OBJECTIVE: Although biomedical informatics has multiple roles to play in addressing the climate crisis, collaborative action and research agendas have yet to be developed. As a first step, AMIA's new Climate, Health, and Informatics Working Group held a mini-summit entitled Climate and health: How can informatics help? during the AMIA 2023 Fall Symposium to define an initial set of areas of interest and begin mobilizing informaticians to confront the urgent challenges of climate change. MATERIALS AND METHODS: The AMIA Climate, Health, and Informatics Working Group (at the time, an AMIA Discussion Forum), the International Medical Informatics Association (IMIA), the International Academy of Health Sciences Informatics (IAHSI), and the Regenstrief Institute hosted a mini-summit entitled Climate and health: How can informatics help? on November 11, 2023, during the AMIA 2023 Annual Symposium (New Orleans, LA, USA). Using an affinity diagramming approach, the mini-summit organizers posed 2 questions to ∼50 attendees (40 in-person, 10 virtual). RESULTS: Participants expressed a broad array of viewpoints on actions that can be undertaken now and areas needing research to support future actions. Areas of current action ranged from enhanced education to expanded telemedicine to assessment of community vulnerability. Areas of research ranged from emergency preparedness to climate-specific clinical coding to risk prediction models. DISCUSSION: The mini-summit was intended as a first step in helping the informatics community at large set application and research priorities for climate, health, and informatics. CONCLUSION: The working group will use these perspectives as it seeks further input, and begins to establish priorities for climate-related biomedical informatics actions and research.

OBJECTIVE: This communication presents the results of defining a tribal health jurisdiction by a combination of tribal affiliation (TA) and case address. MATERIALS AND METHODS: Through a county-tribal partnership, Geographic Information System (GIS) software and custom code were used to extract tribal data from county data by identifying reservation addresses in county extracts of COVID-19 case records from December 30, 2019, to December 31, 2022 (n = 374 653) and COVID-19 vaccination records from December 1, 2020, to April 18, 2023 (n = 2 355 058). RESULTS: The tool identified 1.91 times as many case records and 3.76 times as many vaccination records as filtering by TA alone. DISCUSSION AND CONCLUSION: This method of identifying communities by patient address, in combination with TA and enrollment, can help tribal health jurisdictions attain equitable access to public health data, when done in partnership with a data sharing agreement. This methodology has potential applications for other populations underrepresented in public health and clinical research.

OBJECTIVE: The annual American College of Medical Informatics (ACMI) symposium focused discussion on the national public health information systems (PHIS) infrastructure to support public health goals. The objective of this article is to present the strengths, weaknesses, threats, and opportunities (SWOT) identified by public health and informatics leaders in attendance. MATERIALS AND METHODS: The Symposium provided a venue for experts in biomedical informatics and public health to brainstorm, identify, and discuss top PHIS challenges. Two conceptual frameworks, SWOT and the Informatics Stack, guided discussion and were used to organize factors and themes identified through a qualitative approach. RESULTS: A total of 57 unique factors related to the current PHIS were identified, including 9 strengths, 22 weaknesses, 14 opportunities, and 14 threats, which were consolidated into 22 themes according to the Stack. Most themes (68%) clustered at the top of the Stack. Three overarching opportunities were especially prominent: (1) addressing the needs for sustainable funding, (2) leveraging existing infrastructure and processes for information exchange and system development that meets public health goals, and (3) preparing the public health workforce to benefit from available resources. DISCUSSION: The PHIS is unarguably overdue for a strategically designed, technology-enabled, information infrastructure for delivering day-to-day essential public health services and to respond effectively to public health emergencies. CONCLUSION: Most of the themes identified concerned context, people, and processes rather than technical elements. We recommend that public health leadership consider the possible actions and leverage informatics expertise as we collectively prepare for the future.

The COVID-19 pandemic exposed multiple weaknesses in the nation's public health system. Therefore, the American College of Medical Informatics selected "Rebuilding the Nation's Public Health Informatics Infrastructure" as the theme for its annual symposium. Experts in biomedical informatics and public health discussed strategies to strengthen the US public health information infrastructure through policy, education, research, and development. This article summarizes policy recommendations for the biomedical informatics community postpandemic. First, the nation must perceive the health data infrastructure to be a matter of national security. The nation must further invest significantly more in its health data infrastructure. Investments should include the education and training of the public health workforce as informaticians in this domain are currently limited. Finally, investments should strengthen and expand health data utilities that increasingly play a critical role in exchanging information across public health and healthcare organizations.

The Journal of the American Medical Informatics Association (JAMIA) focus issue on Global Health Informatics (GHI) examines how health informatics can address global health issues. The selected papers discuss how informatics can improve health outcomes, especially in low- and middle-income countries (LMICs). The articles in this issue come from a broad range of researchers, practitioners, and policymakers, provide an overview of GHI initiatives and encourage researchers and practitioners to share ideas and best practices. GHI aims to harness digital health and informatics knowledge and tools to improve the care of individuals and populations in LMIC through achieving these 5 aims: effectiveness, efficiencies, patient satisfaction, provider well-being, and equity. A central consideration is the global north-south divide and the sociotechnical determinants of and impacts on the digital health maturity of LMIC. This issue seeks to document and understand how health informatics approaches have been undertaken in multiple LMIC scenarios and environments and how they can demonstrate the scientific impact of informatics-based best practices applied to COVID-19 and beyond. Increasing the understanding of current GHI work is important for the entire field of biomedical and health informatics; arguably, global health touches upon all 5 of the recognized domains of biomedical informatics, from translational to public health. This focus Issue aims to advance the science and application of GHI in sustainable, scalable, and capacity-building health information technology (HIT) systems that improve individual patient and community health outcomes. In addition, this focus Issue sought to bring to highlight specific innovative health informatics approaches and solutions developed and evaluated to address the COVID-19 pandemic preparedness and response across LMIC. Multiple opportunities exist to leverage and integrate lessons learned from these approaches into our US-based institutions. We share the contents and constraints of this focus issue and identify opportunities for health informatics and the American Medical Informatics Association (AMIA). COVID-19 and other pandemics of noncommunicable diseases have tested the resilience and fitness-for-purpose of HIT systems in all countries, subnationally and internationally, exposing their structural and functional inadequacies and inequities across all the “divides.” Massive investments into HIT systems have helped the response. However, the mainly ad hoc development of new and repurposed digital tools, without explicit reference to or compliance with interoperability standards, is worrisome in terms of an integrated (and interoperable) global response to “long COVID” and the next pandemic. On the other hand, the response to incorporating COVID-19 terminology in WHO ICD-11 was timely, auguring well for the health and informatics communities.1 The pandemic has also highlighted the need to develop guidance and regulatory frameworks for creating, managing, and procuring HIT systems. The GHI community needs to be vigilant that this COVID-driven investment is built by emphasizing interoperability standards and seamless implementation into the healthcare workflow. AMIA and the American College of Medical Informatics (ACMI) have roles in collecting and creating the evidence to support the GHI community to achieve the quintuple aims and improve individual and organizational digital capability maturity concurrently. The call for current research and perspectives was intentionally broad to encourage submissions from multiple authors representing diverse regions. Solicited topics included data governance and sharing, interoperability, data-driven policymaking, clinical-based solutions, telemedicine, consumer-based solutions, and specific COVID-19 informatics responses, including vaccination distribution and vaccine passports. This issue includes 11 articles summarized in Table 1 that reflect these broad topics of interest.2–12 Papers included in this focus issue, grouped by primary theme mHealth COVID-19 mHealth Data governance COVID-19 mHealth COVID-19 Data analysis COVID-19 Interoperability and standards COVID-19 Data analysis COVID-19 Misinformation and global health COVID-19 mHealth COVID-19 mHealth Data governance COVID-19 mHealth COVID-19 Data analysis COVID-19 Interoperability and standards COVID-19 Data analysis COVID-19 Misinformation and global health COVID-19 Papers included in this focus issue, grouped by primary theme mHealth COVID-19 mHealth Data governance COVID-19 mHealth COVID-19 Data analysis COVID-19 Interoperability and standards COVID-19 Data analysis COVID-19 Misinformation and global health COVID-19 mHealth COVID-19 mHealth Data governance COVID-19 mHealth COVID-19 Data analysis COVID-19 Interoperability and standards COVID-19 Data analysis COVID-19 Misinformation and global health COVID-19 Specific GHI insights came from multiple countries, including Brazil, India, Kenya, Pakistan, Uganda, Vietnam, and other regions. Country-specific papers addressed multiple health informatics areas, including database structure within the Observational Medical Outcomes Partnership (OMOP) model,9 specific mobile health (mHealth) applications,7 the implementation and impact of telehealth and digital health wallets (DHW),10 and, from Uganda, a study of COVID-19 on clinical care through the application of interrupted time series and regression models using data from a country-wide HIT system.8 There is a focus on the eHealth component (mHealth and telehealth) during COVID-19. This reflects a long history of emphasis on “shiny” tools without emphasizing vital standards-based informatics (especially usability testing) and data science foundation and the paucity of enterprise-wide platforms to support the spread and scale-up of the tools and data. The limited findings of the OMOP paper support this view from the data networks perspective.9 Governance is growing in importance, and funded organizations like the Health Data Collaborative are promising. This issue includes an exemplar using the application of health data governance principles on simulated global electronic health records informed by data within a digital health passport.5 Global inequity, such as the global north-south divide, must be addressed explicitly in informatics education and professional practice. The north-south divide is real, and only 1 paper expressly discussed it. This used an online simulation of educational activities around digital vaccine passports to address border controls in pandemics, “vaccine nationalism,” and inequity. Digital health diplomacy was identified as an important part of education and training to achieve sociotechnical harmonization and cooperation across the digital spectrum of technical, syntactic, semantic, services, and regulatory layers of interoperability.5 “Scoping Review of Health Information Technology Usability Methods Leveraged in Africa” explored the state of health information technology (HIT) usability (effectiveness, efficiency, and satisfaction) evaluation in Africa.2 Developing and enhancing usable HIT is critical to promoting equitable health service delivery and high-quality care in Africa. Of the 73 articles included in this review, 20 (27%) are from the last 2 years and 31 (42%) from the previous 3 to 5 years. The findings suggest that early-stage evaluations (Stages 1 and 2) and interactions (Types 0 and 1) should receive special attention to ensure HIT usability before implementing HIT in the field. The authors recommend that researchers must incorporate theoretical frameworks in future studies to provide a more robust rationale for their work and enhance the rigor of usability evaluation research. “Clinical Information System (CIS): Implementation in Developing Countries: Requirements, Success Factors, and Recommendations” by Tun and Madanian systematically reviewed the literature on the success factors in Clinical Information System (CIS) implementation for developing countries.3 The aim was to create a set of recommendations, presented as a framework, to enhance the success rate in implementing CIS in these countries. A systematic literature review was conducted, and 83 articles were analyzed using thematic and cross-case analysis to identify the requirements and success factors. Six major requirement categories were identified: project management, financial resources, government involvement and support, human resources, organizational, and technical requirements. The study provided a set of recommendations presented in a framework based on the project management lifecycle approach. The proposed framework could support CIS implementation in developing countries. Future studies should focus on identifying barriers to CIS implementation and conducting country-specific empirical studies based on the findings. It is recommended that projects in developing countries include the results of this research included in Appendix E (page 65). “A Scoping Review of Digital Health Interventions for Combating COVID-19 Misinformation and Disinformation” examined digital health interventions (DHIs) that mitigate COVID-19 misinformation and disinformation seeding and spread.12 With the digitization of information dissemination and community outreach activities through online social media, there is a unique opportunity to capture, monitor, examine, and evaluate the components operationalized in trending misinformation (including semantics, syntax, framing, and behavioral constructs) that are permeating public health risk communications and diffusing in vulnerable communities globally. The study screened 1666 articles from PubMed, PsychINFO, and Web of Science and included 17 experimental and interventional studies that developed and tested public consumer-facing DHIs. The results showed that most studies used social media in DHIs, but there was a lack of platform-agnostic generalizability. Only half of the studies specified a theory or model to guide DHIs, and only 1 DHI was evaluated for user perceptions and acceptance. Although critical appraisal and meta-synthesis of articles are not required in scoping reviews, this paper performed an initial summarization. The conclusion suggests the need for community engagement and theory-guided engineering of equitable DHIs that consider the problem of misinformation and disinformation through a multilevel lens. Future scoping reviews can present a more comprehensive view of the research area by exploring domain areas, search terms, and digital health interventions outside the domain of COVID-19, identifying domain gaps, and improving quality in the literature. “Utilization of Telehealth to Manage the COVID-19 Pandemic in Low and Middle-Income countries: A Scoping Review” explored the utilization of telehealth technology to manage the COVID-19 pandemic in LMIC.4 This scoping review provided insight into the use of telehealth technology for different specialties and highlighted the challenges. The scoping review conducted in 2022 analyzed 18 articles published since 2020 on the use of telehealth for COVID-19 in LMIC (South Asia, sub-Saharan Africa, the Middle East and North Africa, and East Asia and Oceania). They included telehealth interventions such as teleconsultation, telecoaching, teledermatology, televisit, mhealth applications, telerehabilitation, telepharmacy, and telepsychiatry. WhatsApp was the most common way for service delivery, and patients and healthcare providers were satisfied with the services in most cases. Although telehealth use was limited in LMIC during the pandemic, it was effective and had positive outcomes. Difficulties with a network connection and accessing high-speed Internet were among the main challenges in using telehealth technology. According to the results, the outcomes of the telehealth interventions in terms of the providers’ and patients’ satisfaction and clinical improvements were positive in most studies indicating that telehealth technology in LMIC is feasible. Patient privacy and information security were among the reported challenges. The governments and health authorities in LMIC need to develop practical guidelines supported by legal bodies to guarantee telehealth technology’s ethical and legal aspects. The economic aspect of telehealth is also important for patients and healthcare providers. Therefore, transparent legislation for the costs and payments for virtual health care services is required. Moreover, training the end-users and providing adequate technical support can encourage patients, their carers, and healthcare providers to use the technology more than before. The study recommends further investigation into similar interventions’ characteristics and clinical effectiveness in different countries, including LMIC. “The Global Health Informatics Landscape and JAMIA” assessed the state of GHI in selected informatics journals including JAMIA.11 The perspective applied criteria for articles about LMIC, international health, and underserved populations and compared JAMIA to 3 other health informatics journals. The analysis found that JAMIA is a key target journal for GHI dissemination with a high impact factor and that it and other journals play a crucial role in strengthening GHI worldwide. The authors make recommendations for future directions for GHI innovation, evaluation, and policy and the role that journals like JAMIA can play in strengthening GHI worldwide. “Analysis of User Interactions with a Digital Health Wallet for Enabling Care Continuity in the Context of an Ongoing Pandemic” investigated user interactions with a DHW system for addressing care continuity challenges in chronic disease management during the COVID-19 pandemic in Kenya.10 The feasibility study analyzed user interaction log data generated by clinicians, nurses, and patients during the deployment of a DHW. The Hamming distance from Information Theory was used to quantify deviations from predetermined workflow sequences supported by the DHW platform. User interaction log analysis is a valuable alternative method for generating and quantifying user experiences in ongoing pandemics. This can be used to identify potential bottlenecks in patient and provider-facing documentation and data-sharing applications such as the DHW. The results showed that nurses interacted with all the relevant user interface elements for triage, clinicians interacted with only 43% of the relevant aspects for consultation, and patients interacted with 67% of the relevant elements. Most deviations from the predetermined workflow sequences pertained to users returning to previous steps in their usage workflow. The conclusion suggests that user interaction log analysis is a valuable alternative method for generating and quantifying user experiences in ongoing pandemics. However, researchers should consider potential disruptions and use multiple approaches to investigate user experiences of health technology during pandemics. Two papers included in this focus issue concentrated on informatics approaches to problems that persist in many settings but in the context of the COVID-19 pandemic. The article “Integrating Real-World Data From The OMOP Data and Health to COVID-19 in the Global a study that used a health informatics framework to and evidence of COVID-19 in and The study COVID-19 records from and analyzed using a network The study analyzed 2 COVID-19 in and The results showed that COVID-19 outcomes were more in the and with health with international findings. The study that a health informatics framework for and COVID-19 data from the Global can provide a potential framework for global knowledge and clinical in response to pandemics and other healthcare The article “A of Two from LMIC the attention on mHealth in LMIC to the potential they can With the of many are exploring as a of impact for individuals in LMIC. The COVID-19 pandemic has also many governments in LMIC to use to support and manage their pandemic and growing digital and COVID-19 mHealth to and public health practices. the in how were and including telemedicine, and and information were practices for included to emphasizing in and using a and for but of services, but data on their impact is future are and are creating an on best practices and global health and the of different and LMIC are in the that mHealth must be in the context of technology The article the of COVID-19 on Health A of using and is of the articles to evaluate data from an Health Information System Data from the system through was used to the impact of on new and interrupted time series and regression evaluation showed within a Multiple regression models were used to quantify the potential impact of the COVID-19 pandemic. and models to the need for HIT in global health This study also the need for model of and the need for tools to robust impact the this article was of the that evaluated the impact of COVID-19 on care delivery in and that a system is in LMIC and can be used for data and Digital Health WHO how environments have used simulation models to evaluate the impact of solutions to implementation and Digital vaccine passports have been proposed as a to a global electronic health the on 1 proposed digital health vaccine and how this could among diverse and challenges for and were can health informatics domains that need to be addressed in LMIC including and public and within the This work how an can and an international in from simulation to “A for a for mHealth Data Governance In Low Middle-Income evaluated how the Health Data Governance developed and in 2022 by digital health are to be for LMIC health informatics the proposed health data governance principles to mHealth data governance helped 3 data and to ensure equitable from health with patients, and promoting health by enhancing health systems and This application of the Health Data Governance principles to mobile health the digital that can including attention to data the development of to data sharing, and the role of interoperability in mHealth technology. of the common findings across the studies The growing use of telehealth and mobile in and the potential they can bring to support and manage COVID-19 pandemic in The of usability in applications The potential of health informatics frameworks for generating and evidence of COVID-19 in The of data privacy and governance implementing mHealth and the need for a comprehensive data-sharing for mHealth data sharing, and governance in The use of simulation models and regression models can be used to understand the impact of solutions in The need for community engagement and the of public and within the The articles in the focus issue also the evidence in highlight DHI and and DHI address health system challenges and enhance the quality of health and DHI are within digital health applications and information including such as to achieve health Misinformation and disinformation presented a public health and were in the context of the COVID-19 information the effectiveness of health interventions to health DHIs have been developed around the to address misinformation and include 3 that to identify or misinformation There has been an in online platforms in LMIC and social media and can information for health information in social media it for users to from platforms have also the spread of a to have also used to address studies DHI behavioral and such as risk and to COVID-19 misinformation or of the COVID-19 pandemic, and the study limited evaluation of the role of DHIs in addressing misinformation or especially in LMIC. for included a lack of community engagement and research in the development and evaluation of the DHIs. DHIs, and an are important to enhance user and ensure research is to evaluate user and satisfaction with the DHIs. Telehealth was an effective for providing healthcare services during the COVID-19 pandemic. Telehealth and clinical healthcare services, and training information and Telehealth services were and platforms such as and and were telehealth services The and used platforms such as WhatsApp and were and used platforms in showed a in the use and of telehealth services the of the COVID-19 showed positive and in using this The of services include improving to healthcare services, and in most critical components for the implementation of telehealth in LMIC include legal and regulatory identifying telehealth users and telehealth technology financial telehealth and training and healthcare and Telehealth has in technical and challenges The barriers to implementing telehealth in LMIC are the high development technical and Internet The of the technology and and of are among other factors should be especially in Internet and and more and development investment are critical for telehealth and security were other challenges of using telehealth technology in There is a need to develop practical guidelines and evaluate the economic aspect of telehealth technology. training the end-users and providing adequate technical support can encourage individuals to use the technology more than before. This focus issue has to the multiple informatics challenges in LMIC including limited electronic health systems used the of that have been developed to than clinical lack of work that can support interoperability and data sharing, and health informatics limited by resources, to training and among many The COVID-19 pandemic the of HIT support for and health in LMIC. of the that were recognized in the during the pandemic of electronic to share clinical data within the healthcare system as well as public health, limited vaccine within the community and public health were in LMIC as a of informatics The lack of research and development and experimental studies in the focus issue reflects the of digital health maturity in the the of digital tools, a for health information and such as a are The scoping reviews reflect a to guide the and training in LMIC. This suggests that the biomedical and health informatics researchers in LMIC are their best within the and financial The principles are but the implementation and evaluation of a need for more to the of digital health The COVID-19 investments in HIT in are an opportunity to an interoperability standards-based informatics (especially usability testing) and an enterprise-wide to support the and and of the tools and data that have been and to be A global to this enterprise-wide with a common data model and an explicit and governance structure to achieve the quintuple aims a long way to achieving the of COVID-19 has investments in informatics (including public health in LMIC, but the investment support for a robust foundation for standards-based digital and public A framework for GHI must consider the and evaluation of the capability maturity of the digital health in health organizations and individual digital there is a need to develop an equitable based on understanding the impact of This to work is critical to and improve the robust evaluation research such as AMIA and with similar organizations in other countries through the Medical Informatics Association and of Health Informatics can play a role in conducting the and the for to achieve can include work with our governments and institutions. authors to the and of the authors the of the The data this article are in the article and the special issue is a of the Health and is for the in this not the or of the

Large observational data networks that leverage routine clinical practice data in electronic health records (EHRs) are critical resources for research on coronavirus disease 2019 (COVID-19). Data normalization is a key challenge for the secondary use of EHRs for COVID-19 research across institutions. In this study, we addressed the challenge of automating the normalization of COVID-19 diagnostic tests, which are critical data elements, but for which controlled terminology terms were published after clinical implementation. We developed a simple but effective rule-based tool called COVID-19 TestNorm to automatically normalize local COVID-19 testing names to standard LOINC (Logical Observation Identifiers Names and Codes) codes. COVID-19 TestNorm was developed and evaluated using 568 test names collected from 8 healthcare systems. Our results show that it could achieve an accuracy of 97.4% on an independent test set. COVID-19 TestNorm is available as an open-source package for developers and as an online Web application for end users (https://clamp.uth.edu/covid/loinc.php). We believe that it will be a useful tool to support secondary use of EHRs for research on COVID-19.

The Indian Health Service provides care to remote and under-resourced communities in the United States. American Indian/Alaska Native patients have some of the highest morbidity and mortality among any ethnic group in the United States. Starting in the 1980s, the IHS implemented the Resource and Patient Management System health information technology (HIT) platform to improve efficiency and quality to address these disparities. The IHS is currently assessing the Resource and Patient Management System to ensure that changing health information needs are met. HIT assessments have traditionally focused on cost, reimbursement opportunities, infrastructure, required or desired functionality, and the ability to meet provider needs. Little information exists on frameworks that assess HIT legacy systems to determine solutions for an integrated rural healthcare system whose end goal is health equity. This search for a next-generation HIT solution for a historically underserved population presents a unique opportunity to envision and redefine HIT that supports health equity as its core mission.

Over the last 5 years, stimulated by the changing healthcare environment and the Health Information Technology for Economic and Clinical Health (HITECH) Meaningful Use (MU) Electronic Health Record (EHR) Incentive program, EHR adoption has increased remarkably, and there is early evidence that such adoption has resulted in healthcare safety and quality benefits.1,2 However, with this broad adoption, many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction,3 new and burdensome data entry tasks being transferred to front-line clinicians,4,5 and lengthened clinician workdays.6–8 Additionally, interoperability between different EHR systems has languished despite large efforts towards that goal.9,10 These challenges are contributing to physicians’ decreased satisfaction with their work lives.11–13 In professional journals,14 press reports,15–17 on wards, and in clinics, we have heard of the difficulties that the transition from paper records to EHRs has created.18 As a result, clinicians are seeking help to get through their work days, which often extend into evenings devoted to writing notes. Examples of comments we have received from clinicians and patients include: “Computers always make things faster and cheaper. Not this time,” and “My doctor pays more attention to the computer than to me.”

OBJECTIVE: Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed. MATERIALS AND METHODS: The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network. RESULTS: The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day. DISCUSSION: EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.

OBJECTIVES: There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans. DESIGN: We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005. METHODS: The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR. RESULTS: The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records. CONCLUSIONS: Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.