**

    *J Public Health Management Practice*, 2007, 13(5), 481--485