Table 1 Characteristics of the LaPHIE system, February 2009 through January 2011 Characteristics of alerts Alerts issued Of these, alerts issued to providers on time without technical delay* Of these, encounters with documented clinician action in alert Alerts per person, mean (SD), range Speciﬁc actions documented (could be more than one) Any action taken Scheduled and referred Discussed importance of treatment Assessed disease stage Obtained more lab tests Commented in system Admitted Not interested in treatment In treatment elsewhere Other action Characteristics of identiﬁed patients Unique patients linked into surveillance system Previous HIV diagnosis but never received CD4 or viral load monitoring Previous HIV care >12 months prior to identiﬁcation date Median time from last visit to point of identiﬁcation by LaPHIE, months (median, IQR) Any follow-up CD4 or HIV viral load test in study period Of those who had been out of care >12 months, had at least one CD4 count *21 additional alerts were acted upon despite a delay of >2 h. 1.43 (0.89), 1e7 N 488 405 294 315 206 164 81 34 31 22 18 15 27 345 84 261 20 (15e36) 283 183 % 83 73 78 65 52 26 11 10 7 6 5 9 24 76 82 83 and other aspects of the LaPHIE Intervention Note they would like added over time. No negative feedback has been received from providers. Patient acceptability is a critical facet of LaPHIE. Results of acceptability evaluation revealed that: (a) there was general acceptance, indicating support for the proposed secure electronic exchange; (b) the information should only be shared between public health and healthcare providers when there was beneﬁt to the patient and/or the community; and (c) the healthcare delivery setting was the desired environment for communication of these diagnoses and need for follow-up, rather than the traditional community-based outreach methods used by public health. Qualitative post-intervention interviews were conducted with 20 HIV-infected persons identiﬁed via LaPHIE. Content analyses of these data reveal consistency of theme, with those identiﬁed individuals expressing acceptance and recognizing the value of the system. CHALLENGES Challenges encountered with LaPHIE during design, develop- ment, and implementation were substantially less than expected relative to the extensive nature of the initiative. These chal- lenges were largely philosophical in nature and concerned the ethics of the project. For example, there were diverse philoso- phies, perspectives, and policies among public health and healthcare practitioners. The process of data sharing and artic- ulating issues concerning data ownership and understanding and agreeing on methods to legally and ethically protect sensitive protected health information and HIV diagnoses were key J Am Med Inform Assoc 2012;19:448e452. doi:10.1136/amiajnl-2011-000412 Case report components of the dialogue prior to implementation, as the IDN and State strove to balance individual rights and protection of the public’s health. Other issues included characterization of the strengths and limitations of surveillance data for clinical decision making, disparate technical infrastructures and resources, and communication among providers. However, with continued success in linking patients into treatment for HIV, these chal- lenges have rapidly become the system’s strengths. The effort put forth by all stakeholders to build consensus and a commit- ment to protecting patients and public health has been shown to be enormously valuable. The participatory approach and the thoughtful, deliberate process to shared decision making between public health and healthcare delivery stakeholders when surmounting these challenges provided the foundation for success. DISCUSSION LaPHIE demonstrates that real-time, bidirectional electronic information exchange can bridge public health and healthcare delivery, effectively leveraging EMR-based public health alerts, and linking patients into care. Preliminary analyses of LaPHIE reveal its efﬁcacy at increasing linkage and retention in care, systematically improving individual and public health in one of the states most heavily impacted by the HIV epidemic. Providers are responding to LaPHIE alerts at a higher rate than usually observed. Previous research has demonstrated that clinicians responded to ‘public health situational awareness’ alerts at rates of 2e65%.19 One critical factor identiﬁed as most inﬂuencing response to alerts is speciﬁcity.20 Furthermore, inte- grating contextually relevant information at the point of care has been shown to improve compliance with preventive care measures.21e23 LaPHIE alerts are patient speciﬁc, only issued on those in need of treatment and integrated into the work ﬂow. Use of the iterative prototype design approach incorporating usability study ﬁndings has ensured LaPHIE meets all of the goals of any reminder system: ‘right information, right time, right person, right format.’21 More formalized qualitative interviews evaluating system value will examine implementa- tion, utilization, integration in and impact on work ﬂow, use of the LaPHIE Intervention Note, impact on patients, and overall system satisfaction. A purposive sample of at least 10% of clinicians exposed to LaPHIE alerts will be interviewed as part of the demonstration evaluation methodology. The costs of the system are currently being evaluated. After development and initial evaluation efforts, resources (minimal personnel) to monitor the functioning of the system at the healthcare delivery and public health sides of the exchange are needed as are resources to grow the system as new opportunities to expand use are identiﬁed. Costs associated with all directly funded and in-kind personnel as well as infrastructure costs (hardware, network management) have been documented; the cost savings and cost effectiveness of the program have not yet been determined given that evaluation is still ongoing. Models to be used to quantify these will include cost savings associated with prevention of morbidity from patients entering care at an advanced stage of HIV disease as well as costs saved through the prevention of HIV transmission. Discounted lifetime costs to provide treatment for a patient with a CD4 cell count of <350 are estimated at $385 200 and undiscounted costs as high as $618 900 ($2100 per month, life expectancy 24.2 years).24 There is evidence that the annual costs of treatment and care are less for those who initiate treatment with higher CD4 counts.25e27 Potential savings per HIV infection prevented have been esti- mated at $266 600 (2004 dollars).24 28 Efforts such as LaPHIE 451