To understand the need for adoption of standard Public Health Informatics (PHI) design methods requires a brief background of PHI, the environment in which public health information systems are used and the unique challenges encountered in designing information systems for use in public health practice.
The unique field of Public Health Informatics: population-focused and diverse
Public Health Informatics is the "systematic application of information and computer science and technology to public health practice, research, and learning that integrates public health and information technology"[
1]. And, as stated by Yasnoff et al.[
2], PHI needs to use a "systematic and informed approach to the application of information science and technology in order to take full advantage of its potential to enhance and facilitate public health activities." Such activities include:
• Promotion of the health of populations as "opposed to the health of specific individuals."
• Prevention of disease and injury "by altering the conditions or the environment that put populations of individuals at risk."
• Prevention at all vulnerable points in the "causal chains leading to disease, injury, or disability ... not restricted to particular social, behavioral, or environmental contexts."
• Reflection of the "governmental context in which public health is practiced "[
2].
In the application of information science and technology to population health, the challenges of PHI are unique. For example, unlike clinical informatics, PHI design activities cannot simply focus on an individual's data in an Electronic Health Record (EHR), the transmission of a specific patient visit in a data stream between a health care provider organization and public health agency or an intervention targeted to an individual patient. Instead, PHI design activities must take a more systemic approach that allows access to population-level data with functionality tailored to a variety of uses by different groups of practitioners. Instead of individual patient data, public health information systems need to include and manage entire datasets of patient encounters. Supporting prevention-centered activities moves the focus further up the causal chain of health and is less likely to manifest in an individual patient visit, but might instead be seen as a population-level prevention intervention, e.g., a city-wide anti-tobacco campaign. These prevention activities take place in diverse environments since the interventions may be social, behavioral, environmental or individual interventions. In addition, public health informaticians must always consider the governmental context in which these population-level prevention activities take place. Understanding the health services structure and how that structure affects the work done by public health practitioners is an important step in creating systems that will function within that context.
Diversity in public health practice presents challenges for public health informaticians. A perceived lack of standard work practices across local health jurisdictions on the part of practitioners and administrators complicates public health information system design activities. If each state or local jurisdiction has unique information needs and business processes, then each must make individual design decisions to ensure that their needs are met. Recent efforts have been undertaken to create standards for business processes in the nation's local health jurisdictions. These efforts have uncovered unexpected commonalities[
3] as well as developed a taxonomy of common public health work tasks, knowledge and resources[
4]. Yet it has been argued that there is a great deal of variability in local health jurisdictions[
5] and further research is necessary to document the needs and tasks of public health practitioners within specific local health jurisdictions to design technology to support these needs and tasks[
6].
Adding to this diversity of practice and settings is the diversity of national and international settings in which these activities take place. The globalization of public health necessitates a globalization of PHI to address the challenges of disparate data, tools and services within and across nations--both resource-rich and -constrained. Issues of conflicting data standards, the need for interoperable tools for exchanging and sharing data and the need for innovative solutions to address integrated disease surveillance, among many other issues, are driving forces to formalize design strategies in PHI.
The development of public health information systems requires an understanding of the principles, practices, structures and settings in which these systems operate. Although this combination of factors presents unique challenges, PHI is at a point in its evolution as a discipline that public health informaticians can learn from the design theories and experiences of other fields to address these challenges.
Evolution of public health information systems in the US and Europe: three waves
According to Lumpkin, federal-state public health information systems in the United States have been developed in three "waves"[
7]. The first wave began with the independent development of state and federal systems which could not exchange data; the second wave, supported by federal funding to develop state level systems capable of exchanging data using standards in building independent--and therefore costly--state systems[
7]; and the third wave which focused on reducing costs through the integration of "the benefits of state-level system development with the tools of software reuse" and a requirement that "each system that is developed must be standards based"[
7].
Similarly, in Europe, public health information systems developed in three comparable waves[
8]: a first generation of systems focused on collecting basic data on a population and/or the health of a population (for example, birth and death data); a second generation of systems that combined stratifications of time-series data and international comparative data as seen in comparisons of age-standardized breast cancer incidence rates by sex over time and country; and the third generation in the present, with the public health information system that is made possible by information technology advances and is referred to as an ''integrated knowledge system'' in its integration of data, descriptive and analytical information, and evidence-based knowledge[
8].
In both the European and US contexts, this current third wave of public health information systems utilizes electronic data exchanges and standards to solve the information needs of public health workers at different organizational levels, across organizations and with various health care and government stakeholders--thus addressing the challenges of population focus and diversity discussed above. While a common approach to this third wave presumes that system designers both have sufficient knowledge of the work of public health practitioners and can systematically integrate this knowledge into system design, past technology failures suggest that this is not the case and numerous studies have underscored the fact that a system will not be used by health professionals in everyday practice unless the system is usable. While a literature review on challenges to adopting or deploying health information systems is beyond the scope of this paper, these challenges are pertinent to the topic of design and PHI. The reader is referred to the work of Kushniruk et al.[
9] and Peute et al.[
10] for additional information.
Complex problems and design challenges in public health
Ignoring the user experience has led to a literature replete with numerous examples of health information systems being "turned off" or rejected by health professionals because these systems were developed without an understanding of the information needs, workflow, or architecture needs of system users[
11,
12]. As previously noted, public health processes and practices can be difficult to define, developing clear descriptions of this work requires concerted effort[
13], and a public health information system that meets the needs of one group may simultaneously create more work for other groups of public health practitioners[
14].
The focus of public health agencies on the development and implementation of information systems is a relatively new phenomenon. Public health informaticians face significant challenges in designing and implementing flexible, interoperable, usable systems to meet the needs of public health practice. Recommendations for a national agenda for PHI in the United States were not formally outlined until 2001[
15] and competencies for public health informaticians that include "expertise in both public health programs and information systems to help design, implement, and manage computer applications that support public health goals"[
16] were only finalized in 2009. The outcome is that many public health information systems often came into existence through an ad hoc and informal design and development process[
17,
18] yet the public health domain represents a complex design setting.
Complex design problems of the type encountered in the public health domain are not new. Following World War II, Weaver defined problems of disorganized complexity and organized complexity[
19]. Weinberg discusses problems of disorganized complexity as large, random populations that are subject to statistical treatment while individual problem cases are members of small, structured populations that are subject to individual analysis[
20]. Information design in PHI addresses a problem area of organized complexity that is subject to neither individual nor statistical analysis.
Rittel and Webber frame their design discussion by enumerating a list of problems and claim that defining what systems do and planning what they should do in terms of desired outcomes can be difficult, if not impossible in large, societal systems[
21]. Buchanan holds that "the problem for designers is to conceive and plan what does not yet exist and this occurs in the context of the indeterminancy of wicked problems" and this "indeterminancy implies there are no definitive conditions of limits to design problems"[
22]. Nevertheless, public health practice hinges on information that is managed by information systems and those systems
must be designed. Our proposed approach for PHI is not to specify design solutions in advance but to specify a flexible process that involves public health practitioners to design solutions for public health systems of organized complexity. This approach is supported by the writings of Cross who summarizes forty years of design and notes that the "wicked problems" characterized by Rittel are more appropriately satisfied by "an 'argumentative', participatory process in which designers are partners with the problem 'owners'" rather than by a rigid, step-wise process[
23].
Problem representation in the design of complex systems requires reflection. Simon explicated the formidable task of representing new problems that do not fit with previously known patterns[
24] while Lawson reflects on the need for a process that allows problems and solutions to emerge simultaneously and reflect each other[
25]. Numerous design thinkers cite the contribution of Donald Schön's model of the "reflective practitioner" and a model of inquiry that relies on interactive problem framing [
23,
25‐
27]. In formalizing his approach to scenario-based design, John M. Carroll has built on Schön's metaphor of design as a conversation[
28].
We propose that PHI can benefit from design theories and methods developed in other disciplines to improve public health information systems by addressing the unique work of public health practitioners. In the next section we describe six general design problems as defined by Carroll[
29] and provide examples of how those problems express themselves in the unique context of the public health domain. We then present a strategy for creating reusable design knowledge using established participatory and scenario-based design methodologies. Finally, we address some potential challenges to the approach we propose.